Fundamentals of Nursing and Midwifery 2e

Fundamentals of Nursing and Midwifery, 2e

Sample Contents

Chapter 11 Values, ethics and advocacy

Chapter 13 Thoughtful practice: Self-awareness and reflection

Chapter 14 Thoughtful practice: Clinical reasoning, clinical judgement, actions and the process of care

Chapter 15 Assessing

Chapter 16 Identifying health problems

Chapter 17 Planning person-centred care

Chapter 18 Implementing person-centred care

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C H A P T E R

Values, ethics and advocacy

LEARNING OUTCOMES

After completing the chapter, the learner should be able to accomplish the following: 1. List common modes of value transmission 2. Describe steps in the valuing process 3. Use values clarification strategies in clinical practice 4. Compare and contrast the principle-based and care-based approaches to bioethics 5. Describe nursing and midwifery practice that is consistent with the code of ethics 6. Recognise ethical issues as they arise in practice 7. Use an ethical framework and decision-making process to resolve ethical problems 8. Identify four functions of institutional ethics committees 9. Describe three typical concerns of the nurse/midwife advocate.

KEY TERMS

advocacy applied ethics autonomy beneficence bioethics care-based approach clinical ethics

code of ethics ethical/moral agency ethical dilemma ethical distress ethical theory ethics feminist-based approach

fidelity justice meta-ethics morals moral distress non-maleficence normative ethics

nursing ethics paternalism principle-based approach values value system values clarification

T HIS CHAPTER EXPLORES the influence of values on human behaviour and the ethical dimensions of nursing and midwifery practice. The unique nature of nursing and midwifery places them at an individual’s bedside as well as in groups of professionals where critical

decisions are made about the best way to treat injury and illness and to solve healthcare problems. In the framework developed by McCormack and McCance (2010), one of the four constructs of person-centred care relates to prerequi- sites , or the attributes that nurses and midwives bring to the

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relationship. These prerequisites relate not only to skills and clinical competence but to the values and beliefs of the nurse or midwife. Therefore, nurses and midwives must have a well-developed understanding of the role of ethics in professional practice and how their own ethical position will affect the care they deliver. Ethics, or morality, poses ques- tions about how we ought to act and how we should live. It is an inquiry into the justification of particular actions (e.g. Are these actions right or wrong?), as well as a search for traits of moral character that promote more human growth. Nurses and midwives need to have a clear and well- developed personal moral compass to deal appropriately with the trust that is placed in them through the intimate and often privileged relationship they have with communities and individuals. They are increasingly confronted with moral and ethical decisions; the more that science and tech- nology increase the options available to people and healthcare providers, the more frequently nurses and mid- wives will find themselves confronted by situations not previously encountered. In these situations, often the ques- tion you will be confronted with is not ‘How do I do this?’ but, rather, ‘Should I do this?’ or ‘We can do this, but should we, here and now, for this person?’ Healthcare professionals can be distressed by the failure of society to provide adequate care for its most vulnerable members. Nothing is more disturbing for professional nurses and midwives than seeing first-hand the conse- quences of unmet healthcare needs. When caring for people who may lack the ability to comply with medical treatment on an ongoing basis, they have special advocacy obliga- tions. A shortage of nurses further complicates the nursing work environment, creating the necessity for nurses to be skilled advocates for safety, quality care, and their own needs. Never has it been more important for nurses and mid- wives to grasp the ethical dimensions of professional practice and to be confident in ‘doing the ethically right thing simply because it is the right thing to do!’ With their moral integrity under scrutiny every day, they need to be as skilled ethically as they are intellectually, interpersonally and technically. VALUES Ethical issues are a part of daily life in nursing. Such ‘every- day’ nursing practices as administering medication, providing physical care or communicating with patients all have the potential for ethical implications. Therefore, nurses require core professional and personal values. Johnstone (2009, p. 11) suggests that, when discussing and advancing debates on ethical issues in nursing and healthcare, it is vital all parties involved share a working knowledge and under- standing of the meanings of terms and concepts fundamental to the issues being considered. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one’s behav- iour. If you think back to how you spent your last weekend,

