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  • Using these guides I’ve chosen to address disparities, roles and some hot topics
  • First, what guidance do we have?
  • Next steps then another role
  • Huge but focused
  • Let’s move ahead……….

Iowa Nurses Association/Iowa Nurses Foundation Iowa Nurses Association/Iowa Nurses Foundation Presentation Transcript

  • Iowa Nurses Association/Iowa Nurses Foundation Iowa Association of Nursing Students Ethical Issues of Current Topics in Healthcare Delivery, Policy and Research
    • Martha Turner , Ph.D. RN-BC, NEA-BC
    • Colonel, USAF NC (ret.)
    • Assistant Director ANA Center for Ethics and Human Rights
    • 25 October 2009
  • Objectives
    • Link applicable provisions from the ANA Code of Ethics for Nurses to current topics: disparities, diverse practice settings, medical. marijuana, and stem cell research.
    • List five important disparities affecting the public’s health.
    • Identify ethical challenges for nurses in diverse practice roles and settings.
    • Describe three relevant arguments in the medical marijuana debate.
    • Explain how the current governmental activities influence the use of stem cells in health care research.
    • Will do
      • framework
      • resources
      • awareness
      • understanding
    • Won’t do ?
    View slide
    • Won’t do
      • loyalty – competing (role in praxis)
      • technology – what it brings
      • prevention vs. Rx
      • resource allocation / prevent vs. act
      • possibility / probability
      • genetics/genomics ( new book: Genetics and Ethics in Health Care, 2008 )
      • Nurse Jackie
    View slide
  • Maybe next time
    • Disaster nursing:
      • http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR.aspx
      • http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR/TheLawEthicsofDisasterResponse/AdaptingStandardsofCare.aspx
  • Maybe next time…
    • Transplant: donors, markets, organs, faces, hands, determining death
    • Neuroethics: memory, drugs, enhancements, neuroimaging
    • Pediatric issues
    • Global issues
    • Reproductive issues
    • Personalized Medicine
    • Etc………
  • To guide us…..
  • Principles
      • beneficence
      • nonmaleficence
      • justice
      • respect for autonomy
  • Code of Ethics for Nurses
    • 1. 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.
  • Code of Ethics for Nurses
    • 2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
    • 3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient
  • Code of Ethics for Nurses
    • 4. 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 patent care.
  • Code of Ethics for Nurses
    • 5. 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.
  • Code of Ethics for Nurses
    • 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
  • Code of Ethics for Nurses
    • 7. The nurse participates in the advancement of the profession through contribution to practice, education, administration, and knowledge development.
    • 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
  • Code of Ethics for Nurses
    • 9. 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.
  • Caution…….
    • Vocabulary
      • words
      • meaning
      • “ use it in a sentence”
      • inflammatory
      • attention getting
      • confusing
  • Values and Approaches
    • Some definitions
      • Philosophy
      • Ethics
      • health
      • human rights
      • healthcare
    • A model
  • Ethics:
    • Set of rules, principles, values, ideals
    • Systematic study of morals concepts/theories
    • Professional ethics
    • Applied ethics
    • Advocacy ethics
    • Metaethics
      • meanings of “rights”, “duties”, etc.
    • Normative ethics
      • How folks ought to…
  • Normative ethics
    • Consequentialism / teleology
      • utilitarian
        • Bentham, Mill
    • Deontology (duty or rights based)
        • Kant, Locke, Rawls
    • How to apply
    Right act Wrong act Yes ? ? No Good outcome Bad outcome Act Intention Context Outcome
    • Ethical competence
      • moral sensibility
      • moral responsiveness
      • moral reasoning
      • moral character
      • moral value
      • moral advocacy & leadership
    Taylor, 2000
  • Additionally….
