Final Ethics 2024-2025 PDF

Mansoura National University Faculty of Nursing ETHICS AND LEGISLATION FIRST LEVEL FIRST SEMSETER ACADEMIC YEAR 2024-2025 Mansoura National University BSc in Nursing Faculty of Nursing 1st level Professional Ethics and Nursing Legislation...

Mansoura National University Faculty of Nursing ETHICS AND LEGISLATION FIRST LEVEL FIRST SEMSETER ACADEMIC YEAR 2024-2025 Mansoura National University BSc in Nursing Faculty of Nursing 1st level Professional Ethics and Nursing Legislation 1 Aim of the course: This course aims to provide students with the required ethical and legal dimensions skills of nursing profession. Preface Nurses at present are facing various personal, interpersonal, professional, institutional, and socio-cultural challenges in their professional performance. Dealing with these issues may not be always clear. The lack of one correct approach in addressing different contextual issues may lead to ethical dilemmas. It is impossible to separate ethics from nursing; the right type of nursing care is possible only by adopting ethical behavior in nursing care. Ethical principles guide the nurses in exercising quality care to patients. Every nurse, whether he/she is a student, nurse educator, or clinical nurse, will have to follow nursing ethics in accordance with the requirements of the work area. This book provides information about such ethics, values, principles, legal litigations, bioethics, and ethical and legal issues in different areas of nursing 2  Table of Contents Subject Page 1. Introduction and terminology 5 2. Importance of ethics 10 3. Ethical principles in nursing practice 17 4. Code of Ethics 24 5. Patient's Bill of Rights 28 6. Ethical dilemma 39 7. Informed consent 46 8. References 51 3 Introduction and terminology 4  Introduction and terminology Introduction The word ethics is derived from the Greek word “ethos”, which means custom or guiding beliefs. Ethics is defined as a set of rules or principles that govern right conduct and is designed to protect the rights of a human being. Ethics is a branch of philosophy; it is moral philosophy or philosophical thinking about morality, moral problems, and moral judgments. Nursing ethics provides the professional standards for nursing activities, which protect the nurse and the patient. Definitions Ethics may be defined as the system or code of conduct and morals advocated by a particular individual or group. It is also the study of acceptable conduct and moral judgment. Ethics is a system of understanding determinations and motivations based on an individual’s perceptions of right and wrong. It is not determined by strict rules or rigid guidelines, and although it is relatively stable, it can change over time. The code of ethics defines the kind of conduct expected of the members of a profession. It is also used to guide professional behavior, help teachers plan instruction, prevent the below-standard practice, protect a nurse if falsely accused, and provide direction for legal action. 5 Professional ethics Professional ethics is a set of standards adopted by a professional community and it encompasses a greater part of a professional’s life. The concept of professional ethics partly deals with what a professional should or should not do in the workplace. Professional codes of ethics regulate the manner in which professionals conduct themselves while in the workplace and include concepts such as professional respect, avoidance of dishonesty or fraudulent activity, such as plagiarism, and the professional development of the individual. Another important aspect is the enhancement of the profession and the industry within which the professional works. Nursing ethics refers to the professional standards and behavior that helps a nurse to carry out the nursing care in a manner that results in good to the mankind and community. A professional has more moral responsibilities than those held by the population in general. This is because professionals are capable of making judgments and acting on informed decisions in situations that the general public cannot because they have not received the relevant training. In the workplace, managers and supervisors should set the standard for ethics by showing respect, being honest, and promoting trust. If the management team uses unethical forms of communication, the team and business can fail. 6 History of ethics: The word ethics is derived from the Greek word “ethos” meaning character. It is always important to learn the root of a word to understand its full concept. Ethics was not obeying moral values but developing and framing themselves as strong leaders to lead a community of small tribes. The origin of ethics is very vague; it depicts that in the olden days ethics was considered to be bravery. Becoming a strong leader for the tribes by defeating the enemies and believing and worshipping the natural forces such as air, water, land, fire, earth, and light in the form of the sun formed the ethical values of their life. 7 Ancient Three important Greek leaders portrayed the importance of moral and ethical values in the ancient period. Socrates, Plato, and Aristotle:- (a) According to Socrates, a person having good ethical sense achieves “internal harmony” of the parts of the soul, whereas doing evil things will “damage the soul”. This was considered to be the highest moral value in humans. Socrates gave importance to honesty, and truth was always considered to be good than doing injustice. (b) According to Plato, ethics refers to the qualities such as courage and bravery that need to be acquired in life to become a strong leader. Plato has made only a few contributions to the concept of ethics. (c) Aristotle explains ethics as “eudaimonia”, which means happiness, prosperity, and success. According to him, a good-hearted citizen should possess the quality of eudaimonia, which was considered to be the highest target for each human being to achieve an ethical life. He taught society that possessing the quality of fixed virtues and habits such as courage, justice, prudence, and temperance is important to lead a moral life. Each citizen should acquire good intellectual ability and activity to have an ethical sense. 