Journal of Nursing Law, Volume 13, Number 4, 2009

The Legal Basis of Nursing Ethics Education

Mihyun Park, MSN, BSN, RN
With advances in medical technology bringing about extreme changes in health care, various ethical issues arise. Nurses, as health care professionals, are required to participate in ethical decisions and to assume the role of advocate for the patient. While the need of ethics education has increased in nursing, the effectiveness of a current teaching method (i.e., an integrated teaching method) for ethics education has been a concern. Although the integrated teaching method deals with wide varieties of ethic content, the teaching method lacks core content and a systematic approach to ethics education within nursing programs. A structural barrier in nursing programs may hinder achieving the goal of the integrated teaching method for teaching ethics. Development of a policy for ethics education is essential. This article suggests directions for developing a policy for ethics education; it explores the legal basis of nursing ethics education, and examines the legal requirements for nursing professionals to complete ethics courses in five states including North Carolina, California, Florida, New York, and Texas. Keywords: nursing education; ethics; law; legal research

urrent technology has brought about incredible advancements in medicine. At the same time, the advances in health care systems produced various ethical issues. Facing the issues, health care organizations need to formulate policy changes to support the health care professionals as well as the patients in making ethical decisions. In particular, nurses, who keep close relationships with patients through nursing care, have often been posed as advocates for the rights of patients. In Code of Ethics for Nurses with Interpretive Statements, the American Nurses Association (ANA, 2001) recognized the ethical obligations of nursing professionals as patient advocates. The National League of Nursing Accrediting Commission ( NLNAC) included to exhibit ethical behavior in all professional activities (2006, p. 85) as a core competency and encouraged nursing programs to integrate this core competency in nursing curricula. Furthermore, the American Association of Colleges of Nursings Essentials of Baccalaureate Education for Professional Nursing Practice emphasized the importance of ethics in nursing education (American Association of Colleges of Nursing [AACN], 2008). In particular, both the AACN (2008) and the NLNAC (2006) cite advocacy and ethical decision making as two essential components that nursing programs should achieve in their curricula.
106 Copyright 2009 Springer Publishing Company
DOI: 10.1891/1073-7472.13.4.106

Although ethics education has been of concern among nursing programs, nurses have continued to articulate the need for ethics education (Park, 2009). Woods (2005) reported that nursing students have not been prepared to respond effectively to ethical dilemmas in their nursing practice and indicated the need for pragmatic teaching methods as the solution. In Numminen and Leino-Kilpis (2007) study about the nursing students ethical decision making, ethics education in nursing programs has been shown to impact on the moral development of students. The impact resulted from a choice of teaching methods such as a distinct ethics course, a value analysis, or an ethical framework model. Most nursing programs use an integrated teaching method. Nursing educators think that if all nursing faculty could teach ethics and address ethical issues in all nursing areas, students will have a more comprehensive understanding of ethics in nursing (Aroskar, 1977; Milton, 2004). Consequently, while ethics content has been integrated into the core nursing curriculum, ethics has not been a required course in most undergraduate curricula. Some nursing ethicists identify the problems of ethics education in nursing programs as stemming from the current teaching method (Fry, 1989; Gaul, 1989; Krawczyk, 1997). Although the integrated teaching method may be able to deal with a wide variety of ethical content, the

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teaching method has lacked core content and a systematic approach to ethics education within nursing programs (Fry, 1989). Nursing faculties may not have enough time and support systems to devote an extensive amount of efforts to ethics education, and they tend to focus on preparing students to obtain knowledge and technical competencies for licensure. This structural barrier in nursing programs may hinder achieving the goal of the integrated teaching method for teaching ethics. A systematic approach is suggested to overcome the barrier. Nursing schools operate within a highly institutionalized environment. Legal environments controlled by state nursing boards affect many aspects of the schools behaviors and structures. According to institutional theory, to increase legitimacy and to survive, organizations incorporate the practice and procedures that are defined by prevailing rationalized concepts in society (Meyer & Rowan, 1977). State nursing boards approve and monitor nursing professional education programs that lead to initial licensure by the standards and procedures defined in laws. Pursuing an increase in their regulatory legitimacy, nursing schools create structural change in direct response to government mandate. Therefore, legal statements regulating ethics education have coercion power for leading the structural change of nursing schools in relation to teaching ethics, and a powerful resolution for instituting ethics education would be the development of a policy for ethics education. Before proposing a policy for the ethics education in nursing programs, it is meaningful to scrutinize existing regulations. The purpose of this paper is to explore the legal basis of nursing ethics education through examining whether there are legal requirements for nursing professionals to complete ethics courses over five statesNorth Carolina, California, Florida, New York, and Texasand to suggest directions for developing a policy for ethics education.

