Nursing: A Concept-Based Approach to Learning, 2nd Edition

Module 44 Ethics The Concept of Ethics Ethics System of moral principles or standards governing behaviors and relationships Based on professional nursing beliefs and values Refers to standards of right and wrong that influence human behavior Based on values of group that holds those standards Ethics also refers to study and development of ethical standards Individual Community Profession Morality ( similar to ethics Private, personal standards of right and wrong Clues to moral nature of situation Feelings of guilt, hope, shame Tendency to respond to situation with words ought, should, right, wrong Laws reflect moral values of society Nurses have ethical responsibility to be client advocate Advocate ( one who expresses and defends cause of another Values Values ( personal beliefs about truth and worth of behaviors, thoughts, objects Belief ( interpretation or conclusion that one accepts as true Personal values developed Individual social traditions Cultural, ethnic, religious norms within family and associated groups Professional values developed Socialization into nursing profession by established professional codes of ethics, faculty, other nurses Clinical and life experiences Nurses develop insight into own values Values clarification Process of consciously identifying, examining, developing individual values Important in client-centered care Helps nurses learn how to identify client values Helps nurses distinguish client values from their own Ongoing process One model is unit-based discussion Real-time opportunities for nurses to speak about ethics concerns Values essential for the professional nurse Altruism Concern for welfare and well-being of others Autonomy Right to self-determination Human dignity Inherent worth and uniqueness of individuals and populations Integrity Acting in accordance with appropriate code of ethics and accepted standards of practice Social justice Upholding of justice, what is fair, on social scale See Box 441, PROFESSIONAL BEHAVIORS ASSOCIATED WITH ETHICAL NURSING VALUES, p. 2565 See CONCEPTS RELATED TO ETHICS, p. 2566 Case Study Part 1 ( June DAngelo, a 49-year-old female, presented to the emergency department late at night with complaints of severe migraine headache, p. 2567 Clarifying client values Nurses need to identify clients values as those values influence and relate to particular health problem See Table 441, BEHAVIORS THAT MAY INDICATE UNCLEAR VALUES, p. 2565 Processes that may help clients clarify values List alternatives Examine possible consequences of choices Choose freely Feel good about the choice Affirm the choice Act on the choice Act with a pattern Nurse rarely, if ever, offers an opinion when client asks Redirect question back to client Principles of ethical decision making Four primary principles Autonomy Right to self-determination Beneficence Actions one takes should promote good Nurses ethical duty goes beyond beneficence to include nonmaleficence Nonmaleficence ( requires nurse do no harm and safeguard client Risk of harm weighed against potential benefit Justice Upholding of what is just Veracity Tell the truth Principle behind giving complete information for informed consent One principle behind timely and accurate documentation Nursing codes of ethics Codes of ethics General guide for a professions membership Social contract with the public Nightingale Pledge considered first code of nursing ethics in United States Two major codes of ethics for nursing profession American Nurses Association Code of Ethics for Nurses Serves as Statement of ethical obligations and duties of nurse Professions nonnegotiable ethical standard Nursing professions statement of commitment to society Needs to be read and reread Provisions Provision 1value humans without modifiers Right to self-determination Provision 2nurses primary commitment is to client Provision 3apply principle of autonomy to specific bioethical issues Privacyaspects of information that client can control Confidentialityhow information is handled once shared by client Responsibility to identify any practice of an individual that is questionable Provision 4at all times, responsibility and accountability for each nurses actions and judgments belong to individual nurse Provision 5nurses duty to self in seeking professional growth Provision 6nurses role in creating, promoting, maintaining ethical environment Provision 7encourages nurses to use own talents and interests in contributing to advancement of nursing Provisions 8 and 9nurses responsibility in shaping public health policy Nurses obligation to eliminate social inequity, prejudice, oppression International Council of Nurses Code of Ethics See Box 442, THE INTERNATIONAL COUNCIL OF NURSES CODE OF ETHICS, p. 2568 Models of ethical decision making Responsible ethical reasoning Rational Systematic Based on ethical principles and codes See Box 443, ETHICAL DECISION-MAKING MODELS, p. 2569 Nurses have ethical obligations to clients, agency, primary care provider Ethical problems and dilemmas are stressful to nurses Many nursing problems not moral but questions of good nursing practice Important first step in ethical decision making is to determine whether moral dilemma exists Strategies to enhance ethical decisions and practice Strategies to help nurses overcome possible constraints that can hinder ethical practice Become aware of own values Be familiar with nursing codes of ethics Seek continuing education opportunities Respect values, opinions, responsibilities of other healthcare professionals Participate in or establish ethics rounds Serve on institutional ethics committees Strive for collaborative practice National Guideline Clearinghouse one resource for evidence-based ethical practice Joint Commission Mandates that healthcare institutions have written guidelines and policies Case Study Part 2 ( After June DAngelo received her IV hypertension medication, she told both her nurse and her doctor that she felt much better, p. 2570 Conclusion American Nurses Association (ANA) Code of Ethics for Nurses Outlines ethical standards nurses are expected to use Ethical standards are not solely responsibility of nursing Review The Concept of Ethics Relate Link the Concepts Refer Go to Nursing Student Resources Case Study Part 3 ( Before the end of the shift, another staff member in the ED asked the nurse to pick up the phone, p. 2571 Exemplar 44.1 Ethical Dilemmas Overview Ethical dilemma Two or more conflicting rights, values, obligations, or responsibilities Conflict may arise Between nurses personal values and those of another person or organization Between principles and need to achieve a desired outcome Between two or more persons or groups to whom one has obligation Many factors contribute to development of ethical dilemmas Social and technological changes Technology creates new issues Conflicting