8 Importance of ethics 9  Importance of ethics Nursing ethics is a branch of nursing that deals with the activities involved in the field of nursing. It provides the professional standards for nursing activities, which help to protect not only the nurse but also the patient. Nursing ethics refers to the values and ethical principles governing nursing practice, conduct and relationships between the nurse and patient, patient’s family, other members of health profession and general public. There are many reasons for the need for ethics in the nursing profession, the important ones are as follows: Figure 1. Importance of ethics 10 A. Importance for the nurses 1. Ethics provides framed ethical principles to do proper nursing care: The nurse should say the truth and perform only truthful activity in any situation. For example, a nurse should not say that he/she has given the drug to the patient when it has not been given 2. Ethics protects the nurse from all legal and ethical issues: As per nursing ethics, before doing any procedure, a nurse has to get the informed consent signed from the patient after providing all the details about the procedure. If he/she explains all the details, benefits, risks, and alternatives associated with the procedure as per the ethics, the nurse will be safe. However, if the details have not been provided and a problem occurs during the treatment, then the nurse will be at risk. 3. Ethics helps the nurse to attain professional and personal satisfaction: A nurse should follow the code of ethics and hospital policies. Legally approved ethical principles help the nurses to attain personal and professional satisfaction since these ethical principles direct the nurse to do good to the patient and achieve the goal of high-quality care and satisfaction. 4. Ethics Leads to Profits: Both ethics and profits go together. Without a doubt, any management that sticks to strong ethical principles will yield only profit, since these principles work out 11 only to stabilize the unity. Harmony always leads to profits in the long run. 5. Ethical values help in better decision-making: If an institution or management has enforced a standard and strong ethics, its principles will definitely help in decision-making. Whenever issues or problems arise, moral and ethical principles are twined and stitched into each decision- making step. This ensures safety not only for the employee but also for the management and there are no “ups” and “downs”. 6. Ethics controls, modifies, and moulds good ethical behavior in the nurse: Following ethical principles will help not only the nurse but also all health care providers to modify and control their behavior towards patient care since all ethical principles are grounded and framed to the benefit and protection of the society. for example, in the administration of drugs to patients as ordered by the physician. As per the principle, a nurse has to abide the order and provide the drugs safely on time by following the five rights, namely, right patient, right drug, right route, right dose, and providing the drug at the right time. The responsibility does not end with providing the drugs; the nurse has to document and even report the condition to the concerned authority. Here, the behavior of the nurse is controlled and moulded, and the nurse is tuned to behave ethically for each activity. 12  7. Ethics is a rule for right conduct of any human being: The fast pace of advancement in technology has brought about the need to stabilize the strong ethics to safeguard the life of humans. Ethics can be easily framed and followed whereas a law cannot be framed easily and though implemented will not protect always. However, strong ethical principles will do it. Where the law fails, ethics can succeed. Importance in the clinical area The ethical principles guide the nurse in the following: 1. Delegate work responsibility as per the needs and requirements of the patients 2. Practice nursing care as per the nursing care standards 3. Provide good judgment ability 4. Uplift self-determination 5. Help to be accountable and responsible in nursing care 6. Help to alleviate the pain and suffering of the patients 7. Never ignore a patient and attend to and meet all the needs of the patients Importance within the Horizons of the Nursing Profession The ethic B. Importance for the patient Nursing ethics is important for the patient because it helps: 1. Obtain good and efficient nursing care 2. Exercise the patients’ rights 3. Obtain all information needed about patient care 4. Attain patient satisfaction because of high-quality nursing care 13  5. Create a trustworthy relationship between the patients and health care providers 6. Safeguard the patient from all medico-legal problems All principles in the nursing profession help in the following: 1. Maintain a trustworthy relationship among the team members in the medical profession and the health care providers and co- workers such as nurse and colleagues relationship, nurse and patient relationship, nurse and doctor relationship. 2. Evaluate the performance of nursing care by checking for any impaired practice, acceptance of any forms of rewards, tokens, or goodies from the patients or their relatives, and the maintenance of a therapeutic relationship with patients. 3. Maintain confidentiality and ensure that the details of the patients are recorded accurately and are kept safe. 4. Not practice any illegal or criminal offense or allow it in the nurse’s presence. 5. Use the power and potentiality to upgrade professional growth properly 6. Respect all cultural issues of the patient. 7. Maintain good morale. 8. Nursing is not possible without ethics. It is needed in all fields of nursing such as foundations in nursing, nursing education, nursing research, nursing administration, and management 14  C. Importance for the society and the people Nursing ethics is important to society and people because of the following reasons: 1. Following nursing ethics helps a nurse to be a good citizen in society. 2. Nursing ethics never allows a nurse to do harm to society. 