Ehical Liabilities

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UNIT IV

ETHICAL PRINCIPLES OF NURSING

Required readings: Catalano, chapters 6, 7, 13

Ethics in Nursing

Catalano, chapter 6

Every day nurses make ethical decisions in their nursing practice.Sometimes you may find yourself trapped in an ethical dilemma, caught betweenconflicting duties and responsibilities to your patients, your employer, and to yourself.You may wonder later, "Did I do the right thing?"There are no easy answers in solving ethical dilemmas. Such conflicts can be painfuland confusing. But an understanding of the principles of ethics, nursing standards, andethical codes can help you make sound decisions to guide your nursing practice.

There is no static, definitive body of knowledge that will clearly guide us in analyzingand resolving the complex ethical dilemmas surrounding health care delivery.

We are faced with difficult questions such as"How can we ensure full access to health care in the midst of scarce resources?" "What is the most appropriate and necessary care at the end of life?" "How should we use scientfic advances to enhance rather than dimish human

life?"

There are no easy answers.

Analysis, discussion, and debate among nurses and others are needed to developconsensus and , then, public policy.

Ethical decision making is a skill that can be learned, based on understanding of

underlying ethical principles, ethical theories or systems, a decision making model,and the Nursing Code of Ethics.You are legally responsible for using your knowledge and skills to provide for thesafety and comfort of your patients. You are also ethically responsible for acting as a

patient advocate to safeguard patients’ rights.Certain ethical principles articulated by Hippocrates still serve as a basis of manycurrent debates.



The nurse-client relationship is based on trust, as stated in the ANA Code of Ethics.Ethics has its own language. Some important concepts frequently included indiscussions of ethics are:

• Justice

• Values• Laws

• Ethics

VALUES Values are strongly held personal and professional beliefs about worth andimportance.The word "value" comes from the Latin "valere" – to be strong.Values are ideals and concepts that give meaning to an individual’s lifeDerived most commonly from societal norms, religion and family orientation

Often change as a person grows older Value conflicts occur, sometimes requiring a person to set priorities

(eg staying home from work with a sick child…career vs. family) Not all nurses agree with each other’s value statements. Value conflicts are commonamong nurses, doctors, administrators, and families.It is important that you clarify your own values as you develop a professional ethic.Sometimes we tend to rely on hearsay, opinions, or prejudice instead of developing astrong sense of our own values.Stopping from time to time in order to reflect on the values that are mirrored in our conversation and behavior is helpful in clarifying our values.

MORALS Fundamental standard of right and wrong, learned & internalized in early childhood.Based on religious beliefsComes from the Latin word "mores", which means customs or values

(eg cheating on a test, having an affair….what you would do if no onewould find out?)

A moral person (one who exhibits moral behavior) is characterized byresponding to another person in need by providing care and maintaininga level of responsibility in all relationships.

LAWS Laws are binding rules of conduct enforced by authority.Rules of social conduct made to protect society



Based on concerns of fairness and justiceGoal is to preserve the speciesEnforceable by policeShould be applied equally to allIn many instances, laws and ethics overlap. When they diverge, you have to identifyand examine the fine lines that separate them.

ETHICS Ethics is the area of philosophic study that examines values, actions, and choices todetermine right and wrong.Declarations of right or wrong and what "ought" to bePresented as systems of value behaviors and beliefsGovern conduct to protect one’s rightsA system of morals for a particular group

CODE OF ETHICS A written list of a profession’s values and standards of conduct

Nurses must always follow the Nursing Code of Ethics within the limits of the law.

ETHICAL DILEMMA Requires an individual to make a choice between two equally unfavorablealternatives

No simple solution…such a decision involves a great deal of stress.Final decision must be defended against those who disagree

Eg When a nurse must decide whether or not to follow a doctor’s order to administer an unusually high dose of a narcotic drug to a sufferingterminally ill patient.

Moral dilemmas call for ethical choices in the face of great uncertainty. Sometimesyou may not know what is the right or ethical thing to do. Other times, you may

believe completely in the "right-ness" of a particular action.

