PROFESSIONAL VALUES AND

PRINCIPLES OF ETHICAL
PRACTICE
Nursing as a profession
• Profession is a calling in which its members have acquired special
knowledge by training and experience, so that they may provide
services in that special field.
Values
• According to Hall et al (1982), Values are the standards for decision
making in one’s life.
• A value can be described as an individual rule used in conducting one’s
life.
• According to king (1984), values have parts : thinking, choosing, feeling
& behaving.
• People value about work, family, religion, politics, money and
relationships.
• Values influence decisions and actions.
• Beliefs or attitudes about the worth of a person, object, idea, or action.
Values contd…
• Acquired through observation and Experience.
• Affected by Socio-Cultural environment (societal conditions, family and
peers)
• A belief about the worth of something, about what matters, a guide for
behavior
Major categories of values
• Operative values : Indicated by a specific behavior. For example;
honestly sharing one’s observations indicates that honesty is valuable to
that person.
• Terminal values : Values that are regarded as good, transcend
immediate needs & shape long term goals.
• Moral values : Involve correct behavior such as having some of right &
wrong decisions.
Ethics
• The word ethics comes from Greek word ‘Ethos’ meaning customs or
guiding beliefs.
• Ethics are philosophical ideals of right and wrong behavior.
• These are rules and principles that govern right conduct.
• Ethics is a set of principles of right conduct which is based on ideas of
right and wrong.
• It guides to moral behavior by making choices or judgments.
Ethics cont..
• Ethics refers to principles developed from a set of standards that form
the basis for the actions.
• Code of ethics will state what kind of conduct is expected from the
members of a profession.
• What are the responsibilities of the members of a profession towards
those whom they serve, their co-workers, the profession and the society
as a whole.
• Ethics looks at human behavior under different types of circumstances.
Principles of ethics
• Autonomy - “autos” = self, “nomos” = rule. Derived from The New
Testament (freedom to make decisions). Individual rights. Freedom of
choice. Right to make one’s own decisions.
• In Health care Setting “ Principle of INFORMED CONSENT” is IMPORTANT .
While respect patient’s autonomy, it is also our duty to explain clearly to
them the consequences of their decision, explain the purpose of informed
consent.
• OVERRIDING PATIENT’S AUTONOMY(Paternalism) - acting without consent
to benefit the patient and prevent harm (ex. emergency cases,
incompetency etc.)
Principles of ethics cont…
• Beneficence - Do good
• Nonmaleficence - Not to cause harm. Prevent harm. Remove harm.
More binding than beneficence. Because going beyond just trying to do
good, trying to prevent harm.
• Confidentiality - Keep information private. Exceptions - Protecting one
person’s privacy harms another.
Principles of ethics cont…
• Justice - Fairness in service. Equal treatment to all. More specifically,
distribution of benefits and burdens. Equally disbursed according to
need, effort, merit, legal entitlement. TRIAGE SCHEMES: 1. According to
medical prognosis (who is most likely to survive) 2. Social value (must
favor first the socially disadvantaged, ill, elderly, disabled, women and
children. 3. First come first serve (for patients with same cases and
treatment) - this DOESN’T tell us what needs are most important.
• Veracity - The obligation to tell the truth and not to lie.
Ethics in nursing
• Nursing Ethics is a system of principles that govern the actions of the
nurse in relation to patients, families, other health care providers,
policymakers and society.
• Nursing ethics refers to ethical issues that occur in nursing practices.
• Nurses have a duty to practice ethically and morally.
• Code of ethics provide guidelines for safe and compassionate care.
Nursing code of ethics
A code of ethics is a formal statement of a group’s ideals and values. It
is a set of ethical principles that
• Is shared by members of the group
• Reflects their moral judgements over time
• Serves as a standard for their professional actions.
Purpose of Nursing Codes of Ethics
• Inform the public about the minimum standards of the profession and
help them understand professional nursing conduct.
• Provide a sign of the professional commitment to the public it serves.
• Outline the major ethical considerations of the profession.
• Provide standards for professional behaviors.
