NURSING ETHICS

MISS LAKAM MAPUTI, RN, MAN

Legal Issues in Nursing practice

PHYSICIANS ORDER FLOATING INADEQUATE STAFFING

Nurses are responsible Nurses should be given
for their actions orientation to the unit. The
supervisor should be
regardless of who told
informed about a float
them to perform those nurses lack of experience on
actions. the new unit.
A nurse who leaves an
inadequately staffed
unit could be charged
with client
abandonment.

CRITICAL CARE
Constant observation
PEDIATRIC CARE
and assessment of
Suspected child abuse
clients are required,
or neglect be reported.
especially in ICUs that
have monitors.
FUNDAMENTAL HUMAN EVENTS

SENSISTIVE
AREAS
Birth
SUPPORT
Death
ADVOCATE
Suffering
SOUND MORAL
DECISIONS
 HOW?
NURSES NEEDS TO:
1. E x a m i n e t h e i r o w n v a l u e s a n d t h e i r c l i e n t s
values? Understand how their values
i n f l u e n c e t h e i r d e c i s i o n s?
2. D e v e l o p sensitivity to the ethical
dimensions of nursing practice?
3. Th i n k a h e a d w h a t a r e t h e p o s s i b l e m o r a l
problems they are likely to face?
VALUES

Freely chosen

Values underlie all moral dilemmas. though, not all values

are moral values (people values about work, family,
religion, politics, money and relationships.

IMPORTANT: Values influence decisions and actions,

such as nurses ethical decision making.

Beliefs or attitudes about the worth of a person, object,

idea, or action.
 VALUES
BELIEFS
Opinion, interpretation, or
conclusions that people accept as
true (may it not be true)
I believe if I study hard I will get
BELIEFS
BELIEFS
a good grade
Good grades are really
ATTITUDES
ATTITUDES
important to me. I believe I must
study hard to obtain good grades
ATTITUDES
Mental position or feelings
toward a person, object, or idea
Values (compassion, acceptance)
Some clients may feel strongly

about their need for privacy,

whereas others may dismiss it as
unimportant.
VALUES

BELIEFS ATTITUDES

FAITH than FACT. THINKING and BEHAVIORAL

Last only briefly. aspects.

Judged as correct or incorrect. Continuous overtime.

Judged as bad or good,

positive or negative.
 FROM?
VALUES TRANSMISSION
Acquired through Observation and
Experience.
Affected by Socio-Cultural environment
(societal conditions, family and peers)
PERSONAL VALUES
Nurses should keep in mind the
influences of Values on health.
PROFESSIONAL VALUES
VALUES CLARIFICATION
A process by which people identify, examine,
and develop their own individual values.
It promotes personal growth (promotes
awareness, empathy, and insight)
It is an important step for nurses to
take in dealing with ethical problems.
No One set of values is right for everyone.
People can retain or change the freely chosen
values
CLARIFYING THE NURSES VALUES
CLARIFYING CLIENT VALUES
 FROM?

Professional Values Clarifying Nurses Values

Acquired during experience from code

of ethics, nursing, teachers, and peers.