Many moral dilemmas in nursing involve choices involving justice or fairnesEg when limited bed space or inadequate staffing must be divided among patients

with equal needs

Sometimes a decision must be made quickly because a patient’s medical condition israpidly deteriorating. Usually nurses who are compelled to make ethical decisionsdon’t have the luxury of time.



KEY CONCEPTS IN ETHICS

1. Autonomy Right to self-determination

Patient has the right to make health care decisions for himself even if provider disagrees with his decision.

Autonomy is not absolute. Under certain conditions limitations can be imposed.(eg the patient has the right to refuse treatment EXCEPT in cases such astuberculosis or some other contagious diseases)

(Read the thought provoking example in Catalano, p 116)

Dilemmas of autonomy involve deciding what course of action maximizes the patient’s right of self-determination. These decisions can be difficult, especiallywhen someone other than the patient must deterine what’s best for him.

2. Justice Obligation to be fair to all

Expanded to "distributive justice" which states that a person has the right to betreated equally regardless of sex, race, marital status, medical diagnosis, socialstanding, economic level, or religious belief.

Underlies the first statement of ANA Code of Ethics: "The nurse providesservices with respect for human dignity…"

Distributive justice includes ideas such as equal access to health care for all

(read the example in Catalano, p 177)

Dilemmas of justice involve dividing limited health care resources fairly.

3. Fidelity Obligation of a person to be faithful to commitmentsMain support of concept of accountability

(eg: Supervisor asked a nurse to stay and work another shift after she had alreadyworked over 12 hours straight. The nurse must weigh fidelity to herself against

fidelity to her employer and fidelity to her profession and clients)Dilemmas of fidelity involve honoring promises. Such dilemmas my occur when a nurse’s duties to a patient conflict with his/her other duties, such as tothe physician.



4. Beneficence One of the oldest requirements for health-care providers

Views the primary goal of health care providers as doing good for clients under their care.Good care requires a holistic approachDifficulty is in determining what exactly IS good for another.

(read the example in Catalano, p 118)

Dilemmas involving beneficence commonly arise when health care professionals, patients, or family members disagree over what course of actionis in the patient’s best interest.

5. Nonmaleficence Requirement that health care providers DO NO HARM

Maleficence is the opposite of beneficence Nonmaleficence is sometimes violated in short term to produce a greater goodfor the patient in the long term (eg a painful and disfiguring surgery such as aradical neck dissection in order to prolong life in a patient with advancedlaryngeal cancer)

An extension of the principle of nonmaleficence also requries that health care providers protect those from harm who cannot protect themselves (eg children,mentally incompetent, unconscious pts, etc.)

Dilemmas of nonmaleficence involve the avoidance of harm. They may arisewhen a nurse believes another staff member’s actions have compromised

patient safety. She may have a dilemma over whether or not to "blow thewhistle".

6. Veracity Principle of truthfulness

Do not lie or mislead or deceive intentionally… TELL THE TRUTH

Limitations exist (eg if telling a patient the truth would seriouslyharm… nonmaleficence… the pt’s ability to recover or would produce greater illness.Dilemmas of veracity involve telling or concealing the truth, such as when a patient isnot fully informed of his medical condition.



7. Standard of best interest When client is unable to make an informed decision

Based on what health care providers and the family decide is best for the clientMust consider the person’s expressed wishes formally (living will) or informally

(conversations with family)Client may have designated someone to make decisions for him through druable

power of attorney for health care (DPOAHC)In 1990, the Omnibus Budget Reconciliation Act (OBRA) made it mandatory for health care facilities to provide information for Durable Power of Attorney for HealthCare (DPOAHC)Based on the principle of beneficence

8. Obligations Demands made on an individual, a society, a profession or government to fulfill and

honor the rights of others.

Two types of obligations:

• Legal: those that have become foraml statements of law and are enforceableunder law

• Moral: based on moral or ethical principles but are not enforceable under law.(eg nurse stopping to help those injured in an MVA)

9. Rights

Something owed to an individual according to just claims, legal guarantees, or moraland ethical principles.

