Nursing Ethics - Term Paper Example

?NURSING ETHICS 0. Introduction People may ascribe various meanings to ethics, but it would be safe and generally acceptable to declare as Beauchamp and Children (as cited in Butts and Rich, 2005) believe that ethics is a way to understand and evaluate moral life. The emerging developments in healthcare brought about a renewed interest in maintaining a healthy nation, but this has also continually challenged the health professionals with controversial and sensitive ethical issues. Nurses, among others, should therefore, take it incumbent upon themselves to develop their theoretical and practical knowledge with the corresponding skills in dispensing the right actions to everyday decisions on the job. Moreover, nurses should combine intelligent decision-making with moral character so that ethical dilemmas can be resolved compromising neither the patients’ well-being nor the integrity of the nursing profession (Butts and Rich, 2005). The nature of the nursing profession makes social connections practically unavoidable. These social connections also make moral and ethical choices which may affect other people inevitable (Butts and Rich, 2005). The various meaning describes to ethics provided the impetus for the different professions to document and enforce the acceptable norms of practice in their respective spheres. Diversity and geography eventually further necessitated different countries or states to delimit the standard professional practice in more vivid detail. Additionally, the scope of professional practice, like in nursing, is delineated into a legal scope of practice and a scope based on education, training in experience (Small, 2009). In the United States, for example, as cited in Small (2009), the scope of nursing practice may differ from one state to another. This paper will compare nursing ethics as practiced in the states of Florida and California. 2.0. Nursing Practice in Florida and California and the Nursing Code of Ethics The practice of nursing in the US is defined under the Model Nursing Practice Act of 2004: “Practice as a registered nurse means the full scope of nursing with or without compensation or personal profit, that incorporates caring for all clients in all settings; is guided by the scope of practice … through nursing standards established or recognized by the board” (as cited in Small 2009, p 21). The nursing standards include, but is not limited to the following: (1) provision of complete nursing evaluation of the health condition of patients; (2) collaboration with a health care team in the development of coordinated health care plan which is client-focused; (3) strategy development for nursing care coordinated within a client-focused plan of health care which consists of: [a] nursing diagnoses, [b] setting goals within the context of identified health care requirements of patients / clients, [c] identification of applicable nursing interventions; (4) provision of nursing care through the employment of self-directed strategies and nutrition which are requested, ordered or prescribed by authorized health care professionals; (5) execution of health care plans through the designation and assignment of nursing interventions; (6) direct or indirect provision and maintenance of safe and effective nursing care; (7) fostering of a safe and healing environment; (8) providing quality support for patients by recommending / advising practices towards the best interest of the patients / clients; (9) examination of intervention outcomes and efficacy of the health care plan; (10) communication and collaboration with other health care professionals towards health care management and execution of the total health care regimen within and across various health care settings; (11) development and application of significant new information and technologies in nursing care practice; (12) managing, directing and assessing nursing practice; (13) teaching the theory and practice of healthcare; (14) taking part in the formulation of policies, methodology and systems which will support the patients / and clients; and (15) other acts pertaining to education and training as outlined by the National Council of State Boards of Nursing which deals with the continuing professional development of registered nurses, including their demonstrated competencies and their experiences in practice (National Council of State Boards of Nursing, 2008, as cited in Small, 2009). Meanwhile, the shortened definition of the state of Florida of professional nursing practice is shown below: “Practice of professional nursing refers to the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences” (Florida Statutes s. 464.003, 2008, as cited in Small, 2009). Based on the shortened definition, the scope of nursing practice in Florida includes, but is not limited to the following: (1) observation, assessment, nursing diagnosis, planning, intervention and appraisal of care, education and teaching of patients / clients pertaining to their health status, and the encouragement of wellness, maintenance of good health, and prevention of illnesses and diseases among the public; (2) management of recommended medications and treatments as advised by health practitioners authorized by the state to prescribed medications and treatments; and (3) supervision and teaching of other individuals on the theory and application of the aforementioned practices (Florida Statutes s. 464.003, 2008, as cited in Small, 2009). On the other hand, the definition of professional nursing practice according to the state of declares that: “nursing is a dynamic field, the practice of which is continually evolving