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Chapter 4 Ethics in Community Health Nursing Practice
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
Objectives
Describe a brief history of the ethics of nursing in community health. Discuss ethical decision-making processes. Compare and contrast ethical theories and principles, virtue ethics, ethics of care, and feminist ethics. Describe how ethics is part of the core functions of nursing in community health. Analyze codes of ethics for nursing and for public health. Apply the ethics of advocacy to nursing in community health. All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
2
Introduction
The work of nurses in public health involves ethical activities.
Rights-based versus community-based ethical theory
Ethics is a body of knowledge and, as such, is more than “being a good person.”
Basing your actions on ethical principles is a part of clinical decision making and practice
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
3
History
Hippocratic oath 1893: Nightingale pledge 1950: Code for Professional Nurses 1960s: Bioethics emerge in nursing curricula Late 1960s: Bioethics movement
Hastings Center
2001: Code of Ethics for Nurses with Interpretive Statements 2005: most recent version of the ICN Code of Ethics for Nurses 2008: Nursing and Health Care Ethics: A legacy and a Vision
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
4
Ethical Decision Making
Ethical Decision Making Ethical Issues Ethical Dilemmas
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
5
Ethical Decision-Making Frameworks
Use problem-solving processes. Provide guides for making sound ethical decisions that can be morally justified. Remember that when all is said and done we each make our own decisions. Factors affecting this framework: • Growing multiculturalism of the American society • Moral distress
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
6
Generic Ethical Decision-Making Framework
Identify the ethical issues and dilemmas. Place them within a meaningful context. Reformulate ethical issues and dilemmas, if needed. Consider appropriate approaches to actions or option (utilitarianism, deontology, principlism, virtue ethics, ethic of care, feminist ethics). Make decision and take action. Evaluate the decision and the action. •
The steps of a generic ethics framework are often nonlinear, and with one exception, they do not change substantially.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
7
Ethical Issues and Ethnicity Conflicts
Situations in which ethnic diversity can be judged in relationship to cultural standards:
Situations that place persons at direct risk of harm, whether psychological or physical Situations where ethnic cultural standards conflict with professional standards Situations where the greater community’s values are jeopardized by specific ethnic values Situations where specific ethnic community customs are annoying but not problematic for the greater community All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
8
Ways to Handle Moral Distress
Identify the type(s) of situations that lead to distress. Communicate that concern to your manager and examine ways to work toward addressing the stressor. Seek support from colleagues.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
9
Ethics: Definition, Theories, Principles
Ethics Consequentialism
Utilitarianism
Deontology Primary Principles
Respect for autonomy Nonmaleficence Beneficence Distributive or social justice
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
10
Virtue Ethics
One of the oldest ethical theories Asks “What kind of person should I be?” Virtues are acquired excellent traits of character that dispose humans to act in accordance with their natural good.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
11
Caring and the Ethic of Care
Caring in nursing, the ethic of care, and feminist ethics are all interrelated and converged between the mid-1980s and early 1990s. Nurses have written about caring as the essence of or the moral ideal of nursing. Caring and the ethic of care is a core value of nursing in community health.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
12
Feminist Ethics
Feminine Ethic Feminist Ethics Feminists
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
13
Ethics and the Core Functions
Assessment
Policy Development
Competency in research, measurement, and analysis techniques Virtue ethics; moral character “Do no harm” Achieve public good Service to others over service to self What is ethical is also good policy
Assurance
All persons should receive essential personal health services Providers should be competent to provide care and be available
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
14
Nursing Codes of Ethics
ANA’s Code of Ethics for Nurses With Interpretive Statements
Emphasizes political action as the mechanism to effect social justice and reform regarding homelessness, violence, and stigmatization.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
15
Public Health Codes of Ethics
Contains 12 statements that address the moral standards that delineate public health’s values, goals, and obligations
The 12 principles incorporate the ethical tenets of: Preventing harm Doing no harm Promoting good Respecting both individual and community rights Respecting autonomy, diversity, and confidentiality when possible Ensuring professional competency Trustworthiness Promoting advocacy for disenfranchised persons within a community
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
16
Advocacy and Ethics Definitions, Codes, Standards
Advocacy: the act of pleading for or supporting a course of action on behalf of a person, group, or community. Public health nurses have a moral mandate to establish ethical standards when advocating for health care policy.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
17
Conceptual Framework for Advocacy Social Justice
Oriented to community Emphasizes shared responsibility and interconnection and cooperation among individuals in a community Government involvement is necessary
Market Justice
Oriented to person Key values: selfdetermination, selfdiscipline, self-interest, and personal efforts to achieve one’s desired beliefs Focus on individual moral behavior
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
18
Practical Framework for Advocacy
Places the advocate’s core skills within the context of six ethical principles for effective advocacy Ethical Principles for Effective Advocacy
Act in the client’s (group’s, community’s) best interests Act in accordance with the client’s (group’s, community’s) wishes and instructions Keep the client (group, community) properly informed Carry out instructions with diligence and competence Act impartially, and offer frank, independent advice Maintain client confidentiality
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
19
Advocacy and Bioterrorism
September 11, 2001 attack Ethical issues arise with the threat, action, and aftermath of terrorism
Can be difficult to balance goals for the protection of the population and protection of the individual
Moral obligation to respond
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
20
Advocacy and Health Care Reform
Need to advocate for reform that includes ethical considerations
Access to consistent, effective, efficient health care for all people
Affordable Care Act of 2010
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
21
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
Objectives
Describe a brief history of the ethics of nursing in community health. Discuss ethical decision-making processes. Compare and contrast ethical theories and principles, virtue ethics, ethics of care, and feminist ethics. Describe how ethics is part of the core functions of nursing in community health. Analyze codes of ethics for nursing and for public health. Apply the ethics of advocacy to nursing in community health. All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
2
Introduction
The work of nurses in public health involves ethical activities.