Three types of rights:

o Welfare rights: also called legal rights. Guaranteed by law (eg Bill of Rights in the US constitution. Violation is punishable under law.

o Ethical rights: (moral) Based on moral or ethical principles Usually donot require power of law to be enforced. In reality, these are privileges(eg the right to access to health care, as compared to Japan, Great

Britain, Canada, & Germany where health care is a LEGAL right)o Option rights: based on fundamental belief in dignity and freedom of

humans. These are basic human rights. They give individuals freedom of choice, but within boundaries. (eg in our society, we may wear anythingwe like, but we must wear SOMETHING!)



ETHICS COMMITTEES

Found in more and more hospitals

Usually these committees are made up of physicians, administrators, RNs, clergy,

lawyers, person from the community, & a philosopher with a background in ethicsMembers should have no personal agenda and should make decisions without prejudice.

ETHICAL SYSTEMS

Ethical theories attempt to provide a system of principles and rules for resolvingethical dilemmas. These theories consist of fundamental beliefs about what is morallyright or wrong. Two types of ethical theories,utilitarianism and deontology,frequently are used as guides in ethical decision making.

1. Utilitarianism (Teleology, situation ethics, consequentialism)Utilitarianism determines what is right or wrong based on an action’s consequences.It is an ethical system of utility.

Using this system, decision makers determine and choose those actions thatwill result in the greatest good for the greatest number of people.*"good" is defined as happiness

The ends justify the meansSubdivided into "act" and "rule" utilitarianism

Act: the particular situation determines the rightness or wrongness of a particular actRule: the individual draws on past experiences to formulate internal rules thatare useful in determining the greatest good

Using this system, ethical decisions most often are made through a processcalled risk-benefit analysis

eg you may help patients and their families evaluate several courses of

treatment to decide which one will produce the greatest amount of relief (benefit) with the least danger of suffering (risk).

Advantages:Easy to use in most situationsBuilt around individuals’ need for happinessFits well into a society that shuns rules



Truth telling is not a absolute requirement (eg if tellng the truth will producewidespread unhappiness for a large number of people, then it would beethically better than to tell a lie)

Disadvantages:

Certain difficult questions present themselvesDoes happiness refer to the average amount of happiness of all or the totalhappiness of a few?What IS happiness?What constitutes the greatest good for the greatest number?Usually these determinations are quite subjective and can result in inconsistentdecisions.The tenet that "the ends justifies the means" has been consistently rejected as arational for justifying moral action (eg the Nazis used this tenet in 1930-1940)Pure utilitarianism does not work well as an ethical system for decision-makingin health care because of its arbitrary, self-centered nature.

2. Deontology

A system of ethical decision making based on moral rules and unchanging principles

Centers on duty and obligation to othersA follower of pure Deontology believes in the absoluteness of principles regardless of the consequences of the decision.Based on the belief that standards exist for the ethical choices and judgments.These standards are fixed and do not change when the situation changes.eg:

• People should always be treated as ends and never as means. Human life has

value.

• Always tell the truth.

• DO NO HARM.

Deontology emphasizes moral obligation or commitment.According to deontological theory, honoring ethical obligations ensures good, eventhough actions may be difficult and consequences painful.

Advantages:



Useful in making ethical decisions in health care because it holds that an ethical judgment based on principles will be the same in a variety of given situationsregardless of time, location, or individuals involved

Many consider deontology the only acceptable theory for ethical decision making in

health care.Deontological terminology and concepts are similar to the terms and concepts used bythe legal system. Difference: legal rights and duties are enforceable by law.

Disadvantages:

What do you do when the basic principles conflict with each other?It may be difficult for nurses to resolve situations in which duties and obligationsconflict, especially if consequences of following a rule end in harm to the patient.There are few followers of PURE deontology because most people will consider the

consequences.

(eg keeping a brain-dead patient on a ventilator while recipients for a

kidney transplant are found) Nurses usually combine aspects of both teleologic and deontologic theories whenmaking ethical decisions.

