Why is it advantageous for nurses to have knowledge of ethical theories and principles?

Abstract

Nursing ethics is the applied discipline that addresses the moral features of nursing practice. It is a subset of health care ethics or bioethics. Three dimensions of nursing ethics interrelate as they prescribe ethical norms, describe ethical aspects of nursing, and generate ethical guidance. Philosophical nursing ethics assists nurses to understand and deliberate on key ethical concepts. Empirical nursing ethics draws on empirical research to advance an understanding of ethical and unethical nursing practice. Understanding and adopting a critical approach to ethical frameworks devised by professional and regulative organizations is the third dimension of nursing ethics (regulative nursing ethics).

Ethics and Physiotherapy

During approximately the past two decades, there has been a burgeoning interest in the ethical issues associated with medicine and health care. This has been marked by a steady growth in academic and professional texts in this area, and there are both general (e.g., Bioethics and Journal of Medicine and Philosophy) and specific (e.g., Nursing Ethics and Public Health Ethics) journals devoted to ethical questions in health care.

The literature has predominantly focused on ethics within clinical medicine, medical technology, and nursing, but a number of texts have specifically examined legal and ethical issues associated with physiotherapy and occupational therapy. There has been a corresponding growth in the number of papers in rehabilitation journals that have addressed ethical issues with specific reference to clinical physiotherapy. This body of literature is a mixture of normative and empirical papers. Surveys and qualitative studies conducted with physical therapists in the United Kingdom and the United States have identified concerns relating to such issues as consent, confidentiality, treatment priorities, discontinuation of treatment for noncompliant patients, maintenance of competence, the ethical aspects of the patient–therapist relationship, and issues related to third-party payers. The methods by which therapists seek to resolve ethical conflicts and the role and value of codes of ethics have also been examined. Similar topics have been the subject of papers, from many areas of the world, that have taken a more normative focus on physiotherapy practice. The focus of this article will follow this line and be on normative, rather than descriptive, ethics related to physiotherapy.

Feminist ethics

Feminist ethics incorporates the ideas of “feminine” ethics in that it tends to note the gender-based differences in perspectives on caring and relationships (Tong and Wiliams, 2011). But it goes further in emphasizing the importance of power and control in medical relationships (Sherwin, 1992; Allen, 2011). From the feminist perspective, the primacy of principlism in medical ethics is mostly a result of the relative power differential of males and females in medicine. Historically, physicians have mostly been male, whereas nurses and family caregivers have traditionally been predominantly female (one may note that nursing ethics has traditionally been more care-based than physician ethics). Thus the assertion that an ethic which reflects a traditionally male perspective is actually a universal ethical perspective serves the interest of a male-dominated enterprise (i.e., medicine) while serving to maintain a gender-based imbalance of power. It is worth noting that the care-based perspective was proposed by women and has gained traction as women have gained parity in medicine.

However, the insights of feminist ethics regarding the importance of power relationships are not limited to understanding the significance of gender relationships. Once one begins to look at medical care (especially within the modern hospital) through the lens of power relationships, one begins to see the impact in many different ways. For example, patients in the critical care unit are physically powerless and almost entirely dependent on physician decisions. Families of these patients have very limited power and often search for ways to obtain greater power. This can lead to very destructive behaviors, including being excessively demanding, avoiding meetings, and even threats of lawsuits. When these kinds of behaviors are understood as attempts to redress a perceived imbalance of power, they become both more understandable and potentially more manageable.

Likewise, much of the moral distress experienced by nurses and medical trainees can be explained by an imbalance of power between them and the attending physician(s). Both nurses and medical trainees are obligated to carry out the directives of the attending physician(s), yet they have their own individual moral obligations towards patients and families. If they believe that these dual obligations are in conflict, they have limited options to resolve them. Ideally, such a conflict would be addressed by in-depth conversations about the ethical issues and the moral responsibilities of each individual practitioner. However, that rarely happens, nor is it practical for that to occur routinely. Instead, those in positions of inferior power must find ways to deal with their moral distress. Possible responses to such distress can take many forms, including side conversations with family members, passive-aggressive behaviors toward the physician(s), or requesting an ethics consult. Few institutions have acknowledged this source of moral distress, much less attempted to create constructive mechanisms for addressing it.