Research Questions
To explore the legal basis of nursing ethics education, the following questions were posed: (a) How do licensure laws define the ethical practice of nursing profession? ( b) What legal requirements exist for nursing professionals to take ethics courses through continuing education or formal education programs? (c) What legal duties are nursing schools bound to, in order to provide ethics education?

Data Collection
To identify the relevant source of laws, first, the researcher started to search from federal statutes using periodical indexes and the online database LexisNexis. For this search, keywords such as health care, professional, nursing, and education were used. According to search results, related federal statutes focused on the funding (not licensure) for professional education programs. The researcher then consulted experts (i.e., a juris doctor, a law librarian, and a health science librarian) on how best to proceed. It was found that legal controls related to licensure and professional education are delegated to states, and the search was then redirected to the state-level statutes. To limit the range of data collection, the researcher concentrated the search on five states. North Carolina was selected because in 1903, the state of North Carolina was the first state to pass licensure laws for nurses who had completed a formal education program. Since then, North Carolina has led other states in relation to licensing legislation. Therefore, it is meaningful to include the state to get the legal basis of nursing ethics education by its historical aspect. In addition, California, Florida, New York, and Texas were selected because these states have the largest nursing populations and their regulations exert power in nursing. Furthermore, the researcher extended data collection to the other North Carolina health professions (e.g., physicians, pharmacists). Physicians and pharmacists are represented as independent decision makers in the health care system. Therefore, the comparison with their policy will provide useful information for developing the nursing education policy. The primary resources from a state statute were collected from each state government Web site and professional board Web sites. Two main resources were identified from the search: (a) Practice Actlegislative statutes that define professional practice and set standards for the profession in that state; and ( b) administrative coderules and regulations established by

METHODS
This study followed the legal research process identified by Jacobstein, Mersky, and Dunn (1998): (a) identify the legally important facts, ( b) frame the legal issues (develop legal research questions), (c) identify the relevant sources of law (collect data), (d) find answers to the research questions, and (e) communicate the answers to the research questions. This process has been used by nursing scholars to answer policy questions in the nursing care domain (Kjervik & King, 1990). Using this method is regarded as an appropriate way for finding the legal basis of ethics education in health care professionals.

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administrative agencies (e.g., boards of nursing and medical boards) on the authority of the legislators (Catalano & Griffin, 1991). As shown in Table 1, the resources were categorized slightly differently in each state. The researcher defined the key concepts of the ethical practice of the nursing profession based on the 2001 ANA

Code and categorized four concepts: respect for human dignity and rights, accountability for competent professional practice, advocacy, and responsibility for the public (see Table 2). These concepts were used as keywords during data collecting to find answers for the research questions.

TABLE 1. Legal Resource for Ethics Education in Five States States North Carolina Legal Resources General statues NC Administrative Code General statues NC Administrative Code General statues NC Administrative Code California California Business and Professions Code California Code of Regulation Florid statues Florida Administrative Code Education law Rules of the Board of Regents Regulations of the Commissioner of Education Texas Occupations Code Texas Administrative Code References Nursing Practice Act, N.C. G.S. 90171.1947 (2007). Rules of Board of Nursing, 21 NCAC 36.0100.0814 (2008). Medical Practice Act, N.C. G.S. 90 121 (2007). Rules of Medical Board, 21 NCAC 32A .010132W.0115 (2008). Pharmacy Practice Act, N.C. G.S. 9085.244 (2008). Rules of Board of Pharmacy, 21 NCAC 46 .0100.3408 (2008). Nursing Practice Act, CAL. BPC. CODE 27002838.4 (2008). Nursing Practice Act, 16 C.C.R. 14021493 (2007). Nurse Practice Act, 464 F. S. 001027 (2008). Rules of Board of Nursing, 64 F.A.C. 64B9-1.001 64B16.004 (2007). Nursing, N.Y. EDUC. LAW 139.69006910 (2008). Rules of the Board of Regents, 8NYCCR 29.117 (2008). Registration curricula, 8NYCCR 52.12 (2008); Nursing, 8NYCCR 64.17 (2008). Nursing Practice Act, TEX. OCC. CODE ANN. 301305 (2007). Texas Board of Nursing, Rules and Regulation, 22 T.A.C. 211.19; 213.133; 215.113; 216.111 (2007).

