Code of Ethics 2010.pdf

8/14/2019 Code of Ethics 2010.pdf

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Cover image: with thanks to Wellington Hospital Oncologynurse Liz Kaczon and Lyona Sydney.Photo:Anne Manchester

Last reviewed 2010

Revised 1995, 2001New Zealand Nurses OrganisationP O Box 2128, WellingtonPhone 04 931 6747, Fax 04 382 9993

ISBN 0-908669-58-5


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[NZNOCodeofEthics,2010] Page4

Foreword

By NZNO president, Nano Tunnicliff andTe Runanga o Aotearoa NZNO kaiwhakahaere, KerriNuku.

The Code of Ethicsis one of NZNOs most sought afterpublications and we are proud of its wide circulation and usage.

This new edition of the code updates the framework of the codeand provides a new method to assist nurses with decision-makingin clinical contexts.

Nurses from many cultural, ethnic, employment and practicebackgrounds worked together to develop this code. The result isa publication produced by New Zealand nurses, unique to NewZealand, that takes cognisance of our cultural context. Culturalsafety is integral to nursing practice and is reflected in the code.The nursing profession continues to lead other health professionsin this important aspect of partnership.

The need for knowledge on ethics, ethical issues and ethicaldecision making has never been greater. Nursing is undertaken incomplex professional practice environments. Nurses daily facesituations where they are challenged by under-resourcing, timepressures, short staffing and unhealthy roster patterns. Nurseswith a knowledge of ethics, ethical frameworks and processes arebetter prepared for situations requiring ethical judgements.

We are confident the code will be of value and provide nurseswith the support they need in the frequently difficult, complex,stressful, but also rewarding practice environments in which theywork.


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Acknowledgements

NZNO acknowledges the work of the followingindividuals andNZNO colleges and sections who contributed to the 2010 review

of the code of ethics:

Chris Millar, Elizabeth Niven, Martin Woods, Ruth Crawford onbehalf of the Nurses for Children and Young People AotearoaSection, Laurie Mahoney on behalf of the Public Health NursesSection, Lorraine Ritchie on behalf of the Nursing ResearchSection, and Debbie ODonoghue on behalf of the NeonatalNurses College Aotearoa.

NZNO would also like to acknowledge all those individuals andgroups who have contributed to previous editions of the code ofethics.


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Codepreamble

The purpose of this code of ethics [the code] is to guide nurses

practice, and communicate to society the nursing professionsethical values. It has been formulated and updated in response tothe need for a code that closely reflects the current context ofnursing practice.

The New Zealand Nurses Organisation [NZNO] is a professionalassociation and a registered union for nurses in Aotearoa NewZealand, representing over 45,000 nurses and health workers ona range of professional and employment related issues acrossthe public, private and community sectors. Te Runanga oAotearoa NZNO comprises our Mori membership and is the armthrough which our Tiriti o Waitangi NZNO partnership isarticulated.

The Treaty of Waitangi is the founding document of AotearoaNew Zealand and underpins its economic and socialdevelopment. The code is congruent with NZNOs Social Policy

Statement (2009), which acknowledges the principles ofprotection, participation and partnership between nursing and theindigenous people, Mori. Nurses acknowledge the uniquerelationship between Mori and the Crown in applying the code.

Over the past century and a half, people from many countries inEurope, Asia, Africa and the Pacific have settled in New Zealand,which today is home to many different faiths and cultures. Cultureis not only ethno-specific, but includes the cultures of class,

sexual orientation, religion, age and gender. Nurses strive torecognise this cultural diversity and to work with clients and theirfamilies whnau to ensure the health process imposes as little aspossible on moral, cultural or spiritual beliefs and practices.

Values characteristic of ethical frameworks derived from theWestern moral tradition have traditionally been used to developvalue statements that guide nursing practice. These values informthe development of the code, with the addition of specific values


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that have been identified as important in the context of ethics andnursing practice in Aotearoa New Zealand.

At this time of change, challenge and uncertainty in the healthservice, it is important all nurses faced with an ethical dilemmaare guided by ethical practice principles. The nationwide use ofthe code will signal to other health professionals, managers andto the public that nurses are aware of their moral responsibilities.


