Chapter 22
Ethics and Values
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Ethics and Values Defined

Ethics


The study of conduct and character. It is
concerned with determining what is good or
valuable for individuals and society at large.
Values

Personal beliefs about the worth of a given idea,
attitude, custom, or object that set standards that
influence behavior.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Basic Terms in Health Ethics
Autonomy
Commitment to include patients
in decisions
Beneficence
Taking positive actions to help
others
Nonmaleficence
Avoidance of harm or hurt
Justice
Being fair
Fidelity
Agreement to keep promises
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Professional Nursing Code of Ethics



A set of guiding principles that all members of
a profession accept
Helps professional groups settle questions
about practice or behavior
Includes advocacy, responsibility,
accountability, and confidentiality
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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The ANA Code of Ethics


The nurse, in all professional relationships, practices
with compassion and respect for the inherent dignity,
worth, and uniqueness of every individual,
unrestricted by considerations of social or economic
status, personal attributes, or the nature of health
problems.
The profession of nursing, as represented by
associations and their members, is responsible for
articulating nursing values, for maintaining the
integrity of the profession and its practice, and for
shaping social policy.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study


Anna Moreno is an 82-year-old African American
widow and retired schoolteacher. She lives with her
55-year-old daughter and three teenage
grandchildren. Her daughter Lucille is a single mother
and a full-time nurse.
Anna assists with the care of her grandchildren when
her daughter is at work. She also volunteers at the
library and at her church. She has diabetes and high
blood pressure, both controlled with diet and
medication.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
1. Your patient is about to undergo a controversial
orthopedic procedure. The procedure may cause
periods of pain. Although nurses agree to do no
harm, this procedure may be the patient’s only
treatment choice. This example describes the
ethical principle of
A. Autonomy.
B. Fidelity.
C. Justice.
D. Nonmaleficence.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Ethics and Philosophy
Deontology
Defines actions as right or wrong
Utilitarianism
Proposes that the value of something is
determined by its usefulness
Feminist Ethics
Focuses on the inequality between people
Ethics of Care
Emphasizes the importance of understanding
relationships, especially as they are revealed in
personal narratives
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)


Lucille accompanies her mother to the
physician’s office for a routine visit. When her
mother steps out to have some lab work
done, Lucille asks to speak privately to the
nurse, Mary Ann, and reveals some serious
concerns.
Lucille had received a call from the manager
of the library where her mother
volunteers. The manager described finding
Ms. Moreno in the janitor's closet one day,
confused and tearful.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
9
Nursing and Values




Ethical dilemmas almost always occur in the
presence of conflicting values.
To resolve ethical dilemmas, one needs to
distinguish among values, facts, and opinion.
Sometimes people have such strong values
that they consider them to be facts, not just
opinions.
Sometimes people are so passionate about
their values that they provoke judgmental
attitudes during conflict.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Values Clarification
Rank Statement
Statement
Statement
Rank
Life has
has aa predestined
predestined course.
course.
Preparing for the future is an 11 22 33 44 Life
The individual
individual should
should follow
follow that
important activity and reflects
The
maturity.maturity.
course.
reflects
that
course.
Vague answers
answers are
are sometimes
sometimes
Vague answers are
11 22 33 44 Vague
preferred because
because they
they avoid
avoid
dishonest and confusing.
preferred
embarrassment and
and
embarrassment
confrontation.
confrontation.
Punctuality and efficiency are 11 22 33 44
characteristics
of a of
person
are
characteristics
a
who is both
and
person
who intelligent
is both intelligent
concerned.
and
concerned.
When in severe pain, it is
important to remain strong
and not to complain too
much.
Punctuality is
is not
not as
as important
important
Punctuality
as maintaining
maintaining aa relaxed
relaxed
as
atmosphere, enjoying
enjoying the
the
atmosphere,
moment, and
and being
being with
with family
family
moment,
and friends.
friends.
and
When in
in severe
severe pain,
pain, itit is
is better
better
11 22 33 44 When
to talk
talk about
about the
the discomfort
discomfort and
and
to
express frustration.
frustration.
express
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Values Clarification (cont’d)
Statement
Rank
Statement
Addressing someone by his
or her first name shows
friendliness.
1 2 3 4 Addressing someone by his
or her first name is
disrespectful.
Direct questions are usually
the best way to gain
information.
1 2 3 4 Direct questioning is rude
and could cause
embarrassment.
Direct eye contact shows
interest.
1 2 3 4 Direct eye contact is
intrusive.
Ultimately the independence 1 2 3 4 The needs of the individual
of the individual must come
are always less important
before the needs of the family.
than the needs of the family.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)


The manager expressed growing concern
about Ms. Moreno’s ability to finish tasks,
such as reshelving books and taking phone
messages. She recommended that Lucille get
an evaluation of her mother’s mental status.
Lucille tells the nurse that she is not at all
convinced that her mother is having mental
problems.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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How to Process an Ethical Dilemma







Step 1: Ask if this is an ethical dilemma.
Step 2: Gather all relevant information.
Step 3: Clarify values.
Step 4: Verbalize the problem.
Step 5: Identify possible courses of action.
Step 6: Negotiate a plan.
Step 7: Evaluate the plan.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Institutional Resources


