Ethics in Community-Oriented
Nursing Practice
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Objectives
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Describe a brief history of the ethics of the
nursing practice.
Analyze ethical decision-making processes.
Compare and contrast ethical theories and
principles, virtue ethics, caring and the ethic
of care, and feminist ethics.
Comprehend the ethics inherent in the core
functions of public health nursing.
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Objectives
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Demonstrate understanding of the
ethics inherent in the core functions of
PH
Analyze codes of ethics for nursing and
for public health.
Apply the ethics of advocacy to the
nursing practice.
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A brief history of the ethics of
nursing practice
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Nightingale’s vision of
◼ Morality
nursing
◼ Values
Nightingale pledge: first code ◼ Service to the poor
of ethics
◼ Strong Moral character
1950 & 2001: Code of Ethics
◼ Ethics content in nursing
for Nurses with Interpretive
curriculum at the college
Statements
level
1953: 1st. International Code
◼ Bioethics (a new field) is
of Ethics developed
integrated
1960s: Bioethics
◼ Ethics as a course
2002: Public Health Code of
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Ethics
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Ethics
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Principles and rules for behavior and
duty
Basic guide for deciding right and
wrong
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Ethical Decision Making
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Identifying and justifying moral norms
Problem-solving processes
Thinking independently
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Thinking beyond following rules and authorities
Moral responsibility
Hard-won right
Two factors
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Growing multiculturalism
Moral distress
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Ethical Decision-Making Framework
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Identify ethical issues and dilemmas
Find meaningful context
Obtain all relevant facts
Reformulate, if needed
Consider appropriate options
Decide and take action
Evaluate decision and action
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Why Does the Public NOT
Trust the Government?
In the next 3-5 minutes:
Break into small groups or find a
partner.
Brainstorm and record a list of
reasons why the public may not
trust government.
Share with class.
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Reasons why people don’t trust
the government
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Student input here
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The Tuskegee Experiment
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Between 1932 and 1972, the U.S.
Public Health Service (PHS)
conducted an experiment on 399
black men in the late stages of
syphilis.
Never told what disease they were
suffering from or of its
seriousness.
Informed that they were being
treated for “bad blood,” their
doctors had no intention of curing
them of syphilis at all.
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The Tuskegee Experiment
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To discover how syphilis affected blacks as
opposed to whites—the theory being that
whites experienced more neurological
complications from syphilis whereas blacks
were more susceptible to cardiovascular
damage.
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You are government….
Responsibilities
◼ Authorities
◼ Burdens
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How do you conduct
the business of public
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health and instill public trust?
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Public Trust
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Public service
Respect and confidence of the public
Loyalty to the law above private gain
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Ethnic Diversity and Cultural
Standards
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Four Situations You Can Judge:
1.
2.
3.
4.
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Someone is at direct risk of harm.
Ethnic cultural standards conflict with
professional standards.
The greater community’s values are
jeopardized.
The ethnic community customs are
annoying but not problematic for the
greater community.
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Handling Moral Distress
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Identify situations that lead to
distress.
Communicate concern and examine
ways to address the stressor.
Seek support from colleagues.
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Ethics
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Definition, theories, and principles
Virtue ethics
Caring and the ethic of care
Feminist ethics
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Definitions, Theories, and Principles
(Box6-2, pg.126)
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Ethics
Values
Consequentialism
Utilitarianism
Deontology
Respect for autonomy
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Nonmaleficence
Beneficence
Distributive justice
Egalitarianism
Libertarianism
Liberal democratic
theory
Communitarianism
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Virtue Ethics
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“What kind of person should I be?”
Goal: enable persons to flourish as
human beings
Aristotle: “Acting in accordance with our
natural good”
Central to professional ethics in public
health nursing (PHN)
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Caring and the Ethic of Care
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Caring in nursing, the ethic of care, and
feminist ethics are interrelated.
Caring in nursing rose as a response to
desire to differentiate nursing practice
from medical practice.
Erikson (2002): caring science theory
Relationship between caring and ethics
or morality
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Feminist Ethics
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Feminists
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Feminist ethics
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Include women and men
Hold a worldview advocating economic, social, and
political rights for women that are equivalent to
those of men
Reject the devaluing of women
Women’s thinking and moral experiences are
important and should be taken into account in any
fully developed moral theory.
The oppression of women is morally wrong.
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Ethics and the Core Functions of
Population-Centered Nursing
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Assessment
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Policy development
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Assurance
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Assessment
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Three ethical tenets of assessment:
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Competency related to knowledge development,
analysis, and dissemination
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Virtue ethics or moral character
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Do the persons selected to develop, assess, and
disseminate community knowledge possess integrity?
“Do no harm”
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Are the persons assigned to develop community
knowledge adequately prepared to collect data on
groups and populations?
Is disseminating appropriate information about groups
and populations morally necessary and sufficient?
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Policy Development
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Three ethical tenets of policy development:
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Achieve the public good
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Service to others over self (a necessary condition)
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Rooted in citizenship
Serve rather than steer
Serve citizens, not customers
Value citizenship and public service above entrepreneurship
What is ethical is also good policy.
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Assurance
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Two ethical tenets of assurance:
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All persons should receive essential
personal health services.
Providers of public health services are
competent and available.
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Nursing Code of Ethics
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Code of Ethics for Nurses with Interpretive
Statements (2001) purposes
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To be a succinct statement of the ethical
obligations and duties of every individual who
enters the nursing profession
To be the profession’s nonnegotiable ethical
standard
To be an expression of nursing’s own
understanding of its commitment to society
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Public Health Code of Ethics
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Asserts the collective and societal nature of
public health to keep people healthy
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12 principles related to the ethical practice of
public health
11 values and beliefs that focus on health,
community, and action
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APHA Code of Ethics (2002)
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Stresses the mission of disease prevention
“Values of community consent,
involvement, empowerment, respect for
diversity, and trust” (Olick, 2004).