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Use of the code of ethics

The code has been written for nurses to use both as a basis to

explore the ethical beliefs of New Zealand nurses, and as a guideto explore the detail of individual situations arising in nursingpractice.

Each situation is unique and exists in its own context. The mostimportant values from the framework will be specific to theparticular situation. Any one value is not always an over-ridingvalue; the balance of values and their inter-relationships maychange, not only with each situation, but also within eachsituation.

The code does not seek to provide answers to situationsencountered in practice. Ethical concerns and situations areresolved using an approach that incorporates exploring valuesapplicable to the context and a logical process of thinking andaction. The four-box method included in this document mayassist nurses in their decision-making processes.


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Underlying philosophy

Nursing was founded on the moral premise of caring and the

belief that nurses have a commitment to do good. Part ofsocietys expectation of nurses is that they are moral agents intheir provision of care, and that they have a responsibility toconduct themselves ethically in what they do and how theyinteract with persons receiving care.

Ethical nursing practice is based on the elements of acommitment to do good; sensitivity and receptiveness to ethicalmatters; a willingness to enter into relationships with personsreceiving care and with groups, populations and communities thathave health-care needs and problems(Canadian NursesAssociation [CNA], 2008, p. 4). Nurses are responsible forensuring they achieve ethical nursing practice.

Nurses demonstrate ethical nursing practice when they advocateindividually and collectively for the elimination of social inequities.Nurses address social inequities by: collaborating with other

health care professionals and organisations for change inunethical health and social policies, legislation and regulations;advocating for accessible, appropriate and affordable health careservices that are available to all; recognising the significance ofthe socio-economic determinants of health; and supportingenvironmental preservation and restoration.

An ethical code supports nurses to achieve ethical nursingpractice by outlining nurses ethical responsibilities and guiding

nurses in their reflection and decision-making (CNA, 2008).

AssumptionsThe exploration of ethical issues takes place in the unique contextof the specific reality of each situation. Contextual determinantsinclude cultural, family whnau, professional, religious and

personal beliefs. This code is based on several assumptions thatpermeate nursing:


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i) That relationships and interactions take place in a climate ofrespect for the other. This encompasses a respect forculture, religion, life choices, sexual orientation, ethnicity andother life-directing values held by individuals and groups.An example of enacting this assumption is shown inproviding and working within the concept of cultural safety.

ii) That respect for the individual/group/communityencompasses the notion of partnership and collaboration,where the individual/group/community participates actively inthe process of nursing. This stand acknowledges thecontribution of the persons effort, knowledge and expertise

to the partnership.

iii) That relationships and interactions seek to achieve anequitable outcome for the individual/group/community. Thepurpose of nursing is to uphold and improve the health ofthe individual/group/community.

Nursing takes place in a series of unique relationships with

others: client (including family whnau), colleague, organisationsand society. The code provides a framework that is structuredaround these unique relationships and their correlation with thevarying ethical values that may be used to guide nursing practice.

While not exhaustive, the framework of the code describes someexamples of how the ethical values included can be implementedin the context of nursing practice. The framework of the code issummarised in the table below, with specific examples of each

framework in relation to the nurse-client, nurse-colleague, nurse-organisation and nurse-society relationships on subsequentpages.


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Framework of the code

Relationships

UnderlyingValues

nurse-client

relationship

nurse-

colleaguerelationship

nurse-

organisationrelationship

nurse-

societalrelationship

Autonomy(outlined on page 11)

described onpage 15

describedon page 18

describedon page 20

describedon page 23

Beneficence(outlined on page 11)

described onpage 15

describedon page18

describedon page 20

describedon page 23

Non Maleficence(outlined on page 11)

described onpage 16

describedon page18

describedon page 20

describedon page 23

Justice(outlined on page 12)

described onpage 16

describedon page18

describedon page 20

describedon page 23

Confidentiality(outlined on page 12)

described on

page 16

described

on page18

described

on page 21

described

on page 24

Veracity(outlined on page 12)

described onpage 16

describedon page19

describedon page21

describedon page 24

Fidelity(outlined on page 12)

described onpage 17

describedon page19

describedon page 21

describedon page 24

Guardianship ofthe environmentand its resources(outlined on page 12)

described onpage 17

describedon page19

describedon page 21

describedon page 24

Beingprofessional(outlined on page 13)

described onpage 17

describedon page19

describedon page 21

describedon page 24


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Underlying Values

In the ethics of nurses ( or a nurses) practice, the following values arefundamental

Autonomy(self determination)

The right of individuals to self determination,which assumes the individual/group/client/agentof the person, has the wisdom to make the bestchoice for that person.

