STUDENT NOTES ETHICS EXERCISE: Nursing Niceties 1: Fundamental Values and Commitments GENERAL OVERVIEW: The American Nurses Association's Code of Ethics for Nurses with Interpretive Statements (the ANA Code of Ethics) is designed to inform nurses of the values and behaviors idealized by their profession. These values help shape the culture of the nursing community and are designed to help you make ethical choices in your career as a nurse. This series of Ethics Exercises allows you to familiarize yourself with the ANA Code of Ethics in light of four different ethical perspectives and determine which responses not only agree with the ANA Code of Ethics, but also come from a specific value system. This Ethics Exercise in particular covers the ANA Code of Ethics Provisions 1-2, and is structured to instruct students in the basic fundamental values and commitments (respect and compassion for human dignity) of nursing. You may view the relevant Code provisions by going to the menu tab at the top of this Ethics Exercise. We have also added the same provisions to these Teaching Notes. THE ACTUAL ETHICS EXERCISE: The rest of this document provides the questions in the exercise. Learning Objective 1: Identify ethical values in tension. Barely Breathing (Values in Tension) Mrs. Brown is an 88-year-old woman with end-stage congestive heart failure. Due to the severe progression of her disease, she has been admitted to your hospital fourteen times during the past year. She is now so fragile that she becomes exhausted just getting in and out of her wheelchair. While you are completing her admission assessment, she is barely able to speak due to difficulty breathing. She grabs your arm and tells you, I can t do this anymore. I don t want to keep living this way. No one should have to suffer like this. Immediately, her daughter says, Mom, don t talk that way! You're going to get better. Mrs. Brown is a full code every possible measure available will be used to resuscitate her and she has a signed Medical Power of Attorney that designates her daughter. Consider and weigh the values in tension in the above situation. One choice would allow you to honor individual needs and preferences (the value of autonomy) while another option meets the needs and expectations of the community (the value of equality). Once you've identified the tensions that underlie a dilemma, you can begin to move toward ethical action. Questionable Consent (Values in Tension) Mr. Juarez, a 59-year-old patient, speaks limited English. You are the pre-op nurse, responsible for making sure all of the forms are signed before a patient goes in for surgery. Mr. Juarez is scheduled February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 1 of 8
for a procedure during your shift, but his informed consent still hasn't been signed. As you wait, the transporter calls and notifies you that they will pick him up in ten minutes. A few minutes later, Mr. Juarez's physician arrives. "I'm ready to begin," she says. "What's the holdup?" You explain the situation with the consent form and add that no Spanish translator is available. "We have other patients," the physician replies with a heavy sigh. Consider and weigh the values in tension of the above situation. On one hand, you want to follow the principles you've agreed to (the value of rationality) while, on the other, you want to meet the needs of the moment, requiring that the rules be excused in order to act with compassion (the value of sensibility). Once you've identified the tensions that underlie a dilemma, you can begin to move toward ethical action. Learning Objective 2: Recognize foundational ethical values as applied to Provision 1 of the ANA Code of Ethics. Closing the Curtain (ANA Code Provision 1.1/Foundational Values) Mr. King, the husband of one of your patients, comes to you with a complaint. Barely holding back his annoyance, he explains that the CNA who came in to bathe his wife kicked him out and closed the privacy curtain. I've been married to my wife for forty-eight years," he says. "Who does she think she is, kicking me out? I've been the primary caregiver for my wife for over a decade I'm accustomed to taking care of her and I know what I'm doing. I feel that my rights have been violated. Provision 1.1 of the Code respect for human dignity is one of the fundamental principles of the nursing profession. Nurses should have respect for the worth, dignity, and rights of every individual patients, family members, and coworkers alike. Consider how you might respond to Mr. King using the foundational values of the Rights/Responsibilities Lens (deontology). Those who favor this lens support individual rights and believe in following principles standards of behavior that can apply to everyone. According to this lens, if people manage themselves well by following those universal principles, everyone in the community will thrive. Staffing Situation (ANA Code Provision 1.2/Foundational Values) As you make your rounds, you overhear Bella, a fellow nurse, telling a patient, I'm really busy today and we're understaffed. Don't call me unless you urgently need something. Then, I promise, I'll get here as soon as I can. Bella then leaves before the patient even has time to respond. February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 2 of 8
