This course is designed to give an overview of the evolution of nursing ethics and the impact that nursing ethics has on the Advanced Practice Nurse. Focus will be placed on the moral principles and ethical perspectives (justice vs. care) that are important to nursing. The implications of traditional and contemporary ethical theories for nursing will also be explored. The effects that critical thinking has on nursing ethics and the importance of the moral development of the nurse in nursing ethics will be the final focus of this course.
Course Objectives:
Upon completion of this course the student will be able to:
Define Ethics and Bioethics
Plot the course of the evolution of nursing ethics
Describe the moral principles important to nursing ethics
Differentiate the moral perspectives of Care vs. Justice
Explain the effects that critical thinking has on nursing ethics
Discuss the importance of moral development on nursing ethics
Have a better understanding of common ethical situations that frequently arise in the healthcare setting
List 3 NANDA nursing diagnoses that can help guide the plan of care during ethical situations
Defining Ethics:
Ethics which is defined as “a system of rules or principles that are used to guide human behavior” has been a guiding force in the development, implementation and evaluation of nursing practice since the “Florence Nightingale Era”. Biomedical ethics includes in its definition the application of principles, theories and problems that occur in the healthcare or medical field.
The Evolution of the Nursing Code of Ethics:
As the “Nursing Code of Ethics” has been modified and improved over the past century; the fundamental concepts and principles of “doing no harm” and benefiting others in a loyal and truthful manner, has remained intact.
Because ethics in an integral part of the foundation of nursing; the “Nursing Code of Ethics” was established.
The purpose of the code of ethics was to provide a strong, understandable, specific and non-negotiable statement of nursing ethical obligation and duty to patients and members of the community.
The evolution of nursing ethics has been a process of development that began in 1893 with the “Nightingale Pledge” which was patterned after medicines Hippocratic Oath, and is understood to be the first nursing code of ethics.
In 1896 the Nurses Association Alumnae of the United States and Canada (which later became the American Nurses Association), came together with the succinct purpose of establishing and maintaining a nurses code of ethics.
In 1926 a “Suggested Code” and in 1940 a “Tentative Code” was presented, but neither code was formally adopted by the nursing profession.
It was not until 1950 when a final revision of the 1940 “Tentative Code” that the “Code for professional Nurses” (in the form of 17 provisions) was universally adopted by the American Nurses Association (ANA).
The code was amended and revised many times from 1956 to 1968 and in 1976 the 17 provisions as well as newly developed interpretive statements were modified and published as now 11 provisions.
The interpretive statements were again revised in 1985 and the latest complete revision of provisions and interpretive statements occurred in 2001 (Hook and White 2005).
As healthcare organizations are again returning to “ commitment, compassion and caring” as the primary focus for nursing personnel; The 2001 “Code of Ethics for Nurses with Interpretive Statements” is quickly making a comeback as a leading force in driving 21st century nursing care.
The Moral Principles Important to the Advanced Practice Nurse:
Along with assuring that professional nursing practice is guided by ethical decisions and behavior; moral principles (which refer to the norms of human conduct that are viewed as right or wrong) are principles that the professional nurse must incorporate into patient care on a daily basis.
These moral principles are a set of values, rules and modes of conduct that include four basic concepts. These concepts include:
Respect for autonomy – which is a norm of respecting the decision-making capabilities of autonomous people.
Nonmaleficence – which is a norm of avoiding causation or harm.
Beneficence – which is a norm of providing the benefits, risks and cost.
Justice - which is a norm of “fairly” distributing the benefits, risks and cost (this includes accessibility as well).
Of these four modes of conduct; nonmaleficence and beneficence have played a more historical role in moral principles, while autonomy and justice were not recognized as key concepts until more recently.
Ethical Perspectives Important to Nursing (Justice vs. Care), and Nursing Implication:
In order to determine which ethical perspectives are important to nursing, the following question must be answered; should the focus of the professional nurse be on “justice” or “care”, in attempting to assure that all members of society have equal access to healthcare? According to Smith and Godfrey (2002), the answer is “both” based on the realization that past conceptualization of moral development for nurses has been some what limited.
Several of the provisions and interpretative statements found in the “Nursing Code of Ethics” would agree that the professional nurse shares this dual responsibility.
For example, provision number eight states that “the nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs”.
Under this provision, the advanced practice must not only be committed to the promotion of the health, welfare and safety of all people, but also to the “equal” distribution of these services.
This is to be accomplished by developing and implementing an interdisciplinary plan that promotes collaboration between all healthcare professionals at community, national and international levels (ANA, 2001). Both justice and care must be incorporated to meet these challenges.
In addition to the “Nurses Code of Ethics”, the development of several “Moral Theories” has been created to give further guidance to the pursuit of equal distribution of healthcare.
The problem with some of these theories is that they are not consistent in their belief patterns and often suggest competing theories that are critical of one another.
Utilitarianism vs. Kantianism Views:
The Utilitarian view is based on “consequentialism” which is the belief that “the end justifies the means”, as long as the result helps the greatest amount of people (or the greater good).
In complete contrast, the Kantian Model which promotes the “deontological” belief which is concerned with what is right or wrong regardless of who is ultimately benefited.
Because these Moral Theories are so complex with their competing concepts; it becomes imperative that the advanced practice nurse assures that justice and care are both promoted in the delivery of patient care.