3. Nursing ethics guides a nurse to be morally and ethically right and is inculcated in each activity of the nurse that is directed towards the society. Nursing ethics governs the ethical behavior of a nurse to do only good to society 15 Ethical principles 16  Ethical principles Ethical principles are the basis of all nursing practice and provide a framework tohelp the nurse in ethical decision making. ethical principle primary secondary There are primary ethical principles that are traditionally cited when discussingethical concerns in human subject's research. ▪ Respect for autonomy (the right to make one's own decision) ▪ Beneficence (doing good); Non maleficent. ▪ Justice (fairness) Autonomy ▪ Self-governing; having the freedom to make independent choices and decision- making. ▪ self-determination ▪ Do not force or coerce people to do things ▪ Informed Consent' is an important outcome of this principle 17 Beneficence Views the primary goal of health care as ―doing good‖ for clients. Create a safe and supportive environment Our actions must aim to ‗benefit' people – health, welfare, comfort, well-being, improve a person's potential, improve quality of life Client approached in holistic manner. Non-maleficent. ―To do no harm‖ ▪ do not to inflict harm on people ▪ do not cause pain or suffering ▪ do not incapacitate ▪ do not cause offence ▪ do not deprive people ▪ do not kill ▪ Both Beneficence and Non-maleficence underpin EBP Justice Obligation to be fair, and equitable to all people. Regardless of any service you want to give. Showing all individuals, the same degree of respect and concern. 1st statement in ANA Code of Ethics for Nurses. The secondary ethical principles include: 1- Respect: you must respect patient's autonomy, dignity& liberty. 2- Altruism: Is to protect the community by supporting actions, to meet the health and social need of the public. 3- Paternalism: Is to protect the weak person. 4- Veracity: Is the obligation to tell the truth& not intentionally deceive or mislead clients. 18 5- Fidelity: Is the obligation to loyal to the pt., community and profession. Duty to be faithful to one's commitments To keep promises Fidelity or faithful devotion to duty. 6- Confidentiality: Keep privileged information private exceptions. Confidentiality means that nurses & doctors should only discuss the medical conditions & issues of a patient when there is a valid reason for doing so. 7- Egoism: Is the right to maximize personal benefits. 8- Nurses autonomy: the nurse must be autonomous which means: ―Never looking up on another person‖ and has the right to self – determination. 9- Utilitarianism: Is the greatest good for the greatest members. 19 Clinical practice Boundaries Respecting patients’ dignity Right to self determination Delegating tasks appropriately Practicing good judgment Accepting accountability in practice Alleviating suffering Being attentive to patients' interests Working within the nurse practice acts and nursing standards of practice Professional boundaries The nurse must always maintain professional boundaries with patients and colleagues to prevent misunderstandings and inappropriate relationships. Violations of professional boundaries may result in loss of employment and licensure and civil action, depending on the severity of violation. Issues of professional boundaries include: Receiving/Giving gifts: The nurse should decline all personal gifts and should avoid giving personal gifts to patients because either can set up expectations about a relationship that are not realistic. Coercing patients: Forcing a patient to do something against the Patient's will, such as have a treatment, or intimidating a patient into cooperating not only breaches professional boundaries but maybe perceived as assault. Showing favoritism: Giving more attention to one patient than others or doing favors for a patient may indicate over-investment in a patient and may develop dependence on the part of the patient. The nurse, who is a position of power and authority, should avoid beginning a personal relationship with a patient. 20  Sharing personal information: The nurse must maintain a professional distance in terms of sharing and must avoid sharing personal information that one would normally share with family or friends, as the patient may believe this constitutes a more personal relationship than the nurse intended. Using social media: The nurse must always be familiar with the institution's policies about social media (Facebook, Twitter, blogs, email, Skype, YouTube, message boards) as they may be very restrictive in relation to what a nurse can post regarding employment. From a practical perspective, it is usually best to post NOTHING about work, the work environment, patients, or colleagues. The patient's rights to privacy and confidentiality extend to social media, so if the nurse posts a picture or the name or condition of a patient, this is a violation of HIPAA. Posting negative comments about co-workers is not only unethical but may be construed as lateral violence and bullying. Additionally, posting information that might suggest the nurse has questionable moral character, such as pictures or stories of engaging in promiscuous sexual activity, nudity, drinking, or drug taking, may result in loss of employment or even loss of license. Self- Care and self –Development Boundaries and obligations Participating in self-care activities to maintain and promote moral self-respect, professional growth and competence, wholeness of character in nurses actions and in relationships with others, and preservation of integrity. Advancing knowledge and research through professionalism, practice, education, and administrative contributions. Collaborating with other health care professionals and the public to promote community, national and international efforts. 