Purpose and Evolution of the Code and Provisions 13 Nurses and Patients Slide Deck 1 2015 American Nurses Association Provisions 13 Nurses and Patients What do we mean by nurses and patients ID: 784634
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Slide1
© 2015 American Nurses Association
Slide2Purpose and Evolution of the Code and Provisions 1-3, Nurses and Patients
Slide Deck 1
© 2015 American Nurses Association
Slide3Provisions 1-3, Nurses and PatientsWhat do we mean by nurses and patients?
Provisions 1-3 address direct patient care and describe the most fundamental values and commitments of the nurse.
3
Slide4Scope of Nursing Ethics
Unless separately referenced, all content comes from
ANA’s Code of Ethics for Nurses with Interpretive Statements,
2015 (“the Code”) OR Fowler, M. D.M. (2015).
Guide to the code of ethics for nurses: Development, application, and interpretation
(2
nd
Ed.). Silver Spring, MD: American Nurses Association.
*All images are public domain under the Creative Commons license and were retrieved from http://
pixabay.com/en/.The question mark icon throughout indicates a discussion point or question to engage in dialogue.
4
Slide5What Is Ethics?
A specialized area of philosophy dating back to ancient Greece and earlier
Concepts of Hippocrates still inform today’s ethical issues.
A systematic study of what is right and good measured against principles, virtues and core values of a profession.
5
Slide6Scope of Nursing Ethics
Deals with:
Character
(what sort of person one ought to be)
Conduct
(how one should act)
Deals with duties and obligations of nurses to:
Patients
Other health professionals
The profession
The wider publicGlobal humanity
6
Slide7Why Ethics in Nursing?
Because
nurses
…
Serve vulnerable persons
Promise to protect patients
Impact patient well-being
Depend on public trust
Have a moral relationship with
patients that gives rise to ethical obligations
7
Slide8Personal Values and NursingMorality comprises personal values, character and conduct
.
Those entering nursing bring moral values stemming from:
Religion, culture, family, education, life
experience
Embedded moral values are a starting point for ethical behavior and personal integrity.
As nursing core values are learned and practiced, they are integrated with personal values to create a nursing moral identity.
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Slide9Branches of Ethics
METAETHICS
Theoretical
thinking about morality
NORMATIVE ETHICS
What
is right/wrong, good/evil
individual
or collective
choicesAPPLIED ETHICSRight/wrong, good/evil of actions in a specific profession or discipline9
Slide10What Is an Ethical Code?
An
ethical code is an identifying feature of a profession
to:
Facilitate professional self-
regulation and accountability
Describe obligations of client-professional and colleague-to-colleague relationships
Serve as a guide for analysis,
decision
and action
10
Slide11ANA’s Code of Ethics for Nurses with Interpretive Statements (“the Code”)
Conveys shared
ethical values, obligations,
duties and ideals of nurses individually and collectively
Provides an implied contract with the public
Informs society of the moral values and ideals by which it functions
Informs new professionals of the expected moral behaviors
Guides the profession in self-regulation
Provides a framework for ethical decision-making
Is unapologetic, aspirational and nonnegotiable11
Slide12Legacy of the CodeCommitment
to service is the most precious ideal of the nursing profession
.
The Code supports ideals of nursing’s service
.
The Code guides all nurses in living out the values and ideals of the profession
.
The Code is a living, ongoing legacy of core values from Florence Nightingale
in 1850
to 2015 and beyond.12
Slide13Evolution of the Code1893: “Nightingale Pledge
”
1926
: Suggested Code in the American Journal of Nursing (AJN)
1940
: Tentative Code,
AJN
1950
: The Code adopted by
ANA1956, 1960, 1968, 1976, 1985, 2001: Revisions of the Code2015: Major revision of the Code
13
Slide14Maturation of the CodeThe Code was
first adopted in 1950;
it was periodically
updated to reflect the changing context and practice of nursing.
Early versions stressed
Nurse’s obligation to carry out physician’s orders
Rules of conduct, moral character, hygiene
Duty with skill and moral
perfection
Later versions stressedPrinciples, especially respect for patient autonomy
Nurse’s obligation to the patient, including protection from incompetent, unethical or illegal practice
14
Slide15Structure of the CodePrefaceIntroduction
Provisions 1-3 with Interpretive
Statements: Nurses
and Patients
Provisions 4-6 with Interpretive
Statements: Boundaries
of Duties and Loyalty
Provisions 7-9 with Interpretive
Statements: Commitments
Beyond Individual Patient EncountersAfterwordGlossaryTime line: The Evolution of Nursing’s Code of EthicsNote
: The Interpretive Statements for each provision provide more specific guidance for practice, are responsive to the contemporary context of nursing, and recognize the larger scope of nursing’s concern in relation to health.
