Transcript Purpose and Evolution of the Code and Provisions 1-3

© 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.
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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.
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What Is Ethics?
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A specialized area of philosophy dating
back to ancient Greece and earlier
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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.
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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
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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
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Personal Values and Nursing
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Morality comprises personal values, character and conduct.
Those entering nursing bring moral values stemming from:
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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
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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”)
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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
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Legacy of the Code
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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.
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Evolution of the Code
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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
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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
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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.
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Emphasis of the Code
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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
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Revision Considerations
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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
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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
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Ethical Theories
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Nursing draws from many ethical theories, including:
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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
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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.
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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?
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1.2 Relationships With Patients
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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?
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1.3 The Nature of Health
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Care shaped by patient
preferences, needs, values,
choices
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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?
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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.
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Informed Consent for Treatment
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Elements of informed consent:
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Assent if a minor
Advance directives:
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Capacity to decide
Pertinent, understandable information
Voluntary decision
Living will, five wishes, DPAHC
If declared by court “incompetent” to decide:
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Incompetence is a legal/court decision
Power of attorney or next of kin
Substituted judgment
Best interest standard
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Who Is the Patient?
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Individual
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Resident in LTC
Consumer in mental health
Client
Recipient of care
Family
Group
Community
Population
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Who Is the Final Decision-Maker?
Respect for autonomy
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The patient, if competent
If family disagrees with the patient…
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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?
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Compromised Autonomy
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Age: Infant, child
Comatose
Developmentally disabled
Dementia, hypoxia, OBS, head injury
Cognitive impairment from drugs, alcohol
Setting constraints: prisoners, students, patients
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Health Literacy
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Self-determination depends on awareness of decisions to be
made
Patient’s ability to comprehend treatment options may be
impaired by:
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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
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Balance
Protection
Over
Under
Paternalism
Negligence
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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
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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
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Doctrine of Double Effect
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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
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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
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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
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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
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2.1 Primacy of the Patient’s Interests
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Engagement, trust, intimacy, presence
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Based on covenant relationship, existential encounter, response to
vulnerability
Respond in the here and now
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Attentiveness
Responsibility
Competence
Responsiveness
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Anticipate Nuances
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Contextual variables shift
Decision-making never static or complete
Approach may be
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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
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Conflict Resolution
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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.
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2.2 Conflict of Interest for Nurses
If a nurse stands to gain personally from a clinical
situation, a conflict of interest exists.
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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.
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“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
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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
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2.4 Professional Boundaries
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Intensely personal work with vulnerable patients may
generate emotional attachments
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Gifts generally not appropriate
Withdraw from problematic boundary situations with
colleagues
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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
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3.1 Protection of the Rights of Privacy and
Confidentiality
Policies and practices in an age of
technology
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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
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3.2 Protection of Human Participants in Research
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Institutional Review Board (IRB) approval of relevant
research proposal
Voluntary participation of participants
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No coercion, deceit
Informed consent documented
Right to withdraw at any point with no untoward
consequences
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Special Consideration for Vulnerable Subjects
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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
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3.3 Performance Standards and Review
Mechanisms
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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
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3.4 Professional Responsibility in Promoting a
Culture of Safety
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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
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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…
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What guidance does the Code provide?
What ANA position papers provide additional
guidance?
What other policies or procedures need to be
followed?
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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
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What Will Guide Your Moral Compass?
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