Chapter 6 Values, Ethics, & Advocacy Jennifer Dremann RN MSN

Introduction Nurses who understand how patients’ values and their own values shape nurse-patient interactions, and who continually develop sensitivity to the ethical dimensions of nursing practices, are best able to provide quality care and advocate for their patients.

Values Is a belief about the worth of something, about what matters, that acts as a standard to guide one’s behavior Value system-is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct An individual is not born with values, they are formed during a lifetime involving influences from the environment, family, & culture

Common Modes of Value Transmission Modeling-children learn values by observing others Moralizing-children taught a complete value system that allows little opportunity to weigh different values Laissez-faire-children left to explore values on their own, little or no guidance, likely to lead to confusion Rewarding and punishing-children rewarded for values held by parents and punished for demonstrating unacceptable values Responsible choice-encourages children to explore competing values and to weigh their consequences, support and guidance are offered

Tell whether the following statement is true or false. A child is born with values and forms new values during a lifetime from information from the environment, family, and culture. A. True B. False Answer: B. False Rationale: A child is not born with values, but rather forms values during a lifetime from information from the environment, family, and culture.

Professional Values Altruism: concern for welfare and well-being of others Autonomy: right to self-determination Human dignity: respect for inherent worth and uniqueness of individuals and populations Integrity: acting according to code of ethics and standards of practice Social justice: upholding moral, legal, and humanistic rights

Which value involves acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity E. Social justice Answer: D. Integrity Rationale: Integrity involves acting in accordance with a code of ethics and accepted standards of practice. Altruism is a concern for the welfare of others. Autonomy is the right to self-determination. Human dignity is respect for the worth and uniqueness of individuals and populations. Social justice is upholding moral, legal, and humanistic principles.

Three Main Activities of the Valuing Process Choosing Choosing freely from alternatives after careful consideration of the consequences of each alternative Prizing (treasuring) Involves pride, happiness, and public affirmation Acting Combining choice into one’s behavior with consistency and regularity on the value

Ethics Ethics-systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct of human flourishing Morals-refers to personal or communal standards of right and wrong

Types of Ethics Bioethics Encompasses a number of fields of “life sciences” Nursing ethics Formal study of ethical issues that arise in the practice of nursing Analysis used by nurses to make ethical judgments Subset of bioethics Feminist ethics Critiques existing patterns of oppression and domination in society especially affecting women and the poor

Two Categories of Action-Guiding Theories Utilitarian: The rightness or wrongness of an action depends on the consequences of the action. Deontologic: An action is right or wrong based on a rule, independent of its consequences.

Beauchamp and Childress’s Principle-Based Approach to Bioethics Combines elements of both utilitarian & deontologic theories and offers specific action guides for practice. Autonomy: Respect rights of patients to make health care decisions. Nonmaleficence: Avoid causing harm. Beneficence: Benefit the patient. Justice: Give each his or her due and act fairly. Fidelity: Keep promises. Veracity, accountability, privacy, confidentiality Ethical dilemmas-arise when attempted adherence to basic principles results in two conflicting courses of action

Characteristics of the Care-Based Approach to Bioethics Dissatisfaction with the principle based approach to bioethics has led many nurses to look to care as the foundation for nursing’s ethical obligations. Centrality of the caring relationship Promotion of dignity and respect for patients as people Attention to the particulars of individual patients Cultivation of responsiveness to others Redefinition of fundamental moral skills to include virtues

Ethical Conduct Practice based on professional standards of ethical conduct as well as professional values Nurses should: Cultivate the virtues of nursing Understand ethical theories that dictate and justify professional conduct Be familiar with codes of ethics for nurses and standards for professional nursing conduct

Virtues of Nurses There is no official list but the following are frequently named: Competence Compassionate Self-effacement Trustworthiness Conscientiousness Intelligence Practical wisdom Humility Courage Integrity

Purposes of the Code of Ethics for Nurses It is a succinct statement of the ethical obligations and duties of every nurse. It is the profession’s nonnegotiable ethical standard. It is an expression of nursing’s own understanding of its commitment to society.

ICN (International Council of Nurses) Guidelines to Achieve Purposes of Code of Ethics Study the standards under each element of the code. Reflect on what each standard means to you. Discuss the code with coworkers and others. Use a specific example from experience to identify ethical dilemmas and standards of conduct in the code. Work in groups to clarify ethical decision making, and reach consensus on standards or ethical conduct. Collaborate with other professionals to apply standards in practice, education, management, and research.

