CHAPTER 5. Ethics
Kathryn Schroeter, PhD, RN, CNOR∗
Ethics, 60
Nurses as Advocates, 62
Approaches to Ethical Decision-Making, 64
Applications to Infusion Nursing Practice, 66
Ethical Practice for Infusion Nursing, 66
Summary, 69
In the current climate of health care reform, nurses may have difficulty with such ethical issues as patient rights, societal needs, and allocation of resources. Every day, nurses are asked to assist patients and families in dealing with ethical concerns. Since nurses work in an environment where patients are vulnerable, it becomes imperative that nurses be able to understand and articulate the ethical issues that surround their practice.
Bioethics is a branch of applied ethics that studies the philosophical, social, and legal issues that arise in medicine and the life sciences. It is no longer a topic that is discussed only from a philosophical perspective. The principles are being applied to everyday health care decisions and the importance is growing as the current practice changes. There may also be physiological responses that occur as a result of the stress incurred from the attempts by individuals to cope with their situations. Some ethical situations may evolve into legal battles as the perceptions of the patients, families, health care providers, and organization administrators may not always be in agreement. Nurses benefit from understanding and using ethical frameworks to better manage health care dilemmas.
In a report on the nursing shortage, the U.S. General Accounting Office (U.S. GAO) reported that nurses’ sources of dissatisfaction included poor working conditions such as inadequate staffing, heavy workloads, increased use of overtime, and lack of sufficient support staff (U.S. GAO, 2001). Perhaps, while not directly stated as such, these factors may be influenced by nurses’ experiences of moral distress, and this could further compound the current nursing shortage as nurses continue to leave the workforce.
Moral distress is a serious problem in nursing (Nathaniel, 2002). It may be a significant contributing factor to loss of nurses’ integrity and dissatisfaction with their work. It may also contribute to problems with nurse-patient relationships, and thus affect the quality, quantity, and cost of nursing care. Loss of nurses from the workforce is a compelling threat to patient care.
While nurses are often the first to become aware of patients’ ethical quandaries, they often feel unprepared or unqualified to deal with ethical decision-making. Nurses need useful, proactive, and relevant strategies in order to more effectively deal with ethical issues, and ultimately lead to improved clinical practice.
Nurses are responsible for nursing decisions that are not only clinically and technically sound but also morally appropriate and suitable for the specific problems of the particular patient being treated. The medical (technical) aspects of the decision answer the question, “What can be done for this patient?” The moral component involves patient wishes and answers the question, “What ought to be done for this patient?” (Schroeter et al, 2002).
This chapter is designed to educate infusion nurses about principles and applications for the effective management of ethical concerns and issues. By offering an overview of bioethics along with implications for the profession of nursing, this information both enlightens and enhances the professionalism of nurses by guiding decision-making and communication and promoting an understanding of current trends and practices.
ETHICS
As nurses are all too aware, there are ethical conflicts inherent to health care. An ethical conflict can be described as a presenting event that requires commitment to a single obligation when two or more genuine duties exist; the resultant outcomes have option-specific variability; and moral regret is a residual, demonstrative manifestation of the selection process (Beauchamp and Childress, 2001). It is also helpful to have a working definition of the terms “ethics” and “moral” even though they are often used interchangeably:
• Ethics: a mode of inquiry that helps one understand the moral dimensions of human conduct (Fry, 1989)
• Moral: overlaps with “ethical” but is more aligned with personal belief and cultural values (American Nurses Association [ANA], 2001)
Ethical behavior is an extremely complex phenomenon. It reflects society and how the actions of people living in groups affect each other. Discussions of ethics commonly divide the content area into thoughts, behaviors, and emotions. There are subsequent variables within the disciplines that impact ethical behavior. However, the relationships among these elements seem uncertain. The discipline of nursing, with its own history and evolution, has elements that both describe and impact nurses’ ethical reasoning and behavior.