Particular attention should be paid to awarenessand acceptance of cultural differences in theprovision of health care, to ensure cultural safetyof clients and nurses. (A situation is culturallysafe when a client feels their cultural or spiritualneeds are included in care or that they can askand have those needs met without prejudice.)

Many socio-cultural groups in this country placethe importance of the collective on a par with theneeds and rights of the individual. The right ofboth the individual and the collective (whnau,

hap, iwi) must be respected.

Beneficence(doing good)

Performing the action or actions leading to anoutcome that now, or in the future, would beregarded as worthwhile; the concept of doinggood.

Contextual variations on the meaning and valueof good will influence exploration and outcome in

the consideration of beneficence.

Non Maleficence(doing no harm)

Avoidance of harm and the prevention of futureharm. In a situation of where harm isunavoidable, the harm is minimised.

Contextual variations on the meaning and valueof harm will influence exploration and outcome in

the consideration of maleficence.


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Justice(fairness)

The assumption that society has a responsibilityto treat people fairly. Society confirms conceptsof justice in its legal frameworks. There is aninter-relationship between law and justice, which

means that one does not automatically over-ridethe other. Laws are modified through practice toincrease justice in society. Different healthcircumstances may require different resourceallocation or entitlement, to achieve equity.

Confidentiality(privacy)

The privacy of written or spoken information, orof observed body language, acquired throughprivileged access.

The concept of privacy in each situation ismodified by legal and contextual realities.

Veracity(truthfulness)

Actions, speech and behaviour that ensurecommunications between individuals and/orgroups are honest and truthful.

Fidelity(faithfulness)

The obligation to remain faithful to onescommitments to others.

Guardianship of theenvironment and itsresources

The assumption that society has a responsibilityto respect and protect the environment and itsresources.

Cultural/contextual variation in the relationshipbetween person and environment will influence

the value of guardianship.


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Being professional The belief that nursing is a profession with adefined purpose. It has a special relationshipwith society, having been established by societyto provide health related care for those of itsmembers in need.

Nursing possesses a distinct body of knowledge,its own area of independent practice and isguided by the specific set of values identifiedhere.

Nurses are accountable for their nursing practice

and accept responsibility for their actions anddecision-making.


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NurseClientRelationship

Underlying ValuesIn the context of the nurse-client relationship, the

underlying values are demonstrated by thenurse:


Supporting clients to enable freedom of choiceand informed consent. Informed consentrequires that enough relevant information isprovided to enable a reasoned decision to bemade, and that the information is understood.Cultural perception is an important component.Without understanding, no one can make areasoned decision. Nurses support clients inmaking informed decisions by giving informationand assistance, thereby ensuring they becomeactive participants in their own health care.

Ensuring the health service responds to culturaldiversity and that the nurse recognises culturalnorms.

Being aware that people may act as individualsor as part of a collective social system.

Recognising when the clients autonomy maybe limited and engaging family whnau orother acceptable resources to assist inmaximising the client wishes.


Creating a partnership, the outcome of which theclient views as beneficial.

Respecting the right of clients to define safetyfactors related to the beneficence of nursing,through their own subjective experience.

Using expert nursing knowledge to bring about

professional good in relation to the clientshealth.


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Promoting the safety of clients by means ofcompetent and safe nursing practice.

Protecting and advocating for the rights of clients

in order to minimise or prevent harm. Nursesshould assist vulnerable persons who need helpexpressing personal needs and values.

Recognising cultural norms, eg especially whencollecting and storing health, body tissue orgenetic material, while at the same time havingregard for the law, which will ensure the client iskept safe from future harm.

Ensuring cultural safety when nursing peoplefrom other cultures, by undertaking a process ofvigorous examination of their own culturalidentity.

