Provision Three
John G. Twomey PhD, PNP
John G. Twomey, PhD, PNP, is an Associate Professor at the Graduate Program in Nursing at the MGH Institute of Health Professions in Boston, Massachusetts. Dr. Twomey’s doctoral work was in bioethics. He teaches bioethics and research and serves on several human subjects research protection committees. He has completed two National Institute of Nursing Research-supported postdoctoral fellowships in genetics. A member of the International Society of Nurses in Genetics, he does research in the area of the ethics of genetic testing of children. He is the editor of the Ethics Column in the Society’s quarterly newsletter.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
As a modern document, the 2001 Code of Ethics tends to be less directive than other professional codes. A review of the codes of ethics of other allied health professionals (for example, physical therapists and speech and language specialists) reveals that these professions tend be much more prescriptive in language about what is allowable or discouraged behaviors in their respective health professions. This can cause some questioning from nurses who believe that a code of ethics should be rather directive. The Code of Ethics Task Force deliberately created a code that focused on moral concepts that undergird the profession and did not attempt to make statements that would bind the individual nurse in all situations to a single course of action.
Even a deliberative document that states as its goal the provision of a moral framework must provide some specific behaviors for the members to consistently adhere to. In Provision 3, the reader will find language and some guidelines for the nurse who is working in any practice arena.
The Task Force recognized that, even in a document that was fairly revolutionary in its writing, it was necessary to bring forward concepts and language that the members of the profession would recognize from the last and previous Codes. More importantly, the authors had to honor many of the traditional moral beliefs and behaviors that nurses had been taught and were familiar with. So in this provision, concrete terms are used with updated nuances in the interpretive statements. Concepts such as protection of privacy and concern for subjects in healthcare research, as well as the professional values nurses have developed regarding dealing with impaired colleagues are taken from their separate places in the 1985 Code and grouped together here in Provision 3.1
To begin with, what are unifying concepts that help fit Provision 3 and its interpretive statements properly into the Code? First of all, the title of the Provision contains language that focuses the nurse’s actions on encounters with patients. This Provision finalizes the process begun in Provisions 1 and 2, declaring to all
that the ultimate moral duties of professional nurses involve working with people who need nursing care. The first three Provisions reiterate what nursing, through the American Nurses Association, has been stating for decades: When individuals need nursing care, only a professional registered nurse is educationally and morally capable of providing such care. This is a claim that can be traced directly back to Florence Nightingale and her successors, such Adelaide Nutting, Lavinia Dock, and others. Thus, our updated Code serves to link nurses practicing in the 21st century to our roots two centuries ago.2
that the ultimate moral duties of professional nurses involve working with people who need nursing care. The first three Provisions reiterate what nursing, through the American Nurses Association, has been stating for decades: When individuals need nursing care, only a professional registered nurse is educationally and morally capable of providing such care. This is a claim that can be traced directly back to Florence Nightingale and her successors, such Adelaide Nutting, Lavinia Dock, and others. Thus, our updated Code serves to link nurses practicing in the 21st century to our roots two centuries ago.2
But historical traditions need some substance that is recognized by the profession and its members if the legacy given to us is going to be meaningful in today’s practice. The conceptual model that Provision 3 follows is one that nursing has embraced for many years. The phrase used in this provision “to protect” is deliberately chosen because of its recognized place in nursing practice. As the nursing profession matured in the second half of the 20th century, its members embraced the concept of protection as a core part of nursing. The Task Force wanted to be very particular in its use of terms around protection. Once assumed to be defined within the concept of advocacy, the concept of protection is expanded in Provision 3 to include all patients. This concept is extended to not just those with diminished health capacities, but to all who encounter the nurse and need assistance to protect their universal health needs, including but not limited to protection of information, need for education about health, and protection from those healthcare providers who are incompetent and/or impaired. So protection takes on a comprehensive definition within the Code.