15
Slide16Emphasis of the CodeAll nurses, all roles with various scopes of practice and settings
Relationship with other caregivers, including unlicensed personnel
Increasing diversity of patients and nurses
Wholeness of character
: Nursing as a lifetime
endeavor;
core values and dispositions pervading all aspects of life
16
Slide17Revision ConsiderationsNot lightning rod for controversial, divisive public debate
Not political
Timeless language, no
buzzwords
that outdate
Succinct, clear, and understandable to students and new nurses
Useful to all nurses in all roles and settings
17
Slide18Nursing Is Value Laden
Caring for those suffering in the most vulnerable moments of
life:
Finding meaning
Bearing witness
Facilitating healing
Being present
Expressing
caring
18
Slide19Ethical TheoriesNursing draws from many ethical theories, including:
Kantian
Normalism
Utilitarianism
Virtue Ethics
Ethic of Caring
The Code functions at mid-range
Any of these theories can be used “behind” the Code
19
Slide20The nurse practices with compassion and respect for theinherent dignity, worth and unique attributes of every
person.
Interpretive Statements
1.1
Respect for Human Dignity
1.2
Relationships With Patients
1.3
The Nature of Health
1.4 The Right to Self-Determination1.5
Relationships With Colleagues and Others
20
Provision 1
Slide21Patient dignity is the foundation of nursing ethics.Dignity is inherent, not “earned.”A patient
never
loses dignity, e.g., when comatose, delirious, frail, or in an altered state.
A nurse must approach every patient with respect for dignity, regardless of personal attributes, health state, or any other situational or patient variable.
Source: Ferrell, B.R., & Coyle, N. (2008).
The nature of suffering and the goals of nursing
. New York, NY: Oxford University Press.
21
1.1 Respect for Human Dignity
Slide2222How would you react
?
If you had to care for a hospitalized terrorist who injured himself while bombing your hometown…
h
ow does the Code guide you?
Slide23TrustHonoring patient choices, even when riskyHow would you react?
If a patient is self-harming by cutting to soothe anxiety, is this an autonomous choice? Should you stop the patient?
How does the Code guide you?
23
1.2 Relationships With Patients
Slide24Care shaped by patient preferences, needs, values, choicesEvidence provides the science of options; patient particulars help choose the options
24
1.3 The Nature of Health
How would you react?
Can you refuse to care for an Ebola patient to avoid risking your own health?
How does the Code guide you?
Slide25Patients have a right to decide for themselves.The patient, and decisions made by the patient, are to be respected regardless of personal attributes of the patient, conflicting values, or circumstances.
25
1.4 The Right to Self-Determination
Slide26Elements of informed consent:Capacity to decidePertinent, understandable informationVoluntary decisionAssent if a minor
Advance directives:
Living will, five wishes, DPAHC
If declared by court “incompetent” to decide:
Incompetence is a legal/court decision
Power of attorney or next of kin
Substituted judgment
Best interest standard
26
Informed Consent for Treatment
Slide27IndividualResident in LTCConsumer in mental health
Client
Recipient of care
FamilyGroup
Community
Population
27
Who Is the Patient?
Slide28Respect for autonomyThe patient, if competentIf family disagrees with the patient…Are family goals realistic? How do you know?
What about futile treatment recommended by doctor?
If family members disagree among themselves, who arbitrates?
If family makes decision that conflicts with physician’s orders, who arbitrates?
28
Who
Is
the Final Decision-Maker?
Slide29Age: Infant, childComatoseDevelopmentally disabledDementia, hypoxia, OBS, head injury Cognitive impairment from drugs, alcohol
Setting constraints: prisoners, students, patients
29
Compromised Autonomy
Slide30Self-determination depends on awareness of decisions to be madePatient’s ability to comprehend treatment options may be impaired by:
Cognitive capacity
Literacy, language proficiency, or educational level
Visual or hearing impairment
Anxiety in presence of health professionals
F
ear
Important to assess patient’s understanding of treatment options and implications
30
Health Literacy
Slide31Under
31
Protection
Paternalism
Negligence
Balance
Over
Slide32Nurses must live with their own conscienceAdequate ethical justification for decisions and actions to sleep at night
Principles can only go so far
Clinical judgment is in the end situational, contextual and personal
Ethical decisions always entail ambiguity and uncertainty
32
At the End of the Day…
Slide33“Nurses may not act with intent to end life even though such actions may be motivated by compassion, respect for autonomy or quality of life considerations.”
Autonomy to accept, refuse, or terminate care:
Foregoing nutrition and hydration
Withholding or withdrawing life-sustaining treatment
Honoring advance directives
33
Interpretive Statement 1.4
Slide34Nurse may administer medications with the intent of reducing symptoms of dying, even though the secondary impact may decrease respirations and perhaps hasten deathThe nurse’s actions do not cause the death, the terminal illness causes the death
34
Doctrine of Double Effect
Slide35InterdisciplinaryAll colleagues, including unlicensed personnel
Inter-professional
All licensed colleagues (medicine, pharmacy, social workers, dieticians, PT, OT, RT, etc.)