5 VALUES ESSENTIAL FOR

PROFESSIONAL NURSE:
ALTRUISM Nurses and nursing students need
AUTONOMY to examine the values they hold
about life, death, health and illness.
HUMAN DIGNITY
INTEGRITY
SOCIAL JUSTICE
Essential Nursing Values and Behaviors
VALUES
Altruism
Nurses concern for the welfare of patients,
other nurses, and other health care providers.
Autonomy
Nurses respects patients right to make
decisions about their health care.
Human Dignity
Nurses values and respects the inherent worth
and uniqueness of all patients and colleagues.
Integrity
Nurses acts honestly and provides care based
on an ethical framework.
Social Justice
Nurse upholds moral, legal, and humanistic
principles by ensuring equal treatment under
the law and equal access to quality health care.
Professional Behaviors
Understands cultures, beliefs, and perspectives of
others.
Advocates for patients.
Take risks on behalf of patients and colleagues.
Plans care in partnership with patients
Provides culturally competent and sensitive care.
Protects patients privacy.
Designs care with s sensitivity to individual patient
needs.
Provides honest information to patients and the public.
Document care honestly and accurately.
Seeks to remedy errors made by self or others.
Demonstrates accountability of own actions
Supports fairness and nondiscrimination in the delivery
of care.
 FROM?
VALUES TRANSMISSION
Acquired through Observation and
Experience.
Affected by Socio-Cultural environment
(societal conditions, family and peers)
PERSONAL VALUES
Nurses should keep in mind the
influences of Values on health.
PROFESSIONAL VALUES
VALUES CLARIFICATION
A process by which people identify, examine,
and develop their own individual values.
It promotes personal growth (promotes
awareness, empathy, and insight)
It is an important step for nurses to
take in dealing with ethical problems.
No One set of values is right for everyone.
People can retain or change the freely chosen
values
CLARIFYING THE NURSES VALUES
CLARIFYING CLIENT VALUES
 FROM?

Professional Values Clarifying Nurses Values

Acquired during experience from code

of ethics, nursing, teachers, and peers.

5 VALUES ESSENTIAL FOR

PROFESSIONAL NURSE:
ALTRUISM Nurses and nursing students need
AUTONOMY to examine the values they hold
HUMAN DIGNITY about life, death, health and illness.
INTEGRITY
SOCIAL JUSTICE
Theory of Values Clarification (Raths, Harmin, and Simon, 1978)

Valuing Process
Beliefs are freely chosen.
Without outside pressure
Choosing Cognitive After reflecting and considering
consequences or alternatives

Chosen beliefs are cherished or prized

Prizing Affective

Chosen beliefs are affirmed to others,

incorporated into ones behavior and
Acting Behavior repeated consistently in ones life.
Clarifying Client Values

Is an intervention used by the nurse s when clients experiences

unclear values that are harmful to their health.

Behavior Example
Ignoring a health professionals A child clients parent who values the
advice
Inconsistent communication A n elderly who says she dont want anymore to use cane
when walking, but wont cooperate during her therapy.
behavior

Numerous admissions to a A hypertensive client repeatedly seeks help for headache

but does not take the prescribed maintenance medicine.
health agency for the same
problem

Confusion about which course A pregnant woman who values her job to meet financial
obligations, but also needs to have complete bed rest for a
of action to take safe labor and delivery.
Clarifying Client Values

Process How?

List Alternatives Ask: Are you considering other alternative courses of actions?
Tell me about them

Examine possible Ask: What do you think you will gain from doing that?
consequences of choices

Choose freely Ask: Did you have any say in that decision?

Feel good about the choice Ask: How do you feel about that decision? Some people feel
good after a decision is made; others feel bad. How do you feel?

Affirm the choice Ask: What will you say to family or friends about this?

Act on the choice Ask: Will it be difficult to tell your wife about this? (it
determines the clients preparedness to act in his decision)

Act with a pattern Ask: How many times have you done that before? or Would
you act that way again?
 HOW?
NURSES NEEDS TO:
1. E x a m i n e t h e i r o w n v a l u e s a n d t h e i r c l i e n t s
values? Understand how their values
i n f l u e n c e t h e i r d e c i s i o n s?
2. D e v e l o p sensitivity to the ethical
dimensions of nursing practice?
3. Th i n k a h e a d w h a t a r e t h e p o s s i b l e m o r a l
problems they are likely to face?
Standards of Professional Performance (ANA,1998)

Standard V: Ethics
The nurses decisions and actions on behalf of patients are determined in an ethical
manner.

