Values, Ethics, and Advocacy in Nursing

Dr. Nancy A. Hurlock, DNP, AGPCNP-BC provides a comprehensive framework that emphasizes the importance of values and ethics in guiding nursing practice.

Understanding Values in Nursing

• Definition of Values:
  • Fundamental beliefs about the worth of something that serve as standards to guide behavior.
  • Represent what matters most and influence responses in personal and professional contexts.
  • Forms a personal code of conduct based on an organized hierarchy of values ranked by importance.
• Impact of Values in Nursing:
  • Profoundly influence beliefs about human needs, health, and patient care responses.
  • Shape individual practice and collective culture in healthcare teams and institutions.

How Values Are Transmitted

1. Modeling: Learning by observing behaviors and actions of respected individuals (mentors, experienced nurses).
2. Moralizing: Direct teaching about right and wrong, facilitated by educators.
3. Laissez-faire: Personal experience and discovery guide individual value formation.
4. Rewarding and Punishing: Behavioral reinforcement encourages certain values while discouraging others.
5. Responsible Choice: Promoting thoughtful decision-making that considers alternatives and consequences, fostering autonomous value development.

Knowledge Check #1

• Statement: A child is born with values and forms new values during life from environmental, familial, and cultural information.
  • A. True
  • B. False

Answer to Knowledge Check #1

• Answer: B. False
• Rationale: A child does not inherit values; they develop values through experiences shaped by their environment, family, and culture.

Core Professional Values in Nursing

1. Altruism:
   • Genuine concern for others' welfare.
   • Prioritizing patient needs above personal interests; selfless dedication to care.
2. Autonomy:
   • Respect for patients' rights to self-determination in healthcare choices.
3. Human Dignity:
   • Acknowledgment of the intrinsic worth of every individual, regardless of circumstances.
4. Integrity:
   • Adherence to ethical codes and maintaining consistency in moral conduct.
5. Social Justice:
   • Advocacy for fair treatment and equitable access to healthcare resources.

The Three-Step Valuing Process

1. Choosing:
   • Free decision-making from alternatives after evaluating each option's consequences; involves critical thinking.
2. Prizing (Treasuring):
   • Committing to chosen values with emotional attachment and public affirmation.
3. Acting:
   • Consistent integration of chosen values into behavior to showcase authentic commitment and professional integrity.

Knowledge Check #2

• - Which value entails acting according to a code of ethics?
  • A. Altruism
  • B. Autonomy
  • C. Human dignity
  • D. Integrity
  • E. Social justice

Answer to Knowledge Check #2

• Answer: D. Integrity
• Rationale: Integrity involves adherence to established ethical codes and standards.
• Other values focus on different aspects: Altruism on welfare, Autonomy on self-determination, Human Dignity on inherent worth, and Social Justice on ethical principles.

Ethics and Morals: Key Distinctions

• Ethics:
  • A systematic study of principles surrounding right and wrong conduct, involving virtues and vices.
• Bioethics:
  • Addresses fundamental questions regarding duties to others and the common good.
• Nursing Ethics:
  • A specialized domain of bioethics focusing on ethical issues in nursing practice.

Two Major Ethical Theory Categories

1. Utilitarian Ethics:
   • The morality of an action is determined by its consequences (consequentialism).
   • Aims to maximize overall benefit or minimize harm.
2. Deontological Ethics:
   • The morality of an action is considered independent of its outcomes.
   • Focuses on moral rules and duties regardless of the consequences.

Beauchamp and Childress Bioethical Principles

1. Autonomy:
   • Respect for patients' rights to make informed healthcare decisions.
2. Nonmaleficence:
   • Principle of "do no harm"; avoiding actions that cause harm or suffering.
3. Beneficence:
   • Acting in the best interest of patients to promote health and well-being.
4. Justice:
   • Ensuring fair treatment and equitable distribution of healthcare resources.

• Additional Nursing Principles:
  • Fidelity, veracity, accountability, privacy, and confidentiality.

Care-Based Approach to Bioethics

• Centrality of Caring Relationships:
  • Ethical decision-making centers on trust and connection with patients.
• Dignity and Respect for Persons:
  • Recognition of each individual's worth; treating patients as whole persons.
• Attention to Individual Context:
  • Consideration of patients' unique circumstances and cultural backgrounds.
• Responsive to Others:
  • Sensitivity to the needs and emotions expressed by patients.
• Virtue-Based Moral Skills:
  • Redefining essential moral competencies to include character traits essential for caring.

