Nurses today face many ethical dilemmas in the delivery of patient care. What can or should be done for the patient versus the wishes of the patient’s physician conflicting with the personal beliefs the nurse holds to be true. The client’s wishes may conflict with the institutional policies, physician professional opinion, the client’s family desires, or even the laws of the state. According to the nursing code of ethics, the nurse’s first allegiance is to the client (Blais & Hayes, 2011, pg. 60). The ethical ideals of each nurse must be weighed with the laws of the state along with providing the most ethical care for the patient. The advancements in medical technology make it possible to sustain a patient life where previously there was no hope of recovery. These advancements have put nurses in the forefront of decision making begging the question “just because we can, should we” to be answered. Nurses need to understand the legalities involved with these new technologies to practice safely and effectively. Scientific achievements have opened new ground for nursing exploration. In response to the need for nursing input into social and legal issues, nurses now find career opportunities as forensic nurses, legal nurse consultants, and nurse-attorneys (Blais & Hayes, 2011, pg. 75). This paper will explore the ethical and legal issues encountered by nurses in two case studies.
The American Nurses Association Code of Nursing Ethics could influence a final decision in each case study that was presented. The six caps study revealed family members to have conflict in their desires when it came time for a decision in going ahead with surgery (the father’s desire) and having a poor quality of life as the outcome (the adult children’s belief based on physicians prognosis). The adult children believe that their mother would not want to have the surgery and have a poor quality of life. The appropriate decision to involve the ethics committee shows the collaboration between health care professionals. Nurses should be aware of their own values and attitudes in order to recognize when a situation might affect the care they are able to provide (Blais & Hayes, 2011, p.52). The nurses primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (ANA Code of Ethics for Nurses, 2014). Given the information that the adult children believe, their mother would not want to undergo the surgery, it is implied that it was the patient’s wish.
Based on the above information the ANA code of ethics can influence the final decision in that the family members would come to realize that the outcome from surgery would not be what the patient desires. A good decision is one that is in the client’s best interest and at the same time preserves the integrity of all involved (Blais & Hayes, 2011, p. 61). The critical thinking exercise gives information that a nurse is a witness in a malpractice case. The negligence resulted in harm to the client and the case is against the healthcare institution and another nurse who was overtly negligent. The nurses primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the values of the profession through individual and collective action (Blais & Hayes, 2011, p. 59). Given the above ethical codes the nurse failed to uphold and follow ethical practice which resulted in harm to the patient. It is reasonable to assume that the ANA code of nursing ethics would have a significant impact on the courts final decision, as codes of ethics are usually higher than legal standards, and they can never be less than the legal standards of the profession (Blais & Hayes, 2011, p. 58)
Registered Nurses (RN’s) are routinely faced with moral and ethical decisions concerning their patients and fellow employees. In healthcare these issues can be very complex and complicated. An R.N. must frequently challenge their own moral and ethical values when they tasked with supporting their patients and families through difficult end-of-life decision making. Additionally, they may be forced to face the ethical decisions surrounding a fellow co-worker that might be compromising patient care due to impairment, because of an addiction or sleep deprivation. As with other people, there are many issues that influence an RN’s moral and ethical decision making. According to Chitty & Black, an individual’s moral and ethical decision making process is affected by their value system which is largely influenced by their culture and life experiences (Chitty & Black, 2011). Additionally, literature states that ethical decisions are also affected by the social norm of a society or group (Chmielewski, 2013). Unfortunately, when the decision making process for moral and ethical decisions is made through this form of influence, the choices made for moral conduct may go awry.
An example of this might be a group of students that decide as a whole to cheat on an exam. In other words, if the social norm is used as moral compass, there must be an unbiased check and balance system in place. In a hospital setting, this process may involve an ethics committee, an organization’s corporate compliance, or a human resources department. For RN’s that are faced with ethical and moral dilemmas, it is also important to refer to the Code of Ethics for Nurses that has been established by American Nurses Association (ANA). The ANA has set very clear guidelines for RN’s concerning the professional ethical obligations that are expected of nurses when faced with moral decisions concerning patients, colleagues, and the organizations that they work in (American Nurses Association, 2014).