Justice(fairness)

Acknowledging and respecting a clientsperception of fairness and perception of whatwould be an appropriate outcome for them.

Respecting the rights of individual people, theirdignity, needs and values. Nurses should besensitive to such factors as the persons race,age, health status, religion, culture, sexualorientation and gender.

Confidentiality

(privacy)

Being mindful of the privileged nature of client

information they gain.

Safeguarding the physical, emotional and socialrights of clients from unwarranted intrusion.


Communicating with the client in an open,honest and truthful manner.


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Being faithful in all commitments to clients, sopromoting trust as an integral component of thenurse-client relationship.

The withdrawal of services, for whatever reason,creates a particular dilemma for nurses inrelation to fidelity. This needs carefulconsideration. Ensuring opportunities arecreated to give an account of the reasons fordecisions made, may go some way towardmaintaining fidelity.

Guardianship of the

environment and itsresources

Practising and teaching health practices that

actively support the conservation of theenvironment and resources.

Being Professional Providing sound judgement and practising withinthe code.

Providing nursing practice which meetsstandards developed by the profession.

Advocating for appropriate health services forclients.


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NurseColleagueRelationship

Underlying Values In the context of the nurse-col league

relationship, the underlying values aredemonstrated by the nurse:


Being sufficiently self aware to understandreasons for their own actions and those ofothers. If the nurse values their own abilities andperformance, then they are better able toappreciate the contributions of others to peopleshealth.


Contributing knowledge and skill to createpositive relationships with colleagues.

Sharing knowledge and skills to contribute toeffective care.


Participating in mutual/peer monitoringprogrammes to enhance the quality of careprovided and prevent/minimise harm.

Providing support and guidance for peers toensure clients and peers are protected from anyharm.

Justice(fairness)

Being sufficiently self aware to safeguard onespersonal rights, moral values and beliefs, and to

acknowledge/accept those of colleagues. Nurseshave a right to choose to live by their ownvalues, as long as those values do notcompromise the care of their clients.


Safeguarding the physical, emotional and socialrights of colleagues from unwarranted intrusion.

Maintaining confidentiality of personal

information.


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Relating to colleagues openly, honestly andtruthfully to engender trustful and supportiverelationships.


Being loyal to ones self, to the therapeutic teamand to the professional group. Conflictingdemands may require the nurse to balance clientneeds with specific loyalties.


Developing and using processes in personal andcollective professional practice that conserve theenvironment and resources.

Being professional Working with colleagues, to keep informed ofnew trends, to have an up-to-date knowledge oflegal issues and to be able to apply the results ofrelevant research to promote change andinnovation in practice.

Being ready to accept a review of practice bypeers and to intervene in instances of poorpractice. Such intervention may be direct butinformal in the workplace, or may require formalreferral to an organisational or professionalauthority.

Respecting the rights and practice of colleaguesis an integral part of nursing practice. It isinevitable the nurse will encounter conflictingprofessional opinions that will require resolution

by discussion. Good collegial relationships arefree of discrimination or harassment.


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NurseOrganisationRelationship

Underlying ValuesIn the context of practice within an organisation,

the underlying values are demonstrated by thenurse:


Being aware that people may act as individualsor as part of a collective social system, and thatnurses themselves may be members of manydifferent social groupings. When a nurse is a partof a larger organisation, there may be limits toindividual autonomy.


Working with others, having regard for theirindividual rights.

Participating in and contributing to theestablishment and review of systems andstructures for care provision.

Protecting the rights of clients.

Designing and monitoring services provided.

Advocating to ensure services meet therequirements of clients and are perceived asappropriate by those clients.


Participating in organisational activities thatensure the environment is physically, socially,spiritually, emotionally and culturally safe forclients and colleagues.

Justice(fairness)

Supporting and advocating for equality andequity by establishing systems, monitoringservices and supporting resource allocation toensure client and colleague needs are met.


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Ensuring systems established to passinformation from one person to another and/or topass large volumes of personal information donot breach confidentiality.

Being alert to the risk of organisational systemsand standards that may breach confidentialityand challenging those that do.