Measurement Criteria

1. The nurses practice is guided by the Code for Nurses.

2. The nurse maintains patient confidentiality within legal and
regulatory parameters.
3. The nurse acts as a patient advocate and assists patients in
developing skills so that they can advocate for themselves.
4. The nurse delivers care in a non-judgmental and non-
discriminating manner that is sensitive to patient diversity.
5. The nurse delivers care in a manner that preserves patient
autonomy, dignity, and rights.
6. The nurse seek, available resources in formulating ethical
decisions.
NURSING ETHICS

No One profession is responsible for ethical decisions,

nor does expertise in one discipline necessarily
make a person an expert in ethics
(ethics committee)
Nursing Codes of Ethics

Purposes:
Inform the public about the minimum standards of the
profession and help them understand professional nursing conduct.
Provide a sign of the professions commitment to the public it
serves.
Outline the major ethical considerations of the profession.
Provide standards for professional behaviors.
Remind nurses of special responsibility they assume when
caring for the sick.
 CODE OF ETHICS

ETHICAL CODES are:

Systematic guides for developing ethical behavior.

Answers normative questions of what beliefs and values
should be morally accepted.
NO CODE could possibly provide absolute or complete
rules without conflict and ambiguity.
Four-fold responsibilities of nurses (PD 223)
Responsibility Ethical Principles
NURSES AND PEOPLE Values, spiritual beliefs, and
customs held by individual
Respect patients autonomy.
Personal information
confidentiality.
NURSES AND PRACTICE Human Life in inviolable.
Quality in care for patients
Accuracy in documentation of
actions and outcomes of care.
Advocate to patient.
Awareness to ethic-moral and
legal dimensions of practice.
Guidelines to be
observed
Consider individuality when
giving care.
Take into consideration the
spiritual beliefs (diet and
treatment), the rights and the
culture of patients.
However, welfare and safety
must take precedence.
Know the scope of her
practice
Acquire and develop
necessary competence in
knowledge, skills, and
attitudes.
Ensure patient's records.
Respect Patients Bill of
rights
Four-fold responsibilities of nurses
Responsibility Ethical Principles
NURSES AND CO-WORKERS Maintain a collaborative
working relationship
NURSES AND Preservation of life, respect for
SOCIETY/ENVIRONMENT human rights and promotion of a
healthy environment
Establishment of linkages with the
public in promoting local an
national, and international efforts to
meet health and social needs of
people.
Guidelines to be
observed
Maintain their professional
role/identity while working
with other members.
Honor and safeguard the
dignity and reputation of
members of nursing.
Contribute to professional
growth and development of
other members.
Be conscious of their
obligations as citizens.
Be equipped with knowledge
of health resources within the
community
Project an image.
ETHICAL PROBLEMS IN NURSING

Growing awareness of ethical problems has occurred

because of:

SOCIAL AND TECHNOLOGICAL CHANGES

CONFLICTING LOYALTIES AND OBLIGATIONS

 ETHICAL PROBLEMS IN NURSING

SOCIAL AND TECHNOLOGICAL CONFLICTING LOYALTIES AND

CHANGES OBLIGATIONS

Large number of people without health

insurance.
High cost of health care
Workplace redesign under managed care
According to nursing code of ethics, the
nurses first loyalty is to the client.

ISSUES OF FAIRNESS AND RESOURCE However, it is not easy to determine which

ALLOCATION action best serves the clients needs.

Before technology, there was no questions Client needs may conflict with the institutional
about whether to allow.who should be policies, physician preferences, needs of their
treated?... family, or even laws of the state.
 scarce resources
Health resources Allocation of
Advance Directives
Euthanasia
Issues
Termination of Life-sustaining treatment
End-of-Life
Withdraw or withholding Food and fluids
Information.
Nurses should help develop and follow security
measures and policies to ensure appropriate use
Computerized
of clients data. Management of
Sanctity of life vs. principle of Autonomy and the womans
right to control her own body.
No public consensus has yet been reached.
Abortion
Nurses have no right to impose their personal values, instead,
nurses have the right to inform and counsel the client in
making decisions.
SPECIFIC ETHICAL ISSUES
MAKING ETHICAL DECISIONS

It should be based on ethical principles and codes rather

than emotions, intuition, or precedent.
GOOD DECISION
The one that is in the Clients best interest and at the same time
preserve the integrity of all involved.