ICN code of ethics
The fundamental responsibility of nurses is fourfold :
• To promote health
• To prevent illness
• To restore health
• To alleviate suffering
• The need for nursing is universal
• It is unrestricted to consideration of nationality, race, creed, colour,
age, sex, and social status.
• Nurses render health services to the individual, family and the
community.
ICN code of ethics
An international code of ethics for nurses was first adopted by the
International Council of Nurses (ICN) in 1953.
1. Nurses and people
2. Nurses and practice
3. Nurses and the profession
4. Nurses and co-workers
The ICN code of ethics, cont’d..
NURSES AND PEOPLE
• The nurse’s primary professional responsibility is towards people requiring
nursing care.
• In providing care, the nurse promotes an environment in which the human
rights, culture, values, customs and spiritual beliefs of the individual,
family and community are respected.
• The nurse ensures that the individual receives sufficient information to
base consent for care and related treatment.
• The nurse holds in confidence the personal information and uses
judgement in sharing those information.
• The nurse respects patient’s autonomy. Consider individuality when giving
care.
The ICN code of ethics, cont’d..
NURSES AND PRACTICE
• The nurse carries personal responsibility and accountability for nursing practice, and for
maintaining competence by continual learning.
• The nurse maintains a standard of personal health such that the ability to provide care is
not compromised.
• The nurse uses judgement regarding individual competence when accepting and
delegating responsibility.
• The nurse at all times maintains standards of professional conduct which reflect well on
the profession and enhance public confidence.
• The nurse, in providing care, ensures that use of technology and scientific advances are
compatible with the safety, dignity and rights of people.
• Accuracy in documentation of actions and outcomes of care. Advocate to patient.
Awareness to ethical, moral and legal dimensions of practice. Know the scope of her
practice. Acquire and develop necessary competence in knowledge, skills, and attitudes.
Respect “Patient’s rights”.
The ICN code of ethics, cont’d..
NURSES AND THE PROFESSION
• The nurse assumes the major role in determining and implementing
acceptable standards in clinical nursing practice, management, research
and education.
• The nurse is active in developing a core of research-based professional
knowledge.
• The nurse, acting through the professional organization, participates in
creating and maintaining safe, social and economic working conditions
in nursing.
The ICN code of ethics, cont’d..
NURSES AND CO-WORKERS
• The nurse sustains a co-operative relationship with co-workers in nursing
and other fields.
• Maintain a collaborative working relationship
• Maintain their professional role/identity while working with other
members.
• Honor and safeguard the dignity and reputation of members of nursing.
• Contribute to professional growth and development of other members.
American Nurses Association (ANA) Code of Ethics
• Applies to all nurses in all healthcare settings.
• Ethical principles agreed upon by members of the nursing profession.
• Sets standards of conduct and behaviors for nurses.
• The primary commitment is to patient individual, family or community.
• Demonstrates compassion and respect for all patients regardless of status.
• Promotes the health and welfare of patients.
• Accountable for individual practice.
• Maintains and increases own knowledge base.
• Works to improve healthcare environment for both care providers and
patients.
American Nurses Association (ANA) Code of Ethics contd…
• The nurse participates in professional relationships, establishing values of
the practices with compassion and respect.
• The nurse participates in the nurse’s primary advancement of the
profession.
• The nurse collaborates with patient and others to meet health needs.
• The nurse promotes associations and advocates for the rights of the
patient.
• The nurse is responsible and accountable for individual nursing practice .
Legal
• Law bound.
• Standard or rule of conduct established and enforced by government.
• Designed to protect the rights of the public
Types of laws
• Public law—government is directly involved. Regulates relationships
between individuals and government.
• Private law—civil law. Regulates relationships among people.
• Criminal law—Defines criminal actions or misdemeanor, e.g., murder,
theft
Legal Issues in Nursing practice
• PHYSICIAN’S ORDER Nurses are responsible for their actions
regardless of who told them to perform those actions.
• FLOATING Nurses should be given orientation to the unit. The
supervisor should be informed about a float nurse’s lack of experience
on the new unit.
• INADEQUATE STAFFING A nurse who leaves an inadequately staffed
unit could be charged with client abandonment.