21  Promoting healthy practices in the community through political activism or professional organizations by addressing unsafe, unethical, or illegal health practices that have potential to harm the community 22 Code of Ethics 23  Code of Ethics Introduction The Code provides broad principles for determining & evaluating nursing care, but is not legally binding for registered nurses. In most states the Board of Nursing has the authority to reprimand nurses for unprofessional conduct that results from violation of the ethical code. History of the Nursing Code of Ethics: Interestingly, the nursing code of ethics is suggested to have been founded in 1893 and named the Nightingale Pledge‖ after Florence Nightingale, the founder of modern nursing. As a modification of the Hippocratic Oath, taken by medical doctors, the Nightingale Pledge has been recited by nursing students at graduations with little changes since inception. The formal code of ethics was developed in the 1950s by the American Nurses Association (ANA) and has undergone numerous modifications since. The most significant recent change was in 2015 when 9 interpretative statements or provisions were added to the code of ethics to help guide nursing practice in a more definitive way. Many states include the ANA's nursing code of ethics in their practice statements. Even though the code of ethics is primarily ethics-related, it also has legal implications. Given the importance of the code to the nursing profession, revisions continue on a regular basis. Definition of the code of ethics: According to the American Nurses Association (ANA), the nursing code of ethics is a guide for ―carrying out nursing responsibilities in a manner consistent with quality in 24 nursing care and the ethical obligations of the profession. Not legally enforceable as laws but consistent violations indicate unwillingness bythe person to act in a professional manner & license can be suspended or revoked. Professional organizations develop codes that serve as a guideline for ethical conduct. Examples: American Nurses' Association International Council of Nurses American Nurses Association Code of Ethics for Nurses: Currently, the nurse's code of ethics contains 9 main provisions: 1- The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. 2- The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. 3- The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. 4- The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to provide optimal patient care. 5- The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 6- The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 7- The nurse, in all roles and settings, advances the profession through research 25 and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 8- The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 9- The profession of nursing, collectively through its professional organization, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. The aforementioned nine provisions were implemented to help guide nurses in ethical decision-making throughout their practice. Using code of Ethics in Nursing Knowing the nursing code of ethics is essential for nurses because it will help guide everyday practice and navigate the daily complexities of the healthcare profession. Nurses often use the four major ethical principles throughout a shift, even if not fully aware of it. Providing pain medication to a post-operative hip replacement Holding the hand of a dying patient who is alone Advocating for the patient that wants to end chemotherapy and enter hospice care Benefits of a code of ethics Reducing burnout and moral injury: A code of ethics can help providers align their decisions and actions with that of the organization, and vice versa. Establishing an ethical work environment: Providers can be confident that theircolleagues share the same ethical framework, preventing unethical behavior. Improved regulatory compliance: A code of ethics can keep everyone operatingwithin the same regulatory framework. 26 Patients' Bill of rights 27  Patients' Bill of rights Introduction:  Effective health care requires collaboration between patients and physicians and other health care professionals. Open and honest communication, respect for personal and professional values, and sensitivity to differences are integral to optimal patient care. As the setting for the provision of health services, hospitals must provide a foundation for understanding and respecting the rights and responsibilities of patients,  their families, physicians, and other caregivers.  Hospitals must ensure a health care ethic that respects the role of patients in decision making about treatment choices and other aspects of their care. Hospitals must be sensitive to cultural, racial, linguistic, religious, age, gender, and other differences as well as the needs of persons with disabilities. Evolution of the patient's bill of rights:  There's no one single Patient's Bill of Rights. What started in the early 1970‗s has developed into several different kinds of declarations. An early bill of rights was drafted by the American Hospital Association to inform patients of what they could reasonably expect while in the hospital. It also offered a way for hospital staff to talk with patients about their care.  The expectations of quality care are supported for every patient treated in an American Hospital Association (AHA) member hospital. In 1973, AHA member hospitals voted to adopt a Patient's Bill of Rights and revised it in 1992. In 2001, AHA hospitals replaced a Patient's Bill of Rights with the Patient Care Partnership: Understanding Expectations, Rights and Responsibilities.  28   The new statement a straightforward, plain language statement that clearly outlines what patients should expect during their hospital visit.  The American Hospital Association presents A Patient's Bill of Rights with the expectation that it will contribute to more effective patient care and be supported by the hospital on behalf of the institution, its medical staff, employees, and patients. The American Hospital Association encourages health care institutions to tailor this bill of rights to their patient community by translating and/or simplifying the language of this bill of rights as may be necessary to ensure that patients and their families understand their rights and responsibilities.  In 2010, a new Patient's Bill of Rights was created along with the Affordable Care Act. This bill of rights was designed to give new patient protections in dealing with insurance companies. Some of the protections started in 2010, but others will be phased in more slowly and take full effect in 2014. Definition of patient's bill of rights:  A patients' bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy over medical decisions, among other rights.  It offers some guidance and protection to patients by stating the responsibilities that a hospital and its staff have toward them and their families during hospitalization, but it is not a legally binding document. Goals of patient bill of rights:  Strengthen consumer confidence that the health care system is fair and responsive to consumer needs.  