Nursing Ethics Past Paper 2025 - PDF

For 1 st year Nursing Students of Technical Institute of Nursing Prepared by: Dr\ Naglaa Mohamed El-sayed Assist. Prof. of Nursing Administration. Dr\ Aida Mahmoud Abdel-Azeem. Assist. Prof. of Nursing Administration. Dr\ Azza Abd Elmawgod Lecturer of Nursing Administration Dr\ Mansour Mohamed Lect...

For 1 st year Nursing Students of Technical Institute of Nursing Prepared by: Dr\ Naglaa Mohamed El-sayed Assist. Prof. of Nursing Administration. Dr\ Aida Mahmoud Abdel-Azeem. Assist. Prof. of Nursing Administration. Dr\ Azza Abd Elmawgod Lecturer of Nursing Administration Dr\ Mansour Mohamed Lecturer of Nursing Administration 1  contents No Lecture Page 1 3 Concepts to nursing ethics 2 10 Ethical Issues in nursing practice 3 19 Principles of the nursing ethics 4 24 Nursing legal responsibilities and law 5 32 Ethical responsibilities of the nurse 6 39 Code of nursing ethics 7 47 Ethical decision making in nursing practice 8 58 Ethical theories Applying ethics to nursing practice 9-1- Nurse and people 9 65 9-2-Nurses and practice 9-3-Nurses and the profession 9-4-Nurses and co-workers 2  Introduction of Nursing Ethics Objectives At the end of this lecture, each student should be able to: Identify concepts related to nursing ethics. Differentiate between law and ethics. Enumerate types of Ethics. Importance of Nursing Ethics. Conclude Factors Affecting Professional Nursing Ethics Development. Define ethical principles. List Ethical principles of nursing care. Describe of code of ethics. Enumerate fundamental responsibilities of nurses. 3 Introduction Nurses at present are facing various personal, interpersonal, professional, and 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. Responding to this complex issues demand nurses to acquire comprehensive ethical knowledge and skills in various decision making process. Studying nursing ethics is very important to be aware with ethical and legal issues in your field, differentiate between ethical and legal situation, and protect themselves from any legality. Concepts related to Ethics Ethics versus Morality Ethics is derived from the Greek word ethos, meaning custom or character. Ethics can be defined as the branch of philosophy dealing with standards of conduct and moral judgment. It refers to a method of inquiry that assists people to understand the morality of human behavior. (i.e. it is the study of morality). When used in this sense, ethics is an activity; it is a way of looking at or investigating certain issues about human behavior. Ethics refers to the practices or beliefs of a certain group (i.e. Nursing ethics, Physicians' ethics). It also refers to the expected standards as described in the group's code of professional conduct. 4  Ethics is concerned what ought to be, what is right, or wrong, good or bad. It is the base on moral reasoning and reflects set of values. It is a formal reasoning process used to determine right conduct. It is professionally and publicly stated. Inquiry or study of principles and values. It is process of questioning, and perhaps changing, one's morals.  Moral: is principles and rules of right conduct. It is private or personal. Commitment to principles and values are usually defended in daily life.  Nursing Ethics: It‟s the branch of ethics that provide professional standards for nursing for nursing activities, these standard protect both the nurse and the patient.  Bioethics The application of ethical principles in health care settings.  Ethical dilemma: A situation involving competing rules or principles that appears to have no satisfactory solution. Law and Ethics  Law  Rules of conduct  Authored & enforced by formal authorities  Hold people Accountable for compliance. 5   Difference between Law and Ethics Concepts Law Ethics Source External Internal Concerns Conduct and Motive, attitude, culture Actions Interests Society Individual Enforcements Courts, Ethics Committee and professional organizations Types of Ethics:  Descriptive: It is the description of the values and beliefs of various cultural, religious or social groups about health and illness.  Normative: A study of human activities in a broad sense in an attempt to identify human actions that are right or wrong and good and bad qualities. In nursing normative ethics addresses: scope of practice of different categories of nurses and, level of competence expected.  Analytical: Analyzes the meaning of moral terms. It seeks the reasons why these action or attitudes are either wrong or right. Importance of Nursing Ethics 1. Having a code of ethics guides nurses through difficult situations 2. Serves as a common reference point for everyone in the health care team. 6  3. But the primary goal of nursing ethics is to protect patients. Deviating from the code of ethics can lead to a breakdown in team communication and physical consequences for a patient. 4. Know scope of legal defense to our self when faced to any problem. 5. Differentiate between patient rights and responsibilities. 6. Know how to initiate and maintain a therapeutic legally and ethically relationship with our patients. Factors Affecting Professional Nursing Ethics Development Factors 1. Individual character and responsibility, 2. Communication challenges, 3. Organizational preconditions, 4. Support systems, 5. Educational and cultural development. Identify Principles and Rules of Health Care Ethics Ethical principles are defined as basis for nurse‟s decisions on consideration of consequences when making clinical judgments. 7  The major Principles of Nursing Ethics are: Principles of Nursing Ethics  Autonomy.  Justice.  Beneficence.  Paternalism.  Non-maleficence.  Respect for Persons.  Confidentiality.  Sanctity of Life.  Double Effect.  Veracity.  Code of Ethics Is formal statement of a group‟s ideas and values. higher than legal standards and they can never be less than legal standards of the profession. Shared by members of a group. Reflect their moral judgment over time. Serve as standard for their professional action. Nurses have four fundamental responsibilities:  To promote health.  To prevent illness. 8   To restore health.  To alleviate suffering. Caring in Nursing Practice  As most health care systems around the world are undergoing major administrative restructuring, we expose ourselves to the risk of dehumanizing patient care.  Changes in the health care delivery systems around the world have intensified nurses‟ responsibilities and workloads.  Nurses must now deal with patients‟ increased acuity and complexity.  Nurses must find ways to preserve their caring practice. All patients and residents have a right to:  Respect and dignity.  Privacy.  Confidentiality.  Freedom from abuse and neglect.  Know about their medical condition and treatments.  Choose their own doctors.  Make decisions about their medical care. 9  Ethical Issues in Nursing Objectives: At the end of this lecture, each student should be able to:  Describe importance of Ethics in Nursing.  Discuss Ethical Issues and ethical dilemma in Nursing  Conclude best practices to deal with ethical dilemmas in Nursing.  State Strategies for addressing ethical issues in nursing. 10 Introduction  An ethical issue in nursing is a situation in which the nurse must choose between alternatives that must be evaluated as right (ethical) or wrong (unethical). RNs need to be able to identify these ethical issues and resolve them by utilizing the appropriate resources and maintaining a professional practice. These situations may involve complex moral and legal issues that require careful consideration and resolution. Resolving ethical issues in nursing requires a comprehensive understanding of ethical principles, values, and decision-making frameworks, as well as effective communication and collaboration with other members of the healthcare team. Importance of Ethics in Nursing 1. Championing Patients: Nurses advocate for patients, ensuring they receive fair and beneficial care, especially when patients can't speak for themselves. 2. Building Trust: Ethics help nurses maintain boundaries and protect patient privacy, fostering a safe, trustful healing environment. 3. Safety First: Ethical nurses prioritize patient safety by reporting unsafe practices and following best practices to minimize errors. 4. Stronger Together: Ethical behavior promotes teamwork, open communication, and respect, leading to better patient outcomes. 5. Leading by Example: Ethical nurses inspire colleagues and future generations, fostering continuous learning and improvement for better care. 6. Public Trust: Ethical conduct builds public trust in the healthcare system, encouraging patients to seek care and participate in their treatment. 11 Ethical Issues in Nursing Nursing is a wonderful profession established on ethical principles. Nurses are supposed to follow an ethical code that governs their behavior and decision- making. Despite this, ethical difficulties in nursing continue to be a major concern. Some of the most common ethical issues in nursing are as follows: 1. Patient autonomy Patients have the freedom to make their own healthcare decisions, including refusing treatment or receiving therapy that may not be in their best interests. Nurses must respect their patients‟ autonomy and collaborate with them in order for them to make informed decisions. 2. Confidentiality Nurses have access to sensitive patient information and must preserve the privacy of their patients. This includes not disclosing patient information to anyone unless absolutely necessary for patient care. To keep confidentiality, nurse should:  Never leave paper chart/computer screen in a public place.  