Why is it necessary to not only act ethically in the practice of nursing but to be seen to be acting ethically?
Introduction
The application of ethics in the field of medicine has significantly broadened in the past few years. This is brought about by a number of factors like the advancement in medicine which is driven about by technology. Although there is nothing wrong with this, this has posed serious threats to the practice of medicine. This does not mean that in the past the medical and health care communities have been slack in their practice of ethical behavior but rather the changes have made significant ethical implications in the field of medicine and the delivery of health care.
The practice of nursing, being in the front line of medical care, has also been subject to many ethical issues. In their daily work, nurses deal with intimate and fundamental human events such as birth, death, and suffering. They must decide the morality of their own actions own actions when they face the many ethical issues that surround such sensitive areas.
For this particular paper, the question as to why it is necessary to not only act ethically in the practice of nursing but to be seen to be acting ethically will be answered. This paper will use the author’s own perception on the matter as well as literature derived from other sources. The paper will start off with an explanation of ethics and its application in the field of medicine and health care, with emphasis on the field of nursing. Furthermore, other aspects of ethics will also be discussed so as to help provide a better understanding of the whole concept of doing what is ethically right and the importance of being seen while doing what is ethically right.
Overview of Ethics
Ethics is the study of good conduct, character, and motives. It is concerned with determining what is good or valuable for all people. Ethics is the exploration of what kind of person one “should” be or how one “should” act. A well-recognized premise of such exploration is that “ought implies can.” In other words, in saying that someone ought to do X or that X is the ethical thing for him to do, we are assuming that it is actually possible for him to do X. There is no moral obligation to do the impossible. It does not help us in acting ethically to consider whether we have a moral obligation to do something that, quite simply, we cannot do. This is true in health care as it is in other areas of our lives ( 2005).
Philosophical Constructions of Ethics
Discussions about health issues have progressed over time, just as developments in health care and society itself have progressed. The philosophical constructions that shape the discussions also have changed. Ethics began as a standard reference point for the determination of right action. It has now grown into a field of study that is filled with differences in opinion, competing systems of values, and deeply meaningful efforts to understand human interaction with new technologies.
Ethics in the Nursing Profession
Medical ethics, a branch of the philosophy of ethics, deals with moral decisions in medicine. The branch of nursing ethics could be considered under the umbrella of medical ethics. The moral foundation of the nursing profession is based on the perspectives of Florence Nightingale, who described nursing as a self-defining moral practice focused on caring. This moral foundation evolves from the nurse-patient relationship. Morality in nursing practice arises from the idea that it is morally good to promote the physical and psychological well-being of patients. Nurses, however, may find it difficult to prioritize these moral nursing values over their personal values (2002).
In the nursing profession, acts that are ethical often reflect a commitment to standards which are beyond an individual’s personal preferences – standards on which individuals, professions, and societies agree (2004). Ethics has become an important way of life in a post-modern society that does not acknowledge any fixed points of reference.
Nursing is essentially a work of intimacy. The tasks of nursing require the nurse to be in close contact with clients, physically and emotionally. This kind of contact is usually not acceptable in public relationships. As a result, the work of nursing involves the negotiation of values whether those values be of the client, the physician, the employer, or other concerned groups.
Maintaining their own moral integrity is central to nurses’ moral experience. Studies have documented that nurses sometimes feel they are forced to betray their own values. Their position in organizations, a lack of involvement in the decision-making process, and lack of authority seem to contribute to the experience of powerlessness in situations of moral difficulty ( 2005).
Discussion and resolution of ethical issues requires critical thinking skills. Unlike the resolution of clinical problems, however, the resolution of ethical issues involves the negotiation of closely held personal values and philosophies, not facts or measurable clinical data. Resolution of ethical issues incorporates not only the nurse’s personal values but also the interpretation of the client’s personal values, based on the unique perspective of nurses (2004). Ethics guided by one’s own moral values is very important since an ability to make good decisions about one’s health care promotes healthy behaviors across the lifespan (2000).
Origins of Ethical Problems in Nursing
Nurses’ growing awareness of ethical problems has occurred largely because of (a) social and technological changes and (b) nurses’ conflicting loyalties and obligations.
A. Social and Technological Changes
Social changes, such as the women’s movement and a growing consumerism, also expose problems. The large number of people without health insurance, the high cost of health care, and workplace redesign under managed care all raise issues and fairness of allocation of resources.
