Dana Bjarnason, PhD, RN, NE -BC Vice President & Chief ... · responsibilities related to the use of ethical principles and nursing’s code of ethics to create ethical practice environments

Ethics and Nursing Leadership: Oregon Nurses Association CE Day April 12, 2016

Dana Bjarnason, PhD, RN, NE-BC Vice President & Chief Nursing Officer, OHSU Healthcare Associate Dean, Clinical Affairs, OHSU School of Nursing

Object ives • Contextual ize and descr ibe nur sing leader ship

r esponsibi l i t ies r elated to the use of ethical pr inciples and nur sing’s code of ethics to cr eate ethical pr actice envir onments.

• Analyze nur sing leader ship case studies using ethical pr inciples and nur sing’s code of ethics to identi fy and addr ess ethical di lemmas in nur sing pr actice.

True Then, True Now • Never before in the histor y of health care has there

been such a demand for the men and w omen in our profession w ho are able to identi fy, confront, and resolve ethical questions. – Nurses must have a clear aw areness of:

• Per sonal and pr ofessional values • How these values inf luence their decision-making

behavior • Under standing and applying ethical pr inciples • Using an effective decision-making pr ocess for

addr essing ethical di lemmas. Uustal, 1990

Characterist ics of a Profession

• Education and tr aining – Associate, baccalaureate, master , doctoral

preparation

• Ski l l based on theor etical know ledge – Nightingale, Watson, O’Rourke, Leininger , et

al…

• Pr ofessional or ganizations – ANA, AONE, state aff i l iates, specialty

organizations, et al…

• Ser vice to society – Volunteer ism, legislative activi ty, community

health, et al…

• A code of ethics – Since 1893!

Foundational Documents

• Cr eated by nur ses/for nur ses to better under stand and infor m about the social context of nur sing’s contr ibution in health car e

• Fr ame nur ses’ under standing of their : – Ethical obl igations and duties – Obligation to the r ecipients of nur sing car e – Relationship w ith society

Purpose of Nursing’s Code of Ethics

• Statement of the ethical obligations and duties of every individual who enters the nursing profession

• Profession’s nonnegotiable ethical standard

• Expression of nursing’s own understanding of its commitment to society

Provisions 1 - 3: Fundamental values and commitments of the nurse • The nurse practices w ith compassion and respect

for the inherent digni ty, wor th and unique attr ibutes of every person.

• The nurse's pr imary commitment is to the patient, whether an individual, fami ly, group, community, or population.

• The nurse promotes, advocates for , protects the r ights, health and safety of the patient.

Provisions 4 - 6: Boundaries of duty and loyalty • The nurse has author i ty, accountabi l i ty and responsibi l i ty

for nursing practice; makes decisions and takes action consistent w i th the obl igation to promote health and provide optimal care.

• The nurse ow es the same duties to self as to others, including the responsibi l i ty to promote health and safety, preserve w holeness of character and integr i ty, maintain competence, and to continue personal and professional grow th.

• The nurse, through individual and col lective effor t, establ ishes, maintains and improves the ethical envir onment of the w ork setting and condi tions of employment that are conducive to safe, qual i ty health care.

Provisions 5 - 9: Duties beyond individual patient encounters • The nurse…advances the profession through

research and scholar ly inquir y, professional standards development, and the generation of nursing and health pol icy.

• The nurse col laborates…to protect human r ights, promote health diplomacy, and reduce health dispar i ties.

• The profession of nursing…must ar ticulate nursing values, maintain the integr i ty of the profession and integrate pr inciples of social justice into nursing and health policy.

Ethical Principles and Values Professional competence includes understanding

and using pr inciple-based ethics as w ell as k now ing and em br acing other ethical values

• B eneficence • T o do good

• N onm aleficence • T o do no har m

• Autonom y • I ndependence, self-r ule

• Justice • Fair ness

• Pr ivacy • Confidentiality • R espect for per sons • I nfor m ed consent • Self-deter m ination • Advocacy • Dignity

The Ethic of Care • A practice, not a set of r ules and pr inciples

• Requires speci f ic moral quali ties that focus on character istics that connect to the r ight action

– Sympathy

– Compassion

– Fai thfulness

– Truth tel l ing

• Emotional commitment to, and w i l l ingness to act on behalf of persons w i th whom one has a signi f icant r elationship

Questions to Ponder • Is what is legal always ethical? • Is what is ethical always legal?

Consider

• Slavery • Capital punishment • Tuskegee Syphi l is Exper iments • Oregon Death w ith Digni ty Act • Euthanasia • Cloning • Genetic testing

What is the Difference?

• Legal considerations include: – Regulator y agencies – Applicable laws

• Ethical considerations include: – Code of ethics – Pr inciple-based ethics – Ethic of care

Ethical and Moral Terms • Ethical

– Used to r efer to r easons for decisions about how one ought to act, using ethical theor ies (humanist, feminist, social ethics)

– Adher ing to pr inciples and cultivating vir tue

• Mor al

– Over laps w ith ethical but is mor e al igned w ith per sonal bel ief and cultur al values

Responsibility in Nursing

• The complexi ty of the health-car e envir onment necessi tates that nur ses have sound: • Understanding of the legal and professional

standards and pr inciples that affect patient care.