you may observe something about your values. The amount of time and money you devote to relationships, work, study, fitness activities, leisure and other experiences reveal some- thing about the importance (value) you attach to these endeavours. Values are the link that ties together personal perceptions and judgements, motives and actions. A value system is an organisation of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person’s values influence their beliefs about human needs, health and illness; the practice of health behaviours; and human responses to illness. For example, individuals who place a high value on health and personal responsibility often work hard to reach their fitness goals. Individuals who value high-risk leisure activities may attach less value to life and health. Some values held by indi- viduals may be at odds with the values of others in the same family, community or society. This situation raises issues about the rights of individuals to express their values, about societal judgements regarding which values are to be toler- ated, and others’ tolerance for difference. Nurses and midwives who work effectively with people are sensitive to others’ values while being clear about how their own values influence their actions and interactions. The impact of personal and professional value systems can be explored in the following scenario. Abdul Naljib is an alert 32-year-old man in the inten- sive care unit who is begging to be removed from the ventilator. He understands it is highly unlikely he will be able to breathe on his own without the ventilator. He writes on the communication board: ‘If I die, I die. I can’t keep living like this.’ In this potentially very distressing sit- uation, you will have to consider your own personal value position as well as that of the profession. Now reflect on what your own personal value position would be if you were the nurse who had to respond to Mr Naljib. Would your own value system alter the way you responded? Investigate what the value position of the profession is towards such a request made by Mr Naljib. Then further reflect and consider if this aligns with your own values and, if not, does this change your position? Development of values People’s values develop in response to the environment, family and culture in which they are raised and in relation to the meaning they attach to their life experiences. Quality of life can be seen therefore as a product of physical, mental, social, environmental and spiritual health. As children observe the actions of others, they quickly learn what has high and low value for family members. If the parents spend a large portion of each day cooking, and the family spends a long time eating and talking at the table, the children learn to value food and the good times it represents. Similarly, children learn that helpfulness is a good and respected quality if praised when helping parents, grandpar- ents and siblings. Values are further refined through discipline

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• Value statement 4 : Nurses value access to quality nursing and healthcare for all people. The focus is on awareness of equitable provision of services without discrimination. • Value statement 5 : Nurses value informed decision making. The focus is on the provision of accurate and complete information to consumers, as well as an understanding of the potential impact of ill-health on the individual’s capacity for self-determination. • Value statement 6 : Nurses value a culture of safety in nursing and healthcare. The focus is on risk management and responsibility for reduction of adverse events. • Value statement 7 : Nurses value ethical management of information. The focus is on appropriate and accurate documentation and confidentiality of health information. • Value statement 8 : Nurses value a socially, economically and ecologically sustainable environment promoting health and well-being. The focus is on the nurse’s responsibilities in relation to environmental health issues. The New Zealand Nurses Organisation also has a Code of Ethics (NZNO, 2010), written for nurses who practise in a constantly changing multicultural society. The underlying philosophy of the code is that caring as a nurse requires involvement of self in a real concern for the well-being of another. Caring is an experience that cannot be measured, and the complexities of caring as a nurse defy a neat defini- tion (Johnstone, 2009). The code is based on three assumptions that inform nursing, and on the recognition that nursing takes place in unique relationships with individuals, colleagues, society and organisations: • Assumption 1 : Relationships and interactions take place in a respectful manner. This value is enacted within the concept of cultural safety. Relationships include those between the nurse and colleagues, patients, organisations and society. • Assumption 2 : Respect for the individual encompasses the principles of partnership and collaboration, where the patient/group/community participates actively in the process of nursing. The principle here is that the nurse values the contribution of the client/group/community. • Assumption 3 : Relationships and interactions have the purpose of achieving a positive outcome for the patient/group/community. This value relates to the overarching aim of nursing caring. The framework for the Code of Ethics highlights the underlying ethical values of: autonomy, beneficence, non- maleficence, justice, confidentiality, veracity, fidelity, guardianship of the environments and its resources, and being professional. The code individually relates these underlying values to the relationships a nurse has with the four groups of individuals, colleagues, society and organisations. The code was developed from different ethnic, cultural, employment and practice settings and included Ma – ori, New Zealand European, Samoan, Tongan, Nieuean, Chinese, Korean, Filipino and European people. Incorporated in this code is the concept of cultural safety (Ma – ori translation is

that includes a measure of self-sacrifice, restraint and post- ponement of immediate gratification needs. Common modes of value transmission include: • Modelling : Children learn to value certain behaviours and attitudes by observing parents, peers and significant others. Thus, modelling may lead to socially acceptable or unacceptable behaviours. • Moralising : Children whose carers use the moralising mode of value transmission are taught a complete value system by parents or an institution such as their church or school that allows little opportunity for them to weigh different values. • Laissez-faire: Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no one set of values is presented as best for all) and to develop a personal value system. This approach often involves little or no guidance and can lead to confusion and conflict. • Rewarding and punishing: Through rewarding and punishing, children are rewarded for demonstrating values held by parents and punished for demonstrating values that are deemed unacceptable. • Responsible choice: Finally, carers who follow the responsible-choice mode of value transmission encourage children to explore competing values and to weigh their consequences. Support and guidance are offered as children develop a personal value system. Professional values Professional values provide the foundation for nursing and midwifery practice as distinct caring-healing professions, and guide clinicians’ interactions with patients, clients, col- leagues and the public. These values include compassion, competence, confidence, respect for self and others, relation- ships and connections, responsibility and commitment . While these may describe personal values held by individual nurses and midwives, they are primarily the values that are attributed to the nursing and midwifery role, which requires leadership, advocacy and accountability at many levels. The Australian Nursing and Midwifery Council’s Code of Ethics for Nurses presents six broad value statements as a point of reference against which nurses are encouraged to measure and critique their own practice (ANMC, 2008a). These statements, which represent a decision-making framework for determining the best course of action in the face of conflicting alternatives, are set out below: • Value statement 1 : Nurses value quality nursing care for all people. The focus is on quality and accountability in terms of maintaining professional competence. • Value statement 2 : Nurses value respect and kindness for self and others. The focus is on the importance of appropriate professional boundaries in caring relationships. • Value statement 3 : Nurses value the diversity of people. The focus is on human diversity in contemporary society; respect for individual needs, beliefs and values; and awareness of the impact this has on caring relationships.