Establish support system; use of counseling professionals

Collaboration, communication, and compromise
(important skills)
Determine EXISTENCE OF MORAL SITUATION
(important first step)
 EXISTENCE OF MORAL
SITUATION?
1. A d i f f i c u l t c h o i c e e x i s t s ?

2. T h e r e a r e m o r a l p r i n c i p l e s e x i s t t h a t c a n

be used to justify the action?

3. T h e d e c i s i o n m u s t b e f r e e l y a n d

consciously chosen?

4. T h e c h o i c e i s a f f e c t e d b y p e r s o n a l f e e l i n g s ?
MORAL PRINCIPLES

AUTONOMY
NONMALEFICENCE
BENEFICENCE
JUSTICE
FIDELITY
VERACITY
MORAL PRINCIPLES

AUTONOMY
- Autos ( self)
- nomos (governance)
- born from The New Testament (freedom to make decisions)
- In Health care Setting: Principle of INFORMED CONSENT
- IMPORTANT : while you respect patients autonomy, it is also our duty to
explain clearly to them what are the consequences or effect of their decision,
explain to them the purpose of informed consent the treatment and its alternatives
which are all indicated or written in the informed consent.

OVERRIDING PATIENTS AUTONOMY( Paternalism)

> MEDICAL --acting without consent to benefit the patient and
prevent harm (ex. emergency cases, incompetency etc.)
> STRONG benefit is stronger than autonomy (ex. Refusal to
treatment)
> WEAK if our purpose is to help patient in restoring his/her
competence to decide.
 JUSTICE
- the right to demand a just, fair and treatment
- we get what we merit from our conduct in life
- uses TRIAGE SCHEMES:
1. According to medical prognosis (who is most likely to
survive)
2. Social value (must favor first the socially disadvantaged,
ill,elderly,disabled,women and children (ART.III of PHILIPPINE
CONSTITUTION))
3. First come first serve (for patients with same cases and
treatment)

- this DOESNT tell us what needs are most important.

MORAL PRINCIPLES

Fidelity
Being faithful to ones commitments (providing self care and
competence in nursing care) and promises.

Veracity
Telling the truth (essential to nurse-client relationship)
 BENEFICENCE NONMALEFICENCE

-do good (stated in positive form) -do no harm (stated in negative form

-Do good for patients interest -Avoid harm which is against patients
interest.
-However, this can pose patient at risk
of harm (provided, that patients - harm may be INTENTIONAL (never
values and dignity are considered first) accepted because it places patient to
harm) or UNINTENTIONAL (risk was
-Good communication with patient of inevitable or not anticipated, example
his/her desires and needs promotes is catching a falling patient)
acceptance.
-Unintentionally created a needless
harm, provided, that nurse should do
whats best for her patient.

-PATIENT: the one who determines or

interpret what is harmful.
MORAL PRINCIPLES

AUTONOMY self governance; Informed Consent

NONMALEFICENCE- do no harm
BENEFICENCE- do good
JUSTICE- fair treatment
FIDELITY
VERACITY
Criteria if Moral aspects exists

A difficult choice exists?

There are moral principles exist that can be used to

justify the action?

The decision must be freely and consciously

chosen?
The choice is affected by personal feelings?
 APPLICATION
SITUATION

Mrs. L, a 67-year-old woman, is hospitalized with multiple

fractures and lacerations caused by an automobile
accident. Her husband, who was killed in the accident,
was taken to the same hospital. Mrs. L, who had been
driving the automobile, constantly questions her primary
nurse about her husband. The surgeon has told the nurse
n o t t o t e l l M r s . L ; h o w e v e r, h e d o e s n o t g i v e t h e n u r s e t h e
reason for these instructions. The nurse expresses
concern to the charge nurse, who says the surgeons
o r d e r m u s t b e f o l l o w e d . H o w e v e r, t h e n u r s e i s n o t
comfortable with this and wonders what should be done.
MODELS of decision-making