The nurse has a legal duty to assist justice as far as possible (Blais & Hayes, 2011). In the case study of the nurse who observed a nurse violating standards of care, and who was overtly negligent, the nurse has a legal duty to report the incident. The primary responsibility of a nurse is to the patient. It is vital for the nurse to report negligence on any level in order to protect the safety of patients. The nurse also has a legal responsibility to be truthful and honest when testifying as a witness in court (Blais & Hayes, 2011).
In the case study of Marianne, the responsibility of the nurse is to organize discussion between the patient and her family regarding end of life decisions. In this case, there is no advanced directive, which puts the family in a bind, not knowing exactly what to do. According to the American Nursing Association, the nurse should attempt to have the Advanced Directive signed during the admission process (“End of Life Issues”, 2014). Doing this will not only protect the patient, but will assist the family in
knowing what the patient wishes in the event that the patient cannot speak for herself. A nurse has a legal responsibility to put the patient’s needs first, protect the safety of every patient, and act as patient advocate with every patient encounter.
As stated above nurses are faced with many personal and professional dilemmas in their daily duties. The ANA Code of Ethics is intended as an aid to these difficult decisions. The danger, though, with any such “aid” is that it may be applied in an unthinking manner as simply a set of preexisting rules (Dahnke, 2014). Nurses must always keep the focus on delivering the highest quality of care to the patient.
American Nurses Association, Code of Ethics for Nurses. (2014). Retrieved from http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf American Nurses Association, End of life issues. (2014). Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/End-of-Life Blais, K.K., Hayes, J.S. (2011). Professional Nursing Practice: Concepts & Perspectives. (6th ed., cpt. 6). Upper Saddle River, NJ: Pearson/Prentice-Hall. Chitty, K.K. & Black, B.P. (2011). Professional nursing: Concepts and challenges (6th ed.). St. Louis, MO: Elsevier Saunders Chmielewski, C. (2013). Values and culture in ethical decision making. The Global Community for Academic Advising. Retrieved from http://www.nacada.ksu.edu/Resources/Clearinghouse/View-Articles/Values-and-culture-in-ethical-decision-making.aspx Dahnke, M. D. (2014). Lippincott’s nursing center.com: The role of the American Nurses Association code in ethical decision making… Retrieved from http://www.nursingcenter.com/lnc/static?pageid=864590
NURSING ETHICAL LEGAL CONSIDERATIONS IN TODAY’S PRACTICE SETTING.
There is a growing amount of literature and media attention to ethical issues. Every week on medical and legal television shows, such as "ER" and "Law and Order," characters are faced with ethical dilemmas and decisions. In reality, nurses are confronted with an increasing number of ethical decisions within their practice everyday. With unparalleled technological advancement, nursing and bio-medical research, and the present healthcare environment, nurses must be cognisant of their professional and personal views of ethics.
In this essay, a view of the aims of bioethics and more specifically nursing ethics will be explored. The influences of the present healthcare environment and societal developments as they relate to nursing ethics will be addressed, and some of the main ethical legal issues that have impacted recent practice will be identified and examined.
Ethics comes from the ancient Greek word meaning character or customs. Within each society, particular customs and norms develop. While a custom may be sanctioned in one society or context, the custom may not be seen as right by other cultures or societies (Bosek, 2001). Ethics suggests a code of acceptable behaviour or practice and includes the study of social morality as well as philosophical reflection on its norms and practices (Beauchamp and Walters, 1999).
Bioethics and nursing ethics may be considered in the same philosophical realm but differ in both approach and application. Engelhardt (1986) views bioethics as "the study of moral and conceptual problems associated with healthcare and the biomedical sciences." Bioethics tends to be medico-centric in nature and perspective (Johnston, 1999) with focus on identification of ethical concerns in medical and scientific research.
This author agrees with Reich (1978) that the aim of bioethics is the guidance of moral decision-making and discussion in medical science research and study. Bioethics holds to the philosophy that human life must be preserved at any cost, with "the medical ideology that prolonged life of any quality is a prime value (Barnum, 1998). This is contrary to nursing’s philosophy that the preservation of dignity and human rights should take precedence over preservation of life, including the right to die without suffering.
The aim of nursing ethics.
Nursing ethics is not a subcategory of medical ethics, but separate with its own literature, context and application (Veatch, 1985). Nursing ethics refers to the "principles governing the conduct of nurses in relation to patients, their families, associates, and society at large (Wlody, 1998). Johnstone (1999) further describes nursing ethics as "a practice discipline, which aims to provide guidance to nurses on how to decide and act morally in the contexts in which they work.
