VALUES, ETHICS, AND ADVOCACY

 

Values

Values – something of worth; enduring beliefs or attitudes about the worth of a person, object, idea, or action.  They are important because they influence decisions, actions, even nurse’s ethical decision making.

Value set   all the values (eg, personal, professional, religous) that a person holds

Value system   the organization of a person’s values along a continuum of relative importance; basic to a way of life, give direction to life, form basis of behavior

Beliefs   interpretations or conclusions that one accepts as true (based more on faith than fact)

• Judged by others as correct or incorrect
• Beliefs do not necessarily involve attitude.  Example:  “I believe if I study hard I will make good grades.”  Belief and value would be “Good grades are important to me and I believe I can make good grades if I study very hard.”

Attitudes   mental stance that is composed of many different beliefs; usually involving a positive or negative judgment toward a person, object, or idea

• Judged by others as being bad or good, positive or negative 
• They vary greatly among individuals.  Example:  some clients may feel strongly about their need for privacy, whereas others may dismiss it as important. 

Values Transmission

Values are learned through observation and experience. Therefore, they are influenced greatly by cultural, ethnic, and religious groups and by family and peer groups.  Example:  a parent consistently demonstrates honesty in dealing with others, the child will probably value honesty.  Our health beliefs are also learned this way.

American Association of Colleges of Nursing’s 5 Values Essential for the Nursing Professional Altruism – doing good, concern for others Autonomy – right to self-determination Human dignity – respect for the uniqueness of individuals and populations Integrity – honesty; acting in accordance with the code of ethics and standards of practice Social justice – working to ensure equal treatment under the law and equal access to quality health care

Personal Values

Personal values   values internalized from the society or culture in which one lives.  People need societal values to feel accepted, and they need personal values to have a sense of individuality.

 

Professional Values

Professional values   values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers

 

Values Clarification

Values clarification   a process by which individuals identify, examine and develop their own value

Raths, Harmin and Simon described a “valuing process”

•  Choosing (cognitive) – beliefs are chosen freely from alternative and reflection and consideration of consequences
•  Prizing (affective) – beliefs are prized and cherished
•  Acting (behavior) – chosen beliefs are confirmed to others, incorporated into behavior consistently in one’s life

Behaviors that May Indicate Unclear Values Ignoring a health professional’s advice.  Inconsistent communication or behavior  Numerous admissions to a health agency for the same problem  Confusion or uncertainty about which course of action to take

• Clarifying the Nurse’s Values
  • The student nurse needs to examine the values they hold  about life, death, health, and illness.  It is important for  the nurse to be aware of their own values so if helping a client they are not imposed on the client. 
• Clarifying Client Values
  • To plan effective care, the nurse needs to identify the client’s values as they relate to health problems.  If the client is unclear or has conflicting values the nurse can help guide the patient to clarify the client’s values by using the seven following steps: 
• 1.      List alternatives.     Are you considering other courses of action?  Tell me about them.                                         
• 2.      Examine possible consequences of choices.   What do you think you will gain from doing that? What benefits do you foresee from doing that? 
• 3.      Choose freely.  Did you have any say in that decision?  Do you have a choice? 
• 4.      Feel good about the choice.    Some people feel good after a decision is made, others fee bad.  How do you feel? 
• 5.      Affirm the choice.  How will you discuss his with others (family, friends)? 
• 6.      Act on the choice.   Will it be difficult to tell your wife about this?   
• 7.      Act with a pattern.   How many times have you done that before?  Would you act that way again?
• *  The nurse rarely if ever offers an opinion, and then only with great care or when they have expertise in a certain area.  The situation for the client will be different from the nurses situation.

ANA Standards of Professional PerformanceStandard 12: EthicsMeasurement Criteria Uses the code for nurses with Interpretive Statements to guide practice Delivers care in a manner that preserves patient autonomy, dignity, and rights Maintains patient confidentiality within legal and regulatory parameters. Serves as a patient advocate assisting patients in developing skills for self-advocacy. Maintains a therapeutic and professional patient-nurse relationship with appropriate professional role boundaries Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and others. Contributes to resolving ethical issues of patients, colleagues, or systems as evidenced in such activities as participating on ethics committees Reports illegal, incompetent, or impaired practices.

