© 2015 American Nurses Association
PURPOSE AND
EVOLUTION OF THE CODE
AND PROVISIONS 1-3,
NURSES AND PATIENTS
Slide Deck 1
© 2015 American Nurses Association
Provisions 1-3, Nurses and Patients
What do we mean by nurses and patients?
Provisions 1-3 address direct patient care and describe the
most fundamental values and commitments of the nurse.
3
Scope of Nursing Ethics
Unless separately referenced, all content comes from ANA’s Code of
Ethics for Nurses with Interpretive Statements, 2015 (“the Code”) OR
Fowler, M. D.M. (2015). Guide to the code of ethics for nurses:
Development, application, and interpretation (2nd Ed.). Silver Spring, MD:
American Nurses Association.
*All images are public domain under the Creative Commons license
and were retrieved from http://pixabay.com/en/.
The question mark icon throughout indicates a discussion point or
question to engage in dialogue.
4
What Is Ethics?
▪
A specialized area of philosophy dating
back to ancient Greece and earlier
▪
▪
Concepts of Hippocrates still inform today’s
ethical issues.
A systematic study of what is right and
good measured against principles,
virtues and core values of a profession.
5
Scope of Nursing Ethics
Deals with:
▪ Character (what sort of person one ought to be)
▪ Conduct (how one should act)
Deals with duties and obligations of nurses to:
▪ Patients
▪ Other health professionals
▪ The profession
▪ The wider public
▪ Global humanity
6
Why Ethics in Nursing?
Because nurses…
▪ Serve vulnerable persons
▪ Promise to protect patients
▪ Impact patient well-being
▪ Depend on public trust
▪ Have a moral relationship
with patients that gives rise
to ethical obligations
7
Personal Values and Nursing
▪
▪
Morality comprises personal values, character and conduct.
Those entering nursing bring moral values stemming from:
▪
▪
▪
Religion, culture, family, education, life experience
Embedded moral values are a starting point for ethical
behavior and personal integrity.
As nursing core values are learned and practiced, they are
integrated with personal values to create a nursing moral
identity.
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Branches of Ethics
METAETHICS
▪ Theoretical thinking about morality
NORMATIVE ETHICS
▪ What is right/wrong, good/evil individual or collective
choices
APPLIED ETHICS
▪ Right/wrong, good/evil of actions in a specific profession or
discipline
9
What Is an Ethical Code?
An ethical code is an identifying feature of a profession to:
▪ Facilitate professional self-regulation and accountability
▪ Describe obligations of client-professional and colleague-tocolleague relationships
▪ Serve as a guide for analysis, decision and action
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ANA’s Code of Ethics for Nurses with
Interpretive Statements (“the Code”)
▪
▪
▪
▪
▪
▪
▪
Conveys shared ethical values, obligations, duties and ideals
of nurses individually and collectively
Provides an implied contract with the public
Informs society of the moral values and ideals by which it
functions
Informs new professionals of the expected moral behaviors
Guides the profession in self-regulation
Provides a framework for ethical decision-making
Is unapologetic, aspirational and nonnegotiable
11
Legacy of the Code
▪
▪
▪
▪
Commitment to service is the most precious ideal of the
nursing profession.
The Code supports ideals of nursing’s service.
The Code guides all nurses in living out the values and
ideals of the profession.
The Code is a living, ongoing legacy of core values from
Florence Nightingale in 1850 to 2015 and beyond.
12
Evolution of the Code
▪
▪
▪
▪
▪
▪
1893: “Nightingale Pledge”
1926: Suggested Code in the American Journal of Nursing (AJN)
1940: Tentative Code, AJN
1950: The Code adopted by ANA
1956, 1960, 1968, 1976, 1985, 2001: Revisions of the Code
2015: Major revision of the Code
13
Maturation of the Code
The Code was first adopted in 1950; it was periodically
updated to reflect the changing context and practice of nursing.
▪ Early versions stressed
▪
▪
▪
▪
Nurse’s obligation to carry out physician’s orders
Rules of conduct, moral character, hygiene
Duty with skill and moral perfection
Later versions stressed
▪
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Principles, especially respect for patient autonomy
Nurse’s obligation to the patient, including protection from
incompetent, unethical or illegal practice
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Structure of the Code
▪
▪
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Preface
Introduction
Provisions 1-3 with Interpretive Statements: Nurses and Patients
Provisions 4-6 with Interpretive Statements: Boundaries of Duties
and Loyalty
Provisions 7-9 with Interpretive Statements: Commitments Beyond
Individual Patient Encounters
Afterword
Glossary
Time line: The Evolution of Nursing’s Code of Ethics
Note: The Interpretive Statements for each provision provide more specific
guidance for practice, are responsive to the contemporary context of nursing, and
recognize the larger scope of nursing’s concern in relation to health.
15
Emphasis of the Code
▪
▪
▪
▪
All nurses, all roles with various scopes of practice and
settings
Relationship with other caregivers, including unlicensed
personnel
Increasing diversity of patients and nurses
Wholeness of character: Nursing as a lifetime endeavor; core
values and dispositions pervading all aspects of life
16
Revision Considerations
▪
▪
▪
▪
▪
Not lightning rod for controversial, divisive public debate
Not political
Timeless language, no buzzwords that outdate
Succinct, clear, and understandable to students and new
nurses
Useful to all nurses in all roles and settings
17
Nursing Is Value Laden
Caring for those suffering in the most vulnerable
moments of life:
▪ Finding meaning
▪ Bearing witness
▪ Facilitating healing
▪ Being present
▪ Expressing caring
18
Ethical Theories
▪
Nursing draws from many ethical theories, including:
•
•
•
•
▪
▪
Kantian Normalism
Utilitarianism
Virtue Ethics
Ethic of Caring
The Code functions at mid-range
Any of these theories can be used “behind” the Code
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Provision 1
The nurse practices with compassion and respect for the
inherent dignity, worth and unique attributes of every
person.