ANA Code for Nurses Portrays nurses conduct and responsibility Nurse practices with compassion Primary commitment is to the patient Promotes, advocates for, and strives to protect the health, safety, and rights off the patient Responsible and accountable for own practice Owes the same duties to self as to others Establish, maintains, and improves health care environments Participates in advancement of profession Collaborates with others of health care team

Measurement Criteria for Standard 7 (ANA Standards)/The Registered Nurse: Uses Code of Ethics for Nurses with Interpretive Statements to guide practice Delivers care in a manner that preserves and protects health care consumer autonomy, dignity, rights, values, and beliefs Recognizes the centrality of the health care consumer and family as core members of the health care team Upholds health care consumer confidentiality within legal and regulatory parameters Assists health care consumers in self-determination and informed decision making

Measurement Criteria for Standard 7 (ANA Standards)/The Registered Nurse: Maintains a therapeutic and professional health care consumer–nurse relationship within boundaries. Contributes to resolving ethical issues involving health care consumers, colleagues, community groups, systems, and other stakeholders. Takes action regarding illegal, unethical, or inappropriate behavior that can endanger or jeopardize the best interests of the health care consumer or situation. Speaks up when appropriate to question practice when necessary for safety and quality improvement. Advocates for equitable health care consumer care.

7 Basic Tenets of Bill of Rights for RNs/Registered Nurses Must Be Able to: Practice in a manner that fulfills obligations to society and to those who receive nursing care Practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice Work in an environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses Freely and openly advocate for themselves and their patients, without fear of retribution

7 Basic Tenets of Bill of Rights for RNs (cont 7 Basic Tenets of Bill of Rights for RNs (cont.) /Registered Nurses Must Be Able to: Receive fair compensation for their work, consistent with their knowledge, experience, and professional responsibilities Practice in a work environment that is safe for themselves and their patients Negotiate the conditions of their employment, either as individuals or collectively, in all practice settings

Ethical Experience and Decision Making/Ethical Problems Ethical dilemma: Two (or more) clear moral principles apply but support mutually inconsistent courses of action. Ethical distress: Occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action.

Rise Above Moral Distress

Tell whether the following statement is true or false. A nurse who is dedicated to providing culturally competent care to her patients finds herself without the resources to communicate with a patient who speaks a different language. This problem may result in an ethical dilemma for the nurse. A. True B. False Answer: B. False Rationale: This problem may result in ethical distress for the nurse. Ethical distress occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. Ethical dilemma occurs when two (or more) clear moral principles apply but support mutually inconsistent courses of action.

Using the Nursing Process to Make Ethical Decisions Assess the situation (gather data), describe factors that gave rise to the ethical dilemma. Diagnose (identify) the ethical problem, identify that the problem is clearly an ethical one. Plan: Identify options, think ethical problem through, make a decision. Implement your decision. Evaluate your decision-what did you learn?

Examples of Ethical Problems Paternalism Deception Privacy Confidentiality Allocation of scarce nursing resources Valid consent or refusal Conflicts concerning new technologies

Examples of Ethical Problems Unprofessional, incompetent, unethical, or illegal physician practice Unprofessional, incompetent, unethical, or illegal nurse practice Short staffing and whistle-blowing Beginning-of-life issues End-of-life issues

C. Allocation of scarce nursing resources A nurse attempts to obtain an order for a feeding tube for an anorexic teenager who refuses to eat. What is the term for the ethical problem this nurse is experiencing? A. Deception B. Confidentiality C. Allocation of scarce nursing resources D. Advocacy in market-driven environment E. Paternalism Answer: E. Paternalism Rationale: Paternalism occurs when a nurse acts for a patient without consent to secure good or prevent harm. Deception occurs when a nurse deceives a person for a perceived benefit. Patient confidentiality is questioned when a patient confidence may lead to harm. Allocation of scarce nursing resources and advocacy in market-driven environment involve patient harm due to inadequate staffing/finances.

Four Functions of Ethics Committees Education Policy making Case review Consultation Occasionally research

Advocacy in Nursing Practice Advocacy-is protection and support of another's rights Primary commitment to the patient Prioritization of good of individual patient rather than society in general Evaluation of competing claims of patient’s autonomy and patient well-being

Areas of Concern for Patient Advocates Representation of patients-nurses often intermediary between patient and family, patient and medical profession Promoting self-determination-nurses do not make ethical decisions for the patient, they facilitate the decision making of the patient Whistle-blowing-every nurse who witnesses unsafe care has a duty to patients Being politically active-nursing has a voice in the political arena on behalf of those least well served by the health care system