Chapter V

United We Stand

The last three provisions of the code of ethics deal with the collaborative aspect of nursing which extents from the delivery of healthcare services to cooperation in research (ANA, 2001). This chapter gives an overview of those provisions along with examples of how these provisions benefit individual nurses even though the focus is on the collective.

Topics Covered

1. The Ethical Obligation to Advance the profession
2. Collaborating with other nurses

Ethical Advances

A profession or a scientific field can make great advances when the people belonging to that field make it their personal responsibility to work towards targeted improvements (Holm, 2006). These improvements can come from advancing the rules concerning the practice, participating in the education of others, performing administrative and counseling duties and doing active research towards the development of knowledge. The code of ethics for nursing recognizes this as a duty for all nurses even if they are directly engaged in health care delivery (ANA, 2001).

This does raise a question about the role of a nurse who works with patients at their bedsides since it would be rather difficult to expect all nurses to start producing research papers for publication in journals while they are on active duty. In such situations, the code of ethics (2001) provide other means by which the nurse can discharge her duty to the field such as:

• Acting as a mentor and guide for other nurses in the workplace
• Being a part of the various education or research related committees in a health service facility
• Serving as models for integrity

Even participation in civic activities as a nurse improves both the visibility of the field and the respect that the public has for the profession; therefore, such activities can also help in fulfilling the ethical obligations a nurse has to the profession (ANA, 2001).

No one is in a better position to advance the field than the nurses who work as educators and research experts. They are often considered to be mentors for younger nurses who are just venturing into the field, and have the ethical duty to try and enhance the level of commitment for future nurses. Similarly, nurses working as research professionals are in an excellent position to improve the visibility of the field and can support field nursing with their contributions towards increasing the collective knowledge base for nursing (ANA, 2001).

At the same time, there is one area in which all types of nurses can make contributions and that is the creation of standards, ethical guidelines and recommended operational procedures for various situations which nurses can come across (Holm, 2006). For example, nurses on active duty can give first accounts of the situations which they face and make their recommendations for those who are doing research on the topic. Researchers can then consult each other, as well as currently accepted nursing procedures to come with improvements or solutions to a given problem. Finally, educators and nurses working as teachers can convey the message to student nurses, thus completing the cycle of improvements for the field. If all nurses strive for such a cycle of improvements it is very likely that the results would make things better for all concerned individuals.

The development of regulations and standards for nursing practice is also an ethically recommended activity since it allows the field to improve with input from nurses themselves. Of course an expert on the principles of ethics could also compile a code of ethics for nurses by utilizing the commonly accepted ethical rules for various professionals. However, the people who make such standards should be experts in the field as well as expert nurses since they would be more aware of the issues and challenges of modern nursing (Holm, 2006). Any standards or practices which have been developed should be inline with accepted guidelines, and should reflect the level of commitment which the nursing profession has to itself and to society at large (ANA, 2001).

While a nurse could be given a ready made document for ethical guidelines and for acceptable practices in a health care facility, it is also the responsibility of the individual nurse to identify her position as outlined in the code of ethics or the rules which are enforced at the work place. For example, if a nurse works in the children’s ward of a hospital she should focus on the ethical requirements which help her balance the wishes of the patient, as opposed to the wishes of the family decision maker. On the other hand, if a nurse is engaged in the administrative side or is working on a research topic, then the ethics concerning collaboration with other nurses become very important.

Likewise, nurses engaged in education and learning have a different set of ethics which have a higher importance than others. For example, a student nurse would give special importance to the ethics of learning and improving her abilities. In all cases, individual nurses have to understand the ethics which are applicable to them in particular and the field in general (ANA, 2001). This ethical requirement is in addition to understanding and appreciating the social values, local guidelines, state regulations and federal laws which are concerned with the nursing field.

Just as every nurse has an ethical obligation to learn about the field and be aware of happenings in the nursing profession, every nurse also has the obligation to help other nurses in learning and understanding their roles as members of the nursing community. It would be unethical to keep information from other nurses, or to not inform them to the best of one’s ability, if the nurse knows something important regarding the topic being discussed. The code of ethics acknowledges the fact that knowledge is created and shared amongst teachers and researchers in the fields of humanities and sciences which have a direct effect on nursing. Therefore, the study of these fields is also appreciated as a duty towards the collective (ANA, 2001). On a personal level, studying about humanities and other sciences would only make a professional nurse a more rounded individual; therefore, there is a significant personal benefit for nurses who choose to do so.

For such developments to take place, the culture of the facility where the nurse is working, as well as the resources made available at the facility, have to be of a high quality. If a nurse does not find such resources or such an environment she can always make suggestions and work with the administrative bodies to ensure that such an environment can be created with time and effort. Given the high ethical standards that nurses are supposed to adhere to, such efforts clearly come under the dictates of improving the overall nursing environment where the collective and collaborative efforts of many nurses help in improving the situation of the entire field.