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Example of values clarification If respect for human dignity is a value that characterises your practice: you choose freely to believe in the worth and uniqueness of each individual; realise that you have other options (e.g. you could treat with dignity only those people who are most like you); and believe that respecting each person’s human dignity yields the best consequences for you and for all of society. You will also prize your choice . For example, you espe- cially enjoy when people let you know they appreciate your care, and when colleagues and supervisors compliment you on interpersonal skills. You also prize your ability to defend this value when someone’s human dignity is being ignored. Clarifying this value of respect for human dignity will motivate you to incorporate this value into your practice. You strive to respect human dignity consistently in your personal as well as professional life. As you become more conscious of this value, you will be sensitive to those of your actions that are inconsistent with it. For example, you may feel uncomfortable gossiping with other nurses during break about a patient no-one likes, realising that this behaviour contradicts your basic respect for human dignity. Box 11-1 illustrates how the steps in the valuing process can be used in clinical practice to help a person with high blood pressure take charge of his health and manage his medications. Other clinical scenario examples follow. Practising values clarification Practise clarifying values for the people in the following scenarios. Scenario 1: Person who places a low value on health and health behaviours You become frustrated when repeated attempts to teach or counsel a 26-year-old pharmaceutical salesperson meet with failure. Although hospitalised with a serious duodenal ulcer, all he can talk about is his job and meeting his sales quota. Values clarification First help this person to identify his basic life values. Ask him ‘What three things are most important to you in life?’, or have him rank the following behaviours in terms of how he would most likely spend an unexpected free day: _____ Enjoy some quiet time alone (e.g. thinking, reading, listening to music) _____ Spend time with family or friends _____ Do something active (e.g. walking, playing ball, swimming) _____ Watch television _____ Volunteer time and energy to help someone else _____ Use time for working in his job. Discuss with the person what these rankings suggest about his values. Determine whether his rankings would be different if he were asked how he wished he could spend the free day versus how he would most likely spend it.

kawa whakaruruhau ), which was first described in 1989. In Chapter 12, the impact this concept has on law is discussed, but cultural safety also has an ethical or value orientation. Therefore, the nurse or midwife delivering the service must undertake a process of reflection on their own cultural iden- tity and recognise the impact their personal culture has on their professional practice. A shared understanding of both the nurse’s and the patient’s beliefs and values concerning the illness experience and planned nursing care can be gained through establishing a relational narrative focusing on stories of declining health, precipitating factors and issues of concern. This engagement in the patient’s world places the nurse in a privileged position of confidante, educator and guide, who can, through these dialogues, facilitate meaningful explanations of experiences and explore options and possible outcomes. Whether people have an acute illness, which is usually manifest through a severe and possibly life-threatening episode, or exhibit the symptoms and limitations associated with chronic illness, which usually occur over a protracted period of time, the experience may have left them feeling vulnerable or power- less. When these people are actively encouraged to participate in relational narratives they effectively form a power-sharing partnership with the nurse (Hess, 2004) and this in turn has the potential to improve their psychological well-being, reduce their stress and promote wellness. Values clarification As the values statements in the previous section illustrate, values often guide people’s decisions as to what is good and right in a given situation, but this depends as much on their feelings as on their thoughts. People’s values change over time in response to their life experiences, and values clarifi- cation is a process by which they may come to recognise these changes, to gain an understanding of their own values, thoughts and feelings and how they influence their current actions and behaviours. A values clarification exercise is a tool frequently used within practice development for devel- oping a common, shared vision and purpose (Warfield & Manley, 1990; Manley, 1992). It can be used for developing a common vision about many areas, including role defini- tions, working effectively in a team, and developing strategic directions for different purposes. For the purpose of values clarification, Evans and Brown (2012) identify a three-step approach that must be met if a value is to be considered a ‘full’ value. These three cat- egories are: • Choosing —the value must be chosen freely from a list of alternatives, with thoughtful consideration being given to the consequences of each alternative. • Prizing —refers to cherishing the value, being happy with the choice, and willing to affirm the choice with other people when appropriate. • Acting —done so that the value is translated into behaviours consistent with the chosen value and integrated into the lifestyle.