Trans-professional
Licensed colleagues working together on a team across fields of expertise
35
1.5 Relationships
With
Colleagues and Others
Slide36Cultivate civility, collaboration, and collegiality to
e
nsure:
Safe, quality patient care and outcomes
Compassionate, transparent, effective health services
A hospitable work environment
36
Create a Culture of Respect
Slide37The nurse’s primary commitment is to the patient, whether an individual, family, group,
community or
population
.
Interpretive Statements
2.1
Primacy of the Patient’s Interests
2.2
Conflict of Interest for Nurses2.3 Collaboration
2.4 Professional Boundaries
37
Provision 2
Slide38Engagement, trust, intimacy, presenceBased on covenant relationship, existential encounter, response to vulnerabilityRespond in the here and nowAttentiveness
Responsibility
Competence
Responsiveness
38
2.1 Primacy of the Patient’s Interests
Slide39Contextual variables shiftDecision-making never static or completeApproach may beToo broad/too narrowToo hasty/too delayed
Too constrained/too flexible
Too conventional/too visionary
Too reductionist/too expansionist
Too technical/not caring enough
39
Anticipate Nuances
Slide40When patient interests collide with those of others (family members, physician), the nurse’s primary commitment is to the patient.A nurse helps resolve such conflicts, so patient wishes may be honored.
40
Conflict Resolution
Slide41If a nurse stands to gain personally from a clinical situation, a conflict of interest exists.Disclosure of such a conflict to all involved is expected.Professional integrity may be damaged if a nurse does not withdraw from a conflict of interest.
41
2.2 Conflict of Interest for Nurses
Slide4242
“There comes a point in analysis of every ethical dilemma when people finally know what is right and what is wrong, regardless of analytical reasoning.”
-
George Annas, Law Professor
Slide43Trust, respect, transparencyVoicing ethical opinionShared decision-making“Community of moral discourse”Equipping patients with the information, resources and courage to participate in mutual decision-making
Shared responsibility for outcomes
43
2.3 Collaboration
Slide44Intensely personal work with vulnerable patients may generate emotional attachmentsGifts generally not appropriateWithdraw from problematic boundary situations with colleagues
44
2.4 Professional Boundaries
Slide45The
n
urse promotes, advocates for, and protects the rights, health, and safety of the patient.
Interpretive Statements
3.1
Protection of the Rights of
P
rivacy and Confidentiality
3.2
Protection of Human Participants in Research
3.3 Performance Standards and Review Mechanisms3.4
Professional Responsibility in Promoting a Culture of Safety
3.5
Protection of Patient Health and Safety by Acting on Questionable Practice
3.6
Patient Protection and Impaired Practice
45
Provision 3
Slide46Policies and practices in an age of technologyHIPAA: Adhere to federal and state regulations
Facebook
:
Completely off limits for patient photos or identifying information
Caring Bridge:
Patients decide, nurses should not engage
Electronic Health Records:
Only shared with those directly involved in care
46
3
.1 Protection of the Rights of Privacy and Confidentiality
Slide47Institutional Review Board (IRB) approval of relevant research proposalVoluntary participation of participantsNo coercion, deceitInformed consent documentedRight to withdraw at any point with no untoward consequences
47
3.2 Protection of Human Participants in Research
Slide48Fetuses and human embryosPregnant womenChildren and minorsCognitively impaired personsPrisoners
Traumatized and comatose patients
Terminally ill patients
Elderly/aged personsEconomically or educationally disadvantaged persons
Underserved populations
48
Special Consideration for Vulnerable Subjects
Slide49Demonstrate ongoing knowledge, skills, dispositions and integrity for competence in practiceAssume accountability for current, quality nursing practice according to national, state, and institutional standards
49
3.3 Performance Standards and Review Mechanisms
Slide50Avoid or reduce errorsDo not conceal errorsCorrect or treat errorsUse chain of authority when reporting a problemProvide timely responsive communication
Document
50
3.4 Professional Responsibility in Promoting a Culture of Safety
Slide51If a nurse observes a violation of law, policy, or ethical standards that could jeopardize patient safety…
51
3.5 Protection of Patient Health and Safety by Acting on Questionable Practice
What guidance does the Code provide?
What ANA position papers provide additional guidance?
What other policies or procedures need to be followed?
Slide52When impaired practice is suspected, patient safety may be jeopardizedIdentify colleagues whose practice may be impaired or who are placing patients at risk
Follow chain of authority with compassion and caring so remediation and recovery may follow
Access employee assistance program for help
52
3.6 Patient Protection and Impaired Practice
Slide5353What Will Guide Your Moral Compass?