• CRITICAL CARE Constant observation and assessment of clients are
required, especially in ICUs that have monitors.
• PEDIATRIC CARE Suspected child abuse or neglect be reported.
Tips to avoid medicolegal issues
• Follow and keep abreast of current standards of care (Continuing
Education)
• Give competent care
• Develop a caring rapport with the client and family while observing
professional boundaries
• Communicate with other health care providers
• Document assessments, interventions and evaluations fully (best
defense)
• Follow the policy and procedure of the institution
Tips to avoid medicolegal issues contd…
• Be aware of potential sources of injury (falls, med errors, name errors)
• Communicate with the patient and explain procedures
• Report and document changes in patient condition
• Timely, truthful, legible and thorough documentation
• knowing provisions of the State Practice Act and the regulatory law
passed by the State Board of Nursing
• know the policies and procedures of the hospital in which working.
BIOETHICAL ISSUES IN NURSING
Ethics Vs Moral
• Ethics and morals are often used interchangeably but can mean very
different things.
• Morals are an individual frame work for decision making that includes
personal values. Ethics are a generalized conceptual frame work for
decision making.
• Morals refers to our personal beliefs, which may be different from those
of our patients.
• Consider the patient with respiratory failure who chooses not to be
placed on a ventilator. Though an individual nurse may disagree with the
decision from a moral standpoint, but based on the ethical principle of
autonomy, she will support and care for the patient.
• Not morals, ethics guide our interactions with the patients.
Bioethics
• The study of the ethical and moral implications of new biological
discoveries and biomedical advances, as in the fields of genetic
engineering and drug research is bioethics.
• The term “bioethics” was introduced in the 70’s by Van Rensselaer
Potter for a study aiming at ensuring the preservation of the biosphere.
It was later used to refer a study of the ethical issues arising from health
care, biological and medical sciences.
• Bioethics is a branch of applied ethics that studies the philosophical,
social and legal issues arising in medicine and the life sciences.
• It is chiefly concerned with human life and well-being, though it
sometimes also treats ethical questions relating to the non-human
biological environment.
Other forms of ethics
• Professional ethics are the rules or standards governing the conduct of
a person or the members of a profession.
• Health ethics or medical ethics are the rules or standards governing the
conduct of a person or the members of a profession relating to the
study or practice of medicine.
• Clinical ethics is concerned with the ethical issues related to clinical
practice in health care settings/at bedside.
• Research ethics is concerned with the protection of humans,
participating in research.
• Organizational ethics is concerned with fair allocation of health care
resources.
Importance of bioethics
Bioethics education for medical practice is essential in today’s complex
world because;
• Medical policies and patient rights legislation are ever-changing
• Health care system function differently than before
• Clinical practice now involves decision- making about many new
issues
Ethical issues/dilemma happen when…
• Choices need to be made
• The answers may not be clear
• The options are not ideal
• A conflict between two or more ethical principles.
• These are situations in which decisions must be made between two
opposing alternatives when there is not an exact right or wrong
answer.
• Ethical decisions are not made with one’s emotions or feelings but are
based on principles and logical reasoning.
Examples of Ethical Dilemmas in Nursing
• One example of a common ethical dilemma nurses deal with is
establishing boundaries with patients.
• Nurses and nurse managers devote their careers to help patients
receive the care they need, so it can often be difficult to establish
professional boundaries.
• Patients should not rely on nurses beyond their professional capacity
and should not develop romantic relationships with them or offer
them gifts.
• Nurse managers can intervene in situations where ethical and
professional boundaries are crossed by either patients or nurses.
Examples of Ethical Dilemmas in
Nursing
• Patients who have terminal illnesses expressed to end life and wishes to
discontinue treatments, but do not have Advanced Directives.
• Ethical dilemma: Should the nurse ignore the patient, and listen to
family members requesting for all possible care, such as chemotherapy,
tube feedings, ventilatory support.
• Informed Consent – The core underlying value is patient autonomy.