Before moving on to a discussion of each interpretive statement, there must also be some mention of the ethical basis for the ideas in the provision, as well as the overall values reflected within the concept of protection. The 2001 Code uses a variety of ethical theories and concepts to reflect the diverse moral beliefs that American nurses bring to their practice. Despite this diversity, there are some unifying themes that will be described within this reader. Provision 3 reflects the bioethical theory based on the use of principles.3 This approach is probably the most widely used approach to bioethics among clinicians in the Western world and its specific primary principles are widely embraced in clinical practice and often by institutional bioethics committees as well. While the concept of protection fits well within the principle-based system, the reader must be clear about how a specific principle supports protection as it is described in the 2001 Code.
While many nurses would recognize the principle of nonmaleficence, which is often articulated as the duty of “the noninfliction of harm,” it would be incorrect to attribute this principle as the theoretical root of Provision 3. Instead, the ethical
principle of respect for autonomy drives this provision. Provisions 1 and 2 define a basic part of the nurse-patient relationship as respect for individuals, their dignity and worth. The moral foundation for this respect is grounded in the basic value of human dignity and in this sense the individual characteristics of the patient are irrelevant. All persons have worth and dignity. Indeed, what the nursing profession wants its members to do as part of this respect for autonomy is to preserve and safeguard it. An essential piece of autonomy is that those who possess it do so because they have, have had, or will develop the capacity to make decisions for and about themselves. Respect for autonomy is necessary because the nature of health and threats to it mean that the capacity to remain autonomous does not always remain fully intact. So Provision 3 uses a principled approach, through its protection of and respect for autonomy, as its ethical basis.
principle of respect for autonomy drives this provision. Provisions 1 and 2 define a basic part of the nurse-patient relationship as respect for individuals, their dignity and worth. The moral foundation for this respect is grounded in the basic value of human dignity and in this sense the individual characteristics of the patient are irrelevant. All persons have worth and dignity. Indeed, what the nursing profession wants its members to do as part of this respect for autonomy is to preserve and safeguard it. An essential piece of autonomy is that those who possess it do so because they have, have had, or will develop the capacity to make decisions for and about themselves. Respect for autonomy is necessary because the nature of health and threats to it mean that the capacity to remain autonomous does not always remain fully intact. So Provision 3 uses a principled approach, through its protection of and respect for autonomy, as its ethical basis.
Privacy and Confidentiality: Interpretive Statements 3.1 and 3.2
The first two parts of this provision refer to safeguarding information. In the prior two versions of the Code, the concept of protecting the patient’s personal information had been given an entire provision. Because the Task Force wanted to emphasize the concept of protection, it expanded the provision containing this concept to include situations where the need for safeguarding the patient may occur. This expansion resulted in Provision 3 being the longest in the 2001 Code.
To emphasize the complexity of protecting patient information, the definitions of privacy and confidentiality are separated and explained. Privacy relates to those aspects of a patient’s life and information that he or she can control. It is that control that the nurse is charged with helping to preserve. Honoring a patient’s privacy can be as simple as only asking questions that are clinically relevant, but can also extend to constructing policies that maintain privacy, such as hospital environment policies. Confidentiality is a term that refers to making sure that once a patient has shared personal information, such data is used only in ways that are authorized by the patient.
To provide an example of respect for privacy, consider the questions that arise if Mrs. Cummings comes to the surgical clinic for a preoperative breast surgery visit. During the visit and exam, the nurse notes a large bruise along her lower rib cage and she shares with the nurse that her husband inflicted it last night in a fight about the surgery. She explains that he does not want her to have prophylactic breast surgery after she tested positive for the BRCA1 gene mutation, which means she is at higher risk for breast cancer than the general population. After the
nurse determines that the bruise has no physiological implications for surgery and that Mrs. Cummings has arranged to go to her sister’s home for immediate postop care, the nurse should agree when Mrs. Cummings’ requests that no mention of the fight be placed in her medical record. That is her right and if she wishes to keep the information private, she may. Withholding this information from the medical record does not require that the nurse simply ignore what has happened. The nurse is obligated to review the nursing and health literature on domestic violence and to follow up in so far as the patient will permit. Additional assessment is called for. For instance, the nurse should ascertain whether this is a single episode or a habitual situation, whether children are at risk in the home, and so forth. This should not simply be dropped: The nurse may offer Mrs. Cummings additional options, such as referral to counseling, and may engage in patient education regarding domestic violence should such education not be resisted. In some states laws covering domestic violence mandate healthcare professionals to report even a suspicion of domestic violence that is discovered in the process of caregiving. These laws differ from state to state, but nurses need to be aware of these laws.