Nurses have a unique association with patients, a "more direct and therefore more ethically compelling relationship" (Loewy and Loewy, 2001). A recent Gallop Poll ranked nurses above medical doctors, teachers, and even clergy when asked which profession was regarded as "the most honest and ethical" (Www.gallup.com/poll/releases/pr001127.asp)
The aim of nursing ethics should be the examination of ethical issues specific to nursing. This incorporates the protection of patient rights and the deontological principles of autonomy, beneficence, nonmalfience, justice and confidentiality, and offers practical guidance on decision-making in the practice setting, regardless of individual ideologies.
Developments in society and healthcare effecting ethics and law.
There are significant developments in society and healthcare delivery that influence this view of nursing ethics. With rapid technological advance and the present healthcare environment, nurses must deal with an increased number of new and complex ethical dilemmas. Sometimes these issues are previously unknown and "at any given time the practitioner may be confronted with particularities that are not yet accounted for in science or technology" (Puntillo, Brenner, Drought, Drew, Stotts, Stannard, Rushton, Scanlon, and White, 2001).
Within society and healthcare delivery, the profession of nursing is advancing. A professional code of ethics is an important hallmark of a profession (Goldman, 1980). Acquiring a nursing licence does not ensure moral or ethical practice. The American Nurses Association, in response to social and healthcare needs, has developed a Code of Ethics. The Code articulates nursing’s moral duties and obligations, but ultimately the nurse is accountable to the laws of the land.
America has, potentially, the most medically litigious society. Recently in the media, there have been enormous case settlements, such as those for smokers, and, as a result, malpractice insurance costs have escalated. Although nurses make ethically based decisions, they must also be aware of the legal consequences. The laws of the land are still paramount and even those decisions based on a professional ethical code may not be defendable in court. Nurses are encouraged to "Chart for the Lawyer, not the Doctor".
The progression of managed health care, with attention on cost containment and efficiency, has noticeably influenced patient care. The development of health management organizations, and for-profit centres has led to restrictions on patient access to care and even withholding of expensive therapies. The new technologies and procedures can be very expensive to implement but may be required to lure new patients and medical staff. Resource allocation and distribution along with rationing health care reflects a business, rather than patient care, focus.
The Emergency Medical Treatment and Active Labour Act of 1986 (EMTALA) was enacted to ensure access to health screening for all people who present regardless of their ability to pay. The number of people seeking and requiring medical attention without insurance or ability to pay is increasing, causing a shift in healthcare delivery, due to legal mandate to provide care for all. On any given night in a busy Emergency Room, the ‘regulars’, drug seekers and pungent homeless can be found, these individuals still deserve dignity and care, regardless of a nurse’s personal feelings or beliefs. System abuse and limited resources influence nurses’ perspective on ethical care. People in a society have a right to healthcare, but policy makers appear to disregard the ability of resource limited health systems to provide that care, potentially to the detriment of others. As a result there has been significant downsizing, and closures of care centres.
Another aspect influencing the aim of nursing ethics is modern globalisation with changes in patient populations. Immigration in the United States, particularly from Latin-American countries is rising, with the Hispanic population now being the largest minority group.
Issues affecting professional practice
Professional nursing practice has been dramatically impacted by the recent implementation of the Health Insurance Portability and Accountability Act, or "HIPPA", which went into effect April 14 2003. The Act makes legally accountable the ethical obligation to respect patient health information and privacy. Healthcare providers must now take active measures to protect against unauthorized uses and disclosures of personal medical information or be held in breach of confidentiality or criminally liable.
Olson (2003) suggests that nurses have a professional duty and responsibility to maintain confidentiality of patient information and to protect patients’ right to privacy. Protection of these rights is crucial with advancement in nursing informatics, computerized documentation, and medical record storage. However the new privacy law does have a downside: by inhibiting access to information, it can be very frustrating for relatives seeking information about a loved one’s health status. As a recent personal example, a woman’s mother was recently hospitalised and mechanically ventilated rendering her unable to give permission to divulge information. Other parties were then unable to find out the seriousness, and prognosis of her condition. Also the inability to provide information can inhibit or delay patient treatment, as health insurance providers often decide authorization for treatment. Nurses previously could supply information including, condition, injuries and vital signs.