NURSING CODE OF ETHICS

ANA Code – one of the most complete professional codes of ethicsHas been used as a benchmark against which other codes of ethics are concerned.As set of cearly stated prinicples that the nurse must apply to acutal clinicalsituations.ANA code is now undergoing revisions to make it more relevant to current nursing

practice

DECISION MAKING PROCESS

Nurse are problem solvers. Their tool is the Nursing Process.Chief goal of ethical decision-making process is to determine right and wrong insituations where clear demarcations are not apparent.This process supposes that the nurse knows a system of ethics exists and she knows itscontent.

Step 1: Collect, Analyze, and Interpret Data



Know client’s and family’s wishesKnow physician’s beliefsKnow your own orientiation regarding life and death

Step 2: State the Dilemma

State dilemma clearlyDoes the problem involve the nurse or only the patient?Focus attention on ethical principlesFollow the client’s wishes first. In case of unconsciousness, consider family input

Step 3: Consider Choices of Action May require input from outside sources

(Read possible courses of action on p 132)

Step 4: Analyze Advantages & Disadvantages of each course of action Identify the realistic actionA major factor in this step is choosing the correct code of ethics

Step 5: Make the Decision Most difficult part of the process is making the decision, following through with theaction, and then living with the consequences.Ethical dilemmas produce differences of opinion and not every one is pleased with thedecision

Client’s wishes always supercede decision by health care providersIdeally, a collaborative decision is made by client, family, Dr. and nurse and producesfewer complications.

Bioethical Issues

Catalano, chapter 7

Frequent revisions of the Nursing Code of Ethics demonstrates the profession’s

concern with providing ethical health care.

The current Code of Ethics recognizes that the primary responsibility of the nurse isthe client’s well being.

Abortion Implications are religious, ethical, social, and legal



Elective abortion is the voluntary termination of pregnancy before 24 weeksgestation. May be therapeutic or self-selected.1973: Roe vs Wade

The U.S. Supreme Court changed the legal status of elective abortion in the U.S.The ethical basis and moral status are still controversial (court made no decision on

this)The court said that according to the U.S. Constitution, all people have right to self-

determination and that includes termination of a pregnancy.

Controversy over abortion center on two major issues:

• freedom of choice• when life begins

Pro-life proponents believe life begins at the moment of conception

Pro-choice proponents believe fetus is not human until it can survive outside thewomb.

Abortion represents conflict of:

• woman's right to privacy, freedom of choice, self-determination

vs.

• fetus' right to life

As in all complicated ethical dilemmas the client must receive competent, high qulaitycare regardless of nurse's own values or moral beliefs.

Genetics & Genetic Research

The issues that will demand the most of nurses ethically and legally are those that point to new biological possibilities and raise unanticipated questions. For example,the map and sequence of the human genome will lead to new precision in thedevelopment and use of genetic tests, but we haven't yet developed the safeguards

necessary to guarantee genetic privacy or to protect against genetic discrimination.

Genetic map and sequence will also aid in the development of research on preventingtransmission of genetic defects, but society has not yet reached a consensus onoversight of this field of research.For example, it's now possible through preimplantation genetic diagnosis to ascertainthe sex and other characteristics of a human embryo, long before birth and even



before pregnancy. But it remains undecided whether the infant has a right to genetic privacy at birth and, if so, how such privacy will be ensured. The ethical debate ragesover the use of human embryos to obtain stem cells for treatment of diseases such asAlzheimer's and Parkinson's diseases.