Promoting open, honest and truthfulcommunication among colleagues and withemployers, to foster a supportive, trustfulenvironment. Organisational culture may

influence the nurses ability to achieve veracity.


Being loyal and honouring the commitment topractice and to perform the role s/he has agreedto perform.


Informing and participating with management toensure effective nursing practice through theefficient use of human, technical, financial andnatural resources.

Matching resources to client need, monitoringand advocating for change in the allocation ofresources when necessary to ensure theconservation of the environment and resources,while minimising risk to clients and tangatawhenua.

Being professional Using standards for practice as an essential partof quality nursing systems, together with regularreview of competencies. Maintenance ofstandards requires the nurse to be accurate andefficient in the recording of events and toundertake regular reviews of present practice todevelop new and better strategies.

Actively promoting co-operation between the


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various groups of health care professionals andcolleagues.


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NurseSocietalRelationship

Underlying ValuesIn the context of the nurse-societal relationship,

the underlying values are demonstrated by thenurse:


Adapting practice to a variety of interpretations ofthe concept of autonomy.

Understanding and communicating the conceptof autonomy to wider society


Participating in research, education andinnovation to ensure professional practicedevelops to best meet the needs of society.

Ensuring standards for cultural safety, ethicalpractice and health information are establishedand maintained in collaboration/consultation withthe community.


Monitoring services and practice in relation to therequirements of society, particularly in relation tocultural safety and the protection of vulnerablemembers.

Justice(fairness)

Ensuring services are relevant to client groups,and vulnerable clients are treated, regardless oftheir ability to pay.

Ensuring all client groups, irrespective of age,ethnic background, sexual orientation, gender,location or health status, have access tocompetent nursing services. (Accessibilityissues often come to the attention of nurses whoshould be willing to advocate for appropriatehealth care for the communities within whichthey practise.)

Ensuring clients and their family whnau


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understand their right to complain about thehealth care they receive and the steps they cantake to lay a complaint.


Being aware that protecting clients personalinformation may conflict with societys need forknowledge to protect itself from harm.

Being prepared to analyse the contextualvariations of each situation, and being up-to-datewith any legal requirements.

Veracity

(truthfulness)

Practising from the perspective that public

accountability, transparency and openness areessential elements of a democratic society topromote the well-being of the community.


Being true to the commitment made to society onadmittance to the roll or register of nurses.


Practising and teaching health practices in a waythat:

Conserves the environment and resources;

Actively seeks to enhance societysrelationship with the natural environment;

Reduces the use of substances harmful topeople and the environment.

Being professional Participating in ongoing negotiation betweensociety and the profession to ensure the needsof society are met and that:

society is kept informed of progress;

a therapeutic relationship is maintained;

society is assisted to develop healthy beliefs,


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attitudes and lifestyles.

Supporting the concept that nurses should beprepared in an approved nursing programmeand should undertake regular, continuingeducation during their working life.


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Addressing particular clinical ethical issues

ThefourboxmethodThis is a useful tool for addressing clinical ethical issues by asking usto allocate specific salient items of information within four boxes thateach focus on different aspects of care planning for individual patients.The four-box method builds on the recognition that even afterreflection we can and do still disagree on which moral theory isultimately correct. The alternative, not making a decision, is notmorally neutral and is itself open to moral apprasial, and there is aneed to find a way through that will lead to a decision that we canagree is rational and ethical (Godlovitch as cited in Keenan, 2010).

The four-box method is a tool which helps us achieve this.

The four-box method

Something missing here??

CLINICAL ISSUES PATIENT PREFERENCESThe principles of beneficence and non-

maleficence

What is the patients medical history/

diagnosis/prognosis?

What are the treatment options?

What are the goals of treatment?

What is the benefit to the patient?

The principle of respect for autonomy

What are the patients expressed

preferences for treatment?

Is the patient competent?What would they want done?

What is in their best interests?

QUALITY OF LIFE CONTEXTUAL FEATURESThe principles of beneficence and non-maleficence and respect for autonomy

Prospects of survival with and without

treatment?Various effects of patient of treatment?

What are the plans for comfort and

palliative care?

The principles of loyalty and fairness

How does this affect others: family

whnau and team?Cost to Central health system?