Reaffirm the importance of a strong relationship between patients and their health care providers.  Reaffirm the critical role consumers' play in safeguarding their own health 29  The American Hospital Association (AHA) patient's bill of rights: 1. The patient has the right to considerate and respectful care. 2. The patient has the right to and is encouraged to obtain from doctors and other direct caregivers appropriate, current, and understandable information about diagnosis, treatment, and prognosis. Except in emergencies when the patient lacks decision- making ability and the need for treatment is urgent, the patient is entitled to the chance to discuss and request information about the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their risks and benefits. 3. Patients have the right to know the identity of doctors, nurses, and others involved in their care, as well as when those involved are students, patients, or other trainees. The patient also has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known. 4. The patient has the right to make decisions about the plan of care before and during treatment. The patient has the right to refuse a recommended treatment or plan of care to the extent allowed by law and hospital policy and to be informed of the medical consequences of this action. In case of refusal, the patient is entitled to other appropriate care and services thatthe hospital provides or transfers to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution. 5. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy. Health care institutions must tell patients of their 30  rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient records. The patient has the right to timely information about hospital policy that may limit its ability to implement fully a legally valid advance directive. 6. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient's privacy. 7. The patient has the right to expect that all communications and records related to his/her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law. The patient has the right to expect that the hospital will stress the confidentiality of this information when it releases it to any other parties entitled to review information in these records. 31 8. The patient has the right to review the records about his/her care and to have the information explained or interpreted as necessary, except when restricted by law. 9. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to a patient's request forappropriate and medically indicated care and services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. When medically appropriate and legally permitted, or when a patient has requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer. 10.The patient has the right to ask and be informed of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient's treatment and care. 11.The patient has the right to consent to or decline to take part in research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to take part in research or experimentation is entitled to the most effective care that the hospital can otherwise provide. 12.The patient has the right to expect reasonable continuity of care when appropriate and to be informed by doctors and other caregivers of available 32 and realistic patient care options when hospital care is no longer appropriate. 13.The patient has the right to be informed of hospital policies and practices that relate to patient care treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospital's charges for services and available payment methods. Patient responsibilities: The partnership nature of health care requires that patients, or theirfamilies/surrogates, take part in their care. The effectiveness of care and patient satisfaction with the treatment depends, in part, on the patient fulfilling certain responsibilities. The following are patient responsibilities: 1. Patients are responsible for providing information about past illnesses, hospitalizations, medications, and other matters related to health status. To participate effectively in decision making, patients are taking responsible for asking for additional information or explanation about their health status or treatment when they do not fully understand information and instructions. 2. Patients are also responsible for ensuring that the health care institution has a copy of their written advance directive if they have one. 3. Patients are responsible for telling their doctors and other caregivers if they expect problems in following prescribed treatment. 4. Patients should be aware of the hospital's duty to be reasonably efficient and fair in providing care to other patients and the community. The hospital's rules and regulations are intended to help the hospital meet this responsibility. Patients and their families are responsible for making reasonable 33 accommodations to the needs of the hospital, other patients, medical staff, and hospital employees. 5. Patients are responsible for giving necessary information for insurance claims and for working with the hospital to make payment arrangements, when necessary. 6. A person's health depends on much more than health care service. Patients are responsible for recognizing the impact of their lifestyle on their personal health. Johns' Hopkins hospital patient bill of rights and responsibilities: 1. Patients have the right to receive considerate, respectful and compassionate care in a safe setting regardless of your age, gender, race, national origin, religion, sexual orientation, gender identity or disabilities. 2. Patients have the right to receive care in a safe environment free from all forms of abuse, neglect, or mistreatment. 3. Patients have the right to be called by your proper name and to be in an environment that maintains dignity and adds to a positive self- image. 4. have the right to be told the names of your doctors, nurses, and all health care team members directing and/or providing your care. 5. have the right to have a family member or person of your choice and your own doctor notified promptly of your admission to the hospital. 