    • Three kinds of questions
      • technical
      • legal
      • ethical
    • Many resources
  • Resources
    • http://nursingworld.org/
    • http://bioethics.georgetown.edu/
    • http://bioethics.od.nih.gov/withinnih.html#reports
    • http://stemcells.nih.gov/
    • http://medicalmarijuana.procon.org/
    • http://www.ornl.gov/sci/techresources/Human_Genome/elsi/elsi.shtml/
  • More resources
    • http://www.thehastingscenter.org/
    • http://www.iafn.org/
    • http://www.nlm.nih.gov/medlineplus/healthdisparities.html
    • http://www.cdc.gov/omh/AboutUs/disparities.htm
    • http://www.healthdisparities.net/hdc/html/home.aspx
    • http://www.usm.edu/ethicsjournal/index.php/ojhe
  • and more…
    • Human Rights:
      • http://www.un.org/en/documents/udhr/
  • ANA Position Statements
      • Work release during a disaster for RNs and Employers – 6/24/02
      • Tobacco Use: prevention, cessation and exposure to second hand smoke - 4/20/05
      • Stem Cell Research - 1/10/07
      • Risk and Responsibility in providing nursing care – 6/21/06
      • Professional Role Competence – 5/28/08
  • Position Statements cont.
      • Capital Punishment - currently posted
      • Patients’ safe access to therapeutic marijuana – 12/12/08
      • Credentialing and Privileging of Advanced Practice RNs – 10/11/06
      • Assuring safe, high quality health care in pre-k through 12 educational settings – 3/16/07
  • Position Statements Currently under revision:
    • Health Disparities (replaces cultural diversity and discrimination/racism in health care)
    • Expert Care at the End of Life
    • Forgoing Nutrition and Hydration
    • Ethics and Human Rights
    • Mechanisms through which CMAs consider Ethics and Human Rights Issues
  • Position Statements New Drafts
    • Moral Courage
    • Reduction of Patient Restraint and Seclusion in Health Care Settings
  • Health Disparities
    • Economic
    • Environmental
    • Literacy
    • Cultural
    • Personal: age, gender, race, preferences
  • Position Statement Draft Health Disparities
    • Code of Ethics for Nurses with Interpretive Statements - Establishes the profession's ethical standard for practice (2001).
    • 1.1 – A fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual.
    • 3.3 – Stemming from the right to self-determination, each individual has the right to choose whether or not to participate in research.
    • 5.0 – 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.
    • 8.1 – The nursing profession is committed to promoting the health, welfare, and safety of all people.
    • 8.2 – Nurses, individually and collectively, have a responsibility to be knowledgeable about the health status of the community and existing threats to health and safety.
    • Nursing's Social Policy Statement - Defines nursing and describes the basis of practice (2003).
    • The profession mirrors the diverse population it serves and provides leadership to create positive changes in health policy and delivery systems (p1)
    • Human experience is contextually and culturally defined (p7)
    • Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing (p7)
    Position Statement Draft Health Disparities
  • Environmental Disparities
    • Water
    • Traffic
    • Groceries
    • Noise
    • Access
    • Dumps
  • Environmental Disparities
    • Activities for Nurses
      • Advocacy
      • Policy
      • Organizing
      • Teaching
      • Building coalition
    • Other ideas: R.D. Bullard Ph.D
      • http://www.ejrc.cau.edu/staff.html
  • resources
    • Health Literacy:
      • http://www.iom.edu/?id=19750
      • http://nnlm.gov/outreach/consumer/hlthlit.html
      • http://www.hrsa.gov/healthliteracy/
      • http://www.health.gov/communication/literacy/default.htm
      • http://www.nlm.nih.gov/medlineplus/healthliteracy.html
  • Diverse roles and settings
  • Corrections Nurses: Capital Punishment Position Statement - posted
    • Statement of ANA Position: The American Nurses Association (ANA) is strongly opposed to nurse participation in capital punishment. Participation in executions, either directly or indirectly, is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession.
  • Position Statement - posted Capital Punishment
    • The ANA Code states that ethics is “the foundation of nursing.... and has a history of concern for the welfare of the sick, injured, and vulnerable and for social justice” (ANA, 2001, p. 5).
    • This array of concerns extends to the community and “encompasses the ...protection, promotion, and restoration of health” (p. 5).
    • The Code of Ethics for Nurses stipulates that “nurses act to change those aspects of social structures that detract from health and well-being” (p. 5).
    • Addressing end of life care, the Code states, nurses may not act [to alleviate pain] “with the sole intent of ending a patient’s life” (p. 8).
    • The obligation to refrain from causing death is longstanding and should not be breached even when legally sanctioned.
  • Position Statement - posted Capital Punishment
    • The ANA’s Social Policy Statement (2003) places the nurse in a position of public trust to ensure the patient is supported in goals of health and healing. “All registered nurses are educated in the art and science of nursing, with the goal of helping patients to attain, maintain, and restore health, or to experience a dignified death” (p.9).