to include more sophisticated patient care activities” (Business and Professions Code of California, Art. 2725). The Nursing Board of California is aware of some overlapping responsibilities between physicians and registered nurses and intends to provide additional sharing of functions within organized health care systems, to enrich outcomes from the collaboration between physicians and registered nurses. Such health care systems are specified under Chapter 2 of the Health and Safety Code and include clinics, home health agencies, physicians' offices, and public or community health services. Practice of nursing in Florida is governed by the Nurse Practice Act (Florida Board of Nursing, 2007), whereas in California, nursing practice is governed by the Business and Professions Code (2011). A comparative review of salient provisions from the two aforementioned legislations on selected areas is shown in Table 1. Table 1: Nursing Practice on Selected Areas in Florida and California FLORIDA CALIFORNIA Dispensation of drugs or devices Under direction, and only in the capacity of a  licensed practical nurse who is responsible and accountable for making decisions Upon prescription ordered by a licensed physician and surgeon when the nurse is functioning within a licensed clinic as defined in Section 1204 and Section 1206 (Health and Safety Code) Intravenous (IV) therapy When the practical nurse acquired qualification by training and education, and when approved by the institution with  which the licensed practical nurse is employed IV therapy can only be performed by a licensed nurse. Health facilities will not allow any unlicensed personnel to perform IV therapy directly or under the supervision of a registered nurse. (As defined in Chapter 6 Article 2 Section 2725.3 Paragraph a1 of the California Business and Professions Code). Intravenous therapy outside the scope of practice of the licensed practical nurse namely: initiation of blood, blood products and plasma expanders, initiation or administration of cancer therapy and investigational drugs, and mixing of intravenous solution Unless under the  direct supervision of a registered professional nurse or physician, and shall not be performed or initiated by licensed practical nurses without direct supervision Nurses cannot perform any procedure beyond what is allowed as defined in Chapter 6 Article 2 Section 2725 of the California (Business and Professions Code). Home hemodialysis treatment Unlicensed individuals may perform home hemodialysis treatments to a patient when the patients chooses to, as long as this unlicensed person has completed training requirements as stipulated in the Nursing Practice Act, and maintains access to a registered nurse even just through the telephone Home hemodialysis helpers not employed by a licensed facility are required to undergo a home dialysis training program operated by a licensed facility or hospital (California Business and Professions Code Section 1247.6). Licensed (registered) professional nurse functions which may not be delegated Nursing activities which require the use of nursing procedures which entail special knowledge, nursing judgment or skills of registered or practical nurses, such as initial and subsequent assessment of patients; providing nursing diagnosis and interpreting nursing assessments; identification of nursing goals and formulation of a patient care plan; assessment of patient progress based on the plan of care; any other activities for which for which a non-registered nursing practitioner has not demonstrated competency. Nurses are responsible for the planning, supervision, implementation, and evaluation of nursing care plans for reach patient. In terms of implementation, functions may be delegated to other licensed or unlicensed staff subject to limitations as defined in California Nursing Practice Act Business & Professions Code Chapter 6 Section 2725, California Code of Regulations Title 22 Section 70215, and Standards of Competent Performance California Code Of Regulations Title 16 Section 1443.5. Registered nurses cannot delegate RN-level nursing judgment to licensed vocational nurses such as independent analysis, synthesis, and decision-making. Engaging or attempting to engage in the possession, sale or distribution of dangerous drugs and controlled substances Penalties including a combination of monetary fine, Intervention Project for Nurses (IPN) evaluation, probation, or suspension, denial of certification or permanent revocation of license (Florida Comprehensive Drug Abuse Prevention and Control Act) Penalties which may be utilized include: (1) suspending judgment; (2) placing on probation; (3) suspension of right to practice up to one year; (4) revocation of license; and (5) other actions which the board may deem proper. The Nursing Code of Ethics observed among the American states is a standard version from the American Nurses Association (ANA). Since, it is a code, the main provisions are quoted verbatim from the ANA (2011). The first provision of the code states that: “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or nature of health problems” (ANA, 2011, p. 14).  A nurse’s fundamental responsibilities can be classified into four categories: (1) to promote health; (2) to prevent illness; (3) to restore health; and (4) to alleviate suffering. Nurses are expected to assume these responsibilities for the benefit of individuals, families, and communities. However, there are situations wherein nurses may experience conflict with values which require them to exercise judgment in determining the course of action to take (Geyer, Mogotlane & Young 2009).         