Discuss contents only with persons directly involved in patient‟s care or those authorized by the patient. They should be listed by name. (Don‟t assume partners have access to information)  Ask for ID prior to providing information.  Do not discuss patient or patient‟s information in public, places, elevators, cafeteria, or at parties.  Don‟t view patient‟s information not in your care: family; friends; celebrities and etc. 3. Informed Consent Nurses must ensure that patients receive all of the information they need to make informed decisions about their care. This includes informing the patient about the risks and advantages of treatment alternatives and getting informed consent. 12  4. Resource Allocation Nurses may have to make difficult decisions regarding how to allocate limited resources such as medications, equipment, and staff time. They must balance the requirements of individual patients with the needs of the broader healthcare system. 5. Discrimination Nurses must treat all patients equally, regardless of color, gender, sexual orientation, or other personal traits. They must also fight to eliminate discrimination in healthcare and advocate for all patients‟ rights. 6. Conflict of interest Nurses must avoid circumstances in which their personal interests or relationships may conflict with their professional responsibilities. Avoiding conflicts of interest with patients, colleagues, or employers is part of this. Types of ethical issues:  Moral / Ethical dilemma: two or more clear principles apply but they support inconsistent courses of action.  Moral uncertainty / Conflict: when the nurse is unsure which moral principle to apply, or even the problem is. Common with new nurses.  Moral distress: when the nurse knows the right thing to do but organizational constraints keep them from doing it.  Moral outrage: an individual witnesses an immoral act by another but feels powerless to stop it. 13 Ethical Dilemma in Nursing An ethical dilemma is a situation in which ethical principles conflict or when there is no one clear course of action in a given situation. For example, the client who refuses medication or treatment is allowed to do so based on the principle of autonomy. If the client presents an imminent threat of danger to self or others, however, the principle of non-maleficence (do no harm) is at risk. To protect the client or others from harm, the client may be involuntarily committed to a hospital, even though some may argue that this action violates his or her right to autonomy. In this example, the utilitarian theory of doing the greatest good for the greatest number (involuntary commitment) overrides the individual client‟s autonomy (right to refuse treatment). Ethical dilemmas are often complicated and charged with emotion, making it difficult to arrive at fair or “right” decisions. The following are some other examples of common ethical dilemma that nurse managers face:  Another ethical dilemma in nursing is resource allocation. When faced with limited resources, such as medications or equipment, nurses must decide how to share these resources in a fair and equitable manner. When there is a lack of life-saving medication or equipment, for example, a nurse may need to determine which patient to prioritize.  Honesty vs. withholding information. Family members may want to withhold medical information from sick patients to protect their emotions. However, patients have the right to know about their medical conditions. Deciding how to share this information, especially if it goes against the family‟s beliefs, can be a touchy situation. ANA advocates for truth telling, or veracity, as a key factor in nurse-patient relationships. 14 Honesty in nursing: Honesty is more than just telling the truth. It involves a willingness to diligently dig for truth in a rational, methodological way and having the ability to place emphasis on resolve and action, to achieve a just society. There are many ways that nurses can portray honesty. Honesty is also about being honest with oneself. Honesty means being forthright, truthful, and not deceptive. Without honesty there can be no relationship. Telling the truth in nursing: Truthfulness is "not only what we say but, more importantly, how we say it" it is based on the principle of veracity, which means that nurses are ethically obligated to tell the truth and not intentionally deceive or mislead patients. The importance of truth-telling: Trust For the health care system to work accurately and efficiently trust must exist among all persons and agencies involved; trust simplifies human life by endowing some expectations with assurance. Thus, trust is the unrestricted certainty that another (person, agency, or even inanimate object) will perform as expected. Patients should be able to trust that their health care providers are competent and will act to promote the patients' best interest. Nurses must also trust that the patient will be truthful and fulfill his or her responsibilities. The nurse's ability to remove harm and promote good for a patient rests on the nurse's ability to trust in the data provided by the patient in addition to the patient's ability to keep promises and fulfill responsibilities. Ethical issues involving the perception of noncompliance can occur when patients are unable to 15  maintain or implement their portion of the health care plan. Additionally, the patient could experience harm from unnecessary or omitted interventions if the information he or she disclosed is inaccurate or incomplete. Trust relationships are also forged between health care agencies and their employees. When hiring nurses, the health care agency trusts that the nurse will come to work as scheduled and will carry out the responsibilities of the assigned role. Persons and agencies must trust in the actions of inanimate objects. On daily basis, nurses trust that intravenous devices will deliver fluids and medications at the correct rate that label bottles contain the identified substance. Rational is support of truth-telling 1- There is an ethical presumption that lying is wrong. Thus lying should be avoided because it diminishes the social trust within a community, group, or relationship. 2- People desire to be autonomous in their decision-making, and complete, accurate information is needed before an informed decision can be made. 3- The communication of truthful information creates greater long-term benefits than harms. 4- Lies and deception can require a lot of emotional energy to maintain. Once a lie is told, the liar must remember not only the truth, but also the details of the lie so as not to get caught in it later. 5- The risk of having the lie accidentally exposed increases with the number of people involved and the complexity of the situation. Rational to justify lying:  Preventing harm.  Promoting good. 16  Moral quality of the person being told the lie  The truth is not desired or welcomed.  Communicating bad news. ANA code of ethics explains: “Using ethical principles to arrive at a solution should be done in an atmosphere of caring, respect, openness, and honesty. This process should be based on a sound ethical, decision-making model, using the best evidence-based-practice guidelines available.” How to Deal With Ethical Dilemmas in Nursing Nurses undergo many years of education and clinical training before they can become certified nurses, and yet, dealing with real ethical issues in nursing can be far more complex than solving hypothetical issues in textbooks. Nurses can learn how to deal with ethical dilemmas in the workplace through gaining experience and interacting with patients over time. Although nurses have great levels of empathy, it can benefit them to establish professional boundaries with each of their patients at the outset of their careers. Whenever nurses struggle to identify whether something is ethical, they can review the ANA Code of Ethics. Nurses can also benefit by surrounding themselves with well-seasoned nurses as well as experienced nurse managers. They can rely on the guidance of nurse managers when it comes to situations they may not know how to address. Nurse managers can cultivate educational environments; in which they regularly discuss ethical issues with the nurses in their units. By having open dialogues about ethical issues, nurses can learn from the mistakes others have made and learn how to approach ethical issues and challenges. 17 The impact of ethical problems on nurses and patients: Both nurses and patients can suffer as a result of ethical issues. Ethical issues can lead to stress, fatigue, dissatisfaction, irritation, wrath, guilt, humiliation, anxiety, depression, or even PTSD in nurses. Patient‟s quality of life, dignity, autonomy, well-being, trust, and contentment with care can all be impacted by ethical dilemmas. Strategies for addressing ethical issues in nursing Best practices are evidence-based guidelines that assist nurses in improving their ethical performance.  Following the ANA Code of Ethics for Nurses,  Seeking continual ethics education,  Creating an environment where nurses can speak up,  Bringing diverse disciplines together,  Providing ethics experts and adding unit-based ethics mentors,  Employing clinical ethics consultation services,  Participating in ethics committees,  Documenting ethical issues,  Implementing ethical concepts and frameworks are some best practices. 18  PRINCIPLES OF NURSING ETHICS Introduction o Ethics deals with the “rightness” or “wrongness” of human behavior o Concerned with the motivation behind the behavior o Bioethics is the application of these principles to life-and-death issues Ethical Principles o Autonomy o Justice o Beneficence o Paternalism o Non maleficence o Respect for Persons o Confidentiality o Sanctity of Life o Double Effect o Veracity o Fidelity o Accountability Autonomy is o The promotion of independent choice. o Self-determination and freedom of action. o The basis for the client's right to self-determination. o It means clients are entitled to make decision about what will happen to their body. The term autonomy implies for basic elements The autonomous person is respected. The autonomous person must be able to determine personal goals. The goals may be explicit or may be less well defined.  