Rights-based versus community-based ethical theory
Ethics is a body of knowledge and, as such, is more than “being a good person.”
Basing your actions on ethical principles is a part of clinical decision making and practice
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
3
History
Hippocratic oath 1893: Nightingale pledge 1950: Code for Professional Nurses 1960s: Bioethics emerge in nursing curricula Late 1960s: Bioethics movement
Hastings Center
2001: Code of Ethics for Nurses with Interpretive Statements 2005: most recent version of the ICN Code of Ethics for Nurses 2008: Nursing and Health Care Ethics: A legacy and a Vision
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
4
Ethical Decision Making
Ethical Decision Making Ethical Issues Ethical Dilemmas
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
5
Ethical Decision-Making Frameworks
Use problem-solving processes. Provide guides for making sound ethical decisions that can be morally justified. Remember that when all is said and done we each make our own decisions. Factors affecting this framework: • Growing multiculturalism of the American society • Moral distress
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
6
Generic Ethical Decision-Making Framework
Identify the ethical issues and dilemmas. Place them within a meaningful context. Reformulate ethical issues and dilemmas, if needed. Consider appropriate approaches to actions or option (utilitarianism, deontology, principlism, virtue ethics, ethic of care, feminist ethics). Make decision and take action. Evaluate the decision and the action. •
The steps of a generic ethics framework are often nonlinear, and with one exception, they do not change substantially.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
7
Ethical Issues and Ethnicity Conflicts
Situations in which ethnic diversity can be judged in relationship to cultural standards:
Situations that place persons at direct risk of harm, whether psychological or physical Situations where ethnic cultural standards conflict with professional standards Situations where the greater community’s values are jeopardized by specific ethnic values Situations where specific ethnic community customs are annoying but not problematic for the greater community All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
8
Ways to Handle Moral Distress
Identify the type(s) of situations that lead to distress. Communicate that concern to your manager and examine ways to work toward addressing the stressor. Seek support from colleagues.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
9
Ethics: Definition, Theories, Principles
Ethics Consequentialism
Utilitarianism
Deontology Primary Principles
Respect for autonomy Nonmaleficence Beneficence Distributive or social justice
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
10
Virtue Ethics
One of the oldest ethical theories Asks “What kind of person should I be?” Virtues are acquired excellent traits of character that dispose humans to act in accordance with their natural good.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
11
Caring and the Ethic of Care
Caring in nursing, the ethic of care, and feminist ethics are all interrelated and converged between the mid-1980s and early 1990s. Nurses have written about caring as the essence of or the moral ideal of nursing. Caring and the ethic of care is a core value of nursing in community health.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
12
Feminist Ethics
Feminine Ethic Feminist Ethics Feminists
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
13
Ethics and the Core Functions
Assessment
Policy Development
Competency in research, measurement, and analysis techniques Virtue ethics; moral character “Do no harm” Achieve public good Service to others over service to self What is ethical is also good policy
Assurance
All persons should receive essential personal health services Providers should be competent to provide care and be available
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
14
Nursing Codes of Ethics
ANA’s Code of Ethics for Nurses With Interpretive Statements
Emphasizes political action as the mechanism to effect social justice and reform regarding homelessness, violence, and stigmatization.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
15
Public Health Codes of Ethics
Contains 12 statements that address the moral standards that delineate public health’s values, goals, and obligations
The 12 principles incorporate the ethical tenets of: Preventing harm Doing no harm Promoting good Respecting both individual and community rights Respecting autonomy, diversity, and confidentiality when possible Ensuring professional competency Trustworthiness Promoting advocacy for disenfranchised persons within a community
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
16
Advocacy and Ethics Definitions, Codes, Standards
Advocacy: the act of pleading for or supporting a course of action on behalf of a person, group, or community. Public health nurses have a moral mandate to establish ethical standards when advocating for health care policy.
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
17
Conceptual Framework for Advocacy Social Justice
Oriented to community Emphasizes shared responsibility and interconnection and cooperation among individuals in a community Government involvement is necessary
Market Justice
Oriented to person Key values: selfdetermination, selfdiscipline, self-interest, and personal efforts to achieve one’s desired beliefs Focus on individual moral behavior
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
18
Practical Framework for Advocacy
Places the advocate’s core skills within the context of six ethical principles for effective advocacy Ethical Principles for Effective Advocacy
Act in the client’s (group’s, community’s) best interests Act in accordance with the client’s (group’s, community’s) wishes and instructions Keep the client (group, community) properly informed Carry out instructions with diligence and competence Act impartially, and offer frank, independent advice Maintain client confidentiality
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
19
Advocacy and Bioterrorism
September 11, 2001 attack Ethical issues arise with the threat, action, and aftermath of terrorism
Can be difficult to balance goals for the protection of the population and protection of the individual
Moral obligation to respond
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
20
Advocacy and Health Care Reform
Need to advocate for reform that includes ethical considerations
Access to consistent, effective, efficient health care for all people
Affordable Care Act of 2010
All items and derived items © 2014, 2010, 2006, 2002 by Mosby, an imprint of Elsevier Inc.
21
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