Foundations of Ethical Nursing Conduct

• Professional Practice Standards:
  • Nursing practice must be aligned with ethical conduct standards and core values.
  • Establishes a framework for responsible and consistent care delivery.
• Essential Nurse Responsibilities:
  • Cultivate nursing virtues.
  • Understand guiding ethical theories.
  • Familiarize with nursing codes of ethics and standards.
• Moral Agency: Nurses demonstrate moral agency by making ethical decisions and advocating for patients.

Essential Virtues for Nursing Practice

1. Competence & Intelligence:
   • Maintaining clinical expertise for effective patient care.
2. Compassionate Caring:
   • Genuine empathy and concern in all interactions with patients.
3. Patient-Centered Focus:
   • Prioritizing patient interests while maintaining appropriate selflessness.
4. Trustworthiness & Integrity:
   • Building reliable relationships through honesty and moral uprightness.
5. Conscientiousness & Courage:
   • Attention to duties and advocacy for patient needs.
6. Humility & Wisdom:
   • Recognizing limitations and seeking personal and professional growth.

Purpose of the Code of Ethics for Nurses

• Ethical Obligations Statement:
  • Comprehensive statement outlining the ethical obligations of nurses in varied settings.
• Non-negotiable Standard:
  • Represents unwavering ethical standards of nursing practice.
• Professional Commitment:
  • Formal expression of nursing's commitment to society and defining the social contract between nurses and the public.

ICN Guidelines for Code Implementation

1. Study and Reflect:
   • Understand the standards and their personal/professional significance.
2. Engage in Dialogue:
   • Discuss the code with peers to deepen understanding.
3. Apply Real Examples:
   • Use experiences to identify ethical dilemmas connected to the code.
4. Build Consensus:
   • Clarify ethical decision-making in group settings.
5. Collaborate Across Disciplines:
   • Work with other professionals to uphold ethical standards in practice.

Registered Nurse Bill of Rights - Part 1

1. Professional Practice Fulfillment:
   • Right to practice in a manner fulfilling professional obligations and providing quality care.
2. Appropriate Practice Environment:
   • Right to work in environments aligning with professional standards.
3. Ethical Practice Support:
   • Right to environments that facilitate ethical practice congruent with the Code of Ethics.
4. Advocacy Without Retaliation:
   • Right to advocate openly for themselves and patients without fear of repercussions.

Registered Nurse Bill of Rights - Part 2

1. Fair Compensation:
   • Right to compensation reflecting knowledge, experience, and responsibilities.
2. Safe Work Environment:
   • Right to work in safety-prioritized settings with adequate resources.
3. Employment Negotiation:
   • Right to negotiate employment conditions for fair arrangements.

Moral Distress and Building Resilience

• Moral Distress:
  • Arises when the knowledge of the right action is obstructed by personal or institutional factors, causing internal conflict.
  • Common in settings with resource limitations or organizational policies hindering optimal care.
• Moral Resilience:
  • Developing strategies to cope with moral distress and strengthen personal resolve.

Building Resilience Strategies

1. Cultivating Relationships:
   • Building supportive personal and professional networks.
2. Embracing Change:
   • Accepting change as a natural aspect of practice.
3. Overcoming Challenges:
   • Viewing crises as opportunities rather than insurmountable obstacles.
4. Self-Care Focus:
   • Nurturing a positive self-view and prioritizing well-being.
5. Maintaining Perspective:
   • Keeping challenges in the proper context and avoiding extremes.

Nursing Process for Ethical Decision-Making

1. Assess the Situation:
   • Gather comprehensive data about the ethical dilemma and stakeholders involved.
2. Diagnose the Problem:
   • Articulate the ethical issues distinguishing them from other problems.
3. Plan and Weigh Alternatives:
   • Identify action courses and evaluate each against ethical principles.
4. Implement Decision:
   • Put the chosen action into practice, remaining vigilant for emerging issues.
5. Evaluate Outcomes:
   • Assess decision effectiveness and learn for future ethical actions.

Knowledge Check #3

• Statement: A nurse striving for culturally competent care encounters communication issues with a patient due to language barriers. This may lead to moral distress.
  • A. True
  • B. False

Answer to Knowledge Check #3

• Answer: A. True
• Rationale: The nurse's intention to provide optimal care is hindered by institutional limitations, illustrating moral distress.

