Nursing ethics

M I S S L A K A M M A P U T I , R N , M A N
NURSING ETHICS

Legal Issues in Nursing practice
PHYSICIAN’S ORDER
Nurses are responsible
for their actions
regardless of who told
them to perform those
actions.
FLOATING
Nurses should be given
orientation to the unit. The
supervisor should be
informed about a float
nurse’s lack of experience on
the new unit.
INADEQUATE STAFFING
• A nurse who leaves an
inadequately staffed
unit could be charged
with client
abandonment.
CRITICAL CARE
Constant observation
and assessment of
clients are required,
especially in ICUs that
have monitors.
PEDIATRIC CARE
Suspected child abuse
or neglect be reported.

NURSES NEEDS TO:
1. Examine their own values and their client’s
values? Understand how their values
influence their decisions?
2. Develop sensitivity to the ethical
dimensions of nursing practice?
3. Think ahead what are the possible moral
problems they are likely to face?
HOW?

VALUES
Freely chosen
Values underlie all moral dilemmas. though, not all
values are moral values (people values about work,
family, religion, politics, money and relationships.
IMPORTANT: Values influence decisions and actions,
such as nurses’ ethical decision making.
Beliefs or attitudes about the worth of a person, object,
idea, or action.

VALUES
Values
ATTITUDES
BELIEFS
 BELIEFS
 Opinion, interpretation, or
conclusions that people accept
as true (may it not be true)
 “I believe if I study hard I will
get a good grade”
 “Good grades are really
important to me. I believe I
must study hard to obtain good
grades”
 ATTITUDES
 Mental position or feelings
toward a person, object, or idea
(compassion, acceptance)
 Some clients may feel strongly
about their need for privacy,
whereas others may dismiss it as
unimportant.

VALUES
BELIEFS ATTITUDES
 FAITH than FACT.
 Last only briefly.
 Judged as correct or incorrect.
 THINKING and BEHAVIORAL
aspects.
 Continuous overtime.
Judged as bad or good,
positive or negative.

VALUES TRANSMISSION VALUES CLARIFICATION
 Acquired through Observation and
Experience.
 Affected by Socio-Cultural environment
(societal conditions, family and peers)
PERSONAL VALUES
 Nurses should keep in mind the
influences of Values on health.
PROFESSIONAL VALUES
 A process by which people identify, examine,
and develop their own individual values.
 It promotes personal growth (promotes
awareness, empathy, and insight)
 It is an important step for nurses to
take in dealing with ethical problems.
 No One set of values is right for everyone.
 People can retain or change the freely chosen
values
 CLARIFYING THE NURSES’ VALUES
 CLARIFYING CLIENT VALUES
FROM?

Professional Values Clarifying Nurse’s Values
 Acquired during experience from code
of ethics, nursing, teachers, and peers.
 5 VALUES ESSENTIAL FOR
PROFESSIONAL NURSE:
 ALTRUISM
 AUTONOMY
 HUMAN DIGNITY
 INTEGRITY
 SOCIAL JUSTICE
 Nurses and nursing students need
to examine the values they hold
about life, death, health and
illness.
FROM?

Essential Nursing Values and Behaviors
VALUES Professional Behaviors
Altruism
Nurse’s concern for the welfare of patients,
other nurses, and other health care providers.
•Understands cultures, beliefs, and perspectives of others.
•Advocates for patients.
•Take risks on behalf of patients and colleagues.
Autonomy
Nurses respects patient’s right to make
decisions about their health care.
•Plans care in partnership with patients
Human Dignity
Nurses values and respects the inherent worth
and uniqueness of all patients and colleagues.
•Provides culturally competent and sensitive care.
•Protects patient’s privacy.
•Designs care with s sensitivity to individual patient
needs.
Integrity
Nurses acts honestly and provides care based on
an ethical framework.
•Provides honest information to patients and the public.
•Document care honestly and accurately.
•Seeks to remedy errors made by self or others.
•Demonstrates accountability of own actions
Social Justice
Nurse upholds moral, legal, and humanistic
principles by ensuring equal treatment under
the law and equal access to quality health care.
•Supports fairness and nondiscrimination in the delivery
of care.

Theory of Values Clarification (Raths, Harmin, and Simon, 1978)
Valuing Process
Choosing Cognitive
•Beliefs are freely chosen.
•Without outside pressure
•After reflecting and considering
consequences or alternatives
Prizing Affective
•Chosen beliefs are cherished or prized
Acting Behavior
•Chosen beliefs are affirmed to others,
incorporated into one’s behavior and
repeated consistently in one’s life.