6. have the right to have someone remain with you for emotional support during your hospital stay, unless your visitor's presence compromises your or others' rights, safety or health. You have the right to deny visitation at any time. 7. have the right to be told by your doctor about your diagnosis and possible prognosis, the benefits and risks of treatment, and the expected outcome of treatment, including unexpected outcomes. You have the right to give written 34 informed consent before any non-emergency procedure begins. 8. have the right to have your pain assessed and to be involved in decisions about treating your pain. 9. have the right to be free from restraints and seclusion in any form that is not medically required. 10.can expect full consideration of your privacy and confidentiality in care discussions, exams, and treatments. You may ask for an escort during any type of exam. 11.have the right to access protective and advocacy services in cases of abuse or neglect. The hospital will provide a list of these resources. 12.Patient family, and friends with your permission, have the right to participate in decisions about your care, your treatment, and services provided, including the right to refuse treatment to the extent permitted by law. If you leave the hospital against the advice of your doctor, the hospital and doctors will not be responsible for any medical consequences that may occur. 13.have the right to agree or refuse to take part in medical research studies. You may withdraw from a study at any time without impacting your access to standard care. 14.have the right to communication that you can understand. The hospital will provide sign language and foreign language interpreters as needed at no cost. Information given will be appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids to ensure your care needs are met. 15.have the right to make an advance directive and appoint someone to make health care decisions for you if you are unable. If you do not have an advance directive, we can provide you with information and help you complete one. 16.have the right to be involved in your discharge plan. You can expect to be told ina timely manner of your discharge, transfer to another facility, or transfer to 35 another level of care. Before your discharge, you can expect to receive information about follow-up care that you may need. 17.have the right to receive detailed information about your hospital and physician charges. 18.can expect that all communication and records about your care are confidential, unless disclosure is permitted by law. You have the right to see or get a copy of your medical records. You may add information to your medical record by contacting the Medical Records Department. You have the right to request a list of people to whom your personal health information was disclosed. 19.have the right to give or refuse consent for recordings, photographs, films, or other images to be produced or used for internal or external purposes other than identification, diagnosis, or treatment. You have the right to withdraw consent up until a reasonable time before the item is used. Nurses' Bill of Rights  The Bill of Rights is a statement of professional rights, not a legal document. It can help guide development of organizational policy or focus discussions between nurses and employers regarding employment contracts and work agreements. The Bill of Rights supplements other tools such as the Code of Ethics for Nurses with Interpretive Statements (2001), Nursing's Social Policy Statement, (2003) and Nursing: Scope and Standards of Practice (2004) all available from the American Nurses Association (See Below and right).  All of these documents have been developed by expert nurses and approved by a representative national body of practicing nurses. In addition to these tools, all nurses and employers must be familiar with the nurse practice act and the regulations for their individual states, which do spell out essential legal requirements related to practice. 36 Importance of bill of rights for registered nurses: o As nurses go about their daily practice, they cite factors in the workplace that make it difficult for them to do their jobs or to feel safe and respected as professionals. There are several tools that can facilitate discussions about workplace concerns. As one of those tools, the Bill of Rights for Registered Nurses sets forth seven premises concerning workplace expectations and environments that nurses from across the United States recognize are necessaryfor sound professional nursing practice. o As nurses approach employers with patient care or health and safety concerns in the workplace, nationally-recognized consensus documents can lend credibility to their discussions. The Bill of Rights was conceived to support nurses in an array of workplace situations including unsafe staffing, mandatory overtime and health and safety issues such as needle stick injuries, workplace violence, and latex allergies. Nurses realize that bringing these issues to the attention of employers is essential in meeting their responsibilities to their patients – and to themselves. o Employers can refer to the document to help them understand what nurses need in their places of work to fulfill professional responsibilities. As a document developed and approved by practicing nurses, the Bill of Rights can be a reliable basis for dialogue to resolve concerns nurses may have about ensuring work environments that support professional practice. o Nurse educators can use the Bill of Rights when addressing nursing issues and trends and professional practice topics, in certain aspects of discussion about clinical practice, or in an introductory nursing course. 37 The American Nurses Association Bill of Rights for registered nurses:  Registered nurses promote and restore health, prevent illness, and protect the people entrusted to their care. They work to alleviate the suffering experienced by individuals, families, groups and communities. In so doing, nurses provide services that maintain respect for human dignity and embrace the uniqueness of each patient and the nature of his or her health problems, without restriction with regard to social or economic status. To maximize the contributions nurses, make to society, it is necessary to protect the dignity and autonomy of nurses in the workplace. the following rights must be maintained: 1. Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care. 2. Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice. 3. Nurses have the right to a work environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurses with Interpretive Statements. 4. Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution. 5. Nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional responsibilities. 6. Nurses have the right to a work environment that is safe for themselves and for their patients. 7. Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings. 38  Ethical dilemmas Introduction Ethical dilemma is similar to the two faces of a coin, wherein importance needs to be given to two equally desirable and undesirable outcomes. Ethical dilemma discusses an ethical issue to bring out solutions and check the pros and cons, where each alternative action is justified according to the view of ethical practice. Definitions Decision-making is the process of selecting one action from alternatives. Decision-making is the learned and scientific problem- solving process. Ethical dilemma arises when a decision needs to be taken in a situation where in two different controversial options, sometimes equally undesirable exist. Characteristics of ethical dilemma 1. Problem cannot be solved using only empirical data. 2. Problem must be so perplexing and making the decision is difficult. 3. The result of the problem must affect more than the immediate situation. 39  Types of ethical dilemmas in nursing Ethical dilemma is present wherever ethical issues are faced in all fields of nursing. There will be two morally acceptable solutions for the same issue, and it is difficult to find a ‘right’ solution that can be justified. The two main types of ethical dilemmas are as follows: Internal (can be with a patient or with a nurse) External (pertains to the environment or society) Internal Dilemma Internal dilemma occurs when an individual faces an issue that interferes with his/her own beliefs and practices. For example, a nurse, as an individual, tries to give treatment to a dying patient because he/she respects the patient’s rights and believes that he/she is doing good to the patient. However, the patient believes that he/she is going to die, asks for euthanasia or mercy killing, and refuses to take the treatment. In this case, the dilemma involves internal conflicting ideas between the care provider and the recipient. The nurse wants to do good but the patient wants to refuse it. The patient’s rights, in terms of dignity, privacy, information accessibility, autonomy, culture, etc. should be respected, and an internal dilemma arises when the patient refuses care, but the nurse wants to provide care. 40  External Dilemma External dilemma arises when other individuals apart from the nurse and the patient are involved. It involves conflicting ideas relating to issues with the patient’s family members and friends. For example, while treating a child that is dying or is terminally ill, it is necessary to involve the child’s parents and let them see how treatment is being given for their dying child. However, we never allow the parents to see what is being done to the child. The decision to allow the parents to witness the treatment or not according to hospital policies gives rise to an external dilemma. If the child dies, the parents will definitely think that it is due to inappropriate care. Therefore, information about the treatment being given to a patient should be given to the patient’s family so that the patient, his/her parents, and family are satisfied. In such cases, the patient’s parents and family would say that the patient died despite the good care and treatment of the nurse and the health care members. Here, the issue is external and pertaining to the family’s rights, which should be respected. Process of an ethical dilemma Nurses commonly use the nursing process model for decision making, the process generally includes problem identification based on assessment; development of a care plan, guided by desired outcomes; implementation of interventions; evaluation of the outcomes; and revision of the plan over time. 41  Figure 2. Steps involved in processing an ethical dilemma The following are the eight steps involved in processing an ethical dilemma: Step 1: Find the origin of the ethical dilemma. An ethical dilemma arises when an ethical issue needs to be addressed. 42  Step 2: Gather all information relevant to the case. To be sure that it is a true dilemma, it is important to review all pertinent information. Occasionally, an overlooked fact may provide a quick resolution. At this point, patient, family, institution, and social perspectives are the important sources of relevant information. Step 3: Examine and determine the nurse’s values on the issues. Analyzing the values provides a foundation for clarity and for building confidence during discussions, which will be necessary for the resolution of a dilemma. Step 4: Verbalize the problem. A clear, simple statement of the dilemma may not always be easy, but it is essential for progressing to the next step. Step 5: Consider the possible courses of action It is helpful to list potential actions to address all sides of an issue, especially when the list will reflect conflicting opinions. Step 6: Negotiate the outcome. Sometimes, courses of action that seem unlikely at the beginning of the process may become possible later on as they are put to rational and respectful consideration. Step 7: Evaluate the action. Step 8: Reconsideration and motivation. Ethical issues are reconsidered and revised. The revised issues form the motivation for a new solution f or the issues. The newly f orm ed so lu tio n is 43 implemented to prevent the incidence of ethical issues and problems. Ethical Decision-Making Model Ethical decision-making models provide mechanisms or structures that help nurses think through or clarify an ethical issue. There are several models from which to choose, but there is no one best way to approach ethical decision- making. The MORAL model for ethical decision-making The steps involved in MORAL decision-making are as follows: M: Massage the dilemma. Identify the members involved in a particular ethical dilemma, Collect data about the ethical problem. O: Outline the possible options clearly. Examine each option. Consider the realistic and less-conflicting options, and sort out the more-conflicting and less-realistic options. R: Resolve the existing dilemma. Apply the basic ethical principles to each issue listed and decide on the best options that resolve the issues. A: Act or implement the chosen action. Apply or implement the decided options. This involves actually resolving the issue and applying the solution for the issue. L: Look back or evaluate feedback. This is the most important step. Check whether the applied decision has achieved its goal or not. Evaluate the success of the decision-making by ensuring that the ethical dilemma is solved with the first option. If not, choose the second option. The process is repeated with all options until the issue is resolved. 