Nurses should be able to distinguish three crucial terms as they go about their daily activities: (1) liability; (2) responsibility; and (3) accountability. Liability is the state of being culpable for damage caused by an individual to another. Since nurses are expected to exercise safe nursing care to patients, any act whether deliberate or caused by ignorance or negligence which cause harm to a patient will make the nurse liable for damages (Geyer, Mogotlane & Young 2009).         Responsibility is the state of assuming accountability or obligation to comply with a set of fundamental principles. Nurses are responsible for accomplishing tasks which are given to them by their superior. Therefore, a nurse is responsible to both her superior and the patient in relation to how a delegated task is accomplished (Geyer, Mogotlane & Young 2009).         On the other hand, accountability is the state of being answerable for one’s own actions, including how such actions are done to accomplish a specific responsibility. Nurses are accountable for their actions and should be able to justify what they have done or failed to perform. In situations where nurses cause harm to patients, either through negligence, incompetence, deliberate, or acts of dishonesty, sanctions may come in the form of disciplinary action or court penalties (Geyer, Mogotlane & Young 2009). Ellis and Hartley (2004) enumerated several aspects of nursing affected by ethical issues: patient autonomy, beneficence and non-maleficence, fidelity, and veracity. Nurses are expected to respect a patient’s right to decide for themselves, even if such decisions run contrary to a nurse’s personal beliefs. However, the personal right to autonomy does have its limitations, particularly when one’s right to self-determination interferes with another person’s rights, health, or general well-being.         Nurses are obliged to do good, as well as to prevent or avoid harming a patient. This principle also applies to the prevention of intentional harm to the patient. For example, a nurse could report a colleague who is committing unethical practices which could result to an unacceptable level of care. Meanwhile, patients may get harmed unintentionally in the form of nosocomial infections, adverse drug reactions, and side effects of medical treatments such as chemotherapy and irradiation (Ellis & Hartley 2004).         Practicing fidelity in nursing care settings involve faithful compliance to previously agreed-upon commitments, agreements, and responsibilities, both on a personal and professional level. In addition, nurses should be able to determine their responsibilities to individuals, employers, government, society, and self, as well as which of these responsibilities are prioritized. An example would be patient confidentiality issues which could have moral, ethical, or legal repercussions (Ellis & Hartley 2004).         Veracity among nurses is an important aspect of nursing practice. Nurses should be able to tell the truth and should not deliberately attempt to deceive or mislead patients. However, situations occur when telling the truth becomes difficult to accomplish due to the repercussions it would cause. The conflict arises when nurses have to choose between telling the truth and preventing harm from happening to the patient. Moreover, sacrificing veracity usually leads to reduced self-esteem and reliability (Ellis & Hartley 2004). Beneficence is described as a moral obligation to do good, which has been a pillar of nursing practice. In nursing practice, beneficence translates to acts which protect and preserves a patient’s interests and well-being. However, a need exists as to determining how nurses should react and what they should do for specific situations. On the other hand, non-malifecence is concerned with actions that prevent harm on the patient. However, the prevention of harm can become ambiguous since harm may be categorized as physical, as well as psychological. In addition, harm can be interpreted differently by each individual depending on his/her assessment (Hendrik 2000).         Nurses assume a role which burdens them with a host of responsibilities. Therefore, a nurse’s role should be determined in terms of the rights and obligations inherent to the nurse’s position. For example, specialist nurses have a different set of responsibilities compared to nurses in a general health care setting. Likewise, role expansions also affect the level of responsibility a nurse can have. When nurses take on new roles, a corresponding increase in responsibility is observed. Therefore, nurses are responsible for maintaining and improving their professional knowledge and competence to accommodate the added responsibility (Hendrik 2000). A nurse’s sense of accountability rests on their ability to justify why a specific action was or was not done. Accountability involves the utilization of professional knowledge, skills, and judgment in decision-making in the interest and well-being of the patient. There are several kinds of accountability: legal, professional, and moral. For example, a nurse would be legally accountable for her actions if she adjusts the dosage of a patient’s medication, even if it would benefit the patient more. Meanwhile, when a nurse ignores resuscitation policies by allowing a terminally-ill patient to die peacefully, she would be professionally accountable since she opted to disregard standard professional practice. On the other hand, a nurse may feel morally accountable if he/she did not help a patient die peacefully with the least amount of suffering possible. These types of accountabilities pose a serious challenge because different accountabilities do not mix well (Hendrik 2000). Accountability is described as the capacity to decide and exercise choice which is characterized by autonomy, authority, and control of one’s actions and decisions. Nursing professional practice exhibit accountability through the evaluation of individual and group health care outcomes, treatment modifications, intervention strategies, risk analysis, and prevention of unsafe or unethical practices (Altun 2008).         