Clarifying Client Values
 Is an intervention used by the nurse s when clients experiences
unclear values that are harmful to their health.
Behavior Example
Ignoring a health professional’s
advice
A child client’s parent who values the
Inconsistent communication
behavior
A n elderly who says she don’t want anymore to use cane
when walking, but won’t cooperate during her therapy.
Numerous admissions to a
health agency for the same
problem
A hypertensive client repeatedly seeks help for headache
but does not take the prescribed maintenance medicine.
Confusion about which course
of action to take
A pregnant woman who values her job to meet financial
obligations, but also needs to have complete bed rest for a
safe labor and delivery.

Clarifying Client Values
Process How?
List Alternatives Ask: “Are you considering other alternative courses of actions?”
“Tell me about them”
Examine possible
consequences of choices
Ask: “What do you think you will gain from doing that?”
Choose freely Ask: “Did you have any say in that decision?”
Feel good about the choice Ask: “How do you feel about that decision?” “Some people feel
good after a decision is made; others feel bad. How do you feel?”
Affirm the choice Ask: “What will you say to family or friends about this?”
Act on the choice Ask: “Will it be difficult to tell your wife about this?” (it
determines the client’s preparedness to act in his decision)
Act with a pattern Ask: “How many times have you done that before?” or “Would
you act that way again?”

Standards of Professional Performance (ANA,1998)
 Standard V: Ethics
The nurse’s decisions and actions on behalf of patients are determined in an ethical
manner.
Measurement Criteria
1. The nurse’s practice is guided by the Code for Nurses.
2. The nurse maintains patient confidentiality within legal and
regulatory parameters.
3. The nurse acts as a patient advocate and assists patients in
developing skills so that they can advocate for themselves.
4. The nurse delivers care in a non-judgmental and non-
discriminating manner that is sensitive to patient diversity.
5. The nurse delivers care in a manner that preserves patient
autonomy, dignity, and rights.
6. The nurse seek, available resources in formulating ethical
decisions.

NURSING ETHICS
No One profession is responsible for ethical decisions,
nor does expertise in one discipline necessarily
make a person an expert in ethics
(ethics committee)

Nursing Codes of Ethics
 Purposes:
 Inform the public about the minimum standards of the profession
and help them understand professional nursing conduct.
 Provide a sign of the profession’s commitment to the public it
serves.
 Outline the major ethical considerations of the profession.
 Provide standards for professional behaviors.
 Remind nurses of special responsibility they assume when
caring for the sick.

CODE OF ETHICS
ETHICAL CODES are:
Systematic guides for developing ethical behavior.
Answers normative questions of what beliefs and values
should be morally accepted.
NO CODE could possibly provide absolute or complete
rules without conflict and ambiguity.

Four-fold responsibilities of nurses (PD 223)
Responsibility Ethical Principles
Guidelines to be
observed
NURSES AND PEOPLE • Values, spiritual beliefs,
and customs held by
individual
•Respect patient’s autonomy.
•Personal information
confidentiality.
•Consider individuality when
giving care.
•Take into consideration the
spiritual beliefs (diet and
treatment), the rights and
the culture of patients.
•However, welfare and safety
must take precedence.
NURSES AND PRACTICE •Human Life in inviolable.
•Quality in care for patients
•Accuracy in documentation of
actions and outcomes of care.
•Advocate to patient.
•Awareness to ethic-moral and
legal dimensions of practice.
•Know the scope of her
practice
•Acquire and develop
necessary competence in
knowledge, skills, and
attitudes.
•Ensure patient's records.
•Respect “Patient’s Bill of
rights”

Four-fold responsibilities of nurses
Responsibility Ethical Principles
Guidelines to be
observed
NURSES AND CO-WORKERS •Maintain a collaborative
working relationship
•Maintain their professional
role/identity while working
with other members.
•Honor and safeguard the
dignity and reputation of
members of nursing.
•Contribute to professional
growth and development of
other members.
NURSES AND
SOCIETY/ENVIRONMENT
•Preservation of life, respect for
human rights and promotion of a
healthy environment
•Establishment of linkages with the
public in promoting local an
national, and international efforts to
meet health and social needs of
people.
•Be conscious of their
obligations as citizens.
•Be equipped with
knowledge of health
resources within the
community
•Project an image.