Interpretive Statements
1.1
1.2
1.3
1.4
1.5
Respect for Human Dignity
Relationships With Patients
The Nature of Health
The Right to Self-Determination
Relationships With Colleagues and Others
20
1.1 Respect for Human Dignity
Patient dignity is the foundation of nursing ethics.
▪ Dignity is inherent, not “earned.”
▪ A patient never loses dignity, e.g., when comatose,
delirious, frail, or in an altered state.
▪ A nurse must approach every patient with respect for
dignity, regardless of personal attributes, health state, or
any other situational or patient variable.
Source: Ferrell, B.R., & Coyle, N. (2008). The nature of suffering and the goals of nursing . New York, NY:
Oxford University Press.
21
How would you react?
If you had to care for a hospitalized terrorist
who injured himself while bombing your
hometown…how does the Code guide you?
22
1.2 Relationships With Patients
▪
▪
Trust
Honoring patient choices, even when risky
How would you react?
▪ If a patient is self-harming by cutting to soothe anxiety,
is this an autonomous choice? Should you stop the
patient?
▪ How does the Code guide you?
23
1.3 The Nature of Health
▪
Care shaped by patient
preferences, needs, values,
choices
▪
Evidence provides the science of
options; patient particulars help
choose the options
How would you react?
▪ Can you refuse to care for an Ebola patient to
avoid risking your own health?
▪ How does the Code guide you?
24
1.4 The Right to Self-Determination
Patients have a right to decide for themselves.
▪ The patient, and decisions made by the patient, are to
be respected regardless of personal attributes of the
patient, conflicting values, or circumstances.
25
Informed Consent for Treatment
▪
Elements of informed consent:
•
•
•
▪
▪
Assent if a minor
Advance directives:
•
▪
Capacity to decide
Pertinent, understandable information
Voluntary decision
Living will, five wishes, DPAHC
If declared by court “incompetent” to decide:
•
•
•
•
Incompetence is a legal/court decision
Power of attorney or next of kin
Substituted judgment
Best interest standard
26
Who Is the Patient?
▪
Individual
▪
▪
▪
▪
▪
▪
▪
▪
Resident in LTC
Consumer in mental health
Client
Recipient of care
Family
Group
Community
Population
27
Who Is the Final Decision-Maker?
Respect for autonomy
▪
▪
The patient, if competent
If family disagrees with the patient…
•
•
▪
▪
Are family goals realistic? How do you know?
What about futile treatment recommended by doctor?
If family members disagree among themselves, who
arbitrates?
If family makes decision that conflicts with physician’s
orders, who arbitrates?
28
Compromised Autonomy
▪
▪
▪
▪
▪
▪
Age: Infant, child
Comatose
Developmentally disabled
Dementia, hypoxia, OBS, head injury
Cognitive impairment from drugs, alcohol
Setting constraints: prisoners, students, patients
29
Health Literacy
▪
▪
Self-determination depends on awareness of decisions to be
made
Patient’s ability to comprehend treatment options may be
impaired by:
▪
▪
▪
▪
▪
▪
Cognitive capacity
Literacy, language proficiency, or educational level
Visual or hearing impairment
Anxiety in presence of health professionals
Fear
Important to assess patient’s understanding of treatment
options and implications
30
Balance
Protection
Over
Under
Paternalism
Negligence
31
At the End of the Day…
Nurses must live with their own conscience
▪ Adequate ethical justification for decisions and actions to
sleep at night
▪ Principles can only go so far
▪ Clinical judgment is in the end situational, contextual and
personal
▪ Ethical decisions always entail ambiguity and uncertainty
32
Interpretive Statement 1.4
“Nurses may not act with intent to end life even though such
actions may be motivated by compassion, respect for
autonomy or quality of life considerations.”
Autonomy to accept, refuse, or terminate care:
▪ Foregoing nutrition and hydration
▪ Withholding or withdrawing life-sustaining treatment
▪ Honoring advance directives
33
Doctrine of Double Effect
▪
▪
Nurse may administer medications with the intent of
reducing symptoms of dying, even though the secondary
impact may decrease respirations and perhaps hasten
death
The nurse’s actions do not cause the death, the terminal
illness causes the death
34
1.5 Relationships With Colleagues and Others
Interdisciplinary
▪ All colleagues, including unlicensed personnel
Inter-professional
▪ All licensed colleagues (medicine, pharmacy, social
workers, dieticians, PT, OT, RT, etc.)
Trans-professional
▪ Licensed colleagues working together on a team across
fields of expertise
35
Create a Culture of Respect
Cultivate civility, collaboration, and collegiality to ensure:
▪ Safe, quality patient care and outcomes
▪ Compassionate, transparent, effective health services
▪ A hospitable work environment
36
Provision 2
The nurse’s primary commitment is to the patient, whether
an individual, family, group, community or population.