The autonomous person has the capacity to decide on a plan of action. The person must be able to understand the meaning of the choice to be made and 19  deliberate on the various options, while understanding the implications of possible outcomes. The autonomous person has the freedom to act upon the choices. Beneficence Beneficence is doing or promoting good. This principle is the basis for all health care providers. Nurses take beneficent actions when they administer pain medication, perform a dressing to promote wound healing or providing emotional support to a client who is anxious or depressed. The principle of beneficence has three components:  Promote good.  Prevent harm.  Remove evil or harm. Non-maleficence o Requires that no harm be caused to an individual, either unintentionally or deliberately o This principle requires nurses to protect individuals who are unable to protect themselves Confidentiality o Anything stated to nurses or health-care providers by patients must remain confidential o The only times this principle may be violated are: o If patients may indicate harm to themselves or others o If the patient gives permission for the information to be shared 20  o Keep privileged information private o Exceptions  Protecting one person‟s privacy harms another or threatens social good (direct threat to another person)  Drug abuse in employees, elder and child abuse Double Effect o Some actions can be morally justified even though consequences may be a mixture of good and evil o Must meet 4 criteria:  The action itself is morally good or neutral  The agent intends the good effect and not the evil (the evil may be foreseen but not intended)  The good is not achieved by the evil  There is no favorable balance of good over evil Fidelity o The promise to fulfill all commitments o The basis of accountability o Includes the professionals‟ faithfulness or loyalty to agreements & responsibilities accepted as part of the practice of the profession o Duty to be faithful to one‟s commitments o includes implicit and explicit promises  Implicit – those promises that are implied, not verbally communicated – Like when patient comes into the hospital, they expect to be cared for  Explicit – those that we verbally communicate 21  – Like if you tell them you‟ll be back with pain meds, you‟d better come back Justice o Every individual must be treated equally o This requires nurses to be nonjudgmental o Seeks fairness o justice refers to distribution of benefits and burdens Paternalism o When one individual assumes the right to make decisions for another o Limits freedom of choice o Think about parents making decisions for children o Ex. Suppression pertinent information from a pt. Like elderly diagnosed with terminal cancer, and family asks to not tell them that it‟s terminal so they will still be motivated to fight Respect for Persons o Closely tied to autonomy o Promotes ability of individuals to make autonomous choices and should be treated accordingly o Autonomy is preserved thru advanced directives. Sanctity of Life o Life is the highest good o All forms of life, including mere biologic existence, should take precedence over external criteria for judging quality of life o If life is the highest good, is it ethical to keep a brain dead person alive? Veracity 22  o This principle implies “truthfulness” o Nurses need to be truthful to their clients o Veracity is an important component of building trusting relationships Accountability o Individuals need to be responsible for their own actions o Nurses are accountable to themselves and to their colleagues 23  NURSING LEGAL RESPONSIBILITIES AND LAW Objectives: To have knowledge of the nursing legal responsibilities and law Introduction According to the nursing code of ethics the legal responsibilities of professional nurse towards; Client, Profession, Society and herself/himself, legal responsibilities toward client. Patient Bill of rights: The following are patient's rights which nurses have a responsibility to uphold: o Considerable and respectful care. o Information regarding one's diagnosis, treatment and progress. o Information necessary to give informed consent to any procedure. o Refusal of treatment to the extent permitted by law. o Privacy concerning one's own medical care. o Confidentiality in all communication and records relating to one's own care. o Rescannable responses to request for service o Information concerning other health care and educational institution related to one's own care. 24 o Information as to hospital plans to perform human experimentations affecting one's own care and refusal to participate in some. o Reasonable continuity of care o Explanation of one's hospital bill. o Knowledge of what hospital rules and regulation apply to one's conduct as a patient Informed consent Nurses must be aware of all policies regarding patient's consent for any treatment, special procedures, or operation. Informing the patient about a medical procedure is the physician's responsibility, but frequently the nurse is asked to get the operative permit signed. The nurse must make certain that the patient knows the nature of the procedure. If the patient seems not to understand, the nurse should notify the physician and not allow the patient to sign the consent form until the procedure is fully understood. It is essential that the nurse chart what is done and done and who is notified is this situation. I- Legal aspects: Patient's records Medical records can be used as a legal document therefore it should be complete, neat, concise, and accurate in terminology. On writing nursing notes, the nurse should consider: o Note should be simple, direct and clearly understood. o Avoid abbreviations that are not universally standard 25 o Should be in ink. o Signed by full name. o Never write the name of another and never sign for her o Always write nursing note before going off duty o It should include factual observations and not to report value judgment and opinions or conclusion. Example: in observing condition of arm after cast she should not chart "cast too tight" fingers uncomfortable. Rather she should chart " fingers blue and cold:" Drugs and Medication: The nurse must be aware of the law regarding possession, manufacture, distribution and prescription of medication with a special reference to narcotics. Usually qualified nurse is the one to administer drugs. She has to recognize while administering medication. (Five rights - Nature of drug - Average dose – side effect). She should not prescribe medication to itself, family or friend. The nurse should also be aware of handling narcotics in narcotic record She should never administer narcotics unless prescribed by a licensed doctor or dentist. Doctor order:  The nurse should follow, written order only  Telephone orders should be limited to true emergency situations.  The nurse accepting telephone order should read it back to the physician and he should sign it on his next visit 26 Forms of illegal practice A- Negligence: It is the failure to perform one's duty in a manner expected by a similar nurse in similar circumstances. Examples of negligence:  Hot water bottle burned feet of patient  Foreign objects left in patient  Falls  Wrong medication or dose on route 5 R's  Delay in obtaining help  Failure to communicate  Nosocomial infection  Does not carry out sterile technique when changing a patient dressing  Neglect to notify the head nurse or the doctor of a sudden change in a patient's condition. B- Malpractice It is a professional negligence It is any professional misconduct, unreasonable lack of skills in performing professional duties. Malpractice is the neglect of physician or nurses to apply that degree of skill and learning in treatment and nursing a patient which is customarily applied in treating and caring for the sick or wounded similarly suffering in the same community. 27  Types of Law Criminal Laws Felony ‫ جنايه‬- ‫( جريمه‬: An act punishable by death or greater than one year imprisonment. Examples: murder, failure to report child abuse, fraud in business records, patient abuse and neglect, stealing, selling or using illegal drugs. Example: Violation ‫ خرق‬-‫ انتهاك‬of a State Practice Act: A nurse caring for a patient notices a change in the patient's condition & believes she knows the appropriate medication the patient needs. She tries to contact the patient's doctor but is unable to reach him. She writes the order although she has no standing orders to follow and proceeds to administer the medication. Violation: criminal and/or civil. Example: Violation of Narcotic Laws: While doing a narcotic check at the end of her shift, the nurse notices the count is short one controlled analgesic. She finds a patient whose PRN orders allow them to have that med for pain, notice they haven't had any in a long time, and signs the missing dose out to that patient who in reality did not receive that dose. Violation: criminal and/or civil. Misdemeanor ( ‫(جرم تطبق علي عقىب‬: Any other crime. 28 Categories of Civil laws: Intentional Torts ‫او ممتل ها‬ ‫اذي مقصىد او غير مقصهىد يلقهق رهرش ب هو‬: Acts in which the outcome was planned although the person may not have expected the outcome to harm the other person. Types of intentional torts are:  Assault ‫ تهجم و وتدمءو‬to threaten or attempt to touch a person without consent. Example: Patient's orders call for IM injection. Patient refuses to be given the injection & nurse tells patient she IS going to give the shot anyway.  