ETHICAL PROBLEMS IN NURSING
 Growing awareness of ethical problems has occurred
because of:
 SOCIAL AND TECHNOLOGICAL CHANGES
 CONFLICTING LOYALTIES AND OBLIGATIONS

SOCIAL AND TECHNOLOGICAL
CHANGES
CONFLICTING LOYALTIES AND
OBLIGATIONS
 Large number of people without health
insurance.
 High cost of health care
 Workplace redesign under managed care
ISSUES OF FAIRNESS AND RESOURCE
ALLOCATION
 Before technology, there was no questions
about whether to “allow”….who should be
treated?...
 According to nursing code of ethics, the
nurse’s first loyalty is to the client.
 However, it is not easy to determine which
action best serves the client’s needs.
 Client needs may conflict with the
institutional policies, physician preferences,
needs of their family, or even laws of the
state.
ETHICAL PROBLEMS IN NURSING

SPECIFIC ETHICAL ISSUES
• Sanctity of life vs. principle of Autonomy and the woman’s
right to control her own body.
• No public consensus has yet been reached.
• Nurses have no right to impose their personal values,
instead, nurses have the right to inform and counsel the
client in making decisions.
Abortion
• Nurses should help develop and follow
security measures and policies to ensure
appropriate use of client’s data.
Management of
Computerized
Information.
• Advance Directives
• Euthanasia
• Termination of Life-sustaining treatment
• Withdraw or withholding Food and fluids
End-of-Life
Issues
• Health resources
Allocation of
scarce resources

MAKING ETHICAL DECISIONS
 It should be based on ethical principles and codes rather
than emotions, intuition, or precedent.
 GOOD DECISION
 The one that is in the Client’s best interest and at the same time
preserve the integrity of all involved.
 Establish support system; use of counseling professionals
 Collaboration, communication, and compromise
(important skills)
 Determine EXISTENCE OF MORAL SITUATION
(important first step)

EXISTENCE OF MORAL
SITUATION?
1. A difficult choice exists?
2. There are moral principles exist that can
be used to justify the action?
3. The decision must be freely and
consciously chosen?
4. The choice is affected by personal
feelings?

MORAL PRINCIPLES
 AUTONOMY
 NONMALEFICENCE
 BENEFICENCE
 JUSTICE
 FIDELITY
 VERACITY

 AUTONOMY
- Autos ( self)
- nomos (governance)
- born from The New Testament (freedom to make decisions)
- In Health care Setting: “ Principle of INFORMED CONSENT”
- IMPORTANT : while you respect patient’s autonomy, it is also our duty to
explain clearly to them what are the consequences or effect of their decision,
explain to them the purpose of informed consent the treatment and its alternatives
which are all indicated or written in the informed consent.
OVERRIDING PATIENT’S AUTONOMY( Paternalism)
> MEDICAL --acting without consent to benefit the patient and
prevent harm (ex. emergency cases, incompetency etc.)
> STRONG – benefit is stronger than autonomy (ex. Refusal to
treatment)
> WEAK – if our purpose is to help patient in restoring his/her
competence to decide.
MORAL PRINCIPLES

 JUSTICE
- the right to demand a just, fair and treatment
- “we get what we merit from our conduct in life”
- uses TRIAGE SCHEMES:
1. According to medical prognosis (who is most likely
to survive)
2. Social value (must favor first the socially
disadvantaged, ill,elderly,disabled,women and children (ART.III of
PHILIPPINE CONSTITUTION))
3. First come first serve (for patients with same cases
and treatment)
- this DOESN’T tell us what needs are most important.

 Fidelity
 Being faithful to ones commitments (providing self care and
competence in nursing care) and promises.
 Veracity
 Telling the truth (essential to nurse-client relationship)
MORAL PRINCIPLES

BENEFICENCE NONMALEFICENCE
-“do good” (stated in positive form)
-Do good for patient’s interest
-However, this can pose patient at risk
of harm (provided, that patient’s
values and dignity are considered first)
-Good communication with patient of
his/her desires and needs promotes
acceptance.
-“do no harm” (stated in negative form
-Avoid harm which is against patient’s
interest.
- harm may be INTENTIONAL (never
accepted because it places patient to
harm) or UNINTENTIONAL (risk was
inevitable or not anticipated, example
is catching a falling patient)
-Unintentionally created a needless
harm, provided, that nurse should do
what’s best for her patient.
-PATIENT: the one who determines or
interpret what is harmful.

MORAL PRINCIPLES
 AUTONOMY – self governance; Informed Consent
 NONMALEFICENCE- do no harm
 BENEFICENCE- do good
 JUSTICE- fair treatment
 FIDELITY
 VERACITY

Criteria if Moral aspects exists
 A difficult choice exists?
 There are moral principles exist that can be used to
justify the action?
 The decision must be freely and consciously
chosen?
 The choice is affected by personal feelings?