ETHICS CODES
Fortunately, the profession of nursing has standards, practices, and an ethical code to provide some guidance for the discipline (ANA, 2001). According to the American Nurses Association (ANA), nurses have a duty to provide ethical care for patients, but also an ethical duty to care for self and family. The duty to care as an ethical component of the nurse-patient relationship can be inferred from the second provision of the ANA’s Code of Ethics for Nursing, which notes that the nurse’s primary commitment is to the patient (ANA, 2001).
At times, nurses must decide how, when, or if they should take action on behalf of a patient; whether to intervene if a professional colleague (nurse, physician, or other health care worker) is violating the rights of other individuals or is endangering patients; and how they can balance legitimate self-interest against the demands of the institution, patients, and physicians. A nurse must recognize that there is a duty to the patient, but also a duty to self. Professional nurses practice autonomously and also as members of the health care team. Nurses may find themselves in practice situations in which they are expected to conform to institutional routines and practices regardless of their views of appropriate courses of action for patient care.
While issues such as patient/human rights as evidenced in topics like end-of-life decision-making, do-not-resuscitate orders, informed consent, and the right to refuse treatment may be woven throughout, it may be true that some issues are more prevalent in certain nursing specialties than others. For example, end-of-life issues may be encountered more often in the intensive care, hospice, and oncology practice settings than in other outpatient environments. The issues may not only vary in intensity from practice setting to practice setting, but also there may be other factors that affect the nurse’s ability to address ethical issues.
According to Biton and Tabak (2003), work satisfaction is known to be one of the major factors related to nurses’ quality of care. They argued that professionalism, as manifested by the ethical code of practice, needs to be applied on a daily basis in the workplace. These researchers examined nurses’ perceptions of the everyday strains on their work to assess how they experienced the amount of energy invested in following an ethical code of practice. It has become vital that nurses know how to manage ethical decisions appropriately, so that patients’ rights can be honored without compromising the nurse’s own moral conscience.
In today’s climate of cost containment, nurses may feel pressure to “cut corners” in delivering care, to accept understaffing that they feel may jeopardize patient care, and to sacrifice their personal welfare and that of their families to work double shifts or forego earned days off when staffing problems arise. Whether the nurse is employed in a hospital, the community, a clinic, or a home, the employing institution exerts a significant effect on professional practice.
Over the years, the nursing profession has been increasingly articulate in declaring the need for nurses to have autonomy in their professional practice. Improved education and the broadening of nursing responsibilities have certainly contributed to increasing this autonomy. Professional organizations also stress that nurses’ primary responsibility is to their patients. Although they overtly promote the ideal of patients’ needs as their primary concern, institutions may actually expect nurses to be primarily concerned with the agency’s welfare. Incorporating the code of ethics into daily practice and understanding the issues are the beginning of comprehensive and competent nursing practice.
EXPLICATIONS FOR PRACTICE
Each specialty area of nursing practice takes the ANA’s Code of Ethics and derives explications for practice. Nurses who practice infusion therapy must develop knowledge and skill to analyze the ethical aspects of their specific care if they are to effectively fulfill their professional responsibilities. The code can serve as a starting point but there needs to be more understanding and knowledge to provide ethical nursing practice.
How, then, can the moral dimensions of infusion nursing be explained? The nursing literature consistently suggests that patient advocacy provides a model of professional nursing that is highly desirable. Patient advocacy is viewed as an essential component of the role of the professional nurse, but how does the nurse view the component of advocacy? Assuming the stance of a patient advocate involves acting on ethical principles and values.
Nurses in a variety of patient care settings, such as infusion nurses, are available to patients to hear their concerns and wishes. Nurses have always been on the front line and, in that position, are often the first to advocate for their patients. As patient advocates, nurses are in a position where they must act to secure patients’ safety, and this includes acting to prevent an impaired coworker from providing patient care while under the influence of substances such as alcohol or drugs.