Ethically Relevant Considerations in Healthcare

• Benefits vs. Harms Balance:
  • Weigh potential benefits against possible harms in decision-making.
• Informed Consent and Shared Decision-Making:
  • Ensure patients are fully informed and participate in their care decisions.
• Family Life Norms:
  • Respect diverse family structures and values while focusing on patient needs.
• Clinician-Patient Relationships:
  • Maintain professional boundaries while fostering trusting relationships.
• Professional Integrity:
  • Adhere to ethical standards in the face of challenges.
• Resource Allocation:
  • Fair distribution of limited healthcare resources.
• Cultural and Religious Considerations:
  • Acknowledge diverse cultural and religious practices impacting healthcare.
• Power Dynamics:
  • Recognize and address imbalances in provider-patient relationships.

Common Ethical Problems in Nursing - Part 1

1. Paternalism:
   • Involves acting for patients without consent to achieve perceived benefits.
2. Deception:
   • Withholding information or providing misleading details, even with noble intentions.
3. Privacy and Social Media:
   • Challenges of protecting patient privacy in the digital landscape.
4. Confidentiality:
   • Maintaining patient confidentiality while sharing necessary information with care teams.
5. Resource Allocation:
   • Addressing equitable distribution of scarce resources.
6. Consent and Refusal:
   • Ensuring informed consent and respecting patient treatment refusals.
7. New Technology Conflicts:
   • Ethical concerns regarding the use of emerging medical technologies.

Common Ethical Problems in Nursing - Part 2

1. Unprofessional Physician Practice:
   • Addressing unethical or incompetent practices by physicians endangering patient safety.
2. Unprofessional Nursing Practice:
   • Confronting unethical nursing behaviors that threaten patient welfare.
3. Staffing Issues:
   • Ethical concerns arising from inadequate staffing and compromised patient safety.
4. Beginning-of-Life Issues:
   • Navigating ethical dilemmas surrounding fertility and reproductive choices.
5. End-of-Life Issues:
   • Providing support for families facing decisions about terminal care and dignity in death.

Knowledge Check #4

• A nurse seeks a feeding tube order for an anorexic teenager refusing to eat. This situation exemplifies what ethical problem?
  • A. Deception
  • B. Confidentiality
  • C. Allocation of scarce nursing resources
  • D. Advocacy in a market-driven environment
  • E. Paternalism

Answer to Knowledge Check #4

• Answer: E. Paternalism
• Rationale: This example demonstrates paternalism as the nurse attempts to override the patient's autonomy without consent, aiming to act in their best interest.

Functions of Healthcare Ethics Committees

1. Education:
   • Providing ethical training and guidance for healthcare professionals.
2. Policy Making:
   • Developing ethical healthcare practice policies.
3. Case Review:
   • Analyzing ethical dilemmas and providing resolution guidance.
4. Consultation:
   • Offering real-time support for complex ethical situations.
5. Quality Assurance:
   • Monitoring and enhancing ethical quality in healthcare delivery.
6. Research (Occasional):
   • Conducting studies to further understanding of healthcare ethics.

Managing Conflicts of Commitment

• Primary Patient Commitment:
  • The nurse’s central obligation is to the patient, establishing the core of nursing practice.
• Self-Care Responsibility:
  • Nurses must also care for their well-being, maintaining integrity and competence while pursuing growth.
• Essential Balance:
  • Balancing patient needs with personal well-being responsibilities.

Advocacy in Nursing Practice

1. Patient Priority:
   • The commitment to place patient needs above all else.
2. Individual Focus:
   • Advocating for the good of individual patients against broader societal considerations.
3. Autonomy vs. Well-being:
   • Evaluation of conflicts between respecting patient autonomy and ensuring their well-being.

• Effective Advocacy:
  • Navigating complexities where patient desires, family wishes, institutional policies, and professional judgment may conflict.

Key Areas for Patient Advocacy

1. Representing Patients:
   • Speaking for patients unable to voice their needs, ensuring their participation in decision-making.
2. Promoting Self-Determination:
   • Empowering patients to make informed decisions regarding their own healthcare.
3. Whistle-blowing:
   • Reporting unsafe or unethical practices despite personal risks involved.
4. Political Activism:
   • Involvement in healthcare policies and initiatives that enhance patient care and advance nursing.

• Patient Advocacy:
  • A fundamental professional responsibility reflecting nursing values, requiring commitment and ethical practice.