Implications of a Care Perspective: The Health Care Setting as an Example

The ethics of care has provided important stimuli for rich, multifaceted theoretical explorations. However, what are the implications for practical decision making in concrete contexts or for a conceptual analysis of problems that present themselves in specific settings, such as health care?

In fact, the health care setting is an area in which the ethics of care has met with particular interest. Care has been a central theme in medicine throughout its history. In the sense of ‘taking care of the patient,’ it can be understood to refer to technical care, in the form of diagnostic or therapeutic intervention, in contrast to ‘caring for the patient,’ which points more to the concern for the other, who is being accompanied and helped in a difficult situation. There is a trend to ascribe the latter to nursing, whereas technical care or – even more narrowly– cure is thought of as the domain of physicians. This distinction is unhappy insofar as it makes concern and devotion appear less relevant to physicians’ work. It has also led to a misconception of the ethics of care being a form of nursing ethics.

Although caring is without any doubt a prominent concept in nursing, it should not be confined to just one health care profession. Caring is a constitutive moment in the encounter of physician and patient as well. In order to trust their physicians, patients need to know that physicians care about their well-being. A caring attitude is expressed, for example, through attentive listening, interest for the psychosocial context in which a disease occurs, and offering understanding and support. Emphasizing the caring dimension in medicine, however, has also been regarded with some suspicion, for instance, by some feminist bioethicists and those who hold patient’s rights in high esteem. The concern was that promoting the ‘caring’ health care practitioner could be used to move backward to a more paternalistic medicine, away from the focus on patient autonomy that has characterized medical ethics during the past decades. But this, again, would rest on a misunderstanding of the ethics of care, which does not aim to undermine individual autonomy but, rather, aims to encourage a critical reflection of self in its embodiedness and relatedness while trying to empathically understand the individual moral world of the other.

The implications of the ethics of care extend beyond individual relationships between patients, nurses, physicians, other health care workers, and relatives; a care perspective can help to bring the institutional and societal frameworks into view that define how medicine is practiced. Instruments aimed at increasing economic efficiency, such as Diagnosis Related Groups for the in-patient setting, set incentives for limiting care to the necessary technical interventions in a time frame that is profitable for one’s institution. This means that those acts prompted by attentiveness, empathy, concern, and devotion, such as listening and talking or accompanying the patient, are potential distractions from that goal. Health care professionals working under such conditions find themselves in a permanent conflict between working toward the economic well-being of their institution and providing the care to the patient that is in accord with their own ideas of good medicine or good nursing. As a consequence, health care workers feel exploited and are lost due to burnout or because they search for other job opportunities. From a care perspective, such a setting would clearly need to be questioned because it hampers the development of caring relationships that are supposed to unfold in a salutory environment.

Another impediment to such relationships is limited access of patients who are deemed unprofitable or even an economic risk to the respective health care institution. Such marginal groups are typically the chronically and/or psychiatrically ill, the polymorbid, the elderly, and the under- or uninsured. Although access and allocation are clearly matters of justice, they fall fully within the scope of an ethics of care: As a nurse, for instance, you would reflect morally on why you give more attention to the privately insured patient, somewhat less to the publicly insured (who may be even sicker and more in need of your care), and why the uninsured or otherwise financially unattractive patient was turfed so quickly from the ward even though it did not make sense from a medical standpoint.

The ethics of care can also be helpful in identifying conceptual challenges. A classic example for a conceptual stalemate is the discussion of the moral status – some call it moral value – of different groups of human beings, such as embryos or patients in a persistent vegetative state. Whereas utilitarian approaches are usually quite keen on such moral ‘price tags’ because they help in determining how benefit can be maximized, an ethics of care might deviate from the attempt to solve the status question first – which is a near impossible task in pluralist societies, given the metaphysical background that such questions evoke. In the case of preimplantation diagnosis, for instance, a care ethics approach would probably consider the different moral agents involved and try to determine what responsibilities toward others the respective moral agent perceives. For instance, the prospective parents may feel responsible not only for what they see as their future child but also for elder siblings, the reproductive health specialist for the well-being of the couple he or she is treating, and a pro-life activist for embryos discarded in the clinic. This analysis would then be followed by an attempt to identify possible constellations that minimize the potential for conflict and harm but still allow for a respectful exchange of perspectives.