The relationship between nurse and patient is addressed in Provision 1.2 of the Code. Nurses must establish relationships and deliver care with respect for each individual s needs and values, without prejudice. Consider how you might respond to this situation using the foundational values of the Results Lens (consequentialism). Those who use this lens believe that experience is the best teacher and support the freedom of individuals to pursue their own goals. This lens urges you to follow your heart in finding solutions, always in pursuit of the greatest good. Patients and Impatience (ANA Code Provision 1.3/Foundational Values) Mr. Romo is a thirty-two year old quadriplegic suffering from a Stage IV wound infection with osteomyelitis. He's also a bit of a problem. During his hospital stay, he's been angry and aggressive. He doesn t want his dressing changed and he shouts at the staff and calls them vulgar names when they come to do his wound care. As a result, many of the staff members have started refusing to care for him. Today, you saw someone leaving his room saying, I can t take it anymore! I am not going into that room again until he's gone. Sure enough, you could hear a tirade of insults still coming from Mr. Romo's room. Provision 1.3 of the Code calls on nurses to show respect for patients irrespective of the nature of the health problem. A patient s worth should not be affected by disease, disability, functional status, or proximity to death or by a foul temper. Consider how you might evaluate this situation using the foundational values of the Relationship Lens (justice theories). This lens focuses on rationality, believing that universal principles exist and apply equally to everyone, and equality, believing that ensuring the community s well-being through institutions is the best way to treat individuals fairly. If people follow rational processes to ensure that justice is done, the community will thrive. Making the Call (ANA Code Provision 1.4/Foundational Values) One of your patients, Ms. Petrovski, requests that her niece be present before she signs the informed consent form for a procedure. My niece knows best. She asked me not to sign anything without her being here, so we're just going to wait, she says. When the niece arrives, she says, I wasn t there when the surgeon talked to my aunt, and I don t understand all of the details of the procedure. Can you call the surgeon to explain it to me? You were in the room when the surgeon spoke to Ms. Petrovski, so you know the pertinent details. You also know that the surgeon has a tight schedule and may not be available to come speak to the niece. According to Provision 1.4 of the Code the right to self-determination patients have the moral and legal right to determine what will be done with their own person, to be given complete and February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 3 of 8
accurate information, and to be provided with the support necessary to make an informed decision about their care. Consider how you might evaluate this situation using the foundational values of the Reputation Lens (virtue ethics). This lens uses the values of sensibility and equality, urging you to examine each situation in its own context rather than unerringly following processes. Learning Objective 3: Compare ethical gifts with an emphasis on civility as applied to Provision 1 of the ANA Code of Ethics. Coarse Coworker (ANA Code Provision 1.5/Gifts) During your shift, you overhear a conversation between two nurses, Cora and Max. Cora is transferring a patient to Max's care and seems to be in a rush to get the handoff done. Max tries to slow her down and ask questions. As you watch, Cora rolls her eyes at each of Max's questions and makes exaggerated noises of annoyance. Finally, she snaps. "Everything you need is in the record, you idiot. Maybe you should just look it up instead of bothering me!" She then turns abruptly and walks off. Provision 1.5 of the Code addresses the need to create a culture of civility and respect. How you interact with patients is important, but how you interact with the people you work with can be equally important after all, your relationship with coworkers is likely to be longer than your relationship with any patient. Trust and cooperation are crucial among healthcare professionals. Consider how you might evaluate this situation using the Results Lens (consequentialism). The gifts of this lens move along three paths: Path of Intention: As you consider options for