" Nurses have a lot to offer in the debates about these matter in both private and public sectors. For example, in working with patients, nurses are acutely aware of the importance

of privacy and confidentiality in the maintenance of self-esteem, which is eroded by

feelings of powerlessness or lack of control over personal information. We can

analyze legislation intended to safeguard the confidentiality of medical information

and have, through the work of the American Nurses Association, opposed genetic

discrimination in the workplace. For instance, the ANA supported the work

resulting in the president's signing of the first exectuive order of the 21 st century,

Executive Order 13145, which prohibits discrimination based on genetic

information in federal employment. We now have to push this agenda not only for

federal workers, but for those employed in the private sector as well. Genetic

information is extremely powerful, both in its capacity to identify an individual with

almost abolute certainty and in its ability to signal an increased risk of genetic

disease. There is an ongoing debate ...whether genetic information should be

recorded in a special place in health records or be kept entirely separate from the

patient chart. Because nrses maintin, contribute to, and transfer health records, we

surely have a relevant voice in this debate. "*

*excerpted from White, GB, What We May Expect from Ethics and the Law, AJN,October 2000, 100:10. 114-116.Scientists are now able to alter genetic material.

(eg medications such as insulin made from e. coli bacteria; disease-& drought-resistant corn,etc)Abnormal genes have been identified which indicate increased risk for diseases suchas Alzheimers, alcoholism, cancer, Down syndromeTechniques of genetic engineering are ethically neutral, but the potential for misuse isgreat and could even wipe out the human race.

Only one blood sample is required to detect genetic patterns in newborns linked to breast cancer, heart disease, Parkinson's disease, colon cancer, Huntington's disease.

Confidentiality is at risk with genetic screening.Information from genetic screening may have an emotional impact on the patient andmay cause anxiety, depression, even suicide.



Use of Fetal Tissue Research since early 1990sLiving cells from an aborted fetus are transplanted into another person and is helpfulin treating Alzheimer's and Parkinson's diseaseSince 1997 scientists have been growing their own fetal tissue in labs throughartificial insemination and in bitro fertilization.

Test tube fetus is dissected. Abuse of this has created a legal problem and legislation proposes to control use including limiting age of in vitro fetus to 6 weeks.After 6 weeks the fetus must be destroyed.

Fetal tissue is desirable because it lacks genetic material that makes more maturetissues and organs more likely to cause rejection in host.

Fetal tissue is in a rapid growth mode and develops more quickly.

Best tissue comes from fetus aborted in second trimester (nervous, cardiovasculae, GI,and renal systems are well developed... the fetus is also capable of feeling pain at thisage)

Research has not led to increase in abortions but the potential for abuse is there.If payment is being made for fetuses it would violate laws that prevent payment for organs in transplantation, as well as moral codes.

Who give prermission for use of fetal tissue?Does anyone OWN the fetus?

Religious groups question morality of in vetro fertilizationWhat are the right to life of fetus created in a test tube?How are nurses involved? ... as employees where abortions are performed?

Organ Transplantation Many people are involved: donor, donor's family, recipient, recipient's family, society(cost paid from tax $$; insurance premiums are higher)

Two primary sources of organs:

• living related donors• cadaver donors

A child under 18 cannot give informed consent and presents ethical problems. (eg bone marrow transplant)The most widely accepted criterion for death is "brain death"Ethical issue is the selection of recipient



Uniform Anatomical Gift Act was passed to increase supply of organs National organ reciepient list ranks people

Criteria includes need, length of time on list, potentila for survival, prior trnasplantation, value to community, and tissue compatibility.

Many states have laws requiring health care workers to talk to families of potentialdonors.Recipient and family could be manipulativeDonor's family is vulnerable to psychologic trauma and manipulation.

Use of Scarce Resources in Prolonging Life Most public money for health care is spent during last year of life for many elderlyTraditional belief: preserve life at all costsHospice care is growingPalliative care: provides comfort but does not prolong life

Use of public funds for ehalth care is an ethical issue (distributive justice) Is it fair that taxpayers must pay for care for others? Is it fair tfor those who contribute to their own poor health to receive same care as

those who don't take risks? Who decides who will receive the expensive care?

The Right to Die

This is an extension of the right to the self determination issueOverlaps with dilemma of euthanasia and assisted suicide

Living will may say patient wants no extraordinary treatmentWhat constitutes extraordinary treatment?