 

Morality and Ethics

Ethics   the rules or principles that govern right conduct    *** 2005 Gallop pole found that nurses have been  viewed as the most ethical profession ***

Bioethics   ethical rules or principles that govern right  conduct concerning human life or health

Nursing ethics   ethical issues that occur in nursing practice

Morality   a doctrine or system denoting what is right and wrong in conduct, character, or attitude

Law   A rule made by humans that regulate social conduct  in a formally prescribed and binding manner

¬  Nurses should distinguish between law and morality.

• An action can be legal but not moral:  An order for  full resuscitation of a dying client is legal, but one  could still question whether the act is moral.
• An action can be moral but not legal:  If a child at home stops breathing, it is moral but not legal to exceed the speed limit when driving to the hospital.

¬  Nurses should distinguish between morality and religion.

• Example:  some religions think it is acceptable to circumcise women, others think the ritual to be a violation of human rights

 

Moral Development

Moral development   process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done; the pattern of change in moral behavior with age

The moral development theorists are:

¬  Kolberg – emphasizes rights and formal reasoning   ¬Gilligan – emphasizes care and responsibility

Moral Frameworks

Moral theories provide different frameworks through with nurses can view and clarify disturbing client situations.  The following three frameworks are widely used:

1. Consequence-based (teleological) theories   the ethics of judging whether an action is moral
   1. Utilitarianism   a specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of persons; often used in making decisions about the funding and delivery of health care
   2. Utility   the principle of utilitarianism
   3. Principle-based (deontological) theories   emphasize individual rights, duties, and obligations
   4. Relationships-based (caring) theories   stress courage, generosity, commitment, and the need to nurture and maintain relationships

 

Moral Principles

Moral Principles are statements about broad, general philosophical concepts.  They provide the foundation for forming Moral rules – specific prescriptions for actions.  Examples:

• Moral principle – respect other people
• Moral rule – do not lie

Moral Principles that a nurse should follow:

Autonomy   right to make one’s own decisions because each person is unique.  People have “inward autonomy” if they have the ability to make choices; they have “outward autonomy” if their choices are not limited or imposed by others.

• Do not disregard a client’s statement about subjective symptoms they may be having
• Be sure the client gives “informed” consent

Nonmaleficence   the duty to do no harm

• Their is sometimes unintentional harm, such as; an adverse reaction to a medication, bruising a client that you held to tightly in order to keep him from falling, breaking a rib doing CPR

Beneficence   the moral obligation to do good or to implement actions that benefit clients and their support persons

• Doing good can also cause harm, such as; advising a client to do strenuous exercise, but he should for risk of a heart attack

Justice   fairness.  This is not always easy considering time constraints

• A home healthcare nurse must decide to stay with the current client, who is depressed, 30 more minutes, and have to reduce her time with the next client

Fidelity   a moral principle that obligates the individual to be faithful to agreements and responsibilities one has undertaken

• If a nurse says “I’ll be right back with pain medication”, she should do so or find an alternative for relief of the client’s pain

Veracity   a moral principle that holds that one should tell the truth and not lie

• Does a nurse tell a lie when it is known that the lie will relieve anxiety and fear?  The loss of trust in the nurse rarely justifies any benefits gained from lying.

Nurses should also have the following according to the Code of Ethics for Nurses by the ANA

Accountability   being responsible for one’s actions and accepting the consequences of one’s behavior

Responsibility   the specific accountability or liability associated with the performance of duties of a particular role or an obligation to complete a task.

• Thus, the ethical nurse is able to explain the rationale behind every action and recognizes the standards to which she will be held.

 

 

Nursing Ethics

JCAHO mandates the health care institutions provide multidisciplinary ethics committees (or like structures)to provide education, counseling and support on ethical issues.  These committees ensure:

• That relevant facts of a case are brought out ¬  Provide a forum in which diverse views can be expressed ¬  Provide support for caregivers ¬   Can reduce the institution’s legal risks

 

Nursing Codes of Ethics

Code of ethics   a formal statement of a group’s ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions

ANA Code of Ethic for Nurses (approved July 2001) The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development The nurse collaborates with the other health professional and the public in promoting community, national, and international efforts to meet health needs The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy. Inform the public about the minimum

The International Council of Nurses (ICN) and the ANA both have nursing codes of ethics.  They have the following purpose:

 standards of the profession and help them  understand professional nursing conduct.

