Sunday May 26th 2019

Ethical practice environments, empowered nurses

Pamela Cipriano

Almost every nurse practicing today entered the profession after the first Code for Professional Nurses had been adopted by ANA. For 65 years, the Code, renamed in 1976 to its current title, the Code of Ethics for Nurses with Interpretive Statements, has guided ethical practice and decision-making by establishing the goals, values and obligations of RNs across all roles and settings.

Nine provisions of the updated 2015 Code delineate the basis of our commitment and obligations to respect, protect and advocate for those we serve while also assuring the integrity of the profession. Advances in science and technology, changing social and business conventions, and economic pressures have created new challenges for nurses and other health care providers, adding new dimensions to ethical practice. Financial pressures to make a margin have led to practices such as rationing of care, withholding higher-cost treatments for those unable to pay and sending patients miles from home to get care from providers who will provide free or reduced-fee care. Reports of prolonging life support so that a patient’s death does not reflect poorly on an organization’s statistics threaten to undermine the trust in health care providers. Adopting new technologies for lifesaving and life-sustaining treatments are producing immediate results, but often without safeguards against diminished quality of life or false hope for a full recovery. The pressure to find cures and advance science, at times, has resulted in questionable research practices.

Nurses encounter these challenges in many settings and are uniquely positioned to speak up to influence decisions that will lead to the right actions and to establishing an ethical practice environment. Without an ethical practice environment, the patient is unprotected, as is the nurse who must meet moral obligations.

As nurses strive to establish, maintain and improve an ethical practice environment, there is a presumption that nurses will demonstrate virtues such as integrity, respect, moderation and industry. A morally “good” person embodies these virtues and, in addition, demonstrates knowledge, skill, wisdom, patience and compassion, all attributes of the moral character expected of a nurse. It is the display of this character and these virtues that empowers nurses to promote the dignity, self-worth, respect, independence and well-being of those we serve. However, this does not occur in a vacuum of good intentions.

An ethical practice environment that supports the Code is needed. Without this support, nurses risk failing their patients and violating what they know to be ethical practice, resulting in moral distress. The link between an ethical and healthy practice environment and the ability of nurses to provide quality care and keep patients safe is becoming self-evident.

Spelled out in the Code’s interpretive statements is the mutual responsibility for a morally good, ethical work environment that assures safe, quality patient care and professional satisfaction for the nurse. Nurses and their employers share the responsibility to establish a culture of safety that supports reporting errors and near misses. Together they protect privacy and confidentiality, ensure respect and civility among co-workers, and promote excellence. Employers must ensure equitable, fair and just treatment of nurses and include them in decision-making. Nurses must address concerns responsibly and seek solutions when there are impediments to ethical practice. Employers have a responsibility to address any deficiencies rapidly together with their staff.

Recent events with the Ebola virus raised the contentious issue of a nurse refusing an assignment. By following the Code, nurses are supported to speak up for their own personal protection and demand proper equipment to care for patients. Should a nurse believe there is inadequate protection, equipment, security or other conditions that threaten one’s well-being, the nurse should take immediate steps to raise the concern about the assignment, ensure no patient is left without care and then carry out the decision that upholds ethical practice.

When nurses cannot protect themselves, they cannot adequately care for patients. With adequate notice, calm heads can prevail and develop solutions to address the situation so that neither the nurse nor the patient is compromised.

Sometimes it takes courage to take the first step. In this year of ethics, ANA urges all nurses to become familiar with the Code and its contents to guide ethical decision-making in all practice settings.

— Pamela F. Cipriano

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