action, strive to make self-directed choices. You will then be motivated from within rather than responding to external rules and regulations. Path of Empathy: As you become comfortable with allowing people to make their own choices, you will be able to live with integrity in the face of ambiguity. Path of Integration: As you develop the flexibility to look at the past, the future, and also the present, you will bring optimism and enthusiasm to the table. Disparaging Doc (ANA Code Provision 1.5/Gifts) One of the nurses, Linda, comes to you with a complaint. "My patient, Mr. Nelson, was scheduled for surgery. He was up most of the night and only managed to get to sleep shortly before the 6:00 a.m. rounds," she explains. "When the CNA came in to take the patient's morning weight, I advised him to let Mr. Nelson rest and record the weight once he woke up. Well, not long after, the surgeon started snapping at me. He was in the hallway, yelling, 'I'm sick and tired of this incompetence. How hard is it to get a weight done before I show up? How am I supposed to make decisions without the information I need when I need it?' February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 4 of 8
"I'm not the only nurse who's been belittled by the physicians. On a good day, I can grit my teeth and take it, but not every day is a good day. How can we stop incidents like this?" Provision 1.5 of the Code addresses the need to create a culture of civility and respect. Creating that culture requires acting with kindness and knowing how to respond to the incivility of others. Consider how you might frame this situation if you were to bring it to the attention of your CNO using the values of the Relationship Lens (justice theories). The gifts of this lens move along three paths: Path of Intention: With your concern for fair processes, ensure that everyone s perspective is brought forward as decisions are being made. Remember each of the stakeholders involved and make sure they all have a voice. Path of Empathy: As you connect to the stakeholders, strive to make all feel important and included in the call for action. Thus, you ensure buy-in as the decision moves forward. Path of Integration: Seek to balance independence and interdependence as you generously give of yourself while expecting others to also carry their weight. Insulting Instructor (ANA Code Provision 1.5/Gifts) Wendy, a student nurse, seeks you out to report a problem she encountered during her education. "Ursula is my preceptor," she explains, "and she's a nightmare to work with. I was working with her the other day, doing wound care on the patient in Room 306. Frankly, I wasn't at the top of my game and I was asking Ursula a lot of questions. I wasn't sure how to measure the amount of tunneling and Ursula wasn't much help. So I stumbled a bit. Then, Ursula cut in: 'Don't be stupid,' she said, 'that isn't how you do it!' Then she grabbed the measuring device from me and did the assessment herself. I was taken aback even the patient was uncomfortable. He tried to calm the situation down, but I don t think he helped much. "I just want to do a good job, but I'm still learning. Ursula's destroying my confidence. I don't know what to do." Provision 1.5 of the Code addresses the need to create a culture of civility and respect. To help create such a culture, recognizing the effects of bullying or harassment is crucial. Collaboration is impossible if those without power are regularly belittled for mistakes and denied the opportunity to improve. Consider how you might evaluate this situation using the Reputation Lens (virtue ethics). The gifts of this lens move along three paths: Path of Intention: As you reflect on the traits of leadership, you can cultivate your personal virtues while being an effective part of the community. In the process, you will bring balance and perspective to the decision. February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 5 of 8
Path of Empathy: Show compassion and develop a sensitive conscience. You will then be able to articulate options for action that support both the community and individuals. Path of Integration: By taking the long view, you can bring gentleness and empathy to the conversation. Know that the world will not change overnight patience will win out. Learning Objective 4: Define ethical acts according to different ethical perspectives as applied to Provision 2 of the ANA Code of Ethics. Patient s Prerogative (ANA Code Provision 2.1/Definition of an Ethical Act) Mr. Thompson is a 52-year-old man who is about to undergo treatment for Stage 1 pancreatic cancer. The protocol for treatment at this stage is fairly routine, and cases such as Mr. Thompson s tend to be managed in a similar way. But nothing is ever quite so easy. When you talk to Mr. Thompson, he says, "My wife and kids want me to follow the standard procedure by the book, you know? But I'm just not sure. I'm