Collaboration and Cooperation

One nurse working on her own can help towards curing the ailments affecting several different patients. If all the nurses in the world are united, it is logical to assume that they can help do a lot more when and if they work in unison. It is for this reason that the code of ethics suggests that nurses should cooperate with each other when it comes to promoting community welfare, along with countrywide or international efforts to improve health.

Undoubtedly, there are quite a few issues on the global level which one person can not handle, but it would require the strength of the collective to change situations and create an atmosphere where these issues can be tackled (UN, 1998). In the particular case of nurses, as defined by the ANA code of ethics (2001) these problems include:

• Decreasing world health standards
• Increasing world hunger and poverty
• Environmental pollution
• Accessibility of health care services
• Human rights issues

Even things like public smoking and substance abuse can become problems for a society which has to deal with the negative effects of these social issues. Nurses have the responsibility to take on these problems on a collective basis since many of the problems mentioned above can only be handled with legislative change, governmental influence and social intervention. Clearly, the best way to make sure that positive changes can come into force is the use of collective action along with individual support for the solutions to the problems.

It is rather difficult to understand why nurses should be focused on these issues on a collective basis but the code of ethics explains this focus by making the nurse a part of the community she serves (ANA, 2001). A nurse is expected to know what is good for health and what is bad, at the same time, the ethics and morals which are integrated into the person of the nurse show her that those who are suffering should be helped. Therefore, when nurses take collective action, they should seek out what would be better for society rather than looking at the betterment of the individual.

Such collective actions may not necessarily come from working with the nursing community alone. For example, Nurse Edna volunteers for a local church which addresses community issues such as poverty, shelters for the homeless and children on the street. In her capacity as a nurse, she provides medical assistance when she can and this action, as well as her work as a volunteer, certainly fulfills the ethical requirement of working for the community. Similarly, a nurse may choose to work with any organization that deals with social issues and tries to improve society through fields other than nursing.

The Responsibility of Official Organizations

The last provision of the code of ethics brings the entire debate on nursing ethics to a close by coming back on to the role of the professional organizations that control and define the rules which are meant to be followed by nurses. Just as individual nurses are told to seek out the ethics concerning their profession, the ethical nursing organization is told to seek out nurses and inform them regarding their ethical obligations (ANA, 2001).

Additionally, ethics forbid the organization for making their ethical rules the final word on nursing ethics since the door for debate, discussion and change is always open. In fact, professional organizations are supposed to encourage debate and discussion which leads to improvement and further development of the field (ANA, 2001). Moreover, the professional bodies also have a duty towards the public since the public needs to be informed about the position and the status of nursing in a positive light which is reflective of their high value and position in society (Caputo, 2006).

While individual nurses are monitored by their superiors and have performance reviews by groups of their colleagues, the professional agencies are supposed to monitor themselves and the members of the organization. Promotion of the code of ethics and the associated rules and regulations is very important for such an organization since there are few ways in which a breach of ethics can be handled within such a setup. Constant improvements and developments of the ethical code as well as other guidelines for the nursing profession are also an obligation for any such organization (ANA, 2001).

The connection between any such social organization and society at large can not be denied; that is why nursing organizations have an ethical responsibility to work towards social reform. The nursing field does not exist in a vacuum, nor does it exist solely for the benefit of nursing; therefore, nursing organizations also work with social causes and might even be called up to take a role in politics (Caputo, 2006). This is because political activities are one of the most effective ways in which change can be brought into a system that exists with governments and ruling political parties controlling the health services. 

Therefore, whenever an issue of importance comes up which deals with the political, social or economic condition of the general nursing community, the organization which governs professional nursing is ethically bound to present the opinions of the nursing community in a manner which best fits the ethical guidelines and professional regulations for nurses. At the same time, such bodies are supposed to continually monitor important issues which can shape the future of nursing and society at large in relation to the delivery of health services. At times, nursing organizations may even be called upon to speak up on broader issues which go beyond the scope of health care services delivery and reimbursement methods (ANA, 2001).

These issues are very much the same points on which individual nurses can be called to speak on and point out ways in which problems in society can be solved. For example, the violation of individual rights, the concern for the homeless population, the rising violence in society and the negative image associated with illnesses such as mental disorders, AIDS and other diseases are all social problems which need to be solved with collective means. The ANA code of ethics (2001) makes this a particular responsibility of the nursing organizations and a general responsibility for all professionals attached to the nursing field.