Is ventilator extraordinary or not? Issues of CPR, DNR, and no code

Client's wishes should be followed

Nurse should document all communication about desires for future care (AdvanceDirective)

Two forms of advanced directive:

• Living Will

• Durable Power of Attorney



LIVING WILL (instructional directive): allows a competent adult to give directionsfor future care in the event that he becomes incapacitated due to terminal illness or impending death. Limited to instructions given in a document.

MEDICAL POWER OF ATTORNEY (health care proxy): names a trusted person

to act as an agent or proxy in making health care decisions in the event of incapacity.Broader implications for decision making; proxy can clarify living will or makedecisions independently according to patient's values.

PREHOSPTAL ADVANCE DIRECTIVE SPECIFICALLY FOR

EMERGENCY MEDICAL SERVICES (EMS): Depending on state or local law,an advance directive may or may not be honored when EMS (911) is activated. For example, California, Texas, and New Jersey have enacted legislation that requiresspecial forms to be prepared in order the EMTs not resuscitate a person.

"Nearly 90% of all Americans will have a "managed death" in a hospital or skilledcare facility that can lengthen life for up to several years through medical and nursinginterventions. Yet, despite diligent efforts by the AARP, local senior citizen groups,lawyers, and medical personnel to teach the public about their legal rights, only about15% of patients have advance directives in the form of a living will or health care

proxy. Consequently, more than six years after the Patient Self-Determination Act

(PSDA) went into effect, situations in which patients end-of-life wishes are nothonored, are commonplace. Even when patients have advance directives, they'reoften incomplete or ambiguous, unacknowledged by caregivers, or disregarded byfamily members. So while all health care professionals join ethicists in consideringwhat constitutues a "good death", nurses face the additional challenge of trying toensure that [atients' end-of-life wishes are honored."*

*PM Haynor. "Advance Directives" AJN, March 1998, 98:3. 27-32.

The PSDA requires all health care facilities receiving Medicare and Medicaidreimbursement to recognize the living will and durable power of attorney for healthcare (or health care proxy) as advance directives. In addition, the PSDA requriedhealth care facilities that receive Medicarea and Medicaid funds to ask patientswhether they have advance directives and to provide educational materials advising

patients of their rights under existing state law.

On admission, each patient is asked if he has a living will or health care proxy, and if so, the patient or family is asked to provide documentation. This information may bekept on file and, on subsequent admissions, the patient is asked to verify that theserecords are still valid. Documenting this process is a critical step in promoting



compliance with the patient's wishes, and it may be necessary for reimbursement aswell.

The PSDA encourages the public to claim their rights in medical decision making.Ideally, a patient, who has the support of family or significant others, presents a copy

of his advance directive upon admission and has discussed its contents with his primary care providers. This enables the health care team to know that the documentexists, to review the patient's expressed wishes regarding his current condition, and to

plan how caregivers should respond when providing care.

Some patients have no advance directive and are reluctant to put their wishes intowriting. In such cases, the nurse might enocurage the patient to state his wishesclearly to family members and health care providers. In most states, medical recorddocumentation of the competent patient's expressed wishes are as valid as a writtenliving will. This is also a good way to begin helping patient maintain control over

their ovwn medical care.

The situations that create the biggest challenge to the health care team are those inwhich the patient has no written or expressed wishes or designated ehalth care proxy,or the family opposes the patient's advance directive.

Euthanasia & Assisted Suicide Euthanasia: killing or refusing to treat client in order to allow a painless, peacefuldeathPassive euthanasia: allowing an individual to die without extraordinary intervention

Active euthanasia: hastening death through some act or procedure (mercy killing)Homocide: bringing about a person's death or assisting in doing so

The fundamental issue is self determination (person can decide on treatments, but is itmorally right for him to decide to end his life?)Legally ethically and morally suicide in the U.S. has never been an accepted practice.Euthanasia violates principle of non-maleficence or "do not harm"Some states have passes laws permitting assisted suicide and have strict guidelinesANA opposes assisted suicide

Human Immunodeficiency Virus (HIV) & Acquired ImmunodeficiencySyndrome (AIDS) Some nurses now question their obligation to care for HIV/AIDS clients even thoughthey previously7 adhered to principle that all client regardless of sex, race, diagnosis,etc., should be cared for equally.Ethical issues underlying AIDS controversy:

1. Right to privacy: confidentiality is a LAW. Does the nurse have the right to



know a client's diagnosis? Does client have right to know if nurse is HIV positive or has AIDS?