1. Provide a sign of the profession’s commitment to the public it serves.
2. Outline the major ethical considerations of the profession.
3. Provide ethical standards for professional behavior.
4. Guide the profession in self-regulation.
5. Remind nurses of the special responsibility they assume when caring for the sick.

Origins of Ethical Problems in Nursing

• Social and Technological Changes
  • Social – growing consumerism, women’s movement, large number of people without health insurance, workplaces redesigned under managed healthcare, issues of fairness and allocation of resources
• Technology – extending life with monitors, respirators, and parenteral feedings, saving extreme premature babies, definition of death  associated with organ transplants, cloning, tem cell research
• Conflicting Loyalties and Obligations
  • Loyalties and obligations may be conflicted  between; * the client, * the client’s families,  * the physician, * the employing institution, and * licensing bodies.  Nursing code of ethics states that the nurse’s loyalty must always lie with the client, but it is the determination of which action best serves the needs of the client that is sometime difficult
• Example – should the nurse tell her client that marijuana can help with nausea
• Example – should the nurse honor a picket line

 

Making Ethical Decisions

Many nursing problems are not ethical problems at all, but simply questions of good nursing practice.  Therefore, you should decide if an ethical situation exists.  The following criteria may be used:

• I  A difficult choice exists between actions that conflict with the needs of one or more persons.
• I  Moral principles or frameworks exist that can be used to provide some justification for the action.
• I  The choice is guided by a process of weighing reasons.
• I  The decision must be freely and consciously chosen.
• I  The choice is affected by personal feelings and by the particular context of the situation.

If the problem is an ethical one, then, remember that responsible ethical reasoning is rational and systematic.  A good decision is one that is in the client’s best interest and at the same time preserves the integrity of all involved.  Two ethical decision-making models follow:

Thompson and Thompson Model (1985) Review the situation to determine health problems, decision needs, ethical components, and key individuals Gather additional information to clarify the situation. Identify the ethical issues in the situation. Define personal and professional moral positions. Identify moral positions of key individuals involved. Determine who should make the decision. Identify range of actions with anticipated outcomes. Decide on a course of action and carry it out. Evaluate/review results of decision/action.

Cassells and Redman Model (1989) Identify the moral aspects of nursing care. Gather relevant facts related to moral issue. Clarify and apply personal values. Understand ethical theories and principles. Utilize competent interdisciplinary resources. Propose alternative actions. Apply nursing codes of ethics to help guide actions. Choose and implement resolutive action. Participate actively in resolving the issue. Apply stat and federal laws governing nursing practice. Evaluate the resolutive action taken.

 Being involved in ethical problems and dilemmas is stressful for the nurse.  A good support system should be established such as team conferences and use of counseling professionals to allow expressing of their feelings.

Strategies to Enhance Ethical Decision and Practice

The following strategies should be taken by a nurse to overcome the moral distress on the job:

• Become aware of your own values and ethical aspects of nursing.
• Be familiar with nursing codes of ethics.
• Seek continuing education opportunities to stay knowledgeable about ethical issues in nursing.
• Respect the values, opinions, and responsibilities of other health care professional that may be different from your own.
• Serve on institutional ethics committees.
• Strive for collaborative practice in which nurses function effectively in cooperation with other health care professionals.

Specific Ethical Issues

Acquired Immune Deficiency Syndrome (AIDS)

• The ANA’s position on AIDS – the moral obligation to care for HIV-infected client cannot be set aside unless the risk exceeds the responsibility.
• Should health care providers and clients be mandatory?  If so, should the results be released to insurance companies, sexual partners, or caregivers?

Abortion

• The debate continues between the sanctity of life and the right for a woman to control her own body.
• Conscience clauses give the caregiver the right to refuse to participate in abortions, but they cannot impose their values on the client.  The client has a right to be educated about all choices

Organ Transplantation

• Who deserves to be on the lists for possible transplants? Should organs be sold?  Should parents have children just to harvest an organ for another child?  What is the clear definition of death pertaining organ donators?  Is there a conflict of interest between the potential donor and recipients?  There are religious conflicts with both donating and receiving of organs.