loyalties and obligations Nurses may experience many conflicts because of their unique position ANA Code of Ethics for Nurses Nurses first loyalty is to client Not always easy to determine which action best serves clients needs Bioethical issues Ethics as applied to human life or health Acquired immunodeficiency syndrome (AIDS) Bears social stigma ANA position statement Moral obligation to care for client infected with HIV cannot be set aside unless risk exceeds responsibility Other ethical issues Testing for HIV status Presence of AIDS in healthcare professionals and clients Genetic testing Potential cancer diagnosis that result from an inherited genetic predisposition Pregnant clients who may need to consider abortion or other options based on findings from genetic testing Organ transplantation Transplant organs may come from living donors or donors who just died Uniform Anatomical Gift Act Living people may choose to become donors by giving consent Ethical issues Allocation of organs Selling of body parts Involvement of children as potential donors Consent Clear definition of death Conflicts of interest between potential donors and recipients End-of-life issues Growing number of older adults and advances in technology have expanded dilemmas Advance directives All states have advance directive legislation Instruct caregivers as to clients wishes about treatments Provides ongoing voice for clients when no longer have capacity to make or communicate decisions See Module 49 Legal Issues and Exemplar 49.2 Advance Directives for more information Euthanasia and assisted suicide Euthanasiagood death or mercy killing Active euthanasia actions to bring about clients death directly Active euthanasia is forbidden by law Assisted suicidevariation of active euthanasia Giving clients means to kill themselves if they request it 2006U.S. Supreme Court upheld assisted suicide regulations in Oregon ANA Active euthanasia and assisted suicide are in violation of Code of Ethics for Nurses Withdrawing, withholding, terminating life-sustaining treatment Withdrawing or withholding life-sustaining therapy (WWLST) Withdrawal of extraordinary means of life support Usually more troubling for healthcare professionals to withdraw treatment than to decide initially not to begin Decision to withdraw treatment, not decision to withdraw care Withdrawing or withholding food and fluids Generally accepted that providing food and fluids part of ordinary nursing care Some people consider that administering food and fluids by tube to dying client or unconscious client not expected to improve is an extraordinary measure Nurse morally obligated to withhold food, fluids, any treatment if determined to be more harmful to administer than to withhold Nurse must honor competent and informed clients refusal of food and fluids ANA Code of Ethics for Nurses supports this position See LIFESPAN CONSIDERATIONS Ethical Dilemmas and Pediatric Clients, p. 2575 Ethical issues in nursing practice Nursing leads professions viewed as honest and ethical Nurses identity as moral agents shaped by contextual and organizational forces Ethical behavior Day-by-day expression of ones commitment to other persons See FOCUS ON CULTURE AND DIVERSITY VARIATIONS IN APPLYING MORAL PRINCIPLES, p. 2576 Nurses often caught between various players Healthcare providers Client Family Staff members Various other colleagues Conflicts also arise from traditional power structures in health care Staffing shortages also contribute to conflict Resources for ethical practice Supportive colleagues Educators Approachable responsible managers Dr. Patricia Benner ( behavior of nurses shaped by Organizational and professional roles Settings in which they work Responses to ethical problems inseparable form settings in which they arise Academic dishonesty Nursing students can identify increasing conflicting values and variables Development of professional ethical behavior builds on individuals personal ethics Academic dishonesty is an ethical situation Cheating Plagiarism Failure to follow academic policies See Box 445, AN EXERCISE IN ETHICAL DECISION MAKING, p. 2576 Workplace issues Allocation of limited health resources Cannot apply autonomy if not possible to give clients what they choose For more information, see Module 39 Managing Care and Module 46 Healthcare Systems Short staffing Evidence-basedstaffing levels linked to safe client care California first state to mandate specific nurse-to-client ratios Working with clients and families Client privacy and confidentiality Privacy a legal and an ethical mandate Health Insurance Portability and Accountability Act See Exemplar 49.3 HIPAA of Module 49 Legal Issues Nurses should help develop and follow security measures when working with computers Client autonomy Nurses have ethical obligation and legal mandate to support client autonomy Coping with ethical dilemmas Coping with ethical dilemmas challenging for even most experienced nurse To help address ethical dilemmas in professional, responsible manner Thorough knowledge of ANA Code of Ethics Assessment and understanding of clients personal values and beliefs Recognizing ones own personal values and beliefs Primary risk management model Resource accumulation Time Education Organization and planning Peer support and consultation Review Ethical Dilemmas Relate Link the Concepts and Exemplars Refer Go to Nursing Student Resources Reflect Case Study Exemplar 44.2 Patient Rights Overview All clients have certain rights Right to informed consent guaranteed by federal law Many states have additional laws protecting clients Healthcare facilities often have patient bill of rights American Nurses Associations Standards of Practice and Code of Ethics Standards for accreditation by Joint Commission See Box 44-6 Patient Rights from the Joint Commissions Speak Up Campaign Protecting client rights Options for clients who feel their rights have been violated Patient advocates in hospitals and large provider agencies Many states have office to assist clients with issues related to patient rights in long-term care States department of health may provide help State regulates Nursing homes Homes for the aged Licensed facilities for disabled See Box 447, A SUMMARY OF THE BILL OF RIGHTS OF THE U.S. ADVISORY COMMISSION ON CONSUMER PROTECTION AND QUALITY IN THE HEALTH CARE INDUSTRY, p. 2579 American Hospital Association has list of rights and responsibilities See Box 448, PATIENT RESPONSIBILITIES, p. 2580 Nursing Practice Ethical issues affect nursing practice on daily basis Nurses who engage in ethical practice Follow ANA Code of Ethics Employers policies and procedures Employ values clarification exercises as needed Make use of additional resources Review Patient Rights Relate Link the Concepts and Exemplars Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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