CASSELLS and REDMAN (1989)

SITUATION
Mrs. L, a 67-year-old woman, is hospitalized with multiple fractures and lacerations
caused by an automobile accident. Her husband, who was killed in the accident, was taken
to the same hospital. Mrs. L, who had been driving the automobile, constantly questions
her primary nurse about her husband. The surgeon has told the nurse not to tell Mrs. L;
however, he does not give the nurse the reason for these instructions. The nurse expresses
concern to the Charge nurse, who says the surgeons order must be followed. However,
the nurse is not comfortable with this and wonders what should be done.

ACTION CONSIDERATIONS
1. Identify the moral aspects.
Whether to tell the truth or not?
Honesty and loyalty (moral principles)
2. Gather relevant facts that
relate to the issue Clients health problem information?
Who is involved? Nature of involvement? Motives
of actions (not known)
MODELS of decision-making

3. Determine for whom the

decision being made? Who should
decide and why?
4. Clarify and apply personal
values
5. Identify ethical theories and
principles
6. Identify applicable laws or
agency policies
7. Use competent interdisciplinary
resources
8. Propose alternative actions
Mrs. L values her husbands welfare, the charge
nurse values policy and procedure, the nurse
value a clients right to have information.
Autonomy? Beneficence?
The agency may not allow the nurse to follow the
doctors order (instructions rather than order)
Nurse might consult literature
Follow the charge nurse; possible outcome: Mrs.
L might become anxious and angry, wait Mr.s L
to recover
MODELS of decision-making
9. Apply nursing code of ethics
10. For alternative action, identify
the risk and seriousness of
consequences
11. Evaluate the action taken
If the nurse follows the charge nurse and
doctor?
If the nurse tells Mrs. L?
If the client is not satisfied the nurse can review
other alternatives and work through the process
again.
STRATEGIES TO ENHANCE ETHICAL DECISIONS
AND PRACTICE

BE AWARE OF YOUR OWN VALUE.

BE FAMILIAR WITH THE CODE OF ETHICS
RESPECT VALUES, OPINIONS, AND RESPONSIBILITIES

OF OTHER HEALTHCARE PROFESSIONALS

SERVE ON INSTITUTIONAL ETHICS COMMITTEE

STRIVE FOR COLLABORATIVE PRACTICE

PATIENTS BILL OF
RIGHTS
 Right to considerate and respectful care.
Right to obtain from his doctor complete current information about his diagnosis.
Obtain from his doctor complete current information about his diagnosis, treatment and
prognosis in terms patients can be reasonably expected to understand.
Right for complete and accurate information necessary to give informed consent prior to
start of procedure or treatment.
Right to refuse treatment .
Right to privacy.
Right confidentiality.
Right to expect that a hospital must take reasonable response for the clients request for
services, within the hospitals capacity.
Right to obtain information: any relationship of the hospital to other healthcare and
educational institutions concerning his care; human experimentation
Right to expect reasonable continuity of care.
Right to examine and receive an explanation of his bill, regardless of source.
Right to know what hospital rules and regulations apply to his conduct as a patient.
 Project

Using the following phases of the Nursing Care Process, create your own
diagram or illustration on how the process works. (50 points)

Assessing
Diagnosing
Planning
Implementing
Evaluating Criteria 10 5 2
Use of the following All of the items Some of the items All of the items
Rubrics phases given given were used in given were used in given were not used
the diagram the diagram in the diagram
Creativity The illustration is The illustration in The illustration do
creative some way shows not show creativity
creativity
Effectiveness of the The diagram shows The diagram The diagram
illustration exact process on somehow shows a doesnt show any
how NCP works process on how relevance on the
NCP works NCP
Reference

KOZIER, ERB G., BERMAN A., SNYDER S. (2004)

FUNDAMENTALS OF NURSING 7TH EDITION

UDAN FUNDAMENTALS OF NURSING