Battery: Touching without consent (Treating without consent)  False Imprisonment: Unwarranted ‫ غيم مؤم‬- ‫ المبم ل م‬use of restraints or restrictions. Quasi-intentional Torts: Injury to economics and dignity. Types of quasi-intentional torts are:  Invasion of Privacy: e.g. breach of confidentiality, photographing patients without their consent.  Defamation of Character: Slander ‫ تش ي و ؤمع‬or libel ‫قذف و تش ي‬  Example: Talking about a patient to another health care provider in the elevator with other people present; disclosing patient information over the telephone; telling stories about a fellow coworker. Unintentional Torts: Acts in which the outcome was not intended to happen. 29 Types of unintentional torts are:  Negligence: the failure to act as a reasonably prudent person would have acted in a specific situation. (Applies to ALL people, even unlicensed caregivers)  Malpractice: The failure of a professional to use such care as a reasonably prudent member of the profession would use under similar circumstances, which leads to harm. (Applies ONLY to professionals such as licensed nurses. Nurses can be held both negligent and guilty of malpractice.)  Example of negligence: A door to door magazine salesman is leaving your home after you listen to his pitch and he trips on the broken wooden plank of your steps, (you know-the ones you were going to get around to fixing). He breaks his nose when landing on his face on your sidewalk. You are liable for this injury because you failed to repair the steps, provide a warning sign to indicate the problem, etc.  Example of malpractice: A nurse administering medications gives the patient in room 101 the meds that were on the MAR of the patient in room 202. She fails to double check the room number, the patient's name or ID bracelet. After administering the wrong medicines to the wrong patient the nurse continues on her rounds. The patient in room 101 is allergic to one of the medicines she just administered, goes into shock, has to be coded, became vent-dependent & is now on a ventilator for the rest of his life.... 30 In order to prove that negligence or malpractice has occurred, four circumstances must be present and must be proven in a court of law. These circumstances are: 1. Harm must have occurred to the individual. 2. One person must be in a situation where s/he had a duty toward the person harmed. 3. The person must be found to have failed to fulfill his or her duty. 4. The harm must be shown to have been caused by the breach of duty. 31  ETHICAL RESPONSIBILITIES OF THE NURSE Objectives: At the end of this lecture student will be able to:  Know definition of term responsibility, ethical responsibility  Enumerate items of ethical responsibility Outlines  Introduction  Definitions of responsibility and ethical responsibility  Importance of ethical responsibility of nurse  Main ethical responsibility of nurse 32 Introduction Nurses face increasingly complex ethical issues and challenges in today's workplaces. They recognize the mutuality between environment that cultivate ethical practice and the provision of high quality patient centered care. So understanding there ethical responsibility is main importance. Definitions  Ethics: Comes from Greek word ethos which means moral character. In simple terms, ethics means knowing the differences between right and wrong and continuing to do the right thing.  Responsibility: is something you are required to do as an upstanding member of a community  Ethical responsibility: Is the ability to recognize, interpret and act upon multiple principles and values according to the standards within a given field and or context. The International Council of Nurses' Code of Ethics for Nurses (2000) indicates that nurses have four fundamental responsibilities: Promote health prevent illness Restore health Alleviate suffering Promoting health The nurse's responsibility is to promote health is related to the basic right to health long recognized as one of the basic human rights of every person. The right to health is recognized by implementing such public health measures as sanitation and water supply regulations to control the spread of disease. These measures protect the right to not have one's health endangered by the actions of others. Governments recognize this right by enacting laws to prevent the actions of some 33 persons from impairing the health of other persons. All societies expect their leaders and governing bodies to initiate and enforce these laws to promote the health of individuals and society at large. Other rights enable citizens to obtain certain healthcare services or community resources. For example, government sponsored programs of childhood immunizations, food provision, medical care, even education and housing recognize children's rights to health. A pregnant woman's right to health may be protected by subsidized programs for prenatal care, labor and delivery care and even postpartum care. The right to healthcare is a right to goods and services that will maintain or improve an individual's existing state of health These services may range from child care and immunizations to home healthcare, nursing homes for the elderly and, in more developed countries, to such costly, high tech sophisticated procedures as kidney dialysis and organ transplants. Nurses promote the right to health and the right to healthcare by promoting the health of individuals and groups. The ICN Position Statement, Health Care and Quality of Life, (1986) indicates that nurses are primary advocates of the rights of all people to health and healthcare services, and that the focus of healthcare is the individual or group in need of services for health promotion. Nursing responsibility to promote the health of individuals, groups and communities, is built upon the ethical concept of advocacy. Health promoting actions by the nurse are clearly supported by the ethical principles of autonomy (the duty to respect self-determined choices), and beneficence and non-maleficence (the duties to do good and avoid harm). However, ethical issues often arise when carrying out these responsibilities. 34  Nurses carry out a fundamental responsibility to the patient when they promote health. This is an ethical responsibility that takes on additional meaning within the context of specific patient care situations. Providing contraceptive information to a patient whose religious beliefs forbid their use tests the meaning of promoting health. The promotion of health requires the nurse to make an ethical judgment about the measures required for each patient's health. Each patient situation has cultural, social and political dimensions that make the nurse's ethical responsibility to promote health a challenging endeavor. Preventing illness Prevention of illness is one of the most fundamental ethical responsibilities of all healthcare workers. In nursing practice, preventing illness is supported by the ethical concepts of advocacy and caring. As with promoting health, the responsibility is supported by the ethical principles of beneficence and non- maleficence especially the obligation to prevent or avoid harm. Nurses are obliged to prevent harm to people and protect them from experiencing illness and its effects whenever possible. In carrying out this responsibility, the nurse may encounter questions about how far one should go in preventing illness and whether the obligation to prevent illness can override the obligation to respect individual rights to self-determination. 35 Restoring health Restoring the health of patients has been a major focus of nursing practice throughout the world for many years. As various healthcare personnel enter and exit the patient's world, nurses provide continuity, a touchstone for patient and family in the midst of change and crisis. Nurses of care, therefore, play key roles in restoring health, roles supported by the ethical concepts of advocacy, caring and cooperation. They are often responsible for establishing a milieu where the patient's values, customs and spiritual beliefs can be fully utilized to restore his or her health. The ethical responsibility to restore health often creates values conflicts in nursing care. Patients' religious and cultural values often impinge on the nurse's values such as promoting good and treating all patients equally. When delivering nursing care in a foreign country or in a very different cultural environment, nurses need to work within the cultural belief system of that country or environment in order to fulfill ethical responsibilities in nursing. When technological developments and innovative treatments are unavailable, or perhaps even prohibited for political and/or cultural reasons, nurses may need to reinterpret what the ethical responsibility to restore health means within that system. Alleviating suffering All professional codes of nursing ethics refer to the role of the nurse in alleviating the suffering of patients. Relief of suffering is fundamental to the nursing role and often includes caring behaviors. These behaviors protect the 36 human dignity of the patient and promote patient good. They are carried out within the nurse-patient interaction and in the context of a situation. Moral reasons for caring nurse behaviors include concern for how the patient is experiencing his or her world and concern for human need. Supported by the ethical principle fidelity, the obligation to remain faithful to one's commitments, alleviating suffering is another aspect of the fundamental responsibility of the nurse. An ethical question that often arises with this responsibility is the sometimes difficult differentiation between alleviating suffering and