There is undeniable evidence that the issue of nurse-to-patient ratio is a critical issue in current professional practice. A recent study identified staffing patterns that limit patient access to nursing care as the issue "most personally disturbing" to nurses (Fry & Riley, 2002). Studies further show that a lower ratio of licensed nurses to patients increases positive outcomes by decreasing infection rates, complications, re-admissions, and death (Philbrook, 2003). In September 2002, California Governor Gray Davis passed legislation to establish a nurse-to-patient ratio to address the quality of patient care and help meet current workforce needs. By ensuring adequate staffing levels and appropriate workloads, these regulations improve not only patient care but also nursing working conditions and satisfaction.
As a result of cost containment and scarce resource allocation, nurses are presented with ethical challenges of justice in the present fiscal environment in healthcare. Sometimes providing adequate care and maintaining professional nursing practice is challenging in cost-constrained hospital environments (Ritter-Teitel, 2002). Nurses are expected to provide quality patient care based on the same or fewer resources (O’Connor, 1997).
Finally, of end of life care is also a significant issue in professional practice due to the aging population and the increase in life-extending technology. The Patient Self-Determination Act of 1990 provides a means for predetermination of care when the patient is unable to do so. This provides advance directives about withholding resuscitation and life extending measures, and by doing so ensures the patients right to autonomy. However, there can be family or medical refusal to adhere to these wishes and directives, using the excuse of benefiting the patient.
With unprecedented advances in technology and health science, the profession of nursing faces a variety of ethical issues. Nursing’s ethic of care and respect of human rights, along with basic moral principles of autonomy, beneficence, nonmaleficence, justice and confidentiality provide a framework for ethical analysis and decision-making. The continued provision of competent and ethical care, when faced with today’s practice issues, illustrates the commitment of the nursing profession to nursing ethics.
Barnum, B.S. (1998). Nursing theory. New York: Lippincott.
Beauchamp, T., & Walters, LeR. (1990). Ethical theory and bioethics. In Contemporary Issues in Bioethics (5), (pp.1-24). Belmont, CA: Wadsworth.
Bosek, M. (2001). Ethical decision making in anaesthesia. In A Professional Study and Resource Guide for the CRNA. (10), Park ridge, IL: AANA Publishing.
Englehardt, H. T. (1986). The foundations of Bioethics. New York: Oxford University Press.
Fry, S. T., & Riley, J. M. (2002). Ethical issues in clinical practice: A multi-state study of practicing Registered nurses. Retrieved July 10, 2002, from http://jmrileyrn.tripod.com/nen/research.html#anchor195458
Gallop Poll release. (2002). Retrieved July 10, 2002, from http://gallup.com/poll/releases/pr001127.asp
Goldman, A.H. (1980). The moral foundations of professional ethics. Fotowa, NJ: Rowman and Littlefield.
Johnstone, M-J. (1999). Bioethics: A nursing perspective (3rd ed.). Sydney: Harcourt WB Saunders.
Loewy, E.H. & Loewy, R. (2001). Biothics at the crossroad. Healthcare Analysis, 9(4), 463-476.
O’Connor, J. (1997/ 98). Reflecting on 1997. Kai Tiaki: Nursing New Zealand, 3(11), 26-27.
Olsen, L. (2003, Jan-Feb). Privacy and confidentiality in an electronic age. Chart. 100(1), 9.
Philbrook, P. (2002). What happened to the nurse/ patient ratios? Maine Nurse, 4(4), 2, 2002 Nov-2003 Jan.
Puntillo, K. A., Benner, P., Drought, T., Drew, B., Stotts, N., Stannard, D., Rushton, C., Scanlon, C., & White, C. (2001). End of life issues in intensive care units: A national random survey of nurses’ knowledge and beliefs. American Journal of Critical Care, 10(4), 216-219.
Reich, W. T. (1978). Encyclopaedia of Bioethics. New York: The Free Press.
Ritter-Teitel, J. (2002). The impact of restructuring on professional nursing practice. Journal of Nursing Administration, 32(1), 31-41.
Veatch, R. M. (1985). Nursing ethics, physician ethics and medical ethics. Bioethics Reporter, 6(7), pp: 381-383.
Wlody, G. S. (1998). Ethics and advocacy in critical care nursing. Clinical reference for critical care nursing. (12). 219-236.