Florida

New York

Texas

TABLE 2. The Concepts of Ethical Practice Concepts of Ethical Practice Respect for human dignity and rights Code of Ethics for Nursesa Respect for the inherent dignity, worth, and uniqueness of every individual Protect the health, safety, and rights of the patient Primary commitment is to the patient Responsibility and accountability for individual nursing judgments and actions Professional growth and maintenance of competence Protect the health, safety, and rights of the patient Confidentiality, privacy Collaborate with other professionals and the public in promoting community

Accountability for competent practice

Advocate Responsibility for the public

aCodes of ethics for nurses are quoted from American Nurses Association (2001).

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RESULTS
This article reports the findings in three sections: (a) ethical practice of professionals, ( b) requirements of ethics education, and (c) legal duty for ethics education.

All information indicating that an applicant has been convicted of a crime, or has committed an act which raises a reasonable question as to the applicants moral character, shall be referred to the director of the Office of Professional Discipline or his or her designee ( NYCCR 281.2).

Ethical Practice of Professionals

Licensure laws of nursing professionals reflect the institutionalized recognition of their practice and the standards that should be used in professional practice. To examine how licensure laws define the ethical practice of nursing professionals, the definitions, the standards of professional practice, and the prerequisite for licensure were scrutinized using the key concepts about ethical practice. The definitions of professional practice explain activities that health care professionals should perform in health care service and that are related to each unique practice area. They can be understood as explanations of the accountability for competent professional practice in terms of ethical performance (See Table 3). The five nursing boards have similar contents in their licensure regulations. Nursing licensure regulations integrate the concepts of ethical practice to the definition or components of professional nursing practice. In the statement of the responsibility of the RN about teaching and counseling, North Carolina Administrative Code (2007) includes a definition of the RNs role as advocate. Teaching and counseling are for the purpose not only of increasing knowledge but also promoting the patients ability to make informed decisions (21 NCAC 36.0224 (h)). In the standards of competent performance for RNs, California Code of Regulations (2007) clearly states that RNs must act as the clients advocate:
As circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided (16 C.C.R. 1443.5 (6)).

As shown in the above statement, ethical practice appearing in licensure regulations is closely associated with unprofessional conduct or impaired professional acts. The determination of good moral character also includes the criminal history check as requirements for licensure.

Requirements of Ethics Education for Health Care Professionals

Continuing education is designed to promote advanced knowledge, skills, and attitudes for the enrichment of professional practice (ANA, 2000). Therefore, continuing education requirements should reflect the increasing needs of ethics education among health care professionals and ethical concerns in professional practice. Most of the searched boards require their professionals to complete continuing education (See Table 4); however, many boards do not define the specific contents for continuing education, but the boards of nursing in California and Florida point out the specific ethical contents for continuing education. In particular, they both emphasize the important of education in endof-life and domestic violence issues.

Legal Duty of Ethics Education for Professional Education Programs

The curriculum standard for nursing education programs must be designed to be consistent with the standards of practice defined in statues and rules (21 NCAC 36.0321, 2007). Except for the New York nursing board, four boards of nursing include ethics in the contents of curriculum. The North Carolina nursing board includes contents to develop nursing knowledge, skills, and competencies for the curriculum of nursing programs but does not mention ethics courses. Yet, it includes ethical contents such as respecting client differences, values... describing didactic contents (21 NCAC 36.0321 ( b), 2007). Neither the board of pharmacy nor the medical board in North Carolina have any specific regulations related to curriculum standards; however, the medical board requires applicants to graduate from a school approved by the Liaison Committee on Medical Education (2008), which states that ethics education is a required content in the standards for accreditation of medical education programs and lists in detail the kinds of instruction that should be provided to students (See Table 5).

Each states licensure regulation of health care professionals defines the prerequisite for licensure. All boards require graduation from a professional program approved by each board. North Carolina and Florida nursing boards and the North Carolina pharmacy board include in their requirements physical and mental competency, and the North Carolina medical board and the boards of nursing in New York and Texas included good moral character or good professional character in the requirements of licensure (See Table 3). In terms of good moral character, the North Carolina Medical Practice Act (2007) and the Texas Nursing Practice Act (2007) do not define what makes good moral character. The rules of the Board of Regents (2008) in New York requires that:

TABLE 3. Ethical Practice Concepts Subtitle Ethical Practice Concepts in Contents

Subjects

States

Title

Nursing

NC

Nursing Practice Act

Administrative Code

NC. G.S. 90-171.20 Definitions NC. G.S. 90-171.29 Qualifications 21 NCAC 36.0224 Components of nursing practice