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BOX 11-1 Steps in the valuing process

Situation: Mr Jefferson is a 49-year-old man with uncontrolled high blood pressure. Choosing Choosing freely: Mr Jefferson decides from now on to take his medication as prescribed following his readmission to hospital as a result of abruptly stopping his antihypertensive medication. Choosing from alternatives: After a teaching–learning session with a nurse, Mr Jefferson understands he has basically three options: • Adhere with prescribed treatment regime • Refuse to take the medication but try harder to control his blood pressure through diet, exercise, and stress management • Refuse to take the medication and assume a ‘we’ll see’ attitude. After consideration of the consequences. Mr Jefferson understands the probable consequences of these options: • Adherence with the treatment regime will yield the best control of high blood pressure (but may cause some annoying side-effects). • Diet, exercise and stress management may reduce his blood pressure somewhat but did not yield sufficient control in the past. • High blood pressure may result in serious complications such as stroke, kidney disease or impaired vision. Prizing • With pride and happiness. Mr Jefferson states: ‘Now that I understand high blood pressure better and know what I can do to control it, I feel more in charge of my life—and I like that!’ • With public affirmation. Mr Jefferson states to his wife: ‘I now know I was wrong to stop taking that medicine when I blamed it for how lousy I was feeling. That won’t happen again. If you ever hear me complaining about my pills, remind me to see my doctor right away.’

Acting by incorporating the behaviour into lifestyle on a consistent basis • After discharge from the hospital, Mr Jefferson takes the medication as prescribed.

• Mr Jefferson seeks to understand any new medication he is prescribed (i.e. reason for the medication, possible side- effects, consequences of the non-adherence) and successfully manages the treatment regime; he feels proud of his new knowledge and self-care abilities.

Now consider these questions: • How might this activity help this person examine his health-related behaviours? • What changes might you expect the person to make to his lifestyle? • What strategies might assist him to incorporate the changes into his daily routine? Scenario 2: Values of patients and family members in conflict You sense a growing tension while talking with the young parents of a child with asthma. Your questions to them (e.g. ‘You seem uncomfortable with what I’m saying now. Is there something wrong?’) reveal that the wife is a smoker and cat- lover who has told her husband that, even if these behaviours are hurting their child, she is unwilling to give them up. Values clarification Suggest both parents complete the fol- lowing exercise. Ask them ‘Where do you stand on the following issues? Indicate your responses in the following manner: SA, strongly agree; A, agree; D, disagree; SD, strongly disagree; U, undecided’, and then talk with them about their responses:

_____ A parent’s primary obligation is to meet the needs of his or her child. _____ Each member of a family is entitled to pursue personal pleasures, even if these are not in the best interest of all. _____ Pleasure is more important than health. _____ The choices one family member makes can dra- matically affect other family members (positively or negatively). This exercise will help the parents to evaluate their basic values, explore areas of conflict and, perhaps, move towards jointly choosing, prizing and acting on several health-promoting values. Now consider these questions: • How might this activity be seen as threatening or intrusive by the parents? • What support might you require to make this a positive experience? • What strategies might assist these parents to incorporate the changes into their lifestyle?

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ETHICS Ethics is the study of human values in relation to the under- standing and utilisation of concepts such as right and wrong, good and evil. It is formalised through a branch of philoso- phy referred to as moral philosophy and is divided into three primary theoretical areas: meta-ethics (the study of the concept of ethics), normative ethics (the study of how to determine ethical values), and applied ethics (the study of the use of ethical values). As with other values, these con- cepts are developed from childhood, and the ability to make ethical decisions and to act in an ethically justified manner develops gradually. See Chapter 21 for a description of moral development as developed by Kohlberg. Many people use the term ‘ethics’ when describing the systematic ethics incorporated into a code of professional conduct, such as nursing codes of ethics. The term morals is similar in meaning to ethics and the two words are often used in an interchangeable way. Morals usually refer to per- sonal or communal standards of right and wrong. It is important to distinguish ethics from religion, law, custom and institutional practices. For example, the fact that an action is legal or customary does not in itself make the action ethically or morally right. A principle-based frame- work provides a critical, defensible, systematic and intellectual approach to determining ethically what is right or best in a complex or problematic situation. Theories of ethics Ethical theories are systems of thought that attempt to explain how we ought to live and why. As defined above, these theories may be broadly categorised as meta-ethics, normative ethics and applied ethics. Meta-ethics Meta-ethics can be defined as the study of the origin and meaning of ethical concepts and focuses on the extent to which judgements are reasonable or otherwise justifiable. This includes the foundation of ethical principles and their meaning; that is, the issues of universal truths and how such commonly held beliefs underpin actions which may or may not be ethically defensible. Meta-ethics also explores the psychological basis of moral judgements and conduct, par- ticularly in relation to what motivates individuals to act in ways that are classified as ‘morally correct’. Normative ethics Normative ethics has a more practical purpose, focusing on the determination of moral standards and ethical values reg- ulating right and wrong conduct. It examines questions about societal as well as family values associated with col- lective and individual actions and outcomes. Normative ethics identifies the general rules and principles that guide most people’s actions. An example of normative ethics that guides nurses’ actions is the provision of thoughtful care to