  • Position Statement - posted Capital Punishment
    • The ANA document, Corrections Nursing: Scope and Standards of Practice (2007) states: 
    • it is inappropriate for nurses to be involved in the security aspects of the facility and disciplinary decisions or committees. Correctional nurses must be vigilant in maintaining a healthcare role and not participate in non-therapeutic court-ordered procedures such as but not limited to body entry searches or executions by lethal injections, performed solely for correctional purposes and without informed consent. (p. 8)
  • Position Statement - posted Capital Punishment
    • Recommendations: In keeping with the nursing profession's commitment to caring and the preservation of human dignity and rights; the ethical principles of nonmaleficence, beneficence, fidelity, and justice; and the trust that the public has come to expect from registered nurses, the ANA recommends that
    • Nurses abide by the American Nurses Association’s Code of Ethics for Nurses and the Scope and Standards of Nursing Practice in Correctional Facilities prohibiting nurses from assuming any role in the capital punishment of a prisoner.
    • Nurses strive to preserve the human dignity of prisoners regardless of the nature of the crime they have committed.
    • Nurses act to protect, promote, and restore health of prisoners and provide comfort care at the end of life if requested, including pain control.
    • Nurses abide by the social contract to facilitate healing, so should avoid participation in capital punishment, which directly causes death.
  • Position Statement - posted Capital Punishment
    • Nurses who are invited to witness an execution must not represent themselves as a nurse nor assume any nursing role in that execution. 
    • Nurses should strive to preserve the human dignity of prisoners regardless of the nature of the crime they have committed. 
    • Nurse administrators will provide a work environment for nurses that allows them to abide by the recommendations of the American Correctional Health Services Association (ACHSA) and ANA.
    • Nurses scrutinize policies and procedures guiding their practice to ensure there are no contradictions in performance expectations.
    • Nurses help colleagues balance moral burdens with professional ethics when specific death penalty cases cause moral turmoil.
    • Nurse researchers design studies to explore the meaning of participation, motivating factors, consequences of non-participation and fears of patient abandonment in the context of capital punishment
  • Position Statement - posted Capital Punishment
    • Nurses continue to be involved in national and international dialogue on political, scientific, ethical, legal, social and economic perspectives leading to legislation that would abolish the death penalty
    • Nurses as individuals and as a professional community maintain awareness that any nurse participation could contribute to the public’s acceptance of the death penalty and their non-participation may, in fact, contribute to rejection of the death penalty.  
    • Nurse Educators should include and emphasize the knowledge and skills needed to act upon the above recommendations, especially the boundaries of direct and indirect participation.
  • Role: School Nurse Focus H1N1
      • http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR/H1N1-Information.aspx
      • http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR/TheLawEthicsofDisasterResponse/AdaptingStandardsofCare .aspx
  • Role: School Nurse
  • Position Statement – 3/16/2007 …Quality Health Care in pre-k through 12…
    • Summary On any given weekday, as much as 20% of the combined US population of children and adults can be found in schools (AHA, 2004).
    • To best serve the health needs of students and staff in educational settings, ANA supports a collaborative school health model which requires the cooperation and participation of the school nurse, students, families, teachers, school administrators and staff, other health care professionals, and the community..
  • Position Statement – 3/16/2007 …Quality Health Care in pre-k through 12…
    • In addition, the school nurse must limit exposure to students and school staff with communicable diseases; manage unintended injuries, potentially life-threatening environmental and food allergies; monitor and counsel on immune disorders, depression, eating disorders, obesity, substance abuse problems, adolescent pregnancy and parenting issues, and a raft of other general health issues.
    • The school’s emergency and disaster preparedness, as well as more routine activities, such as field trip planning, also require the school nurse’s expert input (AHA, 2004).
  • Role: School Nurse
  • Hot Topics
    • Medical Marijuana
    • Stem Cell Research
  • Medical Marijuana
    • In Iowa
    • Across the nation
    • Relevant arguments: TNTM
      • #of plants
      • Dose variation
      • It works
    • www.medicalcannabis.com
  • Position Statement – 12/12/2008 Medical Marijuana
    • The American Nurses Association supports:
    • 1. The education of registered nurses and other health care practitioners regarding appropriate evidence-based therapeutic use of marijuana including those non- smoked forms of delta-9-tetrahydrocannabinol (THC) that have proven to be therapeutically efficacious
    • 2. Protection from criminal or civil penalties for patients using medical marijuana as permitted under state laws
    • 3. Exemption from criminal prosecution; civil liability; or professional sanctioning, such as loss of licensure or credentialing, for health care practitioners who prescribe, dispense or administer medical marijuana in accordance with state law.