Another example for questions at the conceptual level concerns organ transplantation. The rules for living organ donation seem to be quite straightforward: What is usually required is the consent of a competent individual that is (1) informed and (2) voluntary. Although such decisions are scrutinized daily by psychologists or clinical ethicists, it is far from clear what ‘voluntary’ means in the context of a close relationship between donor and recipient. Does a mother ‘voluntarily’ decide to donate a kidney for her teenage daughter who is not coping well with dialysis? Does a husband ‘voluntarily’ donate a part of his liver to his wife, whose physical deterioration during the past year he has watched with great sorrow?

Whereas the ethics of care cannot give a straightforward answer to current conceptual challenges in bioethics, it can provide an analytical framework for reflecting about the particular nature of the relationships at stake and about how concrete moral agents can be empowered to make decisions that reflect a high level of moral maturity.

4 Conclusion

Nursing ethics in education has immense competition with already content filled nursing programmes. The concepts of nursing ethics and values are contained only in the introductory courses of the nursing curriculum in the Gambia which is not sufficient for the students to master the ethical principles of the Nursing Profession. Many nurse educators and clinicians are not conversant with the nursing code of ethics. Lectures on nursing ethics and values are mostly taught by invited guest lecturers using the lecture discussion teaching method and are usually covered in only one or two lecture sessions. Teaching nursing ethics and values at clinical level is poor due to the limited number of trained senior nurses to serve as mentors and supervisors for students and junior nurses. Most of the health facilities do not provide standard guidelines on the various nursing procedures and sometimes what is taught in the training institution cannot be applied at health facility level due to lack of trained nurses and equipment. Low status and conformist style of training nurses hinder the effective implementation of the code of nursing ethics and values among professional nurses in the Gambia.

In conclusion, there is inadequate teaching and implementation of the code of ethics and values in nursing profession which can have a negative impact on the quality of nursing care and result in increased risk for legal litigation of nurses in the Gambia.

Conclusion

Nursing ethics has always moved beyond the nurse-patient dyad to consider broader contexts. Historically, nurses have practiced relationally, as they seek to understand and support patients as connected members of family, community, and society. Nurses have historically been charged with engagement, or honoring the thinking and feeling aspects of decision-making; with mutual respect, by honoring culture and language as part of patients' complexity and uniqueness; with embodiment, where interactions move beyond task focus to form meaningful relationships; and with seeing the patient's environment as their connection to the broader world.

However, interventional radiology nurses may perceive being limited to the nurse-patient dyad because decisions about appropriateness of procedures are usually made upstream or before meeting the radiology nurse. The radiology nurse often does not know what, if any, family were involved in decision-making, and thus can find it difficult to practice relational ethics. Caring for series of patients, while not knowing the contexts of their lives or the processes of their decisions leading up to their procedures, may lead to moral distress and burnout. The nurse may consider the societal impact of potentially inappropriate treatments relative to the cost of health care. Nurses may attempt to apply ethical principles to ethical dilemmas, but a practice of relational ethics may be limited by the medical-model–dominated health care system itself which may reduce radiology nursing practice to a task focus. The practice of nursing involves more than tasks such as obtaining consent, taking vital signs, and monitoring patients under conscious sedation. However, it seems that is what nurses are limited to in certain practice areas. Radiology nursing is ripe with potential for the nurse to consider broader contexts such as family, community, and society, and they should be supported in doing so. In conclusion, the ARIN, like many specialty areas, should support nurses in “question(ing) and step(ping) out of the taken-for-granted values and assumptions shaping their practice; and help(ing) patients transform their health experiences” (Zou, 2016).

Nursing Implications

The Code of Ethics for Nurses identifies the degree to which a nurse should uphold patients’ rights regarding the nature of health care. Section 1.3 of the Code of Ethics for Nurses states “that the worth, dignity and rights of all human beings irrespective of the nature of the health problem that the worth of the person shall not be affected by disease, disability, functioning status, or proximity to death.”1 The education and training of a clinical research nurse provides the foundation to assist with and guide ethical conduct during a clinical research trial. The clinical research nurse is the advocate for the patient based upon the patients’ dignity and rights as a human being while maintaining fidelity to the research protocol.