Nurses follow a code of ethics which guides them in their daily interaction with patients. The nursing code of ethics is a summary of all ethical obligations and duties which an individual should comply with once they enter the profession. It is composed of nine provisions which reflect the nursing profession’s commitment to society. As the first provision of the code of ethics specify, nurses should show their compassion and respect for human dignity, worth, and uniqueness, regardless of status, personal attributes or nature of health problems. The provision covers the following areas: (1) respect for human dignity; (2) relationships to patients; (3) nature of health problems; (4) right to self-determination; and (5) relationships with colleagues and other people (American Nurses Association 2001).         The second provision identifies the patient as a nurse’s priority, in terms of its individual, family, or community context. This provision covers the following areas: (1) primacy of patient interest; (2) conflict of interest; (3) collaboration; and (4) professional boundaries. Meanwhile, the third provision focuses on the nursing profession’s commitment in the promotion and advocacy for patient health, safety, and rights. This provision is composed of the following areas: (1) privacy; (2) confidentiality; (3) protection of participants in medical research; (4) standards and review mechanisms; (5) acting on questionable practice; and (6) addressing impaired practice (American Nurses Association 2001). The fourth provision describes nursing responsibility and accountability, as well as delegation of nursing duties in the provision of patient care. This provision covers the following areas: (1) acceptance of responsibility and accountability; (2) accountability for nursing judgment and action; (3) responsibility for nursing judgment and action; and (4) delegation of nursing activities. On the other hand, the fifth provision focuses on personal and social responsibility in terms of integrity and safety, competence; and personal and professional growth. This provision elucidates on four areas: (1) moral self-respect; (2) professional growth and maintenance of competence; (3) wholeness of character; (4) preservation of integrity (American Nurses Association 2001). The sixth provision is concerned with the creation and maintenance of an environment which supports the provision of quality health care in terms of individual and collective action. This provision is concerned with addressing the influence of the environment on moral virtues and values, as well as ethical obligations. In addition, the provision describes the nurses’ responsibility for the health care environment (American Nurses Association 2001). The seventh provision describes the nurses’ participation in the advancement of the nursing profession. Nurses can contribute by: (1) active involvement in nursing and health care policy; (2) development, maintenance, and implementation of professional standards in clinical, administrative, and educational practice (American Nurses Association 2001). Moreover, the eight provision deals with working in collaboration with other health professionals and the public in terms of promoting health efforts in the community, national, and international levels. This includes the identification of health needs and concerns, and responsibilities of the nursing profession to the public. Finally, the ninth provision emphasized on the responsibility of nursing practitioners in the articulation of nursing values, integrity of the profession and practice, and shaping social policy. This provision covers the following areas: (1) assertion of values; (2) collective responsibility; (3) intraprofessional integrity; and (4) social reform (American Nurses Association 2001). 3.0. Consequences to the Patients As the third provision of the nursing code of ethics, “the nurse promotes, advocates for and strives to protect the health, safety and rights of the patient” (ANA, 2001, p.1) It is believed that as long as the nurses’ code of ethics is upheld by the nursing practitioner, the health and safety of the patient is deemed safeguarded. However, the rights of patients as mandated by effective legislation, particularly the National Health Act 61 of 2003, includes a specific set of rights, which is sometimes compromised without malicious intent on the part of nurses. To better discuss the consequences of patients, the following rights are guaranteed to patients: (1) treatment for medical emergency; (2) being informed regarding patient’s medical condition; (3) being given informed consent for treatment; (4) participation in decision-making with regard’s to patient’s health; (5) being informed about participation in a research; (6) privacy; (7) access to patient’s health records; (8) submission of complaint regarding health service obtained or currently being obtained; and (9) be treated with respect (Pera and van Tonder, 2005). There are instances when safeguarding the health and safety of the patient sometimes does not necessarily go with the protection of the patients’ rights. For example, this author personally witnessed a predicament where a