Balancing individual and public rights
Guide for tough decisions
http://www.apha.org/codeofethics/
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Advocacy and Ethics
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Codes and standards of practice
Conceptual framework for advocacy
Practical framework for advocacy
Issues with ethical implications
Advocacy and bioterrorism
Advocacy and health care reform
Ethical use of social media
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Codes and Standards of
Practice
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Code of Ethics for Nurses, ANA (2001)
Public Health Code of Ethics, Public
Health Leadership Society (2002)
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Public Health Nursing: Scope and
Standards of Practice, ANA (2007)
Skills for the Ethical Practice of Public
Health, Public Health Leadership Society
(2004)
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Conceptual Framework for
Advocacy
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Contrast social justice and market
justice
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The biggest barrier to achieving social
justice is the competing concept of
market justice.
A focus on market justice, rather than
social justice, influences public dialogue
about public health needs.
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Quick Recall
What school of thought has the greatest
influence on current debates about
public health?
A.
B.
C.
D.
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Social justice
Shared needs
Market justice
Health care reform
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How’d You Do?
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A focus on market justice, rather than
social justice, influences public dialogue
about public health needs.
The biggest barrier to achieving social
justice is the competing concept of market
justice.
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Practical Framework for
Advocacy
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Bateman’s ethical principles for the advocate’s
core skills*:
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Act in the patient’s best interests§.
Act in accordance with the patient’s wishes.
Keep the patient properly informed.
Respond with diligence and competence.
Act impartially and offer frank, independent
advice.
Maintain
patient confidentiality.
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Advocacy and Bioterrorism
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Thoughtfully reflect on and debate
ethical issues that arise with the threat,
action, and aftermath of terrorism.
Consider own responsibilities in terms
of moral obligation to respond.
Make self available in a crisis that
threatens the well-being of a
community.
Advocacy and Heath Care
Reform
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Nurses can be an important voice in
advocating for access to consistent,
effective, efficient health care for all in
our society.
The 2010 health care bill provides an
opportunity for nurses to advocate for
health care for all to ethics and social
justice.
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Ethical Use of Social Media
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Four Key Elements:
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Promote client dignity.
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Seek client’s best interests.
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Avoid inappropriate involvement.
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Refrain from personal gain at client’s
expense.
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ETHICAL CASE STUDIES
ACTIVITY
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An international ethical example
Severe Acute Respiratory Syndrome, SARS
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What Would You Do?
Gifts
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Case Study 1
You are making an inspection to assess
the need for extended health care
services.
◼ You are offered a cup
of coffee and a homemade
pastry.
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What Would You Do?
Conflict of
Interest
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Case Study 2
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Because of your technical experience in the
healthcare industry, you are asked to be on
the Board of Directors of a small, start-up
software company. The new software will
be marketed to nursing home
administrators.
Do you accept?
Does it depend on what job you do?
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What Would You Do?
Confidentiality
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Case study 3
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A 75-year-old woman shows signs of abuse
that appears to be inflicted by her son, her
primary caregiver. She feels dependent on
him and pleads with you not to say anything
about it. In this case, the laws supporting
reporting elder abuse (and child abuse) may
or may not allow you to break confidentiality
and report suspected abuse.
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What Would You Do?
PH
Citizen
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Case Study 4
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You leave your health department job
as a nursing home inspector and
become a lobbyist for the largest food
and beverage association in your state.
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What Would You Do?
Favors
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Case Study 5
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Your mother’s Alzheimer’s has
progressed and she needs extensive
care. As a nursing home inspector, you
have always been impressed with
Shady Side, but you know they have a
long waiting list. Should you ask the
Director to make an exception and get
the best care for your mother?
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What Would You Do?
Research
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Recent Unethical Behavior
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UMDNJ Cardiologists
Steroids and baseball
Mortgages/Wall Street
Public Health?
Others???
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Why follow ethical standards?
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Avoid criminal or administrative
penalties
Protect the reputation of your agency
Protect your own personal and
professional reputation
Ethical behavior is seldom rewarded, but
unethical behavior is rarely ignored.
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What are ethical conflicts you may
potentially face in your position?
In the next 3 minutes:
Write down 1-3 examples of
potential ethical conflicts that you
foresee or have already
experienced in community/public
health or your clinical practice.
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Finally, ask yourself the
following questions:
Is it ethical?
Is it legal?
How would I feel
if my family,
friends, or coworkers were to
read of my actions
in tomorrow’s
newspaper?
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Ethic Principles
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“Sunshine” (out in the open, in writing,
approved by supervisor)
Avoid appearances of impropriety
Know your responsibilities (Is it legal?
Is it ethical?)
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Need to be Informed of…
What are the:
◼ Slippery slopes?
◼ Appearances and perceptions?
◼ Violations of public trust?
◼ Legalities and penalties?
◼ Prior approvals to protect yourself?
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Need to be Informed of…
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What are the penalties?
Fines
Suspension
Removal from office
Loose your license
Jail
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What to Do?
If you are unclear whether a conflict
exists
1.Ask your supervisor (“run it up the
flagpole”).
2. Put it in writing.
3. Don’t keep it to yourself.
4. Seek legal counsel.
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Goal of an Ethical Judgment in a
Situation in the Community
Choose an action that:
◼ Does the most good for the most
people
◼ Is good or right for me and my friends
◼ Makes the most economical use of
community funds
◼ Has a strong certainty of scientific
judgment
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Points to Remember
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Ethics is really about making a choice
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Fast action vs. careful consideration
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Never make it personal
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Don’t abuse your power
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