assisting death in terminally ill and dying patients. Easing the suffering of a chronically ill patient who is not terminal or near death may not pose ethical questions for the nurse. However, when faced with the suffering of a terminally ill patient, nurses may experience ethical conflict between their responsibility to alleviate patient suffering and the moral obligation not to take human life. The responsibility to alleviate suffering should also be extended to nurses caring for those who are escaping armed conflict in their home countries or who have become political refugees. These persons often represent a challenge to nursing care because much of their suffering is emotional and psychological. They have often witnessed the destruction of their homes, their communities and their family members. Their suffering may follow cultural patterns unfamiliar to nurses working with relief services and to those from other cultures. The realities of everyday nursing practice often force the nurse to seriously reconsider his or her ethical responsibilities. While the professionally mandated ethical responsibility to alleviate suffering is clear, acting on this responsibility may not be easy when the patient is terminally ill, elderly or recovering from an 37 unusual and tragic human event. People experience human suffering in different degrees and with different abilities to deal with their suffering. The nurse's responsibility to alleviate suffering means that the nurse must carefully assess the physical and mental suffering of any patient and carefully gauge the patient's internal resources for coping with suffering. Nursing care to alleviate the patient's suffering will then be specific to the individual and the type of suffering experienced. 38  Code of Nursing Ethics Objectives Up on completing this lecture the students will be able to:  Define nursing code of ethics  List purposes to develop code of ethics  Understand elements of code of ethics according to ICN  Identify provisions of nursing code of ethics according to ANA  Outlines:  Introduction  Definitions  Purposes of code of nursing ethics  Elements of code of ethics according to ICN  Provisions of the code of ethics for nurses according to ANA 39 Introduction Ethics is an integral part of the foundation of nursing. Nursing has concern for the welfare of the sick, injured, and vulnerable and for social justice. Individuals who become nurses are expected to adhere to the ideals and moral norms of the profession. A code of ethics makes explicit the primary goals, values, and obligations of the profession Definitions  Code of ethics is formal statement of a group‟s ideas and values that serve as a standards and guidelines for the groups‟ professional actions and informs the public of its commitment. Codes of ethics are usually higher than legal standards, and they can never be less than legal standards of the profession. OR:  Code is a statement of the ethical values of nurses and of nurses‟ commitments to persons with health-care needs and persons receiving care. The Code is both aspirational and regulatory. It is an aspirational document designed to inform everyone about the ethical values and subsequent responsibilities and endeavors of nurses. It is also a regulatory tool. Purpose of code of nursing ethics The Code of ethics for nurses serves the following purposes:  To inform the public about the minimum standards of profession and to help them understand professional nursing conduct. 40   To provide a sign of the profession‟s commitments to the public it serves.  To outline the major ethical considerations of the profession.  To provide general guidelines for professional behavior.  To guide the profession in self-regulation  To remind nurses of the special responsibility they assume when caring for the sick. Elements of the Code The need for nursing is universal. Inherent in nursing is respect for life, dignity, and rights of man. It is unrestricted by considerations of nationality, race, creed, color, age, sex, politics or social status. Nurses render health services to the individual, the family, and the community and coordinate their services with those of related groups. The Code of Ethics for Nurses is a dynamic document. As nursing and its social context change, changes to the Code are also necessary. The Code of Ethics for Nurses consists of two components: the provisions and the accompanying interpretive statements. There are nine provisions that contain an intrinsic relational motif: nurse to patient, nurse to nurse, nurse to self, nurse to others, nurse to profession, and nurse and nursing to society. The first three provisions describe the most fundamental values and commitments of the nurse; the next three address boundaries of duty and loyalty; the last three address aspects of duties beyond individual patient encounters. 41  Each provision is accompanied by interpretive statements that provide greater specificity for practice and are responsive to the contemporary context of nursing. Consequently, the interpretive statements are subject to more frequent revision than are the provisions. Additional ethical guidance and details can be found in the position or policy statements of the ANA or its constituent member associations and affiliate organizations that address clinical, research, administrative, educational, public policy, or global and environmental health issues. Provision 1 The nurse practices with compassion and respect for the inherent dignity, worth, and personal attributes of every person, without prejudice. 1.1 Respect for human dignity 1.2 Relationships to patients 1.3 The nature of health 1.4 The right to self-determination 1.5 Relationships with colleagues and others Provision 2 The nurse‟s primary commitment is to the patient, whether an individual, family, group, community, or population. 2.1 Primacy of the patient's interests 42  2.2 Conflict of interest for nurses 2.3 Collaboration 2.4 Professional boundaries Provision 3 The nurse promotes, advocates for, and protects the rights, health and safety of the patient. 3.1 Protection of the rights of privacy and confidentiality 3.2 Protection of human participants in research 3.3 Performance standards and review mechanisms 3.4 Professional competence in nursing practice 3.5 Protecting patient health and safety by action on questionable practice 3.6 Patient protection and impaired practice Provision 4 The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to provide optimal care. 4.1 Authority, accountability, and responsibility 4.2 Accountability for nursing judgment, decisions, and action 4.3 Responsibility for nursing judgment, decisions, and action 43  4.4 Delegation of nursing activities or tasks Provision 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. 5.1 Duty to self and others 5.2 Promotion of personal health, safety, and well-being 5.3 Wholeness of character 5.4 Preservation of integrity 5.5 Maintenance of competence and professional growth 5.6 Personal growth Provision 6 The nurse, through individual and collective action, establishes, maintains, and improves the moral environment of the work setting and the conditions of employment, conducive to quality health care. 6.1 The environment and moral virtue and values 6.2 The environment and ethical obligation 6.3 Responsibility for the healthcare environment 44 Provision 7 The nurse, whether in research, practice, education, or administration, contributes to the advancement of the profession through research and scholarly inquiry, professional standards development, and generation of nursing and health policies. 7.1 Contributions through research and scholarly inquiry 7.2 Contributions through developing maintaining, and implementing professional practice standards 7.3 Contributions through nursing and health policy development. Provision 8 The nurse collaborates with other health professionals and the public to protect and promote human rights, health diplomacy, and health initiatives. 8.1 Health is a universal right 8.2 Collaboration for health, human rights, and health diplomacy 8.3 Obligation to advance health and human rights 8.4 Collaboration for human rights in complex and extraordinary practice settings Provision 9 The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. 45 9.1 Articulation of values 9.2 Integrity of the profession 9.3 Integrating social justice 9.4 Social justice in nursing and health policy 46  Ethical Decision Making in Nursing Practice Objectives At the end of this lecture students will be able to:-  Define dilemma, ethical decision and decision making  Enumerate factors affecting ethical decision  List steps of ethical decision making process  Understand models for ethical decision-making 47 Outlines:  Introduction  Definitions of dilemma, decision, ethical decision and decision making  Factor affecting ethical decision  Steps of ethical decision making process  Models for ethical decision-making 48 Introduction In health care and nursing practice, moral matters are so prevalent that nurses often do not even realize they are faced with minute-to-minute opportunities to make ethical decisions (Chambliss, 1996; Kelly, 2000). It is vitally important that nurses have the analytical thinking ability and skills to respond to many of the everyday decisions that must be made. Ethical dilemmas in health care involve issues surrounding professional actions and client care decisions. They can lead to discomfort and conflict among the members of the health care team or between the providers and the client and family. Definitions A dilemma: is a situation in which two or more choices are available. It is difficult to determine which choice is best and the needs of all these involved cannot be solved by the available alternatives. Decision: Making a choice from two or more alternatives. Decision making: Is a systematic, sequential process of choosing among alternatives and putting the choice into action. Ethical Decision: is one where we choose how to respond to a given situation based on values of “good/right” and “bad/wrong”, as opposed to mere expediency or efficiency. 