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

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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.

24. Rise Above Moral Distress

25. 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.

26. 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?

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

28. 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

29. 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.

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

31. 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

32. 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