However, some nurses who raise questions about ethical aspects of patient care with a physician or other health care provider may risk personal reprimand, verbal abuse, or disciplinary action within the institution or by the licensing board. Although physicians and other health care providers legitimately need nurses to carry out some medical aspects of patient care, they are not entitled to interfere with aspects of nursing practice that lie outside of their medical expertise, or to expect nurses to abandon their responsibility to patients and the institution because of a physician’s demands. This is a difficult position for nurses to be in and that is why most organizations have a confidential number or contact that employees can use to report unethical practice. Each nurse needs to be aware of the steps within an organization that are available to help deal with ethical issues in practice.
The traditional view that nurses must sacrifice personal and family interests and concerns to meet the demands of patients and the employing institution may occasionally place nurses in ethical dilemmas. A nurse could feel obliged to work extra shifts and holidays to such an extent that primary commitments to family members (e.g., spouse, children, aged parents) would suffer. In these situations, the nurse’s physical and psychological health and well-being could be impaired.
To the extent that nurses feel they cannot fulfill the expectations of society, they may also experience confusion and conflict about such activities as providing artificial feeding, resuscitating terminal patients, and engaging in other life-prolongingefforts when such efforts appear futile. Each nurse must personally reflect on the ethical issues that are evident in his or her own practice, and make a decision about how he or she can continue to practice without compromising individual moral and professional integrity. Whatever the cause, repeated violations of one’s integrity are harmful to oneself and, ultimately, to patient care. The whole reason for the existence of nursing is to contribute to the health of patients.
Furthermore, if nurses fail to comply with demands or cannot meet the expectations of others, they may suffer consequences in their personal and professional lives. Failure to act in accordance with one’s beliefs violates one’s conscience and places one in moral jeopardy. Unfortunately, the correct course of action is not always obvious. In addition, numerous other factors come into play, such as the seriousness of the violation of another’s rights and well-being; the harshness of the consequences for all concerned; and the scope of the nurse’s authority, control, and responsibility.
For example, if a nurse risks negative repercussions from the institution or the physician by fulfilling perceived obligations to the patient, he or she may be tempted to avoid the risk and act in self-interest and for self-protection. Failure to act in accordance with one’s conscience can cause acute discomfort and, as discussed later, can be very detrimental if it develops into an ongoing pattern of behavior. Conflicting demands and potentially serious consequences mitigate nurses’ moral responsibility for actions taken or avoided in a situation.
Nurses should not be required to be heroic in their disagreements with an institution, but rather need to develop a realistic view of others’ duties in ethical dilemmas and to recognize the limits of their own responsibility. The consequences to all parties involved should be considered before the nurse takes any action, and the nurse must make every effort to make sound ethical decisions before choosing a course of action. Incurring a reprimand or the displeasure of a colleague is a small price to pay for taking appropriate action.
However, extreme personal sacrifices, such as losing one’s job or facing legal or professional disciplinary action, should not ordinarily be required to maintain one’s moral integrity, unless the ethical violation involved is sufficiently grave to warrant such sacrifice. In other words, an important question to ask in nurses’ ethical decision-making may be, “How far must I go to resolve this situation?” In some cases the demands of other parties may be so unreasonable and the consequences of failure to comply with those demands so drastic that nurses may have to make a conscious choice about whether or not to continue to work in a given situation.
Fortunately, heroic sacrifice is not routinely required. Even if nurses cannot always successfully and openly confront issues, engaging in ethical analysis may clarify the issue and open the door for realistic efforts at resolution. In any situation, nurses can and must critically examine questionable health care decisions, analyze the constraints and contingencies involved, and ask for reasons or justification for actions taken. The nurse is not justified in standing by passively when ethical dilemmas arise.