44  Informed Consent 45  Informed Consent: Informed consent is an important legal document that a patient has to sign before any invasive procedure is done on the patient. It is the duty of the nurse to inform the patient about the details of the procedure and the benefits and risks associated with it and then obtain the informed consent. In many hospitals, nurses order the patient or his/her relatives to sign the informed consent without giving adequate explanation about the procedure to be done on the patient. The patient will be anxious and feel insecure about the prognosis of his/her illness. As the fear and anxiety are high, the patient may not provide full cooperation for the procedure. Definition - It is defined as a legal document that includes details, risks, and benefits of the invasive procedure and states that the contents of the informed consent have been read and clearly understood by the patient before obtaining his/her signature with date and time. - It is an agreement by the patient, verbal or written, after being given sufficient details of the possible risks in having a procedure performed. - It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. 46 Important principles of informed consent A valid and legal informed consent must meet all these requirements 1. Competence to understand and to decide the matter 2. Voluntary decision-making by the person who gives consent 3. Disclosure of material information that is explained in consent 4. Recommendation of the plan in the consent 5. Comprehensions of terms and conditions in the consent 6. Explain the risk and benefits in the content of the consent Types of informed consent 1. Oral: Oral consent follows written consent. 2. Written: Printed legal document that contains the details of treatment, the reason for the treatment, risks, and benefits of the treatment, and the agreement for the treatment by the patient. Elements of informed consent The following are the elements of informed consent: 1. Information to the client about the nature of treatment 2. Possible alternative treatments 3. Potential risks involved 4. Benefits of the treatment 47  5. Clear understanding by the patient 6. Given by mentally competent adult 7. Written document 8. Consent given by parent if the patient is a child Given by Clear understanding mentally Information competent by patient adult Benefits of Alternative Elements treatment treatment Consent by parent if Potential patient is child Written risks document Figure 3. Elements of informed consent Purpose of getting informed consent 1. Provide adequate information about the procedures or treatment given to the patient. 2. Allows the patient to choose the treatment of his/her choice. It is an act of respecting the patient’s right to information. 3. Helps to serve as a legal written document for the patient as well as health care providers. 48  4. Patients can take legal action if the informed consent is not signed or not given to them. 5. Helps to clear the fear and anxiety of the patient about the treatment and prognosis and mentally prepare him/her for the treatment. Barriers to effective informed consent There are many factors that affect or hinder the patient from signing the informed consent - Education level of the patient - The consciousness of the patient - The mental status of the patient (psychological status) - Religious beliefs - Language - Disability of the patient - Culture - Age Role of nurse in getting informed consent signed A nurse is the first and most important contact for a patient and plays different roles in getting the informed consent signed by the patient: 1. A nurse should recognize the purpose and need of the treatment and get the signature accordingly. 2. A nurse should read clearly the contents of the informed consent and explain it to the patient in simple language. 49  3. If the patient has any doubts, a nurse should clear them by explaining the risks and benefits of the treatment. 4. A nurse should explain the contents of the informed consent to the patient’s spouse, parent or guardian to get the signature. the responsibilities of a nurse in getting the informed consent signed by the patient: 1. Use good communication skills, maintain good interpersonal relationship, introduce, and explain the details of the consent form to the patient. 2. Get the sign of the witness with the date and time. 3. Never barrier or neglect any questions asked by the patient. 4. Use his/her skill in handling the medico-legal cases carefully, for example, rape cases, where the patients are very sensitive and find it difficult to answer the questions in the form. 5. Keep the details of the informed consent confidentially and never disclose them to anyone without the consent of the patient. 6. Act as a mediator between the doctor and the patient. A nurse clarifies all the patient’s doubts and bridges the gap between the doctor and the patient, thus helping to get the informed consent signed smoothly. 50 Reference: 1. Sole M, Klein D, Moseley M, (2020). Introduction to critical care nursing, 6th edit, London, Elsevier co. 2. Morton P, Fontaine D, Hudak C, Gallo B, (2022). Critical care nursing: Aholistic approach, 9th edit, Philadelphia, Lippincott, Williams& Wikins co. 3. Gastmans, C. (2020). "Dignity-enhancing nursing care: A foundational ethical framework". Nursing Ethics. 20 (2): 142–149. 4. Sanjari M, Zahedi F, Aala M, Peymani M, Parsapour A, Aramesh K, Maddah SSB, Cheraghi MA, Mirzabeigi GH, Larijani B. (2022). The Code of Ethics for Nurses in Iran. Iranian Journal of Medical Ethics and History of Medicine. 5(1):17–28. 5. American nurses association code of ethics (2022). 51