Professional Nursing Practice Concepts and Perspectives Seventh Edition Chapter 4 Ethical Foundations of Professional Nursing

Learning Objectives 4.1 Discuss how cognitive development, values, moral frameworks, and codes of ethics affect decision making. 4.2 Explain how nurses can help clients clarify their values to facilitate ethical decision making. 4.3 Analyze ways in which nurses can enhance their ethical decision-making abilities. 4.4 Identify the moral principles involved in ethical decision making. 4.5 Explain the uses and limitations of professional codes of ethics. 4.6 Discuss common bioethical issues currently facing healthcare professionals. 4.7 Describe the advocacy role of the nurse.

Hallmark Features A focus on foundational knowledge related to professional nursing Includes nursing history, nursing theory, ethics, and legal aspects, etc. An overview of professional nursing roles, issues, and changes in the profession Discusses nurses as healthcare providers, learners and teachers, and leaders

Challenges and Opportunities Values conflicts Nurses’ established values and beliefs may conflict with clients’ Ethical-legal conflicts Right thing to do versus what is legal

Learning Objective 4.1 Discuss how cognitive development, values, moral frameworks, and codes of ethics affect decision making.

Values Highly personal Freely chosen Enduring beliefs or attitudes about the worth of a Person Object Idea Action

Values Derived from Motivate behavior, guide choices and decisions Cultural, ethnic, religious background Societal traditions Peer group Family Motivate behavior, guide choices and decisions Moral Nonmoral

Values Exist within a person and affect the person’s relationship with others Becoming aware of one’s values is necessary in order to make ethical decisions

Values Transmission Learned through observation and experience Family, community, cultural and society influences Values are acquired gradually Professional values of the nurse are acquired during socialization into nursing from Nursing experience Teachers Peers

Values Transmission Nurses hold values that relate to competence and compassion Nurses need to be Value-neutral Nonjudgmental

Values Clarification Process by which individual values are identified, examined, and developed No one set of values is right for everyone Identified values can be retained or changed Acts on free choice Fosters personal growth

Values Clarification Valuing process components include Cognitive Affective Behavioral

Identifying Personal Values Nurses need to understand their values about Life Health Illness Death Ability to identify personal values leads to better understanding of situations that may affect care

Learning Objective 4.2 Explain how nurses can help clients clarify their values to facilitate ethical decision making.

Helping Clients Identify Values Help identify how values influence and relate to a particular health problem List alternatives Examine possible consequences of choices Choose freely Feel good about the choice Affirm the choice Act on the choice Act with a pattern

Learning Objective 4.3 Analyze ways in which nurses can enhance their ethical decision-making abilities.

Moral and Ethical Behavior Morals are personal ethics that guide individuals’ behavior and choice Ethics refers to the moral standards and beliefs of a particular group

Moral Development Process of learning what ought to be done and what ought not to be done Morality Moral behavior Moral development

Theories of Moral Development Lawrence Kohlberg Theory focuses on structure of thought about moral issues Moral development progresses through three levels and six stages Not always linked to age or growth and development

Theories of Moral Development Lawrence Kohlberg People progress to different levels of moral development, ranging from Egocentric actions to Behaviors that show concern for society

Theories of Moral Development Kohlberg’s Levels and Stages Level I premoral or preconventional Stage 1: Obedience and punishment Stage 2: Instrumental/self-interest Level II conventional Stage 3: Good boy/good girl Stage 4: Law and order Level III postconventional, autonomous or principled Stage 5: Social contract Stage 6: Universal moral principle

Theories of Moral Development Carol Gilligan Challenged Kohlberg’s theory in Its application to females Females socialized to be compassionate, responsible, and have a sense of obligation Males socialized to organize relationships hierarchically Gilligan’s care perspective is organized around Responsibility Compassion (care) Relationships

Theories of Moral Development Justice or fairness based on idea of equality Typically followed by men Ethic of care Typically followed by women Gilligan’s stages Stage 1: Caring for oneself Stage 2: Caring for others Stage 3: Caring for oneself and others

Moral and Ethical Theories or Frameworks General moral frameworks Teleology, consequential Deontology, nonconsequential Virtue ethics Caring

Learning Objective 4.4 Identify the moral principles involved in ethical decision making.