The Effects of Critical Thinking on Nursing Ethics:
Critical thinking asks questions, distinguishes between fact and opinion, makes detailed observations, uncovers assumptions, defines terms and makes assertions based on sound logic and solid evidence.
These are the same aims and assumptions that are applied to the development and implementation of Nursing Ethics.
Using critical thinking to enhance nursing knowledge regarding ethical theories and practice; can help ascertain if the problem or issue is truly an ethical one. After establishing that a true ethical issue does exist; critical thinking assists the professional nurse to develop skills and tools to tackle the problem.
The Importance of Moral Development on the Advanced Practice Nurse and Nursing Ethics:
The Kohlberg theory of moral development (within the context of nursing ethics) appears to be an acceptable model that adds value to the ethical practice of nursing.
Kohlberg distinguishes between three different stages of moral development and asserts that nurses will look at ethical dilemmas and intervene based on their individual stage.
The first of the three stages of Kohlberg’s theory is the “pre-conventional stage” which assumes that decisions made will directly coincide with immediate personal consequences (punishment or reward).
The second stage of Kohlberg’s moral development theory is known as the “conventional stage”. In the conventional stage a person has the ability to distinguish themselves in relation to others; but still makes ethical decisions based on being “liked” or by adhering to very strict rules or criteria.
It is not until the third stage of Kohlberg’s moral development theory which is known as the “post-conventional stage”, that people feel comfortable giving their own individual opinion of what is right and/or wrong (advocacy).
Kohlberg is careful to point out that the stages of moral development are not ones that simply come with “age”, rather processes that emerge from one’s own thinking about moral problems.
Other areas that help promote advancement of Kohlberg’s moral development stages include; social experience, finding ones views challenged and gaining broader viewpoints.
With the growing complexities of healthcare, the need and importance of moral development in nursing and nursing ethics is becoming increasingly apparent Nurses are faced with moral and ethical judgments such as informed consent, treatment, maintenance of life and/or the need for resuscitation on a daily basis. It is thought that as a result of new technology and biomedical research; the involvement of the advanced practice nurse in the ethical decision making process will certainly increase.
For this reason it is imperative that through formal education and training, the nurse must be provided the necessary skills so he/she can not only advocate for patients, but also effectively participate in the ethical decision making process.
Common Situations that Call for Ethical Consideration:
End of life issues
Organ donation with brain death
Organ donation with cardiac death
Abortion
Teen pregnancy
Quality vs. Quantity of life
DNR vs. Do not treat
Family/ Social issues (abuse)
Drug abuse
Advance directives/Legal medical spokesperson
Suicide attempt
NANDA Nursing Diagnosis for Ethical Considerations:
Knowledge Deficit (Does the patient and/or family have a good understanding of the situation?What educational plan will help them better understand the situation).
Ineffective Coping (Does the patient and/or family need further information or assistance to effectively cope with the situation).
Fear and Anxiety (is fear and/ or anxiety guiding the patient and/or family to make decisions).
Powerlessness (Does the patient and or family have enough information to control their environment).
Social Isolation (Are the decisions being made come from a fear of not complying with societies agenda).
References
Allmark, P. (2005). Can the study of ethics enhance nursing practice? Journal of Advanced Nursing. Vol. 51 Issue 6. pp 618-624. Retrieved on September 19, 2005 from CINAHL database.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. ANA Washington D.C.
American Nurses Association. (2003). Nursings social policy statement (2nd ed.). ANA Washington D. C.
Beauchamp, T., L. & Childress, J., F. (2001). Principles of biomedical ethics. (5th ed.). (Chapter 1, 6, 8). Oxford University Press.
Crain, W.C. (1985). Theories of Development. Prentice-Hall. pp. 118-136. Retrieved on September 17, 2005 at:
Dierckx de Casterle’, B. Grypdonck, M. Vuylsteke-Wauters, M. Janssen, P., J. Nursing Ethics. London: Jan 1997. Vol. 4, Iss. 1; p. 12. Retrieved on September 19, 2005 from ProQuest database.
Ellis, D. (1997). Strategies for Success: Critical thinking. (2000). Retrieved September 17, 2004 at:
Hook, K., G. & White, G., B. (2005). Code of ethics for nurses with interpretive statements: An independent study module. Retrieved on September 18, 2005 at:
Kim, Y., Park, J., Son, Y., and Han, S. A longitudinal study of the development of moral judgment in Korean nursing students. Nursing Ethics. London: May 2004. Vol. 11, Iss. 3; p. 254. Retrieved on September 19, 2005 from ProQuest database.
Krawczyk, R., M. Teaching ethics: Effects on moral development. Nursing Ethics. London: Jan 1997. Vol. 4, Iss. 1; p. 56. Retrieved on September 19, 2005 from ProQuest database.
Northouse, L., L. & Northouse, P., G. (1998). Health communication: Strategies for health professionals. (3rd ed.). (pp. 259-265). Appleton & Lange. Stamford CT.
Smith, K., V. & Godrey, N., S. Being a good nurse and doing the right thing: A qualitative study. Nursing Ethics. London: May 2002. Vol. 9, Iss. 3: p. 301. Retrieved on September 19, 2005 from ProQuest database.
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