the one whose health is at stake, not them. I've got a lot of questions about the options available to me..." Provision 2.1 of the Code looks at the primacy of the patient s interests. The primary commitment of a nurse is to the recipient of the health care services. The patient s uniqueness must be taken into consideration when creating a plan for care. Consider how you might respond using the definition of an ethical act according to the Rights/Responsibilities Lens (deontology). An act is ethical to this lens if it: 1. Fulfills your responsibilities; 2. Remains within your rights; and 3. Is done with care and concern for others. Wealthy Ward (ANA Code Provision 2.2/Definition of an Ethical Act) Laura has been admitted to a psychiatric facility for disruptive behavior and public loitering. She is the daughter of a wealthy and well-known family and has suffered from mental illness her whole life. She won t take her medication and repeatedly tells you she wants to get away from her family. Laura s mother comes to see you to discuss her daughter's treatment. "This has gone on long enough," she says. "You will give my daughter her prescribed antipsychotic, whether she wants to take it or not. Once she is lucid, she'll understand what had to be done and I'm confident she'll come home." The doctor treating Laura also tells you to give her the meds. "Now is not the time to upset the family," he says. "That girl's parents are loaded and they're expected to make a large donation to the hospital to fund research for mental illness. So let's avoid rocking the boat and just do what they say." February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 6 of 8
According to Provision 2.2 of the Code, conflicts of interest can arise in many professional scenarios. Nurses must strive to resolve these conflicts in ways that ensure patient safety, protect patient interests, and uphold the integrity of the profession. Consider how you might evaluate this situation using the definition of an ethical act according to the Results Lens (consequentialism). An act is ethical to this lens if it: 1. Has good results; 2. Creates the greatest happiness for the greatest number of people; and 3. Serves the greater good, resulting in harmony and satisfaction for many individuals. Swapped Meds (ANA Code Provision 2.3/Definition of an Ethical Act) During the morning shift change, the charge nurse on the night shift reports that there was a medication error the prior evening. Mrs. Jacobs received another patient's medication at 4 p.m., which has impacted her level of consciousness. An incident report was completed. The house physician assessed the patients and wrote orders related to the care of Ms. Jacobs. Ms. Jacobs's daughter notices the change right away when she visits. "What's going on?" she asks you. "My mom has never been this groggy before today. Has her condition gotten worse?" Provision 2.3 of the Code covers collaboration. Nurses are required to take an inter-disciplinary approach to the delivery of services in order to better address the health needs of patients and the public. Consider how you might evaluate this situation using the definition of an ethical act according to the Relationship Lens (justice theories). An act is ethical to this lens if it: 1. Creates a fair system for resolution of disputes; 2. Cares for all members and institutions of the community, especially in the allocation of resources and power; and 3. Contributes to each member of the community knowing that they are part of a larger whole. Excessive Care (ANA Code Provision 2.4/Definition of an Ethical Act) Nancy, one of the nurses on your shift who has only recently completed orientation, seems to show a special interest in Mr. Zane, a patient in your unit. Mr. Zane is regularly assigned to Nancy, and she spends more time with him than with other patients. She always rushes to his room when he buzzes for assistance, even if she is busy with other duties. Today, you noticed Nancy crying as you passed her in the hall. When you ask what s wrong, she says, Oh, it s nothing. Only I heard Mr. Zane might be moved to another hospital. February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 7 of 8
Provision 2.4 of the Code addresses professional boundaries appropriate limits to the many relationships in health care. The nature of the nursing profession has an inherently personal and intimate component that requires well-defined and properly maintained boundaries. Consider how you might evaluate this situation using the definition of an ethical act according to the Reputation Lens (virtue ethics). An act is ethical to this lens if it: 1. Is consistent with good character for your role; 2. Is made with an awareness of the interplay of mind and emotions; and 3. Supports and enhances the meaning you have given to your life. February 2016 Nursing Niceties 1: Fundamental Values and Commitments Page 8 of 8