Technology creates new issues that did not exist in earlier times. Before monitors, respirators, and parenteral feedings, there was no question as to whether to “allow” an 800-gram infant to die. Before organ transplantation, death did not require a legal definition that might still permit viable tissues to be removed and given to other living persons. Advances in the ability to decode and control the growth of tissues through gene manipulation present new potential ethical dilemmas related to cloning organisms and altering the course of hereditary diseases and biological characteristics. In line with all these, many questions arise.
B. Conflicting loyalties and obligations
Because of their unique position in the health care system, nurses experience conflicts among their loyalties and obligations to clients, families, physicians, employing institutions, and licensing bodies. Client needs may conflict with institutional policies, physician preferences, needs of the client’s family, or even laws of the state. According to the nursing code of ethics, the nurse’s first loyalty is to the client. However, it is not always easy to determine which action best serves the client’s needs.
Nursing Point of View
Professional nurses play a vital role in the management of health care in both outpatient and inpatient settings. All clients interact with a nurse at some point in the health care system.
When ethical situations arise, the nurse’s point of view is unique and critical. The nurse usually interacts with clients over longer time intervals than do other health care professionals. Because nurses may be involved in intimate physical acts such as bathing, feeding, and special procedures, clients and families reveal information generally not shared with physicians and others. Details about family life, information about coping styles, personal preferences, and details about fears and insecurities are likely to come out during nursing interventions ( 1997).
On the other hand, it is important for nurses to remember that care of any one client has become multidisciplinary and often fragmented. The nursing point of view is part of a larger picture that is best built by all members of the health care team, including the client and family. When involved with ethical decisions, the nurse must also seek the opinion of other health care professionals.
Nurses who face ethical dilemmas in their practice often find their voices and point of views are not heard when it comes to collaborative decision making on the issue. Factors such as conflict within the medical team and the existence of hierarchical structures can mean the nurse at the coal face is not consulted. This is a fact in medical and health care systems and should be given solutions by their respective governing bodies.
Nursing Code of Ethics
In professional practices such as nursing, a code of ethics provides guidelines for safe and compassionate care. Nurse’s commitment to a code of ethics guarantees the public that nurses adhere to professional practice standards set for their profession.
Nursing Errors, Ethics, and the Law
The ethical issues associated with nursing practice are closely tied-in to legal issues. Ethics, in a way, dictates what ought to be done and what ought not to be done. As a result of many nursing practices that failed to consider ethical considerations, some nurse and even other health care professionals face malpractice suits. However, it is important to point out that not all malpractice issues are a result of unethical behaviors.
Nursing errors are a part of the nursing profession. Most often these are not deliberately done by the nurse. However, one just cannot expect the client or the family of the client to just let errors pass, especially if this significantly affects the client. When a nurse commits errors, most often this is subject to ethical considerations and the nurse will have to face legal consequences.
One common error made by nurses is medication administration. Such an error will result in the nurse feeling vulnerable and upset. Not only are they concerned about how the mistake will affect the patient, they also worry about the implications on their careers if they are disciplined. By admitting to the mistake, they may be ridiculed by other nurses or even worse, lose the trust of their patients. The outcome of this distress is that often the nurse will hide the truth when the patient seems to be unaffected. Many ethical questions arise in these instances: Should the nurse tell the truth and disclose the error? Will telling the patient, cause more harm than good? If the patient isn’t ton and they find out later, will the outcome be an erosion of trust? ( 2005).
Hidden mistakes also occur in the nursing profession. This means that problems with procedures are not recognized. This eventually has an impact on the quality of care delivered to our patients. Nurses need to be supported and encouraged by management when they disclose an error. They are then in a position to learn from their mistakes and can hopefully help to identify ways in which a similar event can be avoided. This process can help to alleviate feelings of guilt associated with the event.
Surprisingly, the issue of truth telling in the health care setting is a relatively modern concept. In the past, it was considered preferable to keep unpleasant information concerning diagnosis and the progression of a disease from the patient, under the guise of protecting them from unnecessary distress. It was the health professional’s responsibility to decide whether the patient should or should not know the truth. At times, the family would insist that their loved-one should not be told of their prognosis. The patient had no autonomy at all. Modern legislation, however, recognizes the tights of a person to be given true and accurate information about their illness and treatment ( 2005).
Nurses must accept responsibility for nursing actions to safeguard the privacy rights of patients by carefully protecting confidential information. The patient’s confidence that information given to the nurse will remain private is an important element in the nurse-patient relationship. Without this assurance, the patient might be unwilling to divulge information critical to his or her care ( 2002).