Interpretive Statements
2.1 Primacy of the Patient’s Interests
2.2 Conflict of Interest for Nurses
2.3 Collaboration
2.4 Professional Boundaries
37
2.1 Primacy of the Patient’s Interests
▪
Engagement, trust, intimacy, presence
•
▪
Based on covenant relationship, existential encounter, response to
vulnerability
Respond in the here and now
•
•
•
•
Attentiveness
Responsibility
Competence
Responsiveness
38
Anticipate Nuances
▪
▪
▪
Contextual variables shift
Decision-making never static or complete
Approach may be
•
•
•
•
•
•
Too broad/too narrow
Too hasty/too delayed
Too constrained/too flexible
Too conventional/too visionary
Too reductionist/too expansionist
Too technical/not caring enough
39
Conflict Resolution
▪
▪
When patient interests collide with those of others (family
members, physician), the nurse’s primary commitment is
to the patient.
A nurse helps resolve such conflicts, so patient wishes
may be honored.
40
2.2 Conflict of Interest for Nurses
If a nurse stands to gain personally from a clinical
situation, a conflict of interest exists.
▪
▪
Disclosure of such a conflict to all involved is expected.
Professional integrity may be damaged if a nurse does not withdraw
from a conflict of interest.
41
“There comes a point in analysis of every ethical
dilemma when people finally know what is right
and what is wrong, regardless of analytical
reasoning.”
-George Annas, Law Professor
42
2.3 Collaboration
Trust, respect, transparency
▪ Voicing ethical opinion
▪ Shared decision-making
▪ “Community of moral discourse”
▪ Equipping patients with the information, resources and
courage to participate in mutual decision-making
▪ Shared responsibility for outcomes
43
2.4 Professional Boundaries
▪
Intensely personal work with vulnerable patients may
generate emotional attachments
•
▪
Gifts generally not appropriate
Withdraw from problematic boundary situations with
colleagues
44
Provision 3
The nurse promotes, advocates for, and protects the rights,
health, and safety of the patient.
Interpretive Statements
3.1 Protection of the Rights of Privacy and Confidentiality
3.2 Protection of Human Participants in Research
3.3 Performance Standards and Review Mechanisms
3.4 Professional Responsibility in Promoting a Culture of Safety
3.5 Protection of Patient Health and Safety by Acting on
Questionable Practice
3.6 Patient Protection and Impaired Practice
45
3.1 Protection of the Rights of Privacy and
Confidentiality
Policies and practices in an age of
technology
▪ HIPAA: Adhere to federal and state
▪
▪
▪
regulations
Facebook: Completely off limits for patient
photos or identifying information
Caring Bridge: Patients decide, nurses
should not engage
Electronic Health Records: Only shared
with those directly involved in care
46
3.2 Protection of Human Participants in Research
▪
▪
Institutional Review Board (IRB) approval of relevant
research proposal
Voluntary participation of participants
•
▪
▪
No coercion, deceit
Informed consent documented
Right to withdraw at any point with no untoward
consequences
47
Special Consideration for Vulnerable Subjects
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Fetuses and human embryos
Pregnant women
Children and minors
Cognitively impaired persons
Prisoners
Traumatized and comatose patients
Terminally ill patients
Elderly/aged persons
Economically or educationally disadvantaged persons
Underserved populations
48
3.3 Performance Standards and Review
Mechanisms
▪
▪
Demonstrate ongoing knowledge, skills, dispositions and
integrity for competence in practice
Assume accountability for current, quality nursing practice
according to national, state, and institutional standards
49
3.4 Professional Responsibility in Promoting a
Culture of Safety
▪
▪
▪
▪
▪
▪
Avoid or reduce errors
Do not conceal errors
Correct or treat errors
Use chain of authority when reporting a problem
Provide timely responsive communication
Document
50
3.5 Protection of Patient Health and Safety by
Acting on Questionable Practice
If a nurse observes a violation of law, policy, or ethical
standards that could jeopardize patient safety…
▪
▪
▪
What guidance does the Code provide?
What ANA position papers provide additional
guidance?
What other policies or procedures need to be
followed?
51
3.6 Patient Protection and Impaired Practice
When impaired practice is suspected, patient safety may be
jeopardized
▪ Identify colleagues whose practice may be impaired or who
are placing patients at risk
▪ Follow chain of authority with compassion and caring so
remediation and recovery may follow
▪ Access employee assistance program for help
52
What Will Guide Your Moral Compass?
53
© 2015 American Nurses Association
PROVISIONS 4-6,
BOUNDARIES OF DUTY
AND LOYALTY
Slide Deck 2
© 2015 American Nurses Association
Provisions 4-6, Boundaries of Duty and Loyalty
What do we mean by “boundaries of duty and loyalty”?
Provisions 4-6 focus on the individual nurse’s responsibility
and accountability in nursing practice, as well as the promotion
of safe, quality health care.
Provision 4
The nurse has authority, accountability and responsibility for
nursing practice; makes decisions; and takes action
consistent with the obligation to promote health and to
provide optimal care.
Interpretive Statements
4.1 Authority, Accountability, and Responsibility
4.2 Accountability for Nursing Judgments, Decisions, and Actions
4.3 Responsibility for Nursing Judgments, Decisions, and Actions
4.4 Assignment and Delegation of Nursing Activities or Tasks
4.1 Authority, Accountability and Responsibility
Nurses are always accountable for their own actions,
maintaining their competence to ensure safe practice.
▪ Technological advancements require ongoing learning.
▪ Evidence-informed practice mandates continuous learning.
▪ Shifting patterns of health care delivery demand orientation
to changing lines of authority, communication channels and
multisystem policies.