older people prompted by wanting that level of respect and caring for their own parents or relatives. Applied ethics Applied ethics is the use of ethical values to examine spe- cific controversial issues, such as abortion or euthanasia. The conceptual tools of meta-ethics and normative ethics are used as a framework for discussion and resolution in applied ethics, although the lines of distinction between these three classifications of ethical theories are often blurred. For example, the issue of abortion is an applied ethical topic since it involves a specific type of controversial behaviour. But it also depends on more general normative principles, such as the right of self-rule and the right to life, which in themselves arise from meta-ethics issues such as the origin of people’s rights. Applied ethics has been subdivided into groups, and those of particular concern to the nurse and midwife are bioethics , clinical ethics and nursing ethics . Issues in bioethics include responsible research conduct, genetic enhancement, environmental ethics and sustainable healthcare. Clinical ethics is that branch of bioethics literally con- cerned with ethical problems ‘at the bedside’; that is, ethical concerns that arise within the context of caring for an actual person, such as rights and responsibilities in relation to informed patient consent to treatment. Clinical ethics have developed in response to three criticisms of bioethics: 1. The need for a contextual approach to ethical inquiry that takes a more careful account of the variety of contexts in clinical care and the special needs of ill and suffering people. 2. The need to emphasise the relevance of clinical experi- ence that draws on the knowledge available only through the intimacy of the clinician–patient relationship when doing clinical ethics. 3. The need for an orientation towards service in clinical ethics that addresses ethics education, policy making to address ethical issues in patient care, ethics consultation and clinical ethics research (Fletcher et al., 1997, p. 4). Nursing ethics has been defined broadly by Johnstone (2009, p. 16) as the ‘examination of all kinds of ethical and bioethical issues from the perspective of nursing theory and practice which, in turn, rest on the agreed core concepts of nursing, namely: person, culture care, health healing environment and nursing itself’. As nurses assume increasing responsibility for managing care, it is critical they be prepared to recognise the ethical dimen- sions of nursing practice and to participate competently in ethical decision making. Common ethical issues encoun- tered by nurses in daily practice include cost-containment issues that jeopardise patient welfare, end-of-life deci- sions, breaches of patient confidentiality, and the incompetent, unethical or illegal practices of colleagues. In the following scenario, explore all these dimensions of ethical practice.

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(Table 11-1). Many nurses and midwives add fidelity , verac- ity, accountability, privacy and confidentiality to this list, because they play a central role in the tradition of nursing (and medical) ethics, and guide the behaviour of healthcare professionals towards patients and their families. Principles offer general guides to action. All things being equal, we ought to act at all times in a manner that respects the autonomy of others, does not harm, does benefit others, treats others fairly and is faithful to the promises we make to others. Rarely is this as simple as it sounds. Be sensitive to the fact that each individual (patients, family members and professional carers) may identify benefits and harms differently. A benefit to one may be a burden to another. Ethical dilemmas arise when attempted adherence to basic ethical principles results in two conflicting courses of action. There is no foolproof method for identifying which principle is most important when there is conflict between competing principles. Moral principles are most beneficial to ethical decision in situations when there is disagreement on a course of action. This is the very time that principles can be relied on to find the best approach for the situation. However, it is important to understand that nurses rarely rely on a single principle to address an ethical dilemma. Principles can be used in combination and ethical frame- works or decision-making models are often utilised to guide nursing practice in daily clinical situations. Care-based approach Dissatisfaction with the principle-based approach to bioethics led many nurses to look to the provision of care and caring as the foundation for nursing’s ethical obligations. Provide the information and support patient and families need to make the decision that is right for them; at times, this may mean collaborating with other members of the health- care team to advocate for the person. Seek not to inflict harm; seek to prevent harm or risk of harm whenever possible. (patients, family members and professional carers) may identify benefits and harms differently. A benefit to one may be a burden to another. Always seek to distribute the benefits, risks and costs of nursing care justly. This may involve recognising subtle instances of bias and discrimination. Be faithful to the promise you made to the public to be com- petent and to be willing to use your competence to benefit the people entrusted to your care. Never abandon a person entrusted to your care without first providing for their needs. Implications for practice

Jimmy Banda, a 62-year-old homeless Indigenous man, is being discharged into the community, but requires supervision and support as well as ongoing healthcare. In Chapter 5 the ethical dimension related to continuity of care in the healthcare system was introduced. Consider Jimmy Banda’s situation and reflect on the following questions. Is healthcare a market commodity to which Mr Banda has limited access due to lack of financial resources? Is health- care a social right that should be freely available to all? Now that you have reflected on the broad ethical dimension, reflect further on your own and the profes- sions values. Consider the situation from a nursing ethics perspective. What are the moral obligations of the case manager caring for Mr Banda? Nurse ethicists frequently use two popular theoretical and practical approaches to ‘doing ethics’—the principle-based approach and the care-based approach . The principle-based approach concentrates on the abstract concepts of ethical principles from a more detached perspective, while the care- based approach favours emotional involvement in a moral or ethical dilemma in order to highlight the consequences of nursing actions. Midwives who practise woman-centred care may also use a feminist approach . Principle-based approach Beauchamp and Childress’ (2009) influential principle-based approach to bioethics is based on a common morality. The common morality is a set of norms shared by all persons committed to morality. The authors identify four key princi- ples: autonomy , non-maleficence , beneficence and justice

TABLE 11-1 Principles of bioethics

Principle

Moral rule

Autonomy

Respect the rights of people

(self-determination) or their surrogates to make

healthcare decisions.