CA

Nursing Practice Act

California Code of Regulation

FL

Nurse Practice Act

Administrative Code

NY

Education Law

B.P.C.C. 2725 Practice of nursing B.P.C.C. 2736 Qualifications 16 C.C.R. 1443.5 Standards of Competent Performance: 16 C.C.R. 1443.5 464 F. S. 003 Definitions 464 F. S. 008 Qualifications 64 F.A.C. B9-3.002 Qualifications 6902 Definition 6905 Requirements

TA

Nursing Practice Act

Administrative Code

T.O.C.A. 301.002 Definition T.O.C.A. 301.252 Qualifications 22 T.A.C. 217.11 Standards of Professional Nursing Practice 22 T.A.C. 217.2 Qualifications

Accountability for competent practice 1. Graduation from a course of study approved by the Board 2. Mentally and physically competent to practice nursing 1. Respect for human dignity and rights (k-3) 2. Accountability and responsibility for competent practices (a-k) 3. Confidentiality (g-4) 4. Responsibility for the public (b) 5. Advocacy ( h) Accountability and responsibility for competent practices 1. Completion the courses, programs accredited by the board for training registered nurses 1. Accountability and responsibility for competent practices 1. Acts as the clients advocate 1. The professional nurse shall be responsible and accountable for making decisions 1. Good mental and physical health 2. Graduation from approved programs Accountability and responsibility for competent practices. 1. Education 2. Be of good moral charactera Accountability and responsibility for competent practices (a-k) 1. Respect for human dignity and rights 2. Accountability and responsibility for competent practices 3. Confidentiality 1. Completing a program of professional nursing education approved 2. Good professiwonal character Accountability for competent practice 1. A graduate of a medical school approved by the Liaison Commission on Medical Education (LCME) or American Osteopathic Association (AOA) 2. good moral character (a-3)

Medicine

NC

Medical Practice Act

NC. G.S. 90-1.1. Definitions NC. G.S. 90-9.1. Requirements for licensure as a physician

Pharmacy

NC

Pharmacy Practice Act

NC. G.S. 90-83.3 Definitions NC. G.S. 90-85.15 Prerequisites

Accountability for competent practice 1. Physical and mental competency to practice pharmacy 2. Graduation from a school of pharmacy approved by the board and one year experience approved by the board

aRules of the Board of Regents, Part 28 ( NYCCR 28).

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TABLE 4. Requirements of Ethics Education Subjects Nursing States North Carolina California Statutes Nursing Practice Act/ Administrative Code Nursing Practice Act California Code of Regulations. Florida Administrative Code Subtitle NC. G.S. 90-171.42/ 21 NCAC 36.0223 B.P.C.C. 2811.5. 16 C.C.R. 1456. 64 F.A.C. B9-5.002; B9-5.003; B9-5.009~12 Ethics Contents in CE Specific contents are not defined Spouse or partner abuse detection and treatment/ end-of-life issues Standards for CE: Legal aspects of health care HIV/AIDS, domestic violence, prevention of medical errors, and end of life No CE requirement Specific contents are not defined Specific contents are not defined Specific contents are not defined

Florida

New York Texas Medicine Pharmacy North Carolina North Carolina

Texas Administrative Code Administrative Code Pharmacy Practice Act/ Administrative Code

22 T.A.C. 216.2 21 NCAC 32R.0101 NC. G.S. 90-85.17/ 21 NCAC 46.2200-1

Note. CE = continuing education.

DISCUSSION
Definitions of professional nursing practice in licensure regulations seem to reflect all kinds of social recognition of ethical behavior in the delivery of patient care over time. In the early 20th century, ethical behavior in nurses was defined mostly in relation to the practice of individual moral duties such as loyalty, modesty, honesty, and cheerfulness (Fowler, 1997; Fry, 2004). These individual moral duties can be interpreted as practicing good moral character. The good moral character, as a prerequisite for entry into the nursing profession, is more than having no criminal background. After World War II, changes in health care, such as advancing medical technology and emerging bioethics, brought drastic changes in the nursing role. Nurses are now expected to be independent practitioners and have accountability for what is done to the patient, the profession, and the public in providing nursing care. This role has become the primary moral duty of nursing (Fowler, 1997; Fry, 2004). Nursing licensure laws reflect the norm of the accountability for competent nursing care. The concept of patient advocacy is seen in the standards of North Carolina and California. The concept has recently emerged as morally important in nursing practice. The role of advocate requires nurses to help the patient make decisions most consistent with their personal beliefs and values as well as negotiate with other health care providers in order to protect