2. Right to care: Can nurse refuse to care for AIDS client??Expense of care. From diagnosis to death, treatment for one patient costs > $900,000.Over two million people in the US are already infected. Most of this cost burden is

borne by taxpayers.

Ethics Involving Children This portion of the chapter speaks to child abuseFailure to thriveA legal requirement in most states to report evidence of abuse to child protectiveservicesA conflicting ethical principle is the family's right to privacy

Informed Consent and Children

Does a child have sufficient rational decision making ability to give informedconsent?Can the right to self determination be turned over to the child?

Cultural Diversity

Catalano, chapter 13

CULTURE: A group's acceptance of a set of attitudes, ideologies, values, beliefs,and behaviors that influence the way members of that group express themselves.

CULTURAL EXPRESSION FORMS: Language, works of art, spirituality,decision making, food preferences, world philosophy, group customs and traditions(eg: gypsy), and response to stress, illness, pain, sorrow, anger and bereavement.Cultural orientation begins at birth and continues throughout the life span.

SUBCULTURE: develops when members of a group do not accept all the values of

their dominant culture. (Eg: Rural Oklahoma vs inner city Philadelphia).

Culture is considered a photocopier, society attempts to pass from one generation toanother values, beliefs and customs.

DIVERSITY: difference between cultures. Primary characteristics are: race, color,gender, age, religion. Secondary characteristics are more difficult to identify.



Some are: socioeconomic status, education, occupation, length of time away fromcountry of origin, residential status, sexual orientation.

STEREOTYPING: An over simplified belief, conception, or opinion about another person or group based on limited information.

Eg. "Dumb blonde"

In the early U. S. history, immigrants tried to “fit in” and America became known asthe “melting pot” of world culture. They americanized their names, shed traditionaldress, learned American manners and customs, and attempted to learn English withoutformal schooling. Since the 1970’s, immigrants have clung to their traditional cultureand language, producing multi-culturalism , and this affects health care workers.

Now the U.S. is called the “salad bowl” of cultures. "Salad Bowl" drawback is that itcreates pockets of culturally different folks and it is difficult to advance

socioeconomic status due to language barriers.

Between 1970-1985, legal immigrants increased from 500,000 to 6 million. Minoritygroups are rapidly increasing. However minority nurses still constitute only 10% of R.N.’s practicing in the U.S. Nurses from one culture should be able to giveculturally competent care to people from any other culture.

Developing cultural awareness is the 1st step in becoming a culturally competentnurse.

Nurses must understand client’s perspective of what is happening in the health care

setting.From a cultural viewpoint it may be quite different from the nurse's viewpoint.A nurse develops cultural awareness only when she is able to recognize and value allaspects of a client’s culture including beliefs, customs, responses, language, socialstructure, methods of expression.

Nurses must first understand their own cultural background and explore origins of prejudice and bias. (Tool for measurement on p.328 box 13.2) Remember that validity and reliability of tools vary. In all assessment tool there issome degree of inaccuracy. Insight from the tool is more important than the score.

Basic belief systems of cultures are often a guarded secret.Eg. Native Americans and twin births (attributed to witchcraft) and cradle boards (tillthey walk, it protects from bites but the child’s muscle development is slowed.Vietnamese Americans and mental illness (results from offending a god)



Cultural values are neither right or wrong. They can usually be traced back to a needfor group survival.

A primary function of the nurse may be to change the client’s values about healthcare.

The nurse must:

• Identify culture of client and recognize health care practices that are similar anddifferent from those of the nurse.

• Make a decision about whether it is desirable or possible to change client’svalues. (Eg: Middle Eastern culture doesn’t allow fathers to observe or

participate in births. African tribes value small infants so the mother eatsonly corn mush while pregnant.)