Cultural/religious issues?

Law and Policy?

Ref: McDonald, M., Rodney, P., & Starzomski, R.,( 2001).A framework for ethical decision-making:Version 6. Ethics Software. Adapted from Jonsen, A., Siegler, M., & Winslade, W.(1992).Clinical Ethics (3

rdedition).New York, McGraw Hill.(reproduced with permission from M.

McDonald).The framework is available on line at www.ethics.ubc.ca


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Scenarios/exemplars

A number of scenarios/exemplars from nursing practice areavailable on the NZNO website. These scenarios provide

examples of how differing ethical issues may be addressedusing the framework of the code of ethics in this document.These scenarios may be useful for teaching purposes,individual learning and/or to facilitate discussion on ethicalissues that may arise in practice.

www.nzno.org.nz


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Glossary of Terms

Advocate A deliberate process of speaking out onissues of concern to exert some influence on

behalf of ideas or persons. (verb: advocating)

Aotearoa Mori name for New Zealand.

Client The term client is used to describe theindividual person and/or theirfamily/whnau/group/agent who is/arerecipients of nursing care. It encompassesthe terms patient, customer, consumer andresident, or any other term appropriate to therecipient of the care. This may include therecipients agent.

Cultural SafetyKawa Whakaruruhau A manner which affirms, respects and

fosters the cultural expression of therecipient. This usually requires nurses to have

undertaken a process of reflection on theirown cultural identity and to havelearned to practise in a way that affirms theculture of clients and nurses. Unsafe culturalpractice is any action that demeans,diminishes or disempowers the culturalidentity and well-being of an individual.(Ramsden, 1990)

Cultural values Morals, beliefs, attitudes, and standards thatderive from a particular cultural group.Culture is not only seen as ethno specific, butmust include groups from within cultures e.g.cultures of class, socialisation, sexualorientation, age etc.

Ethical practice The domain of nurses moral behaviour,actions, decisions and ethical decision


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making, in response to conflicts of moralvalue.

Hap Sub-tribe (made up of several whnaugroupings).

Iwi Tribe (made up of several hapgroupings).

Mori The indigenous people of New Zealand.

Nurse A nurse is a health professional who is eitherregistered or enrolled by the Nursing Councilof New Zealand (NCNZ) under the Health

Practitioners Competence Assurance Act2003 (HPCAA). The provision of a currentpractising certificate from the NCNZ isconsidered to be recognition of the nursesability to work under the title of nurse.

However, there are registered or enrollednurses who, for various reasons, do not holda practising certificate for employment.

Nursing students, nurses in management,education or any other field are stillrepresentatives of the profession. The code isjust as relevant to these groups of nurses.

Nursing practice Nursing practice is defined by the NursingCouncil of New Zealand as using nursingknowledge in a direct relationship with clientsor working in nursing management, nursing

administration, nursing education, nursingresearch, nursing professional advice ornursing policy development roles, whichimpact on public safety (Retrieved fromwww.nursingcouncil.org.nz 19 May 2010).Wherever nurses practice, the requirementplaced upon them to act ethically isparamount.

Tangata whenua Indigenous people of Aotearoa.


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Te Runanga oAotearoa, NZNO Te Runanga (TR) is the arm of the New

Zealand Nurses Organisation (NZNO) thatrepresents the concerns and interests ofNZNOs Mori members.

Te Tiriti o Waitangi/The Treaty of Waitangi

Foundation document of New Zealandbetween the Crown and Tangatawhenua/Mori Iwi signed in 1840.

Safety Protection from physical, environmental,cultural, emotional, spiritual, sexual, legal andpsychological harm.

Value(s) A standards or qualities that are esteemed,desired, considered important or have worthor merit. Values are expressed by behavioursor standards a person endorses or tries to

maintain (Fry & Johnstone, 2008).

Whnau Family group, can include extended familymembers up to five generations.


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National OfcePO Box 2128

Level 3Willbank Court

57 Willis StreetWellington 6011

0800 28 38 48

www.nzno.org.nz

Last reviewed 2010Revised 1995, 2001

ISBN 0-908669-58-5

Documents

Code of Ethics 2010.pdf