Ethics committees are usually
multidisciplinary and serve several purposes:
education, policy recommendation, and case
consultation.
Any person involved in an ethical dilemma,
including nurses, physicians, health care
providers, patients, and family members, can
request access to an ethics committee.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Issues in Health Care Ethics
Quality of life: central to discussions about endof-life care, cancer therapy, physician-assisted
suicide, and DNR
Genetic screening: What are the risks and benefits
to individuals and to society of learning about the
presence of a disease that has not yet caused
symptoms, or for which a cure is not yet available?
Care at the end of life: interventions unlikely to
produce benefit for the patient
Access to care: As a nurse, you will certainly deal
with ethical issues related to access to care.
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Ethics and Access to Care



The number of uninsured in the United States
grew from 39 million people in 2000 to more
than 46.3 million people by 2008—more than
15% of the total population.
Many of the uninsured are women and
children.
Although two thirds of the uninsured are poor,
nearly 80% come from working families.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
2. If a nurse decides to withhold a medication
because it might further lower the patient’s
blood pressure, the nurse will be practicing
the principle of
A. Responsibility.
B. Accountability.
C. Competency.
D. Moral behavior.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22 - 18
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Nurses Collaborate With Other
Professionals


Consensus building:
an act of discovery in
which “collective
wisdom” guides a
group to the best
possible decision
A nurse’s point of
view offers a unique
voice in the resolution
of ethical dilemmas.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Culturally Competent Care: End-ofLife Decisions






Acknowledgment of and respect for cultural
differences
Willingness to negotiate and compromise when world
views differ
Being aware of one’s own values and biases
Using communication skills that enhance empathy
Knowing cultural practices of patient groups regularly
seen
Understanding that all patients are individuals who
may not share the same views as others within their
own ethnic group
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)

From Mary Ann’s perspective, Lucille seems
angry and defensive about the manager’s
report. She even accuses the manager of
discrimination against older adults. She
adamantly refuses offers of a physical or
mental evaluation for her mother, or even to
discuss the issues with her mother. Instead,
she requests that the nurse write a letter that
validates her mother’s good health.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Moral Distress
Moral distress describes the anguish
experienced when a person feels unable
to act according to closely held core
values.
Because moral distress is a shared
experience, efforts to alleviate distress are
most successful when they are also shared.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Ethical Issues on Aging



Older people usually are not as familiar with the
concept of autonomy as are people from younger
generations.
As people age, they develop clinical conditions that
affect the communication process. Some patients
become incapacitated by stroke or disease. Most
older adults take multiple medications, some of which
affect cognitive skills in subtle ways.
Consensus about medical goals for the older adult is
hard to achieve.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Quick Quiz!
3. A nurse is working with a terminally ill adult patient.
The nurse decides to tell the adult children that they
need to decide how to advise their father about taking
analgesics during the terminal phase of his illness. This
step of processing an ethical dilemma is
A. Articulation of the problem.
B. Evaluation of the action.
C. Negotiation of the outcome.
D. Determination of values surrounding the
problem.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)


After all, Lucille argues, her mother’s blood
pressure is normal, and her blood glucose
levels are within normal limits.
Mary Ann realizes that this situation is
complex. She will need to get the help of
others to sort out the best response to
Lucille’s request.

Is this an ethical dilemma for Mary Ann?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)

Mary Anne has determined that the situation is an
ethical dilemma. Now she must:
 Step
2: Gather all information relevant to the case.
 Step
3: Examine and determine her own values and
opinions about the issues.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
 Step
4: State the problem clearly.
 Step
5: Consider possible courses of action.
 Step
6: Negotiate the outcome.
 Step
7: Evaluate the action.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Competencies of the New Graduate

Competencies identified by nursing
organizations

National Council of State Boards of Nursing
Competencies


National League for Nursing Competencies

Competencies expressed by other groups
Employers’ expectations regarding
competencies
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Top Ten Nursing Activities Rank Ordered
by Average Total Group Frequency

Apply principles of infection control

Provide care within the legal scope of practice

Ensure proper identification of client when
providing care

Practices in a manner consistent with a code of
ethics for registered nurses

Prepare and administer medications, using rights
of medication administration
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Top Ten Nursing Activities Rank Ordered
by Average Total Group Frequency (cont.)

Prioritize workload to mange time effectively

Use approved abbreviations and standard
terminology when documenting care

Maintain client confidentiality/privacy

Provide individualized/client centered care
consistent with standards of practice

Review pertinent data prior to medication
administration
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Employers Expectation Regarding
Competencies

Possess the necessary theoretic background for
safe client care and for decision-making

Use the nursing process in a systematic way

Recognize own abilities and limitations

Use communication skills effectively with clients
and coworkers
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Employers Expectation Regarding
Competencies (cont.)

Work effectively with assistive personnel,
delegating, and supervising nursing care tasks in
an appropriate manner

Provide accurate and complete documentation

Possess proficiency in the basic technical nursing
skills

Possess basic skill in information technology
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Worker Related Competencies

Demonstrate a commitment to a work ethic

Function with acceptable speed
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Personal Career Goals

Focusing your goals

Setting your goals



Short-term goals—encompass what you want to
accomplish this month and this year
Long-term goals—where you want to be in your
profession five or more years from now
Maintaining and enhancing your competence
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