Chapter VI

Ethical Commitments and Conflicts

After knowing and understanding the provisions of the code of ethics, a nurse should take a deeper look at her primary ethical commitment, as well as the resolution of conflicts of interest which can come up in the workplace. Additionally, there are some situations where a nurse can have moral objections based on personal values rather than ethical objections based on professional rules and this chapter clarifies what a nurse should do in those situations.

Topics Covered

1. The primary ethical commitment
2. Dealing with conflicts of interest
3. Handling moral objections

Primary Ethical Commitment

All nurses have only one primary ethical commitment which is to look out for the interests of the patient. The patient is defined in broad terms by the code of ethics since a nurse can be asked to deal with an individual, a family, a social group or even an entire community. While the diseases that inflict patients may turn out to be very similar on a case to case basis, the individual being treated is always unique. Therefore, there may be specific ethical concerns based on the cultural diversity of patients that a nurse has to deal with (ANA, 2001).

The cultural connection between the needs of the patient and the care provided by the nurse becomes very important when the patient comes from a culture that values collective decision making rather than individual opinions. Ethics demand that a nurse should notice the patient’s place in his family and the importance of other relationships which a patient might have. This is because at times the wishes of the patient can be in conflict with the wishes of others around him and the nurse might have to step in as a mediator to eliminate the differences (ANA, 2001). If the nurse is unable to reconcile the difference of opinion, it becomes her ethical responsibility to follow the wishes of the patient as much as she possibly can.

The case of Nurse Jake clarifies the ethical principle mentioned above. Nurse Jake was providing care services for a young girl and her very conservative parents did not want the girl to be examined by a male doctor. Jake saw that the patient was showing visible signs of discomfort and was in the need for immediate emergency assistance, but no female doctor was present on duty. Jake made the decision to take the girl to a male doctor and the girl readily agreed to be examined by the doctor. In this case, Jake acted ethically even though he went against the wishes of the family decision makers because Jake had the best interest of the patient in mind.

Conflicts of Interest

While such situations are easy to handle with a simple application of ethical guidelines, problems where a nurse has a conflict of interest are rather more difficult. It has been accepted by the nursing community that conflicts of interest are more common today than they have been in the past and the changed requirements of health care providers as well as health plans for patients can lead to some conflicts as well. However, with respect to patient interests, the more common variety of conflict comes when a nurse sees a difference between her personal values and her professional ethics (ANA, 2001).

For example, a nurse may be firmly against the idea of abortion but she may have to assist in an abortion which is in the interest of the patient. Similarly, a nurse may have moral objections to a certain line of research or even a certain method of research which is otherwise acceptable to the medical community at large. In the first case, the interests of the patient become more important and the nurse has to hold her personal opinions, articles of faith and beliefs to be secondary to the primary requirement of helping those in need, even though she may be an objector to the practice. In the second case, a nurse can object to a research study and even refuse participation if she sees a conflict of interest.

A conflict of interest can also come up with regard to the interest of the patient. For example, on any given day, a patient with a highly contagious disease may wish to refuse treatment and leave the hospital at once (Fry & Veatch, 2000). A nurse who only follows the ethics for the rights of the patient may suggest that the patient should be allowed to leave since his autonomy and the individual right to refuse treatment must be respected at all times.

However, a more pragmatic nurse may recognize that there is a danger to public health if this patient is allowed to leave the hospital environment. In this case, the rights of the public and the greater good for society are more important than the rights given to one person; therefore, the patient should be kept and treated. It must be noted however, that such a conflict of interest is rather rare and generally, any constriction of individual rights is very uncommon in the medical profession and often requires an explanation to higher authorities.

A more complicated example was presented by Fry and Veatch (2000) who gave the example of a nurse working with psychiatric patients. She was responsible for assisting with the treatment of adolescent patients suffering from anorexia nervosa. The disease itself is an eating disorder which is characterized by a self distorted body image as well as a dangerously low weight. Individuals who suffer from this disease may control their weight with dieting to the point of starvation, vomiting food, too much exercise or even resort to drugs for weight reduction.

In the given example, the nurse had to make sure that certain privileges and rewards were to be withdrawn from the patient if their weight goes down. However, the nurse also believed on a personal level that individuals should be allowed to keep whatever weight they want. In this case, the nurse had a personal interest in making sure that the individuals she was dealing with could have their desired weight. However, this was not in the best interest of the patient since the patient’s desired weight would be very detrimental in health terms (Fry & Veatch, 2000). The solution to the problem comes from the rule that the nurse has to put the interest of the patient as the primary concern therefore the patients personal wishes as to the ideal weight must be ignored.