49 Factors affecting ethical decision making: 1. Personal values 2. Professional values 3. Competencies 4. Ethical principles 5. Ethical theories and approaches are variables to consider when a moral decision is made. Pondering the questions, “What is the right thing to do?” and “What ought I do in this circumstance?” are ever-present normative considerations in nursing. Ethical decision making process 1. Identify the Ethical Problem The decision maker must be able to determine: 50   If there is a possible violation of an important ethical principle, societal law, or organizational standard or policy  If there are potential consequences that should be sought or avoided that emanate from an action being considered to resolve the problem. 2. Collect Relevant Information  The decision maker should seek to gather as much information as possible about which rights are being forsaken and to what degree.  A consequential focus would prompt the decision maker to attempt to measure the type, degree, and amount of harm being inflicted or that will be inflicted on others. 3. Evaluate the Information  Once the information has been collected, the decision maker must apply some type of standard or assessment criterion to evaluate the situation.  The decision maker might use one of the predominant ethics theories utilitarianism, rights, or justice. 4. Consider Alternatives The decision maker needs to generate a set of possible action alternatives, such as:  confronting another person‟s actions,  seeking a higher authority, or stepping in and changing the direction of what is happening 5. Make a Decision  The decision maker should seek the action alternative that is supported by the evaluation criteria used in Step 3. 51   A decision maker selects a course of action that is supported by all the ethics theories or other evaluation criteria used in the decision- making process. 6. Act or Implement  The decision maker, if truly seeking to resolve the problem being considered, must take action.  Once the action alternatives have been identified in Step 4 and the optimal response is selected in Step 5, the action is taken in Step 6. 7. Review the Action  Once the action has been taken and the results are known, the decision maker should review the consequences of the action.  If the optimal resolution to the problem is not achieved, the decision maker may need to modify the actions being taken or return to the beginning of the decision-making process The ethical decision-making process applies three predominant ethics theories: 1. Utilitarian perspective  Distinguishes good from bad.  Emphasis on the consequences of actions.  Produce greatest happiness for the greatest number.  Requires some sacrificed 2. Deontological perspective  Distinguish right from wrong.  Emphasize adherence to duty. 52   Determined by intentions you right action is must consider the rights of others when you act). 3. Justice perspective Models for ethical decision-making Ethical issues are real life issues. There is no one way of resolving such situations. Each situation will be different, depending on the people involved. There are a number of models from which to choose from, but there is no one best way to approach ethical decision-making. Ethical decision making models are not formulas and they do not ensure that the decision you take will be the right one. Model I: A Guide to Moral Decision-Making It outlines a step-by step process that considers the many aspects of ethical decision-making: 1. Recognizing the moral dimension  Is recognizing the decision as one that has moral importance  Important clues include conflicts between two or more values or ideals  Consider here the levels of ethical guidance of the code of Ethics for registered nurses. 2. Who are the interested parties? What are their relationships?  Carefully Identify who has a stake in the decision in this regard, be imaginative and sympathetic  Often there are more parties whose interests should be taken in to consideration than is immediately obvious.  Look at the relationships between the parties look at their relationship with yourself and with each other, and with relevant institutions 53 3. What values are involved?  Think through the shared values that are at stake in making this decision.  Is there a question of trust? Is personal autonomy a consideration? Is there a question of fairness? Is anyone harmed or helped?  Consider your own and others personal values & ethical principles 4. Weight the benefits and burdens  Benefits might include such things as the production of goods (physical, emotional, financial, and social). 5. Look for analogous cases  Can you think of similar decisions? What course of action was taken? Was it a good one? How is the present case like that one? How is it different? 6. Discuss with relevant other  The merit of discussion should not be underestimated. Time permitting discusses your decision with as many people as have a take in it. 7. Does this decision according with legal and organizational rules.  Some decisions are appropriately based on legal considerations. If an option is illegal, one should think very carefully before thanking that option 8. Am I comfortable with this decision? Question to reflect up on include:  If I Cary out this decision, would I be comfortable telling my family about it?  Would I want my children to take my behavior as an example?  Is this decision one that a wise, informed, virtuous person would make?  Can I live with this decision? 54 Model 2: Clinical Ethics Grid System This grid system helps construct a summary of the facts that must be considered along with ethical principles to guide ethical decisions in a clinical setting out lined as follows. 1. Medical indications:  What is the patient medical problem, history, diagnosis?  Is the problem acute, chronic, critical, emergent, and reversible?  What are the goals of treatment? 2. Patient preference:  What has the patient experienced about preferences for treatment?  Has the patient been informed of benefits and risk, understood, and given consent? 3. Quality of life:  What are the prospects with or without treatment, for a return to the patient's normal life?  Are there biases that might prejudice the provider's evaluation of a patient's quality of life? 4. Contextual factors:  Are there family issues that might influence treatment decisions? 55  Obstacles of decision making  Poor moral awareness: - can either result in a failure to perceive the problem as being an ethical problem at all.  Failure to gather relevant facts: good practical decisions require that we know important facts relevant to the decision, such as those that help us determine the likely impact of the action on stakeholders.  Rationalizing ourselves out of good moral decision-making: it‟s easy to convince ourselves that we can do what we‟d like. The following are poor, but unfortunately all too common, rationalizations we use to excuse our action: - It‟s just part of the job - If it‟s legal, then it‟s moral - It doesn‟t hurt anyone - Everyone‟s doing it  Slippery Slope: - people are willing to do unethical things because they have already done smaller, less extreme acts that make the bigger choice appear less (or not at all) unethical.  Confirmation bias: - is the tendency to notice and remember evidence that supports our beliefs and to ignore evidence that contradicts them. So when we are making decisions and problem solving, we have a tendency to make evidence fit our desired outcome. Thus when we are looking to make decisions, we need to be aware of our biases, likes, and dislikes and be open and honest with ourselves and the evidence that we find.  Not Weighing Consequences: - Sometimes we see a solution or decision that we really like and we will commit and jump in before we consider how that solution or decision will impact others‟ lives,. Thus it is important to 56 flesh out the decisions and solutions to see how they will ultimately impact others‟ lives. 57  Ethical Theories Introduction Ethical theories may be compared to lenses that help us to view an ethical problem. Different theories can be useful because they allow us to bring different perspectives in to our ethical discussions or deliberations. There are four ethical theories: 1.Teleology (utilitarian or end based theory) 2. Deontology theory 3. Intuitionism theory 4. The ethic of caring theory 1. Teleology (utilitarian or end based theory) Utilitarianism is a widely adopted moral theory that is the best known example of consequentialism, a class of moral theories that are solely concerned about the consequences of our actions whether they bring about the desired results. In effect, the end justifies the means. In utilitarianism, morally good actions are those that bring about an increase in states such as pleasure, happiness or wellbeing, known as „utility‟. Actions are not regarded as good in themselves, but good only so far as they increase „utility‟. An act is considered right if it brings about more pleasure than pain, and wrong if it produces more pain than pleasure. Morally right acts are those that maximize (increase) utility and maximize it for everyone, not just individuals. This is often expressed as „the greatest happiness for the greatest number‟. 