▪ APRNs adhere to scope of practice, as state nurse practice
acts vary and reform roles periodically.
4.2 Accountability for Nursing Judgments,
Decisions, and Actions
▪
▪
▪
▪
Fidelity (loyalty, including keeping
promises, honoring agreements,
performing competently, etc.)
Veracity (truth-telling; nondeception)
Beneficence (doing what benefits
the patient)
Nonmaleficence (non-infliction of
harm)
Beauchamp & Childress, 2013
Ethical Virtues of All Health Professionals
▪
▪
▪
▪
▪
Compassion
Discernment
Trustworthiness
Integrity
Conscientiousness
Beauchamp & Childress, 2013
Virtues Specific to Nursing
▪
▪
▪
▪
▪
▪
Wisdom
Patience
Compassion
Honesty
Altruism
Courage
4.3 Responsibility for Nursing Judgments,
Decisions and Actions
▪
▪
▪
▪
▪
▪
Adhere to Nursing: Scope and Standards of
Practice, including APRN scope and
standards
Maintain standards of practice
Participate in peer review, credentialing
Engage in committees and other
mechanisms to make sound decisions
about quality and safety of care
Refuse assignments beyond competence
Seek consultation when in doubt
4.4 Assignment Delegation of Nursing
Activities or Tasks
▪
▪
▪
▪
Delegate tasks consistent with your state’s nurse practice
act
Assess qualifications and competence of those whom you
delegate or assign
Participate in orientation, skill development, continuing
education, competency verification and staffing policies to
ensure safe care
Engage in shared responsibility for educating student nurses
Provision 5
The nurse owes the same duties to self as to others, including
the responsibility to promote health and safety, preserve
wholeness of character and integrity, maintain competence,
and continue personal and professional growth.
Interpretive Statements
5.1 Duties to Self and Others
5.2 Promotion of Personal Health, Safety and Well-Being
5.3 Preservation of Wholeness of Character
5.4 Preservation of Integrity
5.5 Maintenance of Competence and Continuation of Professional
Growth
5.6 Continuation of Personal Growth
5.1 Duties to Self and Others
Nurses must take care of themselves before taking care of
others.
▪ Self-regarding duties include health, safety, integrity,
competence and professional growth.
5.2 Promotion of Personal Health, Safety and
Well-Being
Nurses have a duty to model health promotion to patients
and the public.
▪ Fatigue and compassion fatigue may be occupational
hazards for nurses in intense clinical practice.
▪ Balance in personal and professional life is essential for
well-being.
▪ Good diet, exercise, healthy sleep patterns and healthy
relationships are all factors in maintaining this balance.
5.3 Preservation of Wholeness of Character
Nurses are moral agents in any setting, as they embrace the
values of the profession and display them in their
communication and actions.
▪ Nurses should assess risks to integrity ahead of employment
decisions.
▪ Nurses’ personal values merge with professional values,
creating an identity that is reflected in practice and permeates
private life.
•
•
▪
Thieves, liars and cheats do not make good nurses!
Felonious record disqualifies a person from becoming a nurse
Nurses can foster a community of moral discourse where open
dialogue about crucial health issues is facilitated.
Undue Influence of Patients
Because nurses are respected and have authority, their
influence on patient decision-making may be unduly
influential; nurses should avoid coercion or unintentional
pressure in helping patients articulate their own values and
preferences.
How do you respond?
An elderly patient faces a
tough decision about whether
to undergo chemotherapy to
prolong her life. The patient
asks you what you would do in
her shoes.
▪ How do you respond?
▪ How does the Code guide
you?
5.4 Preservation of Integrity
▪
▪
When integrity is eroded, nurses may experience moral
distress.
Threats to integrity may be encountered in practice.
▪
▪
▪
Nurses may be asked to take action in conflict with personal or
professional values or the Code.
Nurses have a right and duty to express their opposition and only
compromise if such a decision preserves their moral integrity.
Integrity-preserving compromise is more likely in a safe
environment of mutual respect where open moral dialogue is
encouraged.
▪
Conscientious Objection
Conscientious objection enables an individual to refuse
participation in an activity that violates personal values or
beliefs.
▪ Select an employer whose values correspond with your own,
whose routine practices do not violate your beliefs.
▪ Timely appropriate communication to supervisors is
necessary to make alternate arrangements in order to avoid
“neglect of care” or “patient abandonment.”
Conscientious Objection
When is it imperative to refuse to participate in a
practice that conflicts with your values?
Thousand Shades of Grey
“…ethics isn’t about choosing between right and
wrong; it’s about choosing between grey and grey.
It’s about choosing between two equally desirable,
but mutually exclusive courses of action. Freedom
or security? Courage or comfort? Self-examination
or blissful happiness?”
-Will Ferguson, Happiness
Ethical Unloading
▪
▪
▪
▪
▪
Moral distress
Cumulative moral residue
Crescendo effect
Burnout/rustout
Moral courage
5.5 Maintenance of Competence and
Continuation of Professional Growth
5.6 Continuation of Personal Growth
▪
Evaluate performance periodically
using standards and peer review
▪
Commit to lifelong learning and
advanced study
▪
Broaden understanding of the world,
human beings and themselves as
moral agents in the world
Provision 6
The nurse, through individual and collective effort,
establishes, maintains, and improves the ethical
environment of the work settings and conditions of
employment that are conducive to safe, quality health care.