The average nurse still appears to believe that accountability is all about following procedure and making sure that ‘one is covered’ by having the right kind of note or record or witness to refer to when something goes wrong or when, for whatever reason, an accusation is made (1994).
Fighting hospital policy and the fear of lawsuits can influence whether the nurse eventually acts by moral choice. This situation can be frustrating and may lead to considerable distress. A nurse who is not able to find resolution to an ethical dilemma, and then act in a way in which she feels morally comfortable, may experience anxiety, feelings of guilt and possibly burnout. It is therefore very important that our leaders and managers include in their nursing education and hospital in-service sessions, teaching that will prepare today’s nurses for the complex ethical issues they will encounter ( 2005).
To defend against a malpractice lawsuit, the nurse must prove that one or more of the required elements is not met (2004). From this statement alone, one could see that what could practically save a nurse from a malpractice lawsuit is a proof. And what better proof could be provided than a witness that would claim that the nurse did not breach any ethical or moral limits.
The Importance of Being Seen Acting Ethically
To do something ethically in the presence of another person could be a good evidence in case a malpractice suit or ethical complaints are being raised against the nurse. When someone is present while a nurse performs an intervention or procedure, this would minimize and even eliminate questions and doubts as to whether the interventions have been properly performed or not.
The presence of a non-participant observer does threaten a loss of privacy or dignity for the patient concerned. It may also result in such a loss for any other patients who may not themselves be involved in the study but who can be seen or heard by the observer (1994).
Application of the Importance of Being Seen Acting Ethically in the Nursing Profession
Let us consider 2 scenarios wherein the aspect of being seen while doing a nursing practice ethically is of paramount importance:
Scenario 1:
In this scenario, a case of autonomy in ethics is the issue. Autonomy refers to a person’s independence, in this case the client’s independence. As a standard in ethics, autonomy represents an agreement to respect another’s right to determine a course of action. Based on this standard in ethics, the health care professionals should respect the client’s decision as to what should be the next course of action. When a client wants to leave the hospital after a health care procedure, the client should be allowed to do so providing the client is capable of making sound decisions for him- or herself. The health care team has no right to detain a client and impose their decisions on him or her since in the first place the client is not found to be mentally incapacitated.
Respect for another’s autonomy is fundamental to the practice of health care. It serves to justify the inclusion of clients in all aspects of decision making regarding their health care. The decision to be discharged from the hospital may be at the hands of health care professionals but the client also has the right to voice out his or her opinions which should be respected by the health care professionals.
The agreement to respect autonomy involves the recognition that clients are in charge of their own destiny in matters of health and illness. Let us take for example the consent process required prior to surgery, this implies that a client may refuse treatment. In most cases the health care team must agree to follow the client’s wishes. Health care professionals agree to abide by a standard of respect for the client’s autonomy.
In a case where the client manifests autonomy, such as the one where he or she refuses any treatment, someone else should be present in the scenario other than the nurse. The client may refuse treatment but the family of the client may cry foul if anything happens to the client. The family of the client could file a malpractice suit against the nurse or other health care professionals if they have no proof that it is the client’s wish not to be treated and thus would apply to be a client’s exercise of autonomy which is within the bounds of ethical nursing practices.
Since the profession simultaneously expects nurses to ensure autonomy and maintain safety, nursing needs to gather evidence that less restrictive alternatives can maintain safety for their clients and for their own. Rather than encourage changing the procedural laws, nursing needs to ensure that nurses implement involuntary procedures in a manner that protects client safety and clients’ rights.
This is more prominent in situations that concern psychiatric patients. Experienced psychiatric nurses need to articulate more definitive ways to determine risk vs. benefit for ethical decision making in the daily care of psychiatric patients. Nursing education thus must reflect the real situations that psychiatric nurses face and insist that student nurses actually commit to making some choices when faced with a situation ( 2000).
Nurses have little guidance in determining ethical choices in situations such as this where involuntary procedures may be required. Nursing choices are constrained by law and hospital policy, but there are tremendous gray areas where the rules are unclear (2000).
The nurse has of course a moral duty to prevent anything bad from happening to the client. However, if the client does not appear to be mentally ill, he or she should be given the freedom and right to decide regarding her treatment. If the client decides to go home, then he or she should be allowed to go home since in the first place he or she does not appear to be mentally ill and could make sound decisions and judgments. Unless the client is proven to be unable to make sound decisions and judgments, then the health care professionals and the family of the client could decide for the health care of the client. Whatever the decision may be, or whoever may decide for the client, a witness should be around in case issues of unethical practice are raised against the nurse.