Physicians / practitioners obtains consent. Nurses role is to witness /
monitor and make sure that the patient understands everything. The
nurse should not explain again to avoid contradiction with the
physician’s explanation. Obtaining signature of the patient after
providing benefits and risks of treatment
• Management of Computerized Information.
Ethical issues
Reproductive situations
• Voluntary reproductive sterilization as a contraceptive method may be
contrary to the moral, ethical or religious beliefs of a person.
• Consent is required to perform reproductive sterilization.
• Some facilities require consent from the patient’s spouse.
Human experimentation
• Procedures still in developmental stages are performed in clinical
research-oriented facilities with the patient’s informed consent.
• A participant should decide if he or she wants to participate in
experimental procedures.
Ethical issues contd…
Abortion
• Legalized abortions allows for induced termination of pregnancy.
• In 1973, the US Supreme Court ruled that any licensed physician can terminate
pregnancy during the 1st trimester with the woman’s consent.
• During the 2nd trimester, the court regulates abortion on the basis of preservation
and protection of maternal health.
• During the 3rd trimester, legal abortion should consider meaningful life for the
fetus outside the womb and endangerment to the mother’s life and health.
• By selective abortion, one or more fertilized ova may be aborted so that others may
mature properly in a multiple pregnancy, which is perhaps a result of fertility drugs.
• Although, by law, physicians may perform abortions in health care facilities, many
people, individually and collectively, oppose abortion, believing that it is a form of
active euthanasia because it takes the life of an innocent victim without consent.
Ethical issues contd…
Fetal tissue and Stem cell research
• Experimentation with human tissues may be of moral concern to some
individuals.
• The acquisition of the tissues in the form of embryonic tissue and
implantation may take place.
• Fetal tissues lacks in lymphocytes that can cause graft-versus-host
response.
• Advantages of fetal tissue include rapid proliferation of cells, quick
reversal of the host’s condition and differentiation in response to cues
of the host tissue.
• Tissues from spontaneous abortion and ectopic pregnancy has generally
undergo pathologic degradation and is not suitable for this use.
Ethical issues contd…
HIV and other infections
• Knowing that HIV infection is transmitted by blood and body secretions,
conscientious application of standard precautions for infection control
should provide protection against occupational exposure to HIV,
hepatitis, tuberculosis and other communicable infections.
• Other ethical questions concern screening and the reporting of test
results versus confidentiality.
• Confidentiality, privacy and informed consent are human rights that
should be protected, but the right to health care should be protected
also.
Ethical issues contd…
Quality of life
• Physician often must make critical decisions before or during any
interventions regarding the quality of patients’ lives after procedures.
• Palliative procedures may relieve pain (morphine). Therapeutic
procedures may be disfiguring(surgical rejection). Life-support systems
may sustain vital functions(ventilators). Life-sustaining therapy may
prolong the dying process. Many questions arise regarding care of
terminally ill, severely debilitated or injured and comatose patients.
• When should cardiopulmonary resuscitation be initiated or
discontinued? Patients with advance directives have made many of
these difficult decisions while in a lucid mental state. This saves the
family or legal guardians the anguish of making the decision and provide
some sense of satisfaction that the loved one’s wishes were followed.
Ethical issues contd…
Euthanasia
• The idea of euthanasia seems to violate traditional principles of
medicine to preserve life, but our modern technologies can prolong life
without preserving quality.
• Quality of life can be interpreted as life that has a meaningful value.
• Most human beings value having cognitive abilities, physical capabilities,
or both and living free of undue pain and suffering.
• This raises the ethical question of whether physicians could do what
technologies can do.
Ethical issues contd…
Right–to-die
• Courts have determined that patients have a constitutional right to
privacy in choosing to die with dignity or a common law right to refuse
treatment.
• A mentally competent adult older than the age of 18 years can execute a
living will, advance directive, directing physicians and other health care
providers not to use extraordinary measures to prolong life.
• The issue of discontinuation of life-sustaining measures becomes more
difficult in a comatose, mentally incompetent patient who has executed
an advance directive.
• Caregivers are obligated to follow DNR order.