Interpretive Statements
6.1 The Environment and Moral Virtue
6.2 The Environment and Ethical Obligation
6.3 Responsibility for the Health care Environment
6.1 The Environment and Moral Virtue
Virtues Expected of All:
▪ Integrity
▪ Respect
▪ Moderation
▪ Industry
Additional Virtues Expected
of All Nurses:
▪ Knowledge
▪ Skill
▪ Wisdom
▪ Patience
▪ Compassion
▪ Honesty
▪ Altruism
▪ Courage
Moral Milieu
For virtues to flourish, the work climate should foster:
▪ Respect and trust
▪ Mutual caring
▪ Communication
▪ Generosity
▪ Kindness
▪ Equality
▪ Prudence
▪ Transparency
6.2 The Environment and Ethical Obligation
▪
▪
▪
▪
▪
▪
Create a culture of excellence
Formulate clear policies and procedures
Ensure all nurses have working knowledge of the Code
Provide functional Ethics Committees
Treat employees fairly and with dignity
Facilitate mechanisms for grievances to be aired in a fair
and timely fashion
6.3 Responsibility for the Health Care
Environment
▪
▪
▪
▪
Ensure ongoing professional development and evaluation of
all staff
Participate in interprofessional workplace advocacy to
address unethical practice
Continue to express concerns over unacceptable ethical
practice, documenting these sequentially
Resign after repeated unsuccessful attempts to change
unjust or unethical practice in order to preserve integrity, or
risk being complicit in unethical practice
Mutual Ethical Integrity
What can we do collaboratively to
shape a future for nursing that fosters ethical
integrity in all dimensions
of practice?
“Ethical living requires coping well with the lives
fate has dealt us. Our lives routinely demand that
we choose well from among myriad options for
shaping our common destinies. We are enlarged
by the magnitude of our responsibilities for
shaping the future. Every human life takes on a
singular majesty when dedicated to the noble
quest for ethical living.”
-Anita Allen, 2004
© 2015 American Nurses Association
PROVISIONS 7-9,
COMMITMENT
BEYOND INDIVIDUAL
PATIENT ENCOUNTERS
Slide Deck 3
© 2015 American Nurses Association
Provisions 7-9, Commitment Beyond
Individual Patient Encounters
What do we mean by “commitment beyond individual
patient encounters”?
Provisions 7-9 focus on the expanded duties of the nurse and
the nursing profession in advancing nursing and health care
nationally and globally.
3
Provision 7
The nurse, in all roles and settings, advances the profession
through research and scholarly inquiry, professional standards
development, and the generation of both nursing and health
policy.
Interpretive Statements
7.1 Contributions Through Research and Scholarly Inquiry
7.2 Contributions Through Developing, Maintaining, and
Implementing Professional Practice Standards
7.3 Contributions Through Nursing and Health Policy Development
4
7.1 Contributions Through Research and
Scholarly Inquiry
Knowledge development advancing the body of nursing
science.
▪ All nurses engage in scholarly activity by providing evidenceinformed practice.
▪ Nurse researchers follow national/international standards
for conducting research with human participants.
▪ All research must be approved by institutional review boards
(IRBs) in compliance with national standards.
▪ Patient welfare must never be jeopardized for research
findings.
5
Vulnerable Populations
Do not generally have access to government or private
resources to meet basic needs:
▪ Low-income persons
▪ Underserved populations
▪ People with disabilities
▪ Elderly persons
▪ Children
▪ Prisoners
▪ Homeless persons
▪ Mentally ill persons
6
Questions to Ask About Ethics of Research
Studies
▪
▪
▪
▪
▪
▪
▪
Should a study be judged by today’s ethical standards or the
standards applied at the time of the study?
Were participants informed and did they comprehend risks?
Did the research knowingly cause harm?
Was harm a direct and foreseen result of the study or of
some other factors?
Did experimentation continue after harmful results were
known?
Was help available to subjects after the study?
Were results suppressed, falsified or destroyed?
7
Questions to Ask about Ethics of
Research Studies
What are the implications of a research survey of Alzheimer’s
patients?
▪ How could informed consent be obtained?
▪ How valid would verbal responses to a survey be?
▪ What steps could be taken to make such a study ethically
acceptable and meaningful?
8
Research With Marginalized Subjects
Nonmaleficence
Right to
Information
Research Ethics Committees:
Safeguard Dignity, Rights,
Safety and Well-being of All
Research Participants
Right to
Withdraw
Informed Consent
Volunteer to Participate
Autonomy
Professionals’ Use
of Responsible
Advocacy
Research Ethics Committees:
Ensure High-Quality Research
That Offers Benefits to
Participants, Services and
Society
Beneficence
Paternalism
AVOID:
Exploitation, Coercion
and Exclusion and
Discrimination
Facilitative
Informs Policy and Service
Provision
Seek Active
Involvement of Service
Users
Justice
9
7.2 Contributions through Developing, Maintaining
and Implementing Professional Practice Standards
Scope and standards inform practice in multiple specialties
and all settings.
▪ Practice environments should facilitate implementation of
these standards.
▪ Standards should be woven through any nursing program
curriculum.
10
7.3 Contributions through Nursing and Health
Policy Development
Nurses must advocate for health policies through
institutional, local, regional, state, and national initiatives to
improve quality of life for populations.
▪ Health policy advocacy should be included in nursing
curricula.
▪ Nurses are more powerful when their voices are combined
through professional organizations.
11
Provision 8
The nurse collaborates with other health professionals and
the public to protect human rights, promote health
diplomacy, and reduce health disparities.