Non-maleficence Avoid causing harm.

Beneficence

Benefit the person, and balance Commit yourself to actively promoting the person’s benefit benefits against risks and harms. (health and well-being). Be sensitive to the fact that individuals

Justice

Give each their due; act fairly.

Fidelity

Keep promises.

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The clinician–patient relationship is central to the care- based approach , which directs attention to the specific situations of individual patients viewed within the context of their life narrative, including their culture and values relating to care and caring. The care perspective suggests that how you choose to ‘be’ and act each time you encounter a patient or colleague is a matter of ethical significance. In distin- guishing professional therapeutic caring from the care given by family members, care-based ethics emphasise the impor- tance of respect for individuals and encourages a sense of connectedness in the clinician–patient relationship. Charac- teristics of the care perspective include the following: • Centrality of the caring relationship • Promotion of the dignity and respect of patients as people • Attention to the particulars of individual patients • Cultivation of responsiveness to others and professional responsibility • A redefinition of fundamental moral skills to include Feminist-based approach Modern feminist approaches to ethical analysis developed in the 1970s and represent a particular type of ethical approach popular among nurses and midwives. The feminist-based approach aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor. There are many forms of feminist ethics, and their subjects range from gender-related inequities to concern for the least well-off. Nurses and midwives working within a feminist framework promote social policy that reflects a fundamental trust in the moral agency of women and those on the margins. This supports the belief that all persons deserve the opportunity to make legitimate choices about conditions that affect their lives, and are deserving of respect whenever they exercise such agency. Anderson & Pelvin (cited in Pairman et al., 2010, p. 289) discuss a contemporary example of how a feminist approach may differ practically from a principles approach to ethics: Awoman undergoing cosmetic surgery decides to enlarge her breasts. While a principle approach might consider factors such as her competence to consent and her autonomous right to choose, a feminist approach might raise concerns about the subordination of women to oppressive ideas of beauty and youth and how women might be forced to conform to these in order to get work or please a partner. ETHICAL CONDUCT Nurses and midwives committed to high-quality care base their practice on professional standards of ethical conduct. The study of professional ethical behaviour is introduced through foundational studies, continues in formal and informal discus- sions with colleagues and peers, and culminates when nurses and midwives ‘try on’ and adopt the behaviours of role models virtues like kindness, attentiveness, empathy, compassion and reliability (Taylor, 1993).

whose professional practice is consistent with high ethical and professional standards of practice. These behaviours generally include elements of ethical/moral agency and are further reinforced through professional codes of conduct and ethics. Agency Ethics or morals are concepts that require translation into action. This is known as agency . Bandura (2001) described agency as an intentional human activity that makes things happen by one’s actions. It involves intentionality and fore- thought; an agent is a motivator and self-regulator. Agency involves making choices and having ability to shape one’s own decisions as well as influencing the decisions of others. Lastly, agency involves self-reflection and evaluation of one’s motivation and life pursuits. Taking action that trans- lates ethics and morals into practice is ethical or moral agency. These terms are used interchangeably and may be found in the literature under either term. Ethical or moral agency It is unrealistic to assume that the simple desire to be a nurse is accompanied by the natural ability to behave in an ethical way and to do the ethically right thing because it is the right thing to do. This ability, ethical/moral agency , must be cul- tivated in the same way that nurses and midwives cultivate the ability to do the scientifically right thing in response to a physiological alteration. Nurses and midwives who appreci- ate the ethical challenges in professional practice value their ethical development sufficiently to work hard to develop these skills. Essential elements of ethical agency include: • Ethical sensibility : Ability to recognise the ‘ethical moment’ when an ethical challenge presents itself • Ethical responsiveness : Ability and willingness to respond to the ethical challenge • Ethical reasoning and discernment : Knowledge of and ability to use sound theoretical and practical approaches to ‘thinking through’ ethical challenges, to ultimately decide how to respond to a particular situation after identifying and critiquing alternative courses of action; these approaches are used to inform as well as to justify moral behaviour • Ethical accountability : Ability and willingness to accept responsibility for one’s ethical behaviour and to learn from the experience of exercising ethical agency • Ethical character : Cultivated dispositions that allow one to act as one believes one ought to act • Ethical valuing : Valuing in a conscious and critical way, which squares with good ethical character and ethical integrity • Transformative ethical leadership : Commitment and proven ability to create a culture that facilitates the exercise of ethical agency, a culture in which people do the right thing because it is the right thing to do.

Box 11-2 illustrates these elements of ethical/moral agency in action.