Nurses offer a conduit to bridge knowledge between the public and clinical research trials by ensuring protocol validity, providing education, advocacy for research, and trust. Establishing trust provides a platform to promote protection with a focus on the patient experience and should provide a positive community ensuring longevity participation of individuals in clinical trials.19

Nursings’ code of ethics

Today, the Code of Ethics for Nurses (herein referred to as the Code) serves as nursing’s moral compass in articulating the ethical obligations, duties, standards, and principles to which all nurses are both accountable and responsible irrespective of role, position, or practice setting (ANA, 2001). The Code’s nine provisions and corresponding interpretive statements speak to nursing’s fundamental values and commitments, boundaries of duty and loyalty, and the nurse’s obligations that reach beyond an individual patient to the health care needs of the global community and advancement of professional nursing (ANA, 2001). The Code defines what it means to be professionally accountable to oneself and others and instructs that nurses demonstrate ethical behavior in their actions based on “the moral principles of fidelity and respect for the dignity, worth, and self-determination of patients” (p. 4).

The Code describes the nurse’s duty to oneself and others as being equally important and expected. Nurses practice with “wholeness of character,” and “personal integrity,” (ANA, 2001, p. 18) and must be committed to professional development and maintaining competence. Nurses “wholeness of character” includes “an authentic expression of one’s own moral point of view in practice” and “the nurse has a responsibility to express moral perspectives, even when they differ from those of others, and even when they might not prevail” (p. 19). “Wholeness of character” also alludes to nurses’ relationships with patients in maintaining “appropriate professional and moral boundaries” (p. 10). The Code is nonnegotiable—nurses are bound by the values and ethical conduct inherent to the profession—even when their integrity is threatened.

Nurses may engage in compromise as long as it is “integrity preserving” (ANA, 2001, p. 19), that is to say, the compromise will not endanger personal well-being or the well-being of others. Nurses never abandon patients, however, nurses may conscientiously object to any situation or circumstance that limits or prevents them from acting morally and upholding moral standards of the profession. In cases where the nurse conscientiously objects to participating in care, nurses fulfill their obligation to the patient by ensuring the appropriate transfer of care, thus ensuring the patient’s safety (ANA, 2001).

The Code describes the “morally good person” as someone who possesses “wisdom, honesty, and courage” (ANA, 2001, p. 20). The “morally good nurse” demonstrates “excellences” (compassion, patience, and skill) that exemplify good character (p. 20). Further, the Code speaks to nurses’ “responsibility to create, maintain, and contribute to environments that support the growth of virtues and excellences and enable nurses to fulfill their ethical obligations” (p. 21).

Conclusion

The International Council of Nurses Code of Ethics for Nurses [19] clearly emphasizes that “the nurse sustains a collaborative and respectful relationship with coworkers in nursing and other fields.” However, workplace bullying is continuing and most bullying victims do not have the power to successfully terminate bullying by themselves. The severity of workplace bullying only becomes worse and more dangerous without effective management efforts, and a reliable assessment of workplace bullying must be the first step for resolving the issue. A workplace bullying instrument needs to comprehensively include all the different types of bullying behaviors to carefully assess the reality of the bullying and to best prevent or intervene in the bullying issue. Accordingly, the modified taxonomy can be used as a framework for refining the existing instruments to ensure the inclusiveness of a broad range of workplace bullying behaviors.

It is recommended that the modified taxonomy is verified and updated in future studies through the participation of subject experts and workers with direct or indirect experiences in the fields. Based on the taxonomy of workplace bullying, more reliable and homogeneous measures are possible. To assess workplace bullying, a few methodological weaknesses found in this study need to be resolved. The construct of workplace bullying should be more fully explored and precisely defined before developing an instrument. Moreover, a formative measurement model with a set of different categories of psychological abuse needs to be tested to develop a bullying instrument in the future.

Read the Code and Make It Your Friend

Every nurse should be familiar with the Code of Ethics for Nurses. Try making this a topic at your next department meetings and assign individuals to start conversation on the following questions:

What surprised you when you read the Code of Ethics for Nurses?

The code is unambiguous that the nurse's primary commitment is to the patient. Everyday, we work to satisfy multiple stakeholders, our institution, our physician and other health care colleagues, our nurse colleagues, patients and their families, and our own families. Think of situations where it is difficult to make the patient your primary commitment.

The code is also explicit that every nurse owes the same duties to self as to others. What are the situations where you find it difficult to balance your duties to patients and yourself?

The code makes clear that every nurse should work in an ethical environment that supports everyone doing the right thing for the right reason. Does your practice environment support ethical practice? What are the barriers to acting ethically in your practice setting?