End-of-Life Issues

• Advance Directives
  • All 40 states have enacted advance directive legislation.  Having the client complete these saves many moral and ethical decisions.
• Euthanasia and Assisted Suicide
  • Euthanasia, a greek word meaning “good death”
  • Active euthanasia – actions that directly bring about the client’s death with or without consent. This is forbidden by law (especially for the caregiver).
  • Assisted suicide – a form of active euthanasia in which clients are given the means to kill themselves. This is legal in Oregon. 
  • The ANA states that both active euthanasia and assisted suicide are in violation of the Code for Nurses.
  • Passive euthanasia   allowing a person to die by withholding or withdrawing measures to maintain life (aka withdrawing or withholding life-sustaining therapy [WWLST]).  This is both legally and ethically more acceptable to most persons than assisted suicide.
• Termination of Life-Sustaining Treatment
  • Nurses must understand that a decision to withdraw treatment is not a decision to withdraw care.  As the primary caregivers, nurses must ensure that sensitive care and comfort measures are given as the client’s illness progresses.
• Withdrawing or Withholding Food and Fluids
  • A nurse is morally obligate to withhold food and fluids (or any treatment) if it is determined to be more harmful to administer then than to withhold them.  The nurse must ablos honor competent and informed clients’ refusal of food and fluids.

Allocation of Scarce Health Resources

• The moral principle of autonomy cannot be applied if it is not possible to give each client what he or she chooses.  In this situation, health care providers may use the principle of justice – attempting to choose what is most fair to all.
• Some nurses are concerned that staffing in their institutions is not adequate to give the level of care they value.  California is the first state to enact legislation mandating specific nurse-to-client ratios.

Management of Personal Health Information

• Keeping the client’s privacy is both a legal and moral mandate.  The client must be able to trust that the nurses will reveal details of their situations only as appropriate for the health care.  Nurses should help develop and follow security measures and policies.

 Advocacy

Advocate   individual who pleads the cause of another or argues or plead for a cause or proposal

Values Basic to Client Advocacy The client is a holistic, autonomous being who has the right to make choices and decisions. Clients have the right to expect a nurse-client relationship that is based on shared respect, trust, collaboration in solving problems related to health and health care needs, and consideration of their thoughts and feelings. It is the nurse’s responsibility to ensure the client has access to health care services that meet health needs.

Patient’s Bill of Rights Act of 2004 – guarantee of certain rights under their health insurance plans Basic standards for access to care, including clinical trails. The ability to gain access to their own doctor, and doctor’s ability to communicate with the client without fear of insurance company retaliation. The assurance that medical decisions about the client care will be made by doctors according to sound medical principles. A fair, independent external review process if needed care is denied by their insurance company. The right to hold their health plan accountable if a negligent medical decision resulted in injury or harm.

 The Advocate’s Role

The overall goal of the client advocate is to protect client’s rights.  She does this by:

• Informing client’s of their rights
• Providing them with the information they need to make informed decisions
• Supports client’s in their decision giving the responsibility in the decision making when capable
• Remains objective and does not convey approval or disapproval of client’s choices
• Is accepting and respectful of the client’s decision, even if the nurse believes the decision to be wrong
• Intervenes on the client’s behalf, often influencing others

Advocacy in Home Care

• The client reverting to own personal values at home must, nevertheless, still have his autonomy respected.
• Financial considerations can limit the availability of services and materials, making it difficult to ensure the client needs are met.

Professional and Public Advocacy

• Gains made in developing and improving health policy at the institutional and government levels help to achieve better health care for the public.

Being an effective advocate involves:

• Being assertive
• Recognizing that the rights and values of client and families must take precedence when they conflict with those of the health care providers
• Being aware that conflicts may arise over issues that require consultation, confrontation, or negotiation between the nurse and administrative personnel or between the nurse and primary care provider
• Knowing that advocacy may require political action – communicating a client’s health care needs to government and other officials who have authority to do something about these needs.