Obtaining an accurate cultural assessment is necessary so that nurses don’t imposetheir cultural values on clients in practice or care plan development.

Purnell’s Model of Cultural Competence (pp.331-335) is lengthy and most nurseswould not have time to complete this on each client sooooo----------------------1st ask general questions to develop trust. Then ask key questions as a starting pointfor cultural assessment.Why do you think you are ill?What was the cause of the illness?

How does the illness affect your body and health?Do you consider this a serious illness?If you were at home, what type of treatments or medications would you use?What type of treatment do you expect from the health care system?How has your illness affected your ability to live normally?If you do not get better, what do you think will happen?

PROVIDING CULTURALLY COMPETENT CARE: Cultural competence is a21st century buzz word.As it relates to nursing can be regarded as the provision of effective care for clients of

diverse cultures, based on nurses knowledge of beliefs, customs, etc.Requires development of interpersonal skills. (Eg: Communication, understandingand sensitivity.Is an ongoing process that continues throughout the nurses career)

TRANSCULTURAL COMMUNICATION: The ability to communicate is thefoundation.



Requires both verbal and non-verbal communication.Barriers to communication: lack of a common language, loudness and tone of voice,caste system within a culture, incorrect interpretation of non-verbal communication(Eg: Nods and smiling in the U.S. means understanding and compliance. In Asia itmeans a show of respect) silence (may be out of respect or need for privacy)Inappropriate touching, invasion of personal space, eye contact (means attentive,“look at me and say that”. Native Americans believe that the eye is the window to thesoul.

Passive obedience develops when clients from another culture believe the nurse is theauthority figure.Cultural synergy implies that health care providers make a commitment to learnabout other cultures and immerse themselves in that culture.

The transcultural movement began in 1974 with a conference held in Hawaii. A short

time later Transcultural Nursing Society was formed and incorporated in 1981. Thesociety publishes Journal of Transcultural Nursing.

In 1976 ANA recommended multicultural content in Nursing School criteriaANA organized “Council on Intercultural Nursing”.The council publishes Intercultural Nursing Newsletter.Graduate degrees are available in Transcultural and International Cross Nursing.(CTN – certified Transcultural Nurse)

Study Questions

1. Define: morals, values, laws, ethics2. Discuss professional autonomy. As autonomy increases, what also must alsoincrease?3. Define and discuss deontological and teleological systems of ethical decisionmaking.4. What is utilitarianism?5. List characteristics of an ethical code.6. Compare the ethical code for nurses with the law.7. Define: autonomy, fidelity, beneficence, veracity,distributive justice, self-determination.8. Describe the steps in the ethical decision making process.9. What is an "ethical dilemma"?10. Describe the nurse's responsibility to the client in regard to confidentiality.11. Define and discuss passive euthanasia.12. Discuss the implications of Roe vs. Wade.13. Discuss the implications of the practice of genetic screening.



14. Discuss the major ethical considerations involved in genetic research.15. Discuss the major ethical considerations involved in organ transplantation.16. Discuss "Do Not Resuscitate" orders. What are the the nurse's responsibilities andlegal liabilities in relation to these orders?17. Discuss the ethical issues surrounding HIV/AIDs.18. In what ways does a client's culture affect nursing care?19. What is a subculture?20. Describe "melting pot" and "salad bowl" as described in Chapter 13 of your text.21. Discuss ways nurses can increase their cultural awareness.22. Describe ways a nurse can obtain an accurate cultural assessment of his/her client.23. Define: professional negligence, malpractice.24. What is a stereotype? What is a bias?25. Define: mulitculturalism, heritage consistency, cultural awareness.26. Discuss the primary purposes of cultural beliefs and practices.27. What is the most important factor in obtaining an accurate cultural assessment?28. List several causes for noncompliance with health care regimens among culturallydiverse clients.29. Discuss several ways body language, gestures, or facial expression could lead tomiscommunication between nurse and client.30. What is cultural synergy? How can nurses achieve it?

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Ehical Liabilities