58  One attraction of utilitarianism is its simplicity. As a single principle to guide our actions, it can potentially answer any moral question. It also seems to get to the heart of what we feel morality should be about promoting human flourishing (meaning living well) and avoiding suffering. The NHS, for instance, could be said to operate under utilitarian principles, because it intends to use its resources to produce the greatest benefit for the greatest number of people. There are, however, at least two major problems with utilitarianism. One is the difficulty in calculating the maximum utility for a given action. For example, it is not clear whether it is better for one individual to have a significant increase in happiness, or for many individuals to have a small increase in happiness. It is also difficult to foresee the consequences for a particular action and the consequences we expect do not always happen. Utilitarian Perspective: Where the decision maker considers the consequences or out-comes of an action and seeks to maximize the greatest good for the greatest number of those affected by the decision. This theory looks to the consequences of an action in judging whether that action is right or wrong. According to the utilitarian school of thought right action is that which has greatest utility or usefulness. Utilitarian hold that no action in itself is good or bad, the only factors that make actions good or bad are the outcomes, or end results that are derived from them. 59 Types of Utilitarian Theories a. Act utilitarianism: suggests that people choose actions that will in any given circumstances increase the over all-good. b. Rule utilitarianism: suggests that people choose rules that when followed consistently will maximize the overall good 2. Deontology (Duty or rule-Based theory) In utilitarianism, the moral rightness of an action is determined solely by its consequences. Deontology, by contrast, is concerned with certain features of an action itself. The end is never justified by the means; „some choices cannot be justified by their effects that no matter how morally good their consequences, some choices are morally forbidden‟ Deontological systems are built on the belief that there are certain duties, or rules, that are intrinsically good and must be followed to act morally. There are also certain actions that are intrinsically wrong, and these must be refrained from, even if it can be foreseen that they will result in good, or if refusing to do them will result in harm. Doing the right thing takes priority over achieving good things. A well-known example of a deontological system is the Universal Declaration of Human Rights (which states that certain actions such as torture are intrinsically wrong Deontological systems have an advantage over utilitarianism in that they usually imply many scenarios that seem intuitively wrong are immoral (such as sacrificing one person to obtain their organs for the benefit of many). This may be because their rules are originally derived from our common moral intuitions. Of course, this 60 can turn to disadvantage in catastrophic situations, such as where torturing one person is required to save one million people. Deontology has considerable relevance to HCAs. Patients have certain human rights that must be considered in their treatment, such as the right to privacy and dignity, and the right to consent. HCAs also have a code of conduct that encapsulates their moral and clinical duties. For example, HCAs are bound to always act in the best interests of their patients, and to treat them with respect and compassion. It is essential that HCAs are familiar with their code of conduct, as it is a valuable guide to what is expected of them by their patients. “Deontology: patients have certain human rights that must be considered in their treatment, such as the right to privacy and dignity, and the right to consent” This theory proposes that the rightness or wrongness of an action depends on the nature of the act rather than its consequences. This theory holds that you are acting rightly when you act according to duties and rights. Responsibility arises from these moral facts of life. The theory denotes that duties and rights are the correct measuring rods for evaluating action. One place where such factors are presented is in codes of professional ethics. E.g. informed consent, respect of patient 3. Intuitions (Rights perspective) theory Rights perspective decision maker who considers a rights perspective would consider the entitlements of those affected by the decision. The notion that people inherently know what is right or wrong; determining what is not a matter of rational thought or learning. 61  E.g., nurse inherently known it is wrong to strike a client, this does not need to be taught or reasoned out. 4. The Ethic of Caring (Case Based Theory) Unlike the preceding theories which are based on the concept of fairness (justice) an ethical caring is based on relationships. It stresses courage, generosity, commitment, and responsibility. Caring is a force for protecting and enhancing client dignity. Other ethical theory Virtue ethics (VE) is considered to be the oldest of the four ethical theories we are exploring, owing its origins to Aristotle back in the fourth century BC and further developed by Thomas Aquinas in the thirteenth century. In the past several decades, VE has become increasingly prominent and is now considered to have genuine application for those working in the frontline of healthcare. What distinguishes virtue ethics from the other ethical theories is that it is less concerned with what we do (action) and more so with who we become (character) over time. What matters most is acquiring good character; by developing good character one will act appropriately; doing the right thing for the right reason when required. According to VE, doing the right thing is not about following a set of rules (deontology) or trying to bring about the most pleasure or happiness (utilitarianism) it is about becoming the right sort of person by seeking to acquire certain virtues. A virtue is a type of good disposition (or tendency) to act in one way instead of another; for instance, if a colleague is mistreating a patient, an HCA ought to act courageously and confront them about their actions. If someone has the virtue of courage, they will do what is right when it is demanded of them. If 62 someone lacks the virtue of courage, then they ought to practice being courageous when the situation demands it, until they acquire the disposition to respond courageously and it becomes almost „second nature‟ to them. VE is not without criticism; one of the perceived problems is that it does not seem to offer any obvious moral rule for right action. A utilitarian could simply state that you ought to always act so that you produce the greatest good with the least harm. Developing such a rule for VE is more challenging. Principlism Although principlism is not strictly an ethical theory, it is the most widely used moral framework for guiding conduct in healthcare, and is clearly relevant to the HCA. Beauchamp and Childress (2013) first described its four ethical principles as a way to help structure moral thinking and to inform ethical decision-making. The principles are: autonomy, beneficence, non-maleficence and justice. The order of the four principles does not represent any significance of one principle over another. Although autonomy is the first, it is no more important than the other three principles. The four principles of „principlism‟ autonomy, beneficence, non-maleficence and justice are based upon „common morality‟, which describes the types of moral values most people accept as having relevance and importance to their moral lives” The strength of this approach is that the four principles are based upon what Beauchamp and Childress (2013) call „common morality‟, which describes the types of moral values that most people accept as having relevance and importance to their moral lives. This „common morality‟ is generally subscribed to 63 by people, irrespective of their cultural or religious background, which may explain its popularity in the diverse area of healthcare. The four principles draw on aspects of all three moral theories discussed so far in an attempt to provide a practical approach to moral decision-making. The first principle is autonomy, and describes the importance of letting patients make their own decisions about their care. So an HCA must respect the choices a patient makes about their care, whether they agree with it or not; the decision must remain his or hers alone. Principlism is not without its problems; the principles are open to a wide range of conclusions, depending on the emphasis placed on one principle over another, and are liable to producing contradictions which cannot be easily resolved (Herring, 2014). Nevertheless, ethical principlism does provide the HCA with some very helpful moral principles to consider, as they seek to provide the very best care and environment for their patients. 64  APPLYING ETHICS TO NURSING PRACTICE Objectives At the end of this lecture, the student will be able to:  Explain ethical issues between nurses and patients.  Explain ethical issues between nurses and doctors.  Clarify ethical issues between nurses and their employers.  