Another case can be used to throw some light on conflicting situations as per the case of Nurse Jessica and Charlie X. Charlie was a young boy who felt restricted and claustrophobic in the bed he was placed in and wanted to be able to move about the unit whenever he wished. However, Charlie had hurt himself once while trying to leap out of the bed and Nurse Jessica was faced with the dilemma of confining Charlie and refusing him his rights as a patient (Fry & Veatch, 2000). She considered the case and came to the correct ethical decision that the restrictions on Charlie’s movements are for his own benefit as he was asked not to move out of bed without the assistance of a nurse or other medical professional.

A more common conflict of interest can come when a nurse is faced with incentive programs that ask for reduced spending and ethical demands which ask for the best possible treatment (ANA, 2001). Often, a reduction in spending or expenses could be linked with individual bonuses or performance reviews in which case there is a chance of an obvious conflict of interest. The code of ethics (2001) recommends that whenever nurses are faced with such a situation, they should get a clarification of the exact protocols which must be followed from higher authorities so that the spirit of nursing is not harmed.

To better handle actual or perceived conflicts of interest, as well as any other ethical or professional issues being faced by a nurse, the code of ethics (2001) recommends collaborative and cooperative efforts since the overall purpose of health care is to collaborate for a unified cause. However, ethics dictate that collaboration between nurses should be placed within professional boundaries which apply to the relationships between nurses and patients, nurses and the patients’ family as well as between nurses and other professionals. It is perfectly understandable that certain situations may blur the boundaries between professional and personal relationships for example:

• Stressful working environments: Stressful situations and working conditions can influence the nurse’s ability to maintain professional decorum and can even create bonds of camaraderie which extend beyond acceptable professional relationships. 
• Dependence on close colleagues: With continued and long term professional association, an informal nurses club can be formed where members look out for the interests of each other. This loyalty might become dangerous if it extends to hiding errors made by members of the club and not reporting breach of the code of ethics coming from fellow nurses. While loyalty to the field and loyalty to fellow professionals is quite important, excessive or misplaced loyalties can lead to damaging the nursing profession more than helping it.
• Providing prolonged care for a patient: It may happen that a patient develops a close association with a nurse who is providing health care services or that a nurse develops some feelings for the patients under her care. This can lead to the nurse being more considerate of one patient as compared to others under her responsibility, and it may even lead to her giving preferential treatment to one patient, which is certainly against the code of ethics. 

In many cases, blurred boundaries can create additional conflicts of interest for a nurse; therefore, an ethical nurse would continue to be professional in her approach and not allow any positive or negative personal feelings concerning a person to affect his/her work. If a nurse feels that she can not continue a professional relationship on ethical lines she should take her superiors into confidence and discuss the matter with them to find out ways in which the nurse’s responsibilities can be ethically handled. If a situation is getting worse and the nurse feels that the quality of healthcare being provided is suffering from conflicts of interest then she should take the necessary steps to get away from the situation depending on the guidelines of the workplace (ANA, 2001). 

Moral objections

The code of ethics accepts that nurses are morally autonomous individuals and do not have to let go of their morals while they are performing their duties as medical practitioners. In fact, the code of ethics suggests that morals should come into play at work since they help in giving nurses the courage to raise objections when institutes or health service providers go against the values and ethics of the nursing profession. Nurses are permitted to raise moral objections to certain situations and can become conscientious objectors if the situation demands them to be so (ANA, 2001).

There can be situations where the nurse has a moral objection to performing certain duties or in following certain orders, but the duties or orders are inline with acceptable medical practices and ethics. In such cases, a nurse should try and find alternative methods of providing care to the patient of which the easiest method is to find another coworker who has no objection to the care giving methods being used (ANA, 2001). This permission from the code of ethics is very beneficial for the nurse who has moral objections because he can use this to prevent the creation of any situation that may cause him to lose focus of the primary duties in nursing.

A moral objection is an excellent tool since it allows nurses to be a part of the healthcare decision making process by which services are provided to patients. The code of ethics accepts that nurses may operate at various levels within a health care facility, an educational institute or even an administrative body and that they should not ignore their personal character as they work in these positions (ANA, 2001). This gives all nurses the right to present moral objections, and it places them in a very powerful position when anyone asks if there are any objectors to the acts which another person is about to perform.

As with most situations where power is given to an individual, responsibility also comes into play with the given power. For example, a nurse who makes a conscientious objection is not automatically protected from official or unofficial penalties imposed by the workplace. Additionally, the decision to raise a moral objection must be carefully deliberated because an explanation could be asked for. A nurse should take the time to consider the objections and bring the objection to the table before the procedure starts whenever possible so that alternative arrangements can be made. In fact, even with moral objections a nurse is not ethically permitted to withdraw her assistance until the safety of the patient and alternative nursing care can be arranged (ANA, 2001).