nurse determines that the bruise has no physiological implications for surgery and that Mrs. Cummings has arranged to go to her sister’s home for immediate postop care, the nurse should agree when Mrs. Cummings’ requests that no mention of the fight be placed in her medical record. That is her right and if she wishes to keep the information private, she may. Withholding this information from the medical record does not require that the nurse simply ignore what has happened. The nurse is obligated to review the nursing and health literature on domestic violence and to follow up in so far as the patient will permit. Additional assessment is called for. For instance, the nurse should ascertain whether this is a single episode or a habitual situation, whether children are at risk in the home, and so forth. This should not simply be dropped: The nurse may offer Mrs. Cummings additional options, such as referral to counseling, and may engage in patient education regarding domestic violence should such education not be resisted. In some states laws covering domestic violence mandate healthcare professionals to report even a suspicion of domestic violence that is discovered in the process of caregiving. These laws differ from state to state, but nurses need to be aware of these laws.
Contrast this example with the issue of confidentiality that the genetics nurse confronted when Mrs. Cummings originally requested the BRCA1 genetic test and stated that she did not want the result to be placed in her medical record, because she feared that she might face future discrimination in work or in obtaining life or health insurance if the test were positive. While this might appear again to be a request for privacy, it becomes an issue of confidentiality if the policy at the Breast Cancer Genetics Clinic is that all test results must be in a patient record, even if the patient pays for them personally. Now the nurse must discuss with Mrs. Cummings how the information will be preserved and limits to its protection, if she chooses to be tested at this particular clinic. While the duty to protect, here, is still owed to the patient, this example shows that the nurse must be very proactive in being aware of how information will be preserved and protected and in what ways.4 Such a duty extends beyond the clinical encounter to efforts such as participating in establishing institutional policies or even state laws that that protect confidentiality. Thus, in this situation, the patient is protected by being informed in advance, and the nurse protects future patients by participating in policy formulation with regard to confidentiality of clinical information.
The interpretive statements on privacy and confidentiality are necessarily broad so that they can serve as useful guidance in a range of contexts and situations. The Code does not specify concrete and absolute rules about how to protect patient information in a “one rule fits all situations” approach. The complexity of this issue has recently been highlighted by the institution of the Health Information Portability Accountability Act and its Privacy Rule.5 Nurses, like all healthcare providers,
have had to attend in-service educational offerings about the implications of the Rule so that they can advise patients about who may access their health information. In the midst of the well-publicized efforts to implement the Rule, it must not be forgotten that medical information passes through many hands and the nurse is only one participant in the process of storing this data. Often the nurse’s most significant contribution is to be able to advise the patient as to where their data will be stored, who will have access to it, and with whom it will be shared. This facilitates better decision making by the patient. In the prior example of Mrs. Cummings and her concern about her genetic test results, the nurse may be able to advise her that the clinic policy is that no information is released to employers or insurance companies unless she signs a release form. This policy would allow those in the health team to have access to necessary patient information while providing a certain level of protection that the patient can control.
have had to attend in-service educational offerings about the implications of the Rule so that they can advise patients about who may access their health information. In the midst of the well-publicized efforts to implement the Rule, it must not be forgotten that medical information passes through many hands and the nurse is only one participant in the process of storing this data. Often the nurse’s most significant contribution is to be able to advise the patient as to where their data will be stored, who will have access to it, and with whom it will be shared. This facilitates better decision making by the patient. In the prior example of Mrs. Cummings and her concern about her genetic test results, the nurse may be able to advise her that the clinic policy is that no information is released to employers or insurance companies unless she signs a release form. This policy would allow those in the health team to have access to necessary patient information while providing a certain level of protection that the patient can control.
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