Interpretive Statements
8.1 Health Is a Universal Right
8.2 Collaboration for Health, Human Rights, and Health Diplomacy
8.3 Obligation to Advance Health and Human Rights and Reduce
Disparities
8.4 Collaboration for Human Rights in Complex, Extreme or
Extraordinary Practice Settings
12
8.1 Health Is a Universal Right
Radical declaration:
Health Is a Universal Right
Creates obligation to advance health and human rights.
13
8.2 Collaboration for Health, Human
Rights, and Health Diplomacy
“If health is a human right, then a health disparity is a
human rights issue and the struggle to achieve health
equity for all is an issue of social justice.”
-Jacquelyn Miller, CEO, Nebraska DHHS
14
“If we could change the health of the world
by changing one thing, it would be to ensure
equal rights for women.”
-Eleanor Roosevelt
15
United Nations human rights include…
▪
Highest attainable standard of physical and mental health
▪
▪
Equal access to adequate health care and services
▪
▪
▪
▪
▪
▪
Including reproductive and sexual health
Regardless of gender, race, or other status
Equitable distribution of food, safe drinking water and
sanitation
Adequate housing, safe workplace
Freedom from discrimination
Education, including health and sex education
Environment appropriate for a child’s physical and mental
development
16
United Nations Millennium Development
Goals 2000-2015
▪
▪
▪
▪
▪
▪
▪
▪
Eradicate Extreme Hunger and Poverty
Achieve Universal Primary Education
Promote Gender Equality and Empower Women
Reduce Child Mortality
Improve Maternal Health
Combat HIV/AIDS, Malaria and Other Diseases
Ensure Environmental Sustainability
Develop a Global Partnership for Development
17
United Nations Progress Report
Check out the United Nations Progress Report:
www.un.org/millenniumgoals/
▪
▪
▪
▪
▪
▪
▪
▪
Extreme poverty is falling in every region, including Africa
Water sources have improved
Fewer people living in urban slums
More children are in primary school (especially girls)
Deaths under age 5 have fallen
Millions more are receiving HIV antiretroviral therapy
TB deaths are expected to fall dramatically
Malaria cases have decreased
18
Global Challenges Remain
▪
▪
▪
▪
▪
▪
Global economic crises slowed progress for some countries;
unemployment persists
Rural areas haven’t improved water sources enough
Maternal mortality is still too high
Hunger and malnutrition persist
Slums are still growing
Gender inequality and violence undermine efforts of women
to reach goals
19
Underserved in Health Care
▪
▪
Power differential exists between those who can access
health care and those who cannot
Uninsured, underinsured
▪
▪
▪
▪
▪
Marginally insured
Tenuously insured
Periodically insured
Refugees and immigrants
Stigma of welfare in America
▪
Less likely to secure Medicaid benefits
Access to Care Is Still a Huge Issue for Millions
20
But What Can I Do About These
Huge Problems?
21
Some Small Steps for Individual Nurses
▪
▪
▪
▪
▪
▪
Read to stay informed
Write letters to legislators
Foster healthy lifestyles in your community
Be aware of underlying community conditions contributing
to health problems
Create a clinical environment that is culturally sensitive to
diverse cultural perspectives
Join a professional organization that lobbies Congress for
equitable policies
22
Your Voice Is Amplified in Professional
Organizations
▪
Nursing: American Nurses Association
•
▪
Multidisciplinary (Health)
▪
▪
▪
Specialty Organizations
Public Health, American Public Health Association
Rural Health
Multidisciplinary/Multiorganizational
▪
▪
Sociologists, political scientists, demographers
Environmentalists, journalists, historians, geoscientists, climatologists
and more
23
8.3 Obligation to Advance Health and Human
Rights and Reduce Disparities
Collaboration: An Instrument for Social Justice
▪ Inequality, poverty, and stigma erode health
▪ Social determinants of health must be addressed, including…
•
•
•
•
•
•
Contaminated water and air
Poor sanitation
Hunger
Limited education
Violence, warfare
Homelessness
24
Partnerships
Collaborative partnerships with a united voice can impact
legislation, policies, and relief efforts to alleviate suffering
and create living conditions in which populations can flourish.
25
8.4 Collaboration for Human Rights in Complex,
Extreme, or Extraordinary Practice Settings
26
Imagine…
▪
▪
▪
You are the only RN caring for three terminally ill patients in
the ICU on the 5th floor during a hurricane that has knocked
out power, contaminated the water, and produced structural
damage to the hospital.
Evacuation is not possible for four days during which you run
out of IVs and morphine. The pharmacy is shut down and all
pharmacists have evacuated.
Patients are suffering in 105 degree heat with no fluids and
no pain relief. One patient asks you to be merciful and end
his suffering. What are your options? What guidance does
the Code provide?
27
Continuum of Vulnerability
When individuals lose power to represent themselves and
their needs, wishes, values, and choices, others must
advocate for them.
▪ Potentially vulnerable
▪ Circumstantially vulnerable
▪ Temporarily vulnerable
▪ Episodically vulnerable
▪ Permanently vulnerable
28
Provision 9
The profession of nursing, collectively through its professional
organizations, must articulate nursing values, maintain the
integrity of the profession, and integrate principles of social
justice into nursing and health policy.
Interpretive Statements
9.1 Articulation and Assertion of Values
9.2 Integrity of the Profession
9.3 Integrating Social Justice
9.4 Social Justice in Nursing and Health Policy
29
9.1 Articulation and Assertion of Values
Unified Voice to Assert Shared Values.