• Know ledge base in ethics and the abi l i ty to use ethical pr inciples and practices that guide care and decision making.

Accountability in Nursing • Mor al

• Being able to r ecognize and respond to si tuations in which unethical practices or fai lure to provide quali ty patient care exists

• Ethical • Ski l l using and applying ethical pr inciples and

practices in r esolving value-laden subjects: • Pr ofessional pr actice • Human r elationships • Effective communication and • The end of l i fe

Questions to consider

• What are the issues/confl icts r aised in the fol low ing scenar ios?

• Should staff be requir ed to honor these requests? On what grounds?

• Are rel igious/cultural grounds suff icient r easons for honor ing patient r equests?

• What actions should be taken? • What kind of pol icies should exist?

A Nurse Manager’s Ethical Dilemma

• A white patient is admitted to hospital. The patient r equests that only white care takers provide care for this patient. The request is suppor ted by hospital administr ation.

Ethical Principles/Values/Provisions Guiding Our Actions • Pr inciples

– Nonmalef icence – Justice

• Values – Respect for persons – Digni ty

• Provisions – Provision 1, 2, 3, 5, 6, 8, 9

A Clinical Environment Dilemma

• A holiday “bus” par ty attended by healthcare team members fr om a hospital depar tment stops at the hospital to use the faci l i ties.

• Several health team members enter the patient care area, interacting w ith on-duty col leagues and patients.

• They appear to be visibly intoxicated.

Ethical Principles/Values/Provisions Guiding Our Actions • Pr inciples • Values

– Pr ivacy – Respect for persons – Digni ty

• Provisions – Provision 1, 4, 5, 6, 9

An Organizat ional Dilemma

• A nurse requir es intermittent fami ly medical leave for her chronical ly i l l chi ld. The cur rent medical cer ti f icate is expir ing. She falsi f ies a physician signature and submits the documents to her employer .

• Dur ing routine due di l igence monitor ing, the physician denies signing the FML form and demands that the nurse be charged w ith fr aud.


– Nonmalef icence – Justice

• Values – Pr ivacy – Respect for persons

• Provisions – Provision 1, 4, 5, 6, 9

End-of-Life C are: Still a Dilemma

• Staff on the MICU are clear ly suffer ing as they str uggle w ith goals of care decisions that are being made by a patient’s fami ly which seem out of l ine to them based on their know ledge of the patient’s w ishes.


– Beneficence – Nonmalef icence – Autonomy – Justice

• Values – Respect for per sons – Self-deter mination – Advocacy – Dignity

• Pr ovisions – Provision 1, 2, 3, 4, 6, 8

A CNO Dilemma

• The CNO is noti f ied by Corporate Compliance that a Facebook post by a r egistered nurse violates hospital pol icy and patient confidential i ty. – The nurse has described an encounter with a

pat ient the clearly could be associated with a part icular pat ient.


– Beneficence – Nonmalef icence

• Values – Pr ivacy – Confidential i ty – Digni ty

• Pr ovisions – Provision 1, 2, 3, 6, 8, 9

A Culture of Safety Dilemma

• Nationally healthcare workers admit that they often fai l to r epor t potential or actual patient safety events for fear of r epr isal.


– Beneficence – Nonmalef icence – Justice

• Values – Respect for persons – Advocacy

• Pr ovisions – Provision 1, 2, 3, 4, 6, 7, 8, 9

An EHR Dilemma

• A healthcare worker is shot in a burglar y attempt and is tr anspor ted to the emergency depar tment of the hospital where he works. By the time “break the glass” is ini tiated on his electr onic medical r ecord, f ive nurses w ithout the “need to know” have accessed his char t.


– Nonmalef icence • Values

– Pr ivacy – Confidential i ty – Respect for persons – Digni ty

• Pr ovisions – Provision 1, 2, 3, 5, 6, 8, 9

2015 Code of Ethics for Nurses with Interpretive Statements

As we reflect on these scenarios, our ethical obligations relative to the relational pattern of our responsibilities becomes clear.

• Nurse to patient • Nurse to nurse • Nurse to self • Nurse to others • Nurse to profession • Nurse to society • Nursing to society

To Ponder, To Be Proud

• Today’s Code of Ethics for Nurses embodies the patient as the focus and substantiates nurses’ duties, obl igations, and responsibi l i ties in r egard to faci l i tating patient care, no matter the nurses’ r ole

• Using ethical pr inciples, values and the Code for Nurses establishes a fr amework fr om which nurses can: – Do their work – Find their voices – Justi fy, val idate and suppor t their actions

• Professional duty of nurses

• Pr inciples of beneficence and nonmalef icence

• Ongoing development of nursing and the profession

• Confidential i ty

• Commitment to other health-care providers and to patients

1893 – 2015: Constant Characterizat ions

Discussion

Sources • Amer ican Nurses Association (2015). Code of

ethics for nurses with interpret ive statements. Si lver Spr ing, M D: N ur sebook s.or g.

• B eaucham p, T . L . & Childr ess, J. F . (1994). Pr inciples of biomedical ethics. 4th ed. N ew Yor k : Ox for d Univer sity Pr ess.

• T r onto, J. C. (1994). Moral boundar ies: A polit ical argument for the ethic of care. N ew Yor k : R outledge, Chapm an, and H all.