Ethical issues contd…
Organ donation and transplantation
• As a result of the uniform Anatomical Gift Act of 1968, many adult carry cards
stating that at death they wish to donate their body organs or parts for
transplantation, therapy, medical research or education.
• Most states include this information on a driver’s license. If this legal authority
is not available, in the event of legally defined brain death, the caregivers are
required by this law to ask the family if they wish to allow organ retrieval for
transplantation.
• The accepted definition of irreversible coma for potential donors includes
unresponsiveness, no spontaneous movement of respiration, no reflexes and a
flat ECG.
• Caregivers learn to cope with feeling associated with the procurement of
donor organs in a manner similar to dealing with the sudden death of any
patient.
Ethical issues contd…
Death and dying
• Intellectually, we know that death is inevitable. Death can be a difficult burden
for caregivers to bear because our education, experience and philosophy are
dedicated to survival.
• Regardless of religious or cultural beliefs, death is a mystery, a passage from
the known to the unknown.
• Coping strategies that can help team members may include – Realize that
everyone involved is part of a team effort.
• Encourage each other to share feelings.
• Crying is acceptable behavior.
• Deal with patient’s death by identifying personally with the loss since empathy
is a positive emotion.
• Arrange a visit with the hospital chaplain.
Examples of common ethical
situations that nurse managers face
Honesty vs. withholding information
• Family members may want to withhold medical information from sick
patients to protect their emotions.
• However, patients have the right to know about their medical
conditions.
• Deciding how to share this information, especially if it goes against the
family’s beliefs, can be a touchy situation.
• ANA advocates for truth telling, or veracity, as a key factor in nurse-
patient relationships.
Examples of common ethical
situations that nurse managers face
Science vs. spirituality
• Medical interventions are based on science and technology. Some religions
restrict medical interventions and lifesaving techniques.
• Nurses focus on providing medical care to reduce suffering and to allow patients
to concentrate on self-care.
• For patients or their families with strong religious or spiritual convictions, the
focus may be on adhering to a strict set of guidelines.
• The ANA Code of Ethics states that nurses should respect the “unique differences
of the patient,” including “lifestyle, value system, and religious beliefs.”
• However, respect for the belief “does not imply that the nurse condones/accepts
those beliefs or practices on a personal level.”
Examples of common ethical situations
that nurse managers face contd…
Healthcare needs vs. resource allocation
• The rising cost of healthcare is increasingly putting nurse managers at
odds with budgeting constraints and patient needs.
• A large number of medical facilities have scarce resources, which puts
patients at risk for not getting the care they need.
• These resources range from medical equipment to healthcare staff.
• Research suggests that nurse leaders must include staff in the
budgeting process so that they can better understand the needs and
demands.
Examples of common ethical situations
that nurse managers face contd…
Autonomy vs. beneficence
• Nurses are required to administer prescribed medicine, but patients, at
the same time, can refuse them. Patient autonomy can go against
medical directives, despite clearly defined needs. Patients have a right
to refuse all medical care.
• ANA highlights that it is important for nurses and nurse managers to
understand patient backgrounds and individual circumstances to inform
the patient of the medical necessity.
• ANA explains: “Using ethical principles to arrive at a solution should be
done in an atmosphere of caring, respect, openness, and honesty.”
How to solve ethical issues in nursing?
• Review the ANA Code of Ethics
• Implement the code of ethics
• Get guidance of nurse managers when it comes to situations they
may not know how to address
• Nurse managers can cultivate educational environments, in which
they regularly discuss ethical issues with the nurses in their units.
• Have open dialogues about ethical issues, learn from the mistakes
others have made and learn how to approach ethical issues and
challenges.
Nurses’ Code of Ethics
• ANA adopted its first Code of Ethics in 1950. Since then, it has undergone
several revisions due to the changes in research, technology, law and
overall challenges in nursing.
• The guidelines cover topics that include human dignity, confidentiality,
moral virtue and healthcare as a right.
Ethics Committees
• Many health care agencies now recognize the need for a systematic
manner whereby to discuss ethical concerns.
• Ethics committees can lead to the establishment of policies and
procedures for the prevention and resolution of dilemmas.