Scenario 2:
In another scenario, let us consider the case of a nurse who is in charge of the care of a terminally ill man. In the physician’s orders, the man is not to have any liquid taken orally. The nurse is aware of this order yet the nurse did not follow this and instead gave the man a few sips of water to drink.
The nurse in this scenario did not behave ethically. This could be discussed through the aspect of medical ethics which is beneficence. This refers to taking positive actions to help others. The practice of beneficence encourages the urge to do good for others. Commitment to beneficence helps to guide difficult decisions wherein the benefits of a treatment may be challenged by risks to the client’s well-being or dignity.
In the scenario, the nurse probably went against the doctor’s orders because she felt pity for the client. Given the fact that the client is terminally ill, the nurse could have felt that it was a little selfish and harsh for the doctor not to give the client anything to eat or even drink. Or the nurse could have thought that she owe it to the client to give him something to drink since he is dying anyway and the nurse just wants to grant a dying man’s wish. Thus, the nurse went against the doctor’s orders and gave the terminally ill man small sips of water. Although the nurse did this with good intentions in her mind, it is possible that it could have a bad effect on the client, and thus the nurse still did not behave ethically.
The nurse should have thought that the doctor’s orders may cause discomfort to the client, but the benefits, both for the individual and the society, outweigh the temporary discomfort. If the nurse has doubts of the doctor’s orders, she could have simply asked the doctor about it and why it should be done. The nurse should not act on her own without asking for advice, especially since this is a case wherein orders from a higher authority is given. The agreement to act with beneficence also requires that the best interests of the client remain more important than self-interest.
The nurse must remember that whatever she did on the client, she is accountable and responsible for. If what she did could harm the client, she could be blamed for it, and worse, she could be sued for malpractice. Depriving a client of something to eat and drink could sound harsh, but there are rationales for such actions. In ethics, such is done for the benefit for the client. No matter how terminally ill a client is, health care professionals must abide by what should be done clinically within the bounds of their established code of ethics.
Suppose the client died just five hours after the nurse gave the man sips of water, the nurse would likely be partly one to be blamed for the incidence if someone else knew what she has done. If there was no one to witness, then it will be in the conscience of the nurse that if perhaps she followed the physician’s orders the client would still have been alive.
If it was another scenario still where the nurse followed the physician’s orders with witnesses around and still the man died after a few hours, then it is unlikely that the nurse will be blamed for the man’s death. Granting that the nurse only followed the orders of the physician and there were other people around to witness that the nurse indeed behaved ethically, then the nurse does not have to bear any ethical question regarding what she did.
This situation given here occurs when a nurse disagrees with the treatment decisions made by the attending physician but which she nonetheless is required to follow. In some cases, the nurse may recognize that the orders are mistaken or violate the accepted standard of care. Under the ethical codes of both the nursing and medical professions, a nurse has no duty to carry out such orders (2005). However, the nurse cannot act only on her own. She has to talk over with the physician or other concerned health care professional if she deemed the orders unethical or wrong.
Conclusion
In the past, nurses looked on ethical decision making as solely the physician’s responsibility. However, one should consider that no one profession is responsible for ethical decisions, nor does expertise in one discipline such as medicine or nursing necessarily make a person or expert in ethics. The ethical decision thus cannot be left only to the hands of the physicians. And thus it goes also to say that one cannot say that a nurse is an expert in the field of nursing ethics just because he or she is a nurse. Additionally, the advent of technology coupled with numerous other factors has significantly changed ethical concerns and behaviors. This has brought about many issues regarding the conduct of ethical behavior.
The practice of doing what is ethical is not sufficient alone in the contemporary times. There is increasing importance given to the fact that one also needs to be seen when doing what is ethical behavior or practice. This is very important especially with the advent of medical malpractice lawsuits. A witness to a nurse doing what is ethical may save not only a nurse’s profession but also the nurse’s whole life. Perhaps, as the old adage says, to see is to believe. To be able to see that the nurse does what is right and ethical would perhaps be a lifesaving factor for the nurse from anything that can harm him or her and the nursing profession in general. Being seen doing what is ethically right could not only boost the morale of the nursing profession but also serves to protect nurses against unreasonable complaints from their clients.
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