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BOX 11-2 Ethical or moral agency Situation: A 75-year-old patient with end-stage lung cancer suffers a respiratory arrest and is resuscitated, ventilated, and admitted to the intensive care unit (ICU). When the receiving nurse reviews his chart, she discovers that, upon admis- sion, his nurse documented that he ‘did not want to be resuscitated’ and that he wanted to prepare an advance directive specifying ‘no heroics’. There is no do-not-resuscitate order on the chart, and the nurse can find no advance directive. Sensibility The ICU nurse notes the discrepancy between the patient’s documented preferences and the care he has received. She senses personal discomfort about this disregard for his wishes. Responsiveness The nurse can decide to ignore her discomfort and simply provide excellent technological care or acknowledge her dis- comfort and respond to it. She decides to talk with the attending doctor about his knowledge concerning the patient’s preferences and learns he was unaware of the patient’s documented preferences and has no personal knowledge of these. She contacts the nurse who originally admitted the patient and learns that although the patient was quite clear about his preference, no-one followed up and translated this conversation into orders on his chart. The attending doctor states that once treatment has been initiated it must continue but the nurse calls an ethics consultant. Reasoning and discernment During the ethics consultation, family members agree the patient would not be happy to find himself on a ventilator and request he be weaned—even if this results in his death. The ethicist explains that weaning him from an ineffective treat- ment (the ventilator will not cure his lung cancer) that is disproportionately burdensome is an ethically justified action. Accountability The nurse initiated the ethics consult because she believed she could not be an advocate for this patient and merely provide good physical care. Once she knew (or suspected) that his preferences had been ignored, she felt accountable for determining how the system had failed this patient and for remedying the problem. The nurse prides herself on being responsible and accountable and therefore could not ‘stick her head in the sand’ and pretend that this was not her problem! After the ethics consult, she participates in plans to wean the patient from the ventilator and makes sure that his family is present. The patient does not survive the weaning, and although they are grieving, his family members are grateful to the nurse for her care for the patient and for them. Character Because she had cultivated the virtues of responsibility and fidelity, the nurse’s course of action was natural. Valuing Because she places a high value on being an effective patient advocate, the nurse was willing to confront the attending doctor and initiate an ethics consult, even though these actions caused her some discomfort and the expense of time and inconvenience. Transformative leadership When her colleagues asked her where she got the ‘guts’ to follow through with this course of action, the nurse knew that the culture within the hospital had to change so that more nurses would choose to do the same thing she did without fearing negative consequences. She asks the nurse educator on her unit to explore the possibility of pursuing this theme in a future professional forum and is willing to work to make this happen.

mental responsibilities for nurses: to promote health, to prevent illness, to restore health and to alleviate suffering (see Box 11-3). The codes of ethics and conduct in Australia and New Zealand accommodate the increasing ethical demands on the nurse’s role and provide frameworks for making ethical decisions based on the professional expectations of nurses’ behaviour. Other functions of these professional nursing codes include the following:

Codes of ethics A code of ethics , based on universal values relating to nurses’ responsibilities for assisting others to achieve and maintain their health, was first introduced by the International Council of Nurses (ICN) in 1953. Such codes provide a standard or template for nurses in the areas of professional practice, accountability and public protection. The recent review of the ICN’s Code of Ethics for Nurses (2012) identifies four funda-

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BOX 11-3 International Council of Nurses Code of Ethics for Nurses

• The fundamental responsibility of the nurse is fourfold—to promote health, to prevent illness, to restore health and to alleviate suffering. • The need for nursing is universal. Inherent in nursing is respect for life, dignity and rights of humans. It is unrestricted by considerations of nationality, race, creed, age, sex, politics or social status. • Nurses render health services to the individual, the family and the community, and coordinate their services with those of related groups. Nurses and people • The nurse’s primary responsibility is to those people who require nursing care. • The nurse, in providing care, promotes an environment in which the values, customs, and spiritual beliefs of the individual are respected. • The nurse holds in confidence personal information and uses judgement in sharing this information. Nurses and practice • The nurse carries personal responsibility for nursing practice and for maintaining competence by continual learning. The nurse maintains the highest standards of nursing care possible within the reality of a specific situation. • The nurse uses judgement in relation to individual competence when accepting and delegating responsibilities. • The nurse, when acting in a professional capacity, should at all times maintain standards of personal conduct that reflect credit on the profession. Nurses and colleagues • The nurse sustains a cooperative relationship with colleagues in nursing and other fields. The nurse takes appropriate action to safeguard the individual when their care is endangered by a colleague or any other person. Nurses and the profession • The nurse plays the major role in determining and implementing desirable standards of nursing practice and nursing education. • The nurse is active in developing a core of professional knowledge. • The nurse, acting through the professional organisation, participates in establishing and maintaining equitable social and economic working conditions in nursing.

Source: Adapted from International Council of Nurses, 2012.

• Nursing Council of New Zealand’s Code of Conduct for Nurses (NCNZ, 2012). Codes of ethics and conduct for midwifery include: • Australian Nursing and Midwifery Council’s Code of Ethics for Midwives in Australia (ANMC, 2008b) • Midwifery Council of New Zealand’s Code of Conduct (MCNZ, 2010) • New Zealand College of Midwives’ Code of Ethics (NZCM, 2008a). See the reference material at the end of this chapter for resources and links to the respective nursing and midwifery codes. Australia and New Zealand have professional codes of ethics for nurses and midwives. Investigate the code of relevance to your professional practice and compare it to the International Code (see Box 11-3): • Are there differences that reflect the individual countries, or are the principles enshrined applicable wherever you practice?