In summary, the conflicting expectations of multiple roles (professional, employee, family member, and individual) place nurses in ethical dilemmas. Nurses may feel they are obliged to be “all things to all people” and are adversely affected when they are unable to please everyone in a given situation. Feeling caught between opposing duties is stressful and demoralizing for the nurse, who may retreat into inaction in an effort to escape psychological conflict.
Values and Valuing
To function as competent, caring, and professional health care providers, today’s nurses must use strategies that develop values into motivational and collaborative visions and goals. Values influence the relational and behavioral aspects of patient care and the functioning of organizations.
Nurses who understand how values impact on recruitment and retention can provide staff enrichment and enhance multidisciplinary partnerships. Aiken, Havens, and Sloane (2000) reported that the organizational context in which nurses practice is important. The values and ethics inherent to nursing are also inherent to creating a Magnet culture of nursing practice. The Magnet program designated by the American Nurses Credentialing Center (ANCC) recognizes those hospital facilities that foster an environment that attracts and retains competent nurses through respect for the values, art, and science of nursing. Magnet hospitals allow nurses to focus on patients, resulting in positive outcomes that can be directly attributed to nursing care.
Values are integral to creating a Magnet culture and can enhance the practice environment. The strength in understanding culture lies in the relationships that can be made between beliefs and values that are inherent to various cultures. Value and valuing are notions intrinsic to ethics, culture, and social behavior.
Within the nursing process, the nurse uses values that have been acquired through education and experience; these values are involved, perhaps unconsciously, in the day-to-day decisions the nurse makes about nursing practice. The values involved in the ethical decision-making process may not be obvious to the nurse. Many of these values have their origins in the nurse’s religious, cultural, and ethnic childhood experiences. They are an integral part of the nurse’s personality, and play a major role in the nurse’s intuitive response to ethical dilemmas encountered in practice. Furthermore, each nurse has a different value system. Many of the beliefs, assumptions, and attitudes that contribute to the value system may need to be examined systematically before they are put into action in ethical decision-making.
NURSES AS ADVOCATES
It is important to examine advocacy as a concept in its relation to the discipline of nursing since it presents as a common theme throughout the current literature. Primarily, it has been argued that the ethical constraint facing nurses is that they are not free to be ethical because they are dispossessed of the free action of moral agency, the ability to act independently for one’s patient(s).
In the discipline of nursing, advocacy is viewed as a duty or obligation. This relates to the ANA code statement (2001, p. 14) that “as an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice….” This duty arises from the nurse’s role as continual observer of the patient’s condition. Deontology, or duty-based ethics, prescribes actions to be done solely out of obligation. It is questionable whether such action(s) can be, or is (are), demonstrated consistently, and nurses may have differing perceptions of this concept.
ADVOCACY
The concept of advocacy reflects the confusion, and potential conflict, between the responsibility of nurses to support the patient as well as the institution, and also the need of nurses to support themselves. Empirical evidence is sparse and philosophical arguments prevail in the field of patient advocacy (Hewitt, 2002). There are other health care providers, such as physicians, social workers, and therapists, who fill the role of patient advocate.
Nurses follow their code of ethics and that directs them to be patient advocates; however, they may not always be working in partnership with other health care providers who are also advocates for the patient. As nurses collaborate with these other health care providers, they can involve them in the process of facilitating ethical decision-making and may promote improved patient care. Nurses may invite other health care providers to participate in family care conferences related to ethical concerns, or even in ethics consultation meetings that may occur within the sphere of patient care.
How can advocacy, as it relates to the role of the nurse, be described?Kohnke (1980) suggests that the nurse’s role as a patient advocate has three basic components: (1) to inform patients of their rights in a particular situation, (2) to ensure that patients are given all the information necessary to make an informed decision, and (3) to support patients in decisions they make. This research is reflective of what can be found in many hospital or health care organizational policies that address nursing care and responsibilities.
