Nursing Values and Ethics
The Nursing profession, today, has built for its members a high level of academic excellence leading them to a state where they have an ability to provide specific service and complete professional autonomy to make decisions. Professional autonomy means that a nurse is independent reasonably and self-governing in making decisions in practice. There are independent measures a nurse can initiate without medical orders.
The nurse is a "client advocate". She has to protect the human and legal rights of the patient under her care, based on his/her cultural and religious affiliations (Patricia A Potter, 2005). The nurse is a "Care Giver" helping the patient regain health through the process of healing. The nurse is also the pivot of all communications in the health care delivery system.
Thus, it is important that this professional autonomy is always governed by a code of ethics and values. A nurse, by profession, is constantly in situations that pose an ethical or moral conflict. This includes various core aspects like the patient's Right to Life, Right to Choose, Right and Ability to give Consent to treatment, End of life treatment options and the Right to end life.
Why Nursing Values and Ethics need to be Taught?
Patient care should be based on the universal principles of Beneficence, Justice and Autonomy. Beneficence is the concept where human participants are treated in an ethical manner by maximizing benefits and minimizing possible harm. Justice is all about the ethical considerations or risks versus benefits leadings to the question of law. Respect for Autonomy is all about respecting the individual decisions.
But, there seems to be a gap and significant perception differences among nurses between a learning environment and actual professional situations. Hence, teaching ethics and nursing values is important to bridge this gap. Further, there are numerous reports of medical teams trying to use patients to explore and explain links of a disease without consent. There are also reports on long medical litigations involving medical professionals for negligence and unethical practices. Yvette Coldicott et.al (2003) in their exploratory survey reveal that best practice guidelines are not always followed.
What To Teach And How?
There is no doubt that ethics, as a field of study, has its own theories of moral development. The problem is with teaching ethics that is exclusively for the nurses which requires unique theories and curriculum models.
This also throws a need for reliable instruments to measure the values in professional nurses. Darlene Weis and Mary Jane Schank (2000) have described the development, reliability and validity of a Nursing Professional Values Scale (NPVS).This 44-item instrument with a Likert-scale format has been tested and the responses of participants to this instrument subjected to principal axis factor analysis with varimax rotation. Results have been shown to have a high level of reliability and validity.
Ethics learning is a personal process that always goes with everyday nursing work. Hence, there is also a need for development of a pedagogy that integrates this self learning experience along with professional training where they see ethics as a natural component of their being instead of a rule that they should follow as professionals.
Core Situations in Nurse Practice:
There are some core situations in nurse practice that demands ethical decision making with regards to the patient's Right to Life, Right to Choose, Right and Ability to give Consent to treatment, End of life treatment options and the Right to end life.
Dorothea Orem in 1971 (McFarlane , 1980) defined nursing with emphasis on client's self-care needs which is a learned, goal-oriented activity directed towards the self in the interest of maintaining life, health, development and well being. The Right to Life is the corner stone of any human rights law and hence, a nurse, by duty, has to strive to safeguard the life of every patient.
As per US laws, a patient or his health attorney should give a well-documented Informed Consent before any treatment procedures are carried out. Informed consent refers to legal rules that prescribe behaviors for medical professionals in their interactions with patients based on the ethical doctrine rooted in the value of autonomy that facilitates patient's right to self-determination.
It is an interpersonal process whereby professionals interact with patients to select an appropriate course of action. Informed consent means that tests, treatments and medications have been explained to the person, as well as outcomes, possible complications and alternative procedures before the treatment and his consent is documented.
There is no second opinion on the fact that only a competent individual can give an informed consent. But the concept of competence is broad with moral, medical and legal implications. It is first important to determine a patient's competence to give consent. It is important to see if he/she is competent or incompetent. However, there seems to be a group of individuals who are marginally competent and recognizing them as a distinct group has recently become important.
Problems pertaining to "End-of-life" are on the rise especially when concepts of euthanasia and physician assisted deaths are trying to find legitimate positions in the society. The state of Oregon in U.S.A already has a legal backing and the bill introduced by Lord Joffe in U.K parliament recently has stirred a chain of debates on the ethical aspects of assisted death of the terminally ill.
Research studies have confirmed that patients went information about their illness and end of life choices (McSkimming et.al, 1994). According to Cardozo,the decision to limit care for critically ill patients is not uncommon, and most deaths in the intensive care unit are now preceded by do not resuscitate orders, which are regarded by some as a way to make death more humane and respect patient autonomy (Margaret Cardozo,2005 ).
Rosalia Hamilton (1995) advocates simple instead of complex approaches for teaching ethics to nursing students. She recommends a nursing pedagogy that will help students in learning basic principles involved in ethical decision-making and train them in applying those principles in the analysis and interpretation of clinical events.
She describes specific "teachable moments" in clinical practice that allows the integration of the clinical application of ethics and values in the curriculum. She views ethics as a continuing and recurring curricular theme that will permit the teaching of core principles and values, such as, critical thinking, analysis of management principles, power and practice issues and analysis of client educational needs.
She also stresses the need for reviewing the curriculum on a regular basis to ensure that nurse education reflects current health care practices. Thus, it is important to teach core nursing values and ethics with regards to various complex nurse situations discussed that demand ethical decision-making.
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Agency San Francisco, Inc.
San Francisco, California
Charles L. Berman
Liz Di Bernardo