▪ Professional organizations articulate and share mutual
values with the profession, colleagues, and the public.
▪ Unwavering Central Values
•
•
•
Promotion or restoration of health
Prevention of illness and injury
Alleviation of pain and suffering
30
The Perils of Social Change
“All progress is precarious, and the solution of one problem
brings us face to face with another.”
-Martin Luther King Jr., 1963
“Be not afraid of going slowly, be afraid only of standing
still.”
-Ancient Chinese Proverb
“Make haste, but do it cautiously.”
-Marge Hegge
31
9.2 Integrity of the Profession
▪
▪
▪
▪
▪
▪
Encouraging respect, fairness, and caring in all facets of
nursing
Ensuring nursing workforce sustainability
Fostering higher education of nurses
Advancing nursing science
Supporting certification and licensure
Facilitating evidence-informed practice
32
9.3 Integrating Social Justice
Vigilance to influence those in power to:
▪ Improve health and health care
▪ Address unjust systems and structures
▪ Address underlying determinants of health
▪ Redress wrongs
33
Creating the Landing Strip to the Future
“In today’s turbulent times, engaging people’s best
thinking about complex issues without easy
answers will be the key to creating the futures we
want rather than the futures we get.”
-Eric Vogt, The Art of Powerful Questions
34
9.4 Social Justice in Nursing and Health Policy
▪
▪
▪
Open and honest communication
Work in concert to advance common good
Environmental restoration
35
Global Burden of Disease
(World Health Organization)
30 Richest
Nations
Population Disease Health $ Providers
Africa,
Southeast Asia
Are Poorest
Nations
Population Disease Health $ Providers
36
Global Health Inequities
Less than 10% of the world’s health research
budget is spent on conditions that account for 90%
of the world’s diseases!
37
World Health
Americans can no longer isolate themselves from epidemics and
pandemics in faraway places.
We all share this fragile small planet, and share risk of infectious
diseases fanning across the globe.
38
Global Injustice
How are we
to respond?
39
“Even if you’re on the right track,
you’ll get run over if you just sit
there.”
-Will Rogers
40
“Nurses are messengers of hope for
troubled times. Leave your footprints of hope
for the next generation to follow.”
-Marge Hegge
41
Chapter 6
Ethics and Legal Issues
CHAPTER 6 OBJECTIVES
• Apply ethical principles to decision
making.
• Discuss the importance of ethics to the
nursing profession and its professional
recognition.
• Summarize current ethical issues.
CHAPTER 6 OBJECTIVES
• Define major legal terms.
• Discuss the relevance of legal issues to
nursing practice.
• Explain how malpractice relates to nursing
practice.
• Discuss examples of ethical and legal
issues.
INTRODUCTION
• Nursing profession has ethical
responsibilities
• Legal issues arise that every nurse must
understand
• Ethics and legal issues involve
– professionalism
– health policy
– reimbursement issues
– the organizations that provide health care.
ETHICS AND ETHICAL
PRINCIPLES (1 of 4)
• Definitions
– Ethics: a standard code or guide to behavior
– Morals: an individual’s code of acceptable behaviors
• Ethical Principles
– Autonomy: focuses on the patient’s right to make
decisions about matters that impact the patient
– Beneficence: relates to doing something good and
carding for the patient
ETHICS AND ETHICAL
PRINCIPLES (2 of 4)
• Ethical Principles
– Justice: is about treating people fairly
– Veracity: is truth
– Other suggested principles:
•
•
•
•
•
•
Advocacy
Caring
Stewardship
Respect
Honesty
Confidentiality
ETHICS AND ETHICAL
PRINCIPLES (3 of 4)
• Ethical Decision Making
– Ethical dilemma: occurs when a person is
forced to choose between 2 or more
alternatives, none of which is ideal.
•
•
•
•
Involvement
Assessment
Plan
Implementation
ETHICS AND ETHICAL
PRINCIPLES (4 of 4)
• Professional Ethics and Nursing Practice
– Benner et al, 2010
• Nursing education needs to focus more on ethical
comportment
• Students need to develop skills to respond ethically to errors
and to make ethical decisions.
• American Nurses Association Code of Ethics
• Reporting Incompetent, Unethical, or Illegal
Practices
– Role of the State Board of Nursing
CURRENT ETHICAL ISSUES
(1 of 2)
• Rationing Care: Who Can Access Care
When Needed
• Healthcare Fraud and Abuse
• Ethics and Research
– Informed consent
– Institutional review boards (IRBs)
– Physical harms
– Psychological harms
– Social and economic harms
CURRENT ETHICAL ISSUES
(2 of 2)
• Organizational Ethics
– Reimbursement compliance
• Compliance officer
– Whistle-blowing
• False Claims Act
LEGAL ISSUES: AN
OVERVIEW (1 of 4)
• Licensure
• Nurse practice act
• Critical Terminology
– Assault
– Battery
– Civil law
– Criminal law
– Doctrine of res ipsa loquitur
LEGAL ISSUES: AN OVERVIEW
(2 of 4)
• Critical Terminology
– Emancipation
– Expert witness
– False imprisonment
– Good Samaritan laws
– Malpractice
– Negligence
– Proximate cause
LEGAL ISSUES: AN
OVERVIEW (3 of 4)
• Critical Terminology
– Respondent superior
– Standards of practice
– Statutory law
– Tort
LEGAL ISSUES: AN
OVERVIEW (4 of 4)
• Malpractice: Why Should This Concern
You?