the patients right (Fry, 2004). The National Council of State Boards of Nursing (2008) included advocacy in the 2008 NCLEX-RN Test Plan. Advocacy should be clearly explained in the regulations that explain the standards of nursing practice and curricula in nursing programs. Continuing education maintains and improves the knowledge and skill of nurses in relation to the change in the health care system. Our society recognizes a nurse as a professional who is trained to be able to respond sensitively to the current issues in health care systems. Nursing boards respond to the societal need through regulations regarding continuing education and nursing programs. For instance, in terms of the growing elderly population, end-of-life issues are one of the biggest ethical concerns. According to U.S. Census Bureau (n.d.), California and Florida have the largest number of elderly (more than 1 million) and thus, have the largest need related to end-of-life care. In response to the need, the nursing boards in both states have established endof-life training as a continuing education requirement. Such policies can increase nurses knowledge about and awareness of end-of-life issues in a systematic way. Historically, ethics education has been one of the main required curricula of a nursing program. Beginning in the 1970s, changes in ethics teaching methods have led nursing programs to integrate ethics contents into core curricula. The current regulations also reflect the trends of ethics education in the nursing profession. Although regulations of curricula for nursing programs require ethics education,

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TABLE 5. Legal Duty of Ethics Education for Professional Education Programs Subjects Nursing States North Carolina Statutes Administrative Code Subtitle 21 NCAC 36.0321 Curriculum Ethics Contents in Curriculum Standard To develop nursing knowledge, skills, and competencies: didactic content Respecting client differences, values, preferences, and expressed needs ( b-2-B). (d) Theory and clinical practicelegal, social, and ethical aspects of nursing (d). (6) Curriculum for professional nursing education program (vi) The role of RN in the health care system: legal aspects and ethics (6-vi). New York does not have the curriculum guideline (contents). The program of study: Professional values: ethics, safety, diversity, and confidentiality. Medical schools approved by the LCME or AOA. A medical school must teach medical ethics and human values, and require its students to exhibit scrupulous ethical principles in caring for patients, and in relating to patients families and to others involved in patient care (ED-23). The Board shall approve schools and colleges of pharmacy upon a finding that students successfully completing the course of study offered by the school or college can reasonably be expected to practice pharmacy safely and properly.

California

California Code of Regulations Florida Administrative Code

16 C.C.R. 1426 Required curriculum: 64 F.A.C. B9-2.015

Florida

New York

Texas

Texas Administrative Code

22 T.A.C. 215.9

Medicine

North Carolina

21 NCAC 32B.0301 Medical Education Standards for Accreditation of Medical Education Programs by the LCME (2008)

Administrative Code

Pharmacy

Pharmacy Practice Act

NC. G.S. 90-85.13 Approval of schools and colleges of pharmacy

Note. LCME = Liaison Committee on Medical Education.

the requirements of ethics education are explained in part by theories, nursing roles, or professional values. However, the medical board in North Carolina strongly requires their professional schools to teach ethics, even though the board does not describe ethics education in its regulation statements. There are differences between nursing boards and the North Carolina medical board. While each nursing board of the five states has approved processes and the standard curricula for the professional education program, the North Carolina medical board delegates the accreditation of medical education to professional agencies such

as the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association. The LCME makes a clear statement for the ethics education of medical schools providing the standards of what is expected of medical students and what outcomes will be expected from ethics education. The nursing boards we examined for this article do not give clear standards for ethics education. The accreditation process can result in the standard ethics education among medical schools over states that regulate the approval of the agencies. A national accreditation process as used in the North Carolina medical board

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can result in the standardized ethics education among medical schools over states that regulate the approval of the agencies. Therefore, using a national accrediting procedure may be a good strategy for the standardized ethics education among nursing programs. Curricula in the most nursing schools focus on preparing nursing students for licensure examination. The increasing impact of technical skills on nursing has facilitated decreasing the portion of ethics education in the nursing program. Yet, the advanced medical technology simultaneously increases the need for ethics education. Reconsidering the effect of integrated teaching methods in ethics, some leading nursing schools have made changes in their curriculum. Although the schools have reported benefits of the changes, they have not made a major impact on nursing programs. Assuming that a nursing school is an institutional organization influenced by state law, this study suggests that developing well-defined requirements of ethics education in licensure regulations could be a more effective way to change the current structure of ethics education in nursing programs. This study has not examined whether the licensure regulation has actual impact on the ethics education in nursing schools. Further studies would be required to examine the effects of the regulations on ethics education in nursing schools. Nursing involves making complicated and ethically challenging health care decisions. To help nurses make the right decisions, ethics education should move to the forefront of the curriculum, and to encourage nursing programs to change their curricula, nursing boards need to state clearly what type of role ethics education should have in nursing education.

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