hypertensive and asthmatic patient was brought to a clinic with a splinter on the back of the leg. The patient categorically gave instructions that under no circumstances will the treatment be a surgery no matter how minor the procedure will be. The patient further informed both the nurse and the doctor of her phobia of being cut. The doctor knew that the splinter is already infected because of the foreign body embedded deep in the patient’s left. The patient also provided the information that the splinter had been causing pain for two days already. The doctor and the nurse were in a quandary because the infection may jeopardize the patient’s health and safety. Sedating the patient so that the splinter can be taken out and cleaned through a minor surgical procedure will be the physician’s best option. Going over the patients’ rights specified in the previous paragraph, the first four patient rights were upheld and the fifth to eighth patient right is not affected in the scenario narrated. It should, therefore, be apparent that if the simple procedure is performed to treat the patient’s medical emergency, the right to informed consent is violated and technically, in this researcher’s honest opinion, the last right about being treated with respect would have been violated. This constitute a classic example of an ethical dilemma which the legal tacticians already had concocted the best solution to the paradox. Be that as it may, however, the point which this researcher wishes to tackle is that in this scenario, the health and safety of the patient is never put in danger with the violation, or non-conformance with nursing ethics. The health consequences to the patient is positive. But should the health care professionals choose to perform the simple procedure without the patient’s consent, they will be criminally liable.         Though patients have the basic right to receive medical treatment, their right to refuse treatment must also be respected. Refusal to accept medical treatment may be grounded on personal or religious convictions, and it is only if the patient has a contagious disease or mentally incapacitated that an exception to the rule will be made. Otherwise, treatment provided against the will of the patient is considered a criminal offense. Therefore, nurses should learn to respect a patient’s right to exercise autonomy, and the refusal to receive treatment should not affect the quality of nursing care. This applies even if it meant that such an act will ultimately cause the patient to die by his own accord (Pera and van Tonder, 2005).         Another point is that patient may invoke his right to request for the discontinuation of treatment being provided to him/her. This usually occurs in cases where the patient is suffering from a fatal illness or in its terminal stages. However, consultations together with the patient should be done in order to discuss the available options regarding switching from a therapeutic approach to a terminal care approach (Pera and van Tonder, 2005). Telling the truth to a patient was never an easy task. Nurses would need to know if telling the truth to a patient would do more harm than good. There are three basic reasons wherein nurses are allowed to withhold information from the patient. First, patients only have a limited idea of what their illness is. Second, the truth will prejudice the patient; and (3) only beneficial information should be provided to the patient. However, withholding information from the patient undermines his/her dignity and right to autonomy (Pera and van Tonder 2005). In other cases though, non-conformance with the code of practice and nursing ethics would entail serious repercussions on the health outcomes of patients. The most prominent example will be offering treatment even if the health practitioner does not have the medical qualification to perform a procedure, even if the act is done in good faith. 4.0. Conclusion Ethics are standard or norms which dictate how nurses or other professional should comport themselves in the practice of their professions. Lives are at stake in most of the decisions that nurses had to make several times a day in the bedside of a sick patients. In some instances, the thin line between living and dying depends on the decision-making of nurses attending to emergency and life-threatening cases. Specifying a code of practice and ethics is the first steps towards making the health professional accountable for the decisions that can save the life of a patient. Nurses need to take the complementary step of subscribing to these standards equipped with presence of mind and the required competencies to discern between options which at first glance seem to be equally beneficial for the patient’s well-being. When a life is at stake, it will surely matter if nurses are guided with the most important set of rules to conduct their practice. It will doubly matter if the nurses entrusted with such patients’ lives can make a difference with theoretical skills and practical competencies. 5.0. References Butts, JB, and Rich C, 2005, Nursing ethics: across the curriculum and into practice, Jones and Bartlett Publishers, Sudbury, MA. Ellis, JR & Hartley, CL 2004, Nursing in today’s world: Trends, issues, and management, Lippincott, Williams and Wilkins, Philadelphia, PA. Fitzpatrick, JJ, Glasgow, A, and Young, JN, 2003, Managing your practice: a guide for advanced practice nurses, Springer Publishing, Geyer, N, Mogotlane, S & Young, A 2009, Juta’s manual of nursing volume 1,  2nd edition, Juta and Co, Lansdowne, ZAF. Small, AG, 2009, ‘Legal issues for critical care advanced practice nurses’, in pp. 17-48. Read More