S I T U A T I O N
Mrs. L, a 67-year-old woman, is hospitalized with multiple
fractures and lacerations caused by an automobile
accident. Her husband, who was killed in the accident,
was taken to the same hospital. Mrs. L, who had been
driving the automobile, constantly questions her primary
nurse about her husband. The surgeon has told the nurse
not to tell Mrs. L; however, he does not give the nurse the
reason for these instructions. The nurse expresses
concern to the charge nurse, who says the surgeon’s
order must be followed. However, the nurse is not
comfortable with this and wonders what should be done.
APPLICATION

MODELS of decision-making
 CASSELLS and REDMAN (1989)
SITUATION
Mrs. L, a 67-year-old woman, is hospitalized with multiple fractures and lacerations
caused by an automobile accident. Her husband, who was killed in the accident, was
taken to the same hospital. Mrs. L, who had been driving the automobile, constantly
questions her primary nurse about her husband. The surgeon has told the nurse not to
tell Mrs. L; however, he does not give the nurse the reason for these instructions. The
nurse expresses concern to the Charge nurse, who says the surgeon’s order must be
followed. However, the nurse is not comfortable with this and wonders what should be
done.
ACTION CONSIDERATIONS
1. Identify the moral aspects.
2. Gather relevant facts that
relate to the issue
Whether to tell the truth or not?
Honesty and loyalty (moral principles)
Client’s health problem information?
Who is involved? Nature of involvement? Motives
of actions (not known)

3. Determine for whom the
decision being made? Who should
decide and why?
4. Clarify and apply personal
values
5. Identify ethical theories and
principles
6. Identify applicable laws or
agency policies
7. Use competent interdisciplinary
resources
8. Propose alternative actions
Mrs. L values her husband’s welfare, the charge
nurse values policy and procedure, the nurse
value a client’s right to have information.
Autonomy? Beneficence?
Nurse might consult literature
Follow the charge nurse; possible outcome: Mrs.
L might become anxious and angry, wait Mr.s L
to recover
The agency may not allow the nurse to follow the
doctor’s order (instructions rather than order)

9. Apply nursing code of ethics
10. For alternative action, identify
the risk and seriousness of
consequences
11. Evaluate the action taken
If the nurse follows the charge nurse and
doctor?
If the nurse tells Mrs. L?
If the client is not satisfied the nurse can review
other alternatives and work through the process
again.

STRATEGIES TO ENHANCE ETHICAL DECISIONS
AND PRACTICE
√ BE AWARE OF YOUR OWN VALUE.
√ BE FAMILIAR WITH THE CODE OF ETHICS
 RESPECT VALUES, OPINIONS, AND RESPONSIBILITIES
OF OTHER HEALTHCARE PROFESSIONALS
 SERVE ON INSTITUTIONAL ETHICS COMMITTEE
 STRIVE FOR COLLABORATIVE PRACTICE

• Right to considerate and respectful care.
• Right to obtain from his doctor complete current information about his diagnosis.
• Obtain from his doctor complete current information about his diagnosis, treatment and
prognosis in terms patients can be reasonably expected to understand.
• Right for complete and accurate information necessary to give informed consent prior to
start of procedure or treatment.
• Right to refuse treatment .
• Right to privacy.
• Right confidentiality.
• Right to expect that a hospital must take reasonable response for the client’s request for
services, within the hospital’s capacity.
• Right to obtain information: any relationship of the hospital to other healthcare and
educational institutions concerning his care; human experimentation
• Right to expect reasonable continuity of care.
• Right to examine and receive an explanation of his bill, regardless of source.
• Right to know what hospital rules and regulations apply to his conduct as a patient.

Project
Using the following phases of the Nursing Care Process, create your own
diagram or illustration on how the process works. (50 points)
•Assessing
•Diagnosing
•Planning
•Implementing
•Evaluating
Rubrics
Criteria 10 5 2
Use of the following
phases given
All of the items
given were used in
the diagram
Some of the items
given were used in
the diagram
All of the items
given were not used
in the diagram
Creativity The illustration is
creative
The illustration in
some way shows
creativity
The illustration do
not show creativity
Effectiveness of the
illustration
The diagram shows
exact process on
how NCP works
The diagram
somehow shows a
process on how
NCP works
The diagram doesn’t
show any relevance
on the NCP

KOZIER, ERB G., BERMAN A., SNYDER S. (2004)
“FUNDAMENTALS OF NURSING” 7 TH EDITION
UDAN “FUNDAMENTALS OF NURSING”
Reference

Nursing ethics

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