• Identifying the fundamental moral commitments of the nursing profession • Providing nurses with a basis for self- and professional reflection on ethical conduct • Providing the community with an overview of the moral values that nurses can be expected to hold. Codes are effective in accomplishing their goals only to the extent that members of the profession uphold them. Code requirements may exceed legal requirements. Viola- tions of the law subject a nurse to civil or criminal liability (see Chapter 12), and violations of the codes of ethics and conduct may result in reprimands, censure, suspension or expulsion. Codes of ethics and conduct for nursing include: • Australian Nursing and Midwifery Council’s Code of Ethics for Nurses (ANMC, 2008a) • International Council of Nurses’ Code of Ethics for Nurses (ICN, 2012) • New Zealand Nurses Organisation’s Code of Ethics (NZNO, 2009)

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Director of Proceedings. The Code of Health and Disability Services Consumers’ Rights sets out ten rights, which include the right to be treated with respect, to be free from discrimination or exploitation, to dignity and independence, to services of an appropriate standard, to give informed consent, and to complain (Health and Disability Commis- sioner, 2009; Parliamentary Counsel Office, 2004). Often the ethical issue involved in a patient’s rights is not immediately obvious because it might be due to an omission rather than to something someone does or says. Consider this point in the following scenario. Rebecca Wright, a 48-year-old woman who has just recently undergone extensive surgery to treat uterine cancer, is experiencing several serious postoperative complications. She states: ‘I don’t know why all of these things are happening. I ask the doctors. So does my family. But we get no answers. We just want to know what is happening.’ The nurse is surprised to observe that not only does the surgeon not answer Rebecca’s questions, but that he also dismisses her fears without any explanation. The nurse would likely feel that the surgeon and medical team are not being faithful to their responsibility to address the patient’s questions and fears. Unless the nurse can effectively advocate for Rebecca with the medical team, her own ability to be faithful to Rebecca and accountable for her well-being will be compromised. In this scenario the ethical issue is situated in an omis- sion. What patient right was contravened in this situation? How could you use your knowledge of patients’ rights to ensure the questions from Rebecca Wright and those of her family are acknowledged by the treating doctor and answered appropriately? ETHICAL DECISION MAKING Two types of ethical problems commonly faced by nurses and midwives are ethical dilemmas and ethical distress. In an ethical dilemma, two (or more) clear moral principles apply but support mutually inconsistent courses of action. Ethical distress occurs when you know the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action. You need sound analyti- cal skills and the ability to engage in ethical reasoning to resolve ethical dilemmas and ethical distress. Resources for ethical decision making are highlighted in Box 11-4. Making ethical decisions Every nurse and midwife needs to be confident in using a process of ethical decision making. Using the process of person-centred care to make ethical decisions involves fol- lowing the steps discussed below. The accompanying care study illustrates this model of ethical decision making (Box 11-5).

• Reflect on your own value system. What principle in the code that covers your country is the most mean- ingful to you? • Is there a value you believe is important for you that is not captured in the International, Australian or New Zealand codes? Now think about these questions: • Which ethical principles are involved in assessment of clinical practice standards? • How might the assessee’s moral judgement be taken into account in the assessment decision? • How might the underlying power structure inherent in the assessor/assessee relationship contribute to the assessment outcome? Should this be taken into account when making the assessment decision? Patients’ rights The principle-based approach to bioethics identifies auton- omy as the first principle in a list of four (Beauchamp & Childress, 2009), acknowledging the individual’s right to make choices based on personal values and beliefs. The rights of the individual to question the quality of their healthcare, and to have their personal views and beliefs about their health taken into account during the planning of their care, are supported in Australia by the Australian Charter of Healthcare Rights, developed by the Australian Commission on Safety and Quality in Health Care (ACSQHC, 2012). This charter sets out the following rights for patients in the Australian health system: • Access to healthcare • Safe, high-quality treatment • Respect, dignity and consideration • To be informed about services, treatment, options and costs • To be included in decisions and choices about care • To privacy and confidentiality • To comment on care and have concerns addressed. Similar patient charters have been developed by state and territory governments (e.g. Patients’ Charter of Rights, Queensland Health, 2002). They are regularly audited for compliance through quality accrediting bodies such as the Australian Council of Healthcare Standards (ACHS). With care moving increasingly from the hospital to the commu- nity, nurses and midwives must be familiar with how different institutions and professional groups define patient rights and responsibilities. New Zealand also has a system dedicated to the preserva- tion and monitoring of patient rights. The Health and Disability Commissioner Act 1994 of New Zealand created the Office of the Health and Disability Commissioner, whose role is to promote and protect the rights of health and disability consumers. The office is also charged with the res- olution of complaints in a fair and timely manner. A national network of advocates implements the services under the Director of Advocacy and an independent prosecutor, the