    • 4. Reclassification of marijuana’s status from a Schedule I controlled substance into a less restrictive category.
    • 5. Confirmation of the therapeutic efficacy of medical marijuana.
  • Position Statement – 12/12/2008 Medical Marijuana
    • Marijuana is seen as efficacious in:
      • Reducing nausea and vomiting associated with chemotherapy
      • Stimulating the appetite of patients coping with the wasting syndrome associated with HIV/AIDS and cancer
      • Short-term relief of the intraocular pressure associated with glaucoma
    • Decreasing spasticity, pain, and tremor in some patients with multiple sclerosis (MS), spinal cord injuries, or other trauma
    • Decreasing suffering from chronic pain (ACP, 2008; APHA, 1995).
  • Stem Cell Research
    • U.S. Policy on Stem Cell Research
    • On March 9, 2009, President Obama issued Executive Order 13505, entitled "Removing Barriers to Responsible Research Involving Human Stem Cells.”
    • Exec Order 13435 of June 2007: revoked
  • Stem Cell Research
    • Q: Why not use adult stem cells instead of using human embryonic stem cells in research?
    • A: Human embryonic stem cells are thought to have much greater developmental potential than adult stem cells. This means that embryonic stem cells may be pluripotent—that is, able to give rise to cells found in all tissues of the embryo except for germ cells rather than being merely multipotent—restricted to specific subpopulations of cell types, as adult stem cells are thought to be.
    • http://stemcells.nih.gov/info/faqs.asp (2009)
  • Position Statement – 1/10/2007 Stem Cell Research
    • The American Nurses Association (ANA) supports the ethical use of stem cells for research and therapeutic purposes that impact health.
    • Stem cell research is the foundation for cell-based therapies in which stem cells are induced to differentiate into the specific cell type required to repair damaged or destroyed cells or tissues.
    • Stem cells have the ability to divide for indefinite periods in culture and they can give rise to specialized cells. Both embryonic and adult cells are used in this research.
    • Embryonic cells have the potential to become a wide variety of specialized cell types. These undifferentiated cells are derived from a 5-day preimplantation embryo.
    • Adult cells are undifferentiated cells found in a differentiated tissue. They can renew and differentiate (with certain limitations) to give rise to all the specialized cell types of the tissue from which they originated (National Institutes of Health (NIH, 2006).
  • Position Statement – 1/10/2007 Stem Cell Research
    • ANA Supports:
      • Federal funding of stem cell research. Funding for research without conditions that may unnecessarily impede its progress and achievements.
      • Research conducted within strict scientific and ethical guidelines.
        • Effective oversight of research in all settings.
        • Collaborative research efforts among academic, public and private research sectors.
        • Compliance with the NIH Guidelines on Research Using Human Pluripotent Stem Cells, published in August of 2000 (NIH, 2000). Equal and unconstrained access to stem cell research findings as has been exemplary in the Human Genome Project
  • Position Statement – 1/10/2007 Stem Cell Research
    • ANA supports……
    • The ethical use of somatic cell nuclear transfer (SCNT or “therapeutic cloning”) and rejects the use of stem cell technology, or any technology, for the purposes of reproductive cloning.
    • Public policy on stem cell research that considers the ethical and health issues. Participation in the ethical, legal, and social debate surrounding this research by all communities including public and private, professional and citizen.
  • Position Statement – 1/10/2007 Stem Cell Research
    • Recommends that the ANA:
    • 1. Support the education of nurses through their academic curricula and continuing education in matters related to stem cell research and therapies as they are developed for use in clinical practice.
    • 2. Continue to be involved in national and international dialogue on political, scientific, ethical, legal, social and economic perspectives of stem cell research.
    • 3. Encourage nurses as individuals and as a professional community to maintain awareness of the practice outcomes translated from stem cell research and respond appropriately.
  • Tiny ticklers
      • now / later
      • here / there
      • self / other
      • us / them
      • cause/effect
      • hear+/ask -
  • Together…..with
    • Honesty
    • High energy
    • Humor
    • Humility