The third point in Kohnke’s definition may be perceived as relativistic in that it tells the nurse to support whatever the patient decides. This implies an “anything goes” philosophy of ethics, but the definition does not, however, reflect the concept of choice. The nurse still has the ability to choose whether or not to support the patient’s decisions. Some nurses can support patients’ decisions while other nurses cannot if there is too great a disparity between the decision and the nurse’s moral conscience.
Since patients and nurses are individuals, they may not have the same beliefs or values, but this does not necessarily mean that they must cross a line within their personal moral code that they do not wish to cross. If nurses are to value individuality and treat patients objectively and without judgment, then nurses may need to opt out of providing care in those situations where they feel ethically compromised.
An example of patient advocacy as identified in the role of the infusion nurse is described by Gorski (2008):
“I made a visit to a long term home infusion therapy patient whom I had never seen before. This patient was independent with fluid administration in management of her conditions including short bowel syndrome and malabsorption. The purpose of my home visit was to perform a routine monthly assessment to address any changes in condition and infusion needs. She immediately shared with me that she had a small crack in her Hickman catheter near the hub. This occurred when she accidentally forgot to open the catheter clamp during line flushing. She did not call the home infusion pharmacy but had sought help through her physician. The physician gave her a prescription to have the catheter repaired. She took the prescription to the outpatient department and was referred to the nurse who was known as the clinic’s infusion ‘expert.’ This nurse told her that her catheter was not repairable and that she would need to have it replaced…in terms of additional background to this case, the patient’s Hickman catheter was over one year old and the exit site looked good—other than the small crack near the hub—and that this patient had several catheters over quite a few years…and a previous physician was unable to place a catheter due to thrombotic changes in her vasculature… The patient voiced frustration because she still believed her line could be repaired. During the visit, I called and spoke to the clinic infusion nurse who was insistent that the catheter could not be repaired. The end result was that I ordered the appropriate repair kit through the home infusion pharmacy and successfully performed the procedure. Six months later, all continues to go well with this patient and her catheter and she was pleased to avoid another procedure.”
In this example the author discusses two infusion nursing standards—Standard 57: Access Device Repair; and Standard 7: Ethics (INS, 2006). The Infusion Nursing Code of Ethics related to standards of practice (INS, 2001) provides clarification and guidance for the nurse practicing in this specialty area. Key to note in the standard is the focus on advocacy for nursing practice. The standards stress that ethical principles shall be the foundation for decision-making and patient advocacy and that the principles of beneficence, nonmaleficence, fidelity, protection of patient autonomy, justice, and veracity shall dictate nursing action (INS, 2006). The nurse shall act as a patient advocate; maintain patient confidentiality, safety, and security; and respect, promote, and preserve human autonomy, dignity, rights, and diversity.
According to Gorski (2008), when the possibility of access device repair is considered, the RN must be competent in performing the procedure, and if the device is not repairable, it must be removed. Gorski suggests, however, that nurses may lack the knowledge that some catheters are repairable and that catheter damage is a relatively uncommon occurrence. Because much infusion therapy is provided by nurses and other health care providers who are not specialists in infusion therapy and who are not familiar with the Infusion Nursing Standards of Practice, we as infusion nurses must continually address this lack of knowledge (Gorski, 2008). While the infusion nurse has an ethical obligation to act as a patient advocate, his or her lack of knowledge may interfere with taking the necessary action. In the previous example, the clinic nurse might not have known that the catheter was repairable and, though she may have wanted to provide the best care possible for her patients, she was unable to consider the risks and benefits of catheter replacement. The potential benefits of catheter repair included avoiding a potentially difficult catheter replacement, the risks associated with another surgical procedure, disruption in the patient’s life, and the out-of-pocket costs to the patient as well as insurance costs. When objectively weighing the risks versus the benefits, the benefits of catheter repair outweighed the risks of catheter replacement (Gorski, 2008). Repairing the catheter was following the principle of beneficence, doing “good” for the patient, and, as such, being able to act as a patient advocate.
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