– Negligence occurs in nursing and can lead to
a malpractice suit
•
•
•
•
Nurse has duty to patient
Duty was breached
Breach of duty was cause of harm
Damage or injury to the patient occurred
– Need to prove all elements for successful suit
– Professional liability insurance for nurses
CRITICAL ETHICAL AND LEGAL
PATIENT-ORIENTED ISSUES
• Confidentiality and Informed Consent
• Advance Directives, Living Wills, Medical Power
of Attorney, and Do-Not-Resuscitate
• Organ Transplantation
• Assisted Suicide
• Social Media and Ethical and Legal Issues: A
New Concern
ANA Code of
Ethics
What came before
Provisions 1-9
What are Ethics
O 1896-The Nightingale Pledge
O Considered the first code of ethics for
O
O
O
O
nurses
Patterned after the Hippocratic Oath
Focus was on the moral purity of nurses
Written by a nurse educator in honor of
the ethical example displayed by
Florence Nightingale
Often administered at nursing
graduations and pinnings
Florence Nightingale
Pledge
“I solemnly pledge myself before God and in the
presence of this assembly, to pass my life in
purity and to practice my profession faithfully. I
will abstain from whatever is deleterious and
mischievous, and will not take or knowingly
administer any harmful drug. I will do all in my
power to maintain and elevate the standard of
my profession, and will hold in confidence all
personal matters committed to my keeping and
all family affairs coming to my knowledge in the
practice of my calling. With loyalty will I
endeavor to aid the physician in his work, and
devote myself to the welfare of those
committed to my care.”
1926
O 1926-A Suggested Code
O Elegant, but not specific
O 1926-published in American Journal of
Nursing (AJN)
O Provisionally accepted-but not specific
at practical level
O Never adopted
1940
O 1940- A Tentative Code
O Organized around relationships
O Nurse-to-patient, nurse to profession
O Emphasized nursing as a profession
O 1940-publish in AJN and again asked
for comments from AJN readers
O Never adopted
ANA 1940 Code
“The nurse has a basic concern for
people as human beings, confidence in
the power of personality for good,
respect for religious beliefs of others, and
a philosophy which will sustain and
inspire others as well as herself.”
Ethical Codes
O Many versions proposed
O 1950 version was the first to be officially
accepted
O The Code for Professional Nurses
O Enumerated specific provisions
O Professional relationships no longer
overt organizing framework
ANA 1950
“professional nurses do not
permit their names to be used
in connection with
testimonials in the
advertisement of products.”
Speaks for itself
Revised in 1956
“Professional nurses assist in
disseminating scientific knowledge
through any form of public
announcement not intended to endorse
or promote a commercial product or
service. Professional nurses or groups of
nurses who advertise professional
services do so in conformity with the
standards of the nursing profession”
1950 Code
“The nurse must adhere to
standards of personal
ethics which reflect credit
upon the profession.”
1960’s bring changes
1960
O Shift to how to uphold and enforce the
code
O Developed guidelines for handling alleged
violations of the code
1968
O Dropped professional in title-code applied
to professional and technical nurse
O Dropped reference to private ethics of
nurse
O No specific mention of physicians
O Provisions condensed down to 10
1970’s Bring more changes
O 1976-Code of Nurses with Interpretive
Statements
O Patient participation in care
O Nurse autonomy
O Nurse as advocate
O Use of client in place of patient
O Nonsexist language
2001
O 2001 Code of Ethics with Interpretive
Statements
O Social justice
O Recognition of intrinsic worth of all
humans
O Providing care according to
professional standards
O Just treatment of the nurse
2001ANA Code
“the need for health care is
universal, transcending all
individual differences. The nurse
establishes relationships and
delivers nursing services with
respect for human need and
values, and without prejudice.”
Provision 1
“The nurse practices with
compassion and respect for
the inherent dignity, worth,
and unique attributes of every
person.”
Therapeutic use of self
O In every human encounter we convey
one of three messages-which one do
you want to convey?
O Go away, my world would be better
without you
O You are an object, a task to be done,
you mean nothing to me
O You are a person of worth, I care about
you
Provision 2
O “The nurse’s primary commitment is to
the patient, whether an individual,
family, group, community, or
population”
O This provision intentionally singled out
to demonstrate its significant
importance to the code of nursing
Provision 3
“The nurse promotes,
advocates for, and protects
the rights, health, and safety
of the patient”
Provision 4
“The nurse has authority,
accountability, and responsibility
for nursing practice; makes
decisions; and takes action
consistent with the obligation to
promote health and to provide
optimal care.”
Delegation is
O “….transferring the responsibility
for the performance of an
activity from one person to
another while retaining
accountability for the outcome.”
O ANA 1995
Provision 5
“The nurse owes the same duties
to self as to others, including the
responsibility to promote health
and safety, preserve wholeness of
character and integrity, maintain
competence, and continue
personal and professional growth”
Provision 6
“The nurse, through individual and
collective effort, establishes,
maintains, and improves the
ethical environment of the work
setting and conditions of
employment that are conducive
to safe, quality health care.”
Provision 7
“The nurse, in all roles and settings,
advances the profession through
research and scholarly inquiry,
professional standards
development, and the generation
of both nursing and health policy.”
Provision 8
“The nurse collaborates with
other health professionals and
the public to protect human
rights, promote health
diplomacy, and reduce
health disparities.”
Provision 9
“The profession of nursing,
collectively through its
professional organizations, must
articulate nursing values,
maintain the integrity of the
profession, and integrate
principles of social justice into
nursing and health policy”
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