Moral and Ethical Principles Ethical principles that help guide decision making Sanctity of life Utility Autonomy Respect for person Nonmaleficence Beneficence Justice Fidelity Veracity

Ethics in Nursing Ethics Bioethics Method of inquiry that helps people understand morality of human behavior Refers to practices, beliefs, and standards of behavior Bioethics Applies ethics to life sciences and health care in an interdisciplinary setting

Ethics in Nursing Nurses are accountable for their ethical conduct Standard 7 in Nursing: Scope and Standards of Practice relates to ethics

Learning Objective 4.5 Explain the uses and limitations of professional codes of ethics.

Nursing Codes of Ethics Formal statements of a group’s ideals and values Higher than legal standards Established by the International Council of Nurses (ICN) First adopted in 1953, revised in 2012 ANA first adopted a code of ethics in 1950, revised in 2001 Published in a booklet called Code of Ethics for Nurses with Interpretive Statements

ANA Nursing Code of Ethics Purposes Succinct statement of ethical obligations and duties Nonnegotiable ethical standard Expression of nursing’s commitment to society

Canadian and Australian Nurses Codes of Ethics Canadian Nurses Association adopted a code of ethics in 1980, revised in 2008 Australian Nurses adopted a code of ethics in 1993, revised in 2002

Nursing Codes of Ethics Nurses are responsible for being familiar with the code that governs their practice Purposes Inform the public of minimum standards Sign of professional commitment Outline ethical considerations Guidelines for professional behavior Guide for self-regulation Responsibility when assuming care for clients

Learning Objective 4.6 Discuss common bioethical issues currently facing healthcare professionals.

Types of Ethical Problems Decision-focused What should I do? Action-focused Moral distress What can I do?

Making Ethical Decisions Catalano developed a five-step ethical decision- making algorithm for nurses Components of decision-making process Facts of specific situation Ethical theories and principles Nursing codes of ethics Clients’ rights Personal values Factors that contribute to or hinder ability to make a choice

Making Ethical Decisions Questions that help determine ownership of the decision For whom is the decision being made? Who should be involved in making the decision, and why? What criteria should be used in determining who makes the decision? What degree of consent is needed by the subject? When compromise is necessary, the desirable outcome is preservation of each person’s integrity

Making Ethical Decisions Winslow and Winslow’s elements of an integrity- preserving moral compromise Some basic moral language must be shared A context of mutual respect must exist The moral perplexity of the situation must be honestly acknowledged Legitimate limits to compromise must be admitted

Specific Ethical Issues Increased incidences of conflict Elective abortion End-of-life care Organ donation Genetic engineering Allocation of health care Three categories of ethical issues Moral uncertainty Moral dilemma Moral distress

Strategies to Enhance Ethical Decision Making Become aware of one’s own values and ethical aspects of nursing situations Be familiar with nursing code of ethics Understand the values of other healthcare professionals Participate on ethics committees Participate in or establish a nursing ethics group Participate in or establish educational ethics rounds

Learning Objective 4.7 Describe the advocacy role of the nurse.

Advocacy Advocacy – providing support for a patient’s rights/best interests Three models of nurse advocacy Rights protection Values-based Respect-for-persons To be an advocate a nurse needs Self-knowledge Professional knowledge

Advocacy Advocacy encompasses range of approaches Legal Self Collective Citizen Defining attributes of patient advocacy include A therapeutic nurse-patient relationship in which to secure patient’s freedom and self-determination Promoting and protecting patients’ rights Acting as an intermediary

Advocacy An advocate supports clients in decisions; support can involve Action Nonaction Underlying client advocacy are clients’ individual rights To select values deemed necessary to sustain own life To decide which course of action will best achieve the chosen values To dispose of values in a way they choose without coercion by others

Advocacy To be a client advocate involves Being assertive Recognizing that the rights and values of clients and families must take precedence when they conflict with those of healthcare providers Ensuring that clients and families are adequately informed to make decisions about their own health and health care

Advocacy To be a client advocate involves Being aware that personal conflicts may arise Working with unfamiliar community agencies or lay practitioners Political action