Clarify ethical issues between nurses and nurses  Discuss ethical issues between nurses and the profession Outlines  Introduction  Ethical issues between nurses and patients  Ethical issues between nurses and doctors  Ethical issues between nurses and their employers  Ethical issues between nurses and nurses  Ethical issues between nurses and the profession 65 Introduction Most of ethical issues in nursing are problems of constraints: Occasionally conflicting ways by the hospital (The hospital nurse finds herself constrained in various and which employs her), the physician (with whom she works), the client (for whom she provides care), and the nursing profession (to which she belongs).to what extent can she be her own-person Ethical issues in nursing Most of the ethical issues in nursing are problems of constraints: The hospital nurse fined herself constrained in various and occasionally conflicting ways by:  The hospital  The physician  The client, and  The nursing profession. Ethical issues in nursing If we can't produce solutions, it is important to be able to Offer enough time to listen to the person Hear to what is to be told Disclose the divide between ourselves and others. Pay attention to what they see on their side. 66  Ethical issues between nurses and patients Many issues of ethical importance in the relationship between nurses and patients. They are mainly to do with the type of care given. Confidentiality It is a complex issue over which can nurses are often in conflict with doctors. Confidentiality All nursing codes of ethics have a clause regarding confidentiality. the question is: What is meant by confidentiality? What is confidential material? How does the nurse combine confidentiality and safeguarding the lives of fellow citizens? There are four categories under which information may be disclosed:  With the consent of the patient/ client.  Without consent of the patient / client when the disclosure is required by the law or order of the court.  By accident.  Without the consent of the patient /client when the disclosure is considered necessary in the public interest. 67 Advocacy An advocate is first and foremost a person who can and does enter into a relationship with another person. Advocacy is based upon:  Our common humanity.  Our common needs.  Our common human rights. Advocacy: is not something straightforward. Advocacy: is a fundamental aspect of an ethic of caring. The concept of advocacy above all others embodies the ideal of an ethic of caring: listening, relationship between I and you; and acting with compassion, competence, confidence, conscience and commitment. The four reasons why nurses should advocate on behalf of patients are: The first area: the quality of care which patient receives. The second area: the access to care. The third area: the patient should be fully informed about the care he receives. The fourth area: the patient should understand the alternative of the care proposed. 68 The four different level of advocacy 1- A personal level- such as the help provided by many voluntary groups to individuals. 2- A professional level- advocacy provided by solicitors and others. 3- A public level – where campaigns take place, demanding better services. 4- A practical level- advocacy an innovation, demonstrating new projects and being catalysts for new services. Ethical issues between nurses and doctors: The relationship between nurses and doctors is a particularly important one The relationship between nurses and doctors has largely been characterized by social and professional inequality. Questions of inequality are always situation of power. Nursing autonomy Personal and professional autonomy should be egalitarian. Patients, nurses and all health personnel are equal in their own right and should not be dominated by any one group of them. Such autonomy is based on reason, mutual confidence through having listened, identification with other, and avoidance of coercion to obtain one's own needs. 69 Making independent decisions When nurses become more conscious of their role and ability, and their responsibilities and rights, then making decision based on this aspect will inevitably be independent if they are viewed from within a framework of control. Steps of ethical decision making: 1- Step one: assessment 2- Step two: planning 3- Step three: implementation 4- Step four: evaluation When a nurse in a situation of conflict, she or he needs support and help Challenging medical opinion or treatments The various aspects of inequality between nurses and doctors are strong arguments why the doctor should accept it. But there are equal strong arguments why the opposite should be true Ethical issues between nurse and the profession To practice any job or profession means to give the best service within given frameworks or limits, to step outside these limits may be harmful to the client and the profession. 70 Political action Should nurses be involved in politics? Perhaps the question in rather, can they afford not to be? Strikes One area where nurses do run into difficulties with their profession is on the question of strikes. The contract between employer and employee implies that there are two sides to a bargain. There is a duty and a right on both sides. Strikes can take place when one side of the bargain is not kept. In most instances, this means that nurses feel they are not adequately remunerated for the service they give. Some health agencies have pledged themselves not to take strike action. Other health services unions, have not taken the same line, and permit strike action. Striking or not striking "Striking or not striking" is really a question about the status of nurses. If nurses want to be professionals, then they have to act and look like professionals, and share with the clients their knowledge and be committed to their care. These values cannot easily be compatible with strike action. Professionalism A profession is distinguished by three factors: -  Teaches its students itself in a body of specific knowledge that must be higher than necessary for ordinary survival. 71   It regulates its own control over admission to, and dismissal from, the profession.  The existence of a set of ethical principles regulating the conduct of the Professional towards the clients. The aspect of communication between patients and nurse as the major issue on which nursing and professionalism depend. The extra dimension of a profession is to share with the client what it has, and to prefer the client's interests to their own Principles for professionalism 1. Breaking current patterns of care and untidiness of nursing. 2. Acknowledging the complexity and tidiness of nursing. 3. A need for multidisciplinary discussion and research 4. Exposing staff and students to moral conflict to learn ethical decision making skills 5. Distinguishing between enduring values in nursing and what is an over lay of tradition. 6. Fostering creativity and autonomy. Professionalism A genuine professional nurse is a person who responds to an individual sick person rather than a patient by availability and attendance (listening and talking) and by communication which includes interest, acceptance of the person as he (or she) is rather than as she (or he) might like him (or her) to be, empathy and, where appropriate, touch. 72 The employers is one who fires and hires. The relationship between the employee and employer is: * One of contract and obligation, * Not one of consensus, * It is formal not friendly. The relationship between the employee and the employer should be based on: Care, Care based on receptivity, reciprocity, and responsivity. The ethical issues which arise between nurses and employers arise out of conflict of what the employer demands and does, and how the nurse responds to this demand. 1. Standards Of Care. 2. Accountability. 3. Responsibility. 4. Conflict with managers. 5. Objection to treatments and policies “Nursing Standards of Care” pertain to professional nursing activities that are demonstrated by the nurse. 73 “Standards of care “are valid, acceptable definitions of the quality of nursing care. They are often written to solve a problem. But are intended to ensure that practice moves forward and does not stagnate. Standards are presented in statements of performance to be achieved within an agreed time, and are acceptable, achievable, observable and measurable. We use standards to guide and evaluate nursing care. To set standards, and to have professional control on them, nurses need to know the extent of their authority, responsibility and accountability to carry out their job effectively. Bennie et al (1984) describe it as “being personally responsible for the outcome of one‟s professional actions”. Accountability is being responsible for your actions and for the outcomes of these actions - is part of the framework of clinical governance, which aims to provide good quality, cost-effective, evidence-based care. Accountability means not only having to answer for one Action when something went wrong, but it is a continuous process of monitoring how a nurse performs professionally. A distinction needs to be made between legal & moral accountability; legal accountability arises out of the training a person had, and relates to the position held. moral accountability which relates to the ethical principles i.e. respect, goodness, justice and honestly. 74 In order to be legally accountable needs certain specific things: A degree of autonomy. A freedom to act or practise in accordance with the training and education. To use her or his judgement and to act on it. It is the ability to respond in order to able to care based on freedom, goodness and rightness. Whoever has responsibility has accountability. the two are intertwined and not separable. Many managers of small and large unites are administrator and managers with no experience of hospitals, health care or nursing. Any type of coercion inevitably undermines and limits a person‟s autonomy, freedom and judgement. The fact is that it will more likely come from peers and even from outside her immediate colleague circle. But support should be there, otherwise a nurse may not be able to cope with a situation. Employers have a duty to support their staff; and staff are responsible to the employer to carry out care as well as possible. When these are both happening, then all concerned will be satisfied. 75