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college of nurses of ontario

Guidelines for

Ethical Behaviour in Nursing

Approved September 1 980

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Table of Contents

C£f.!TER f:OR THE STUDY Of ETHICS

IN THE P ~\OfESS~ONS

Preface .. . ..... . .. . . . ..... . ... . .. . . . . ... . . . .. .. ..... .......... 2

Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Statements and Interpretations Role of the Nurse . . . . .. .. ... .. .. . . . ... .. .... . 6 Competence . ... .. . ..... . .. . . .... . . . .. . .... . . 7 Expanding Knowledge .... . . . .. .... . .. . . . . ... 8 Quality of Care .... . . .... ...... . . .. ... . . .. .... 9 Accountability . . . ... .... . . . . .. . .. . . . ....... . . 10 Truth ... . . . . ..... . . ....... . . . .. . . ... . .. .. . .... 11 Consent .... .. ..... . . . .. . ........ . .. . .... . . . . 12 Confidentiality . . . . .. . . .. .. . . . ......... . ...... 13 The Health Team .... .. . ... . .. . . . . .. . .. .. ... . . 14 Professional Goals .. . ..... . . ............... . . 15 Nurse as Citizen . .... . .............. . ... . .. . . 16

Appendix A Preface to the Examples . . . . . .... . . . ... .. . ... 18 Examples of Ethical Situations .. .. . . . ..... . . . 19 Annotated Bibliography .... . . .. .... .. . .. . . .. . 27

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Preface

Nursing confronts nurses with ethical dilemmas . Sometimes right conduct is easy to recognize: one should not steal from one's client 1 or employer, for instance, or strike a client, or gossip about a client. Such dictates, if written , would comprise a code of ethics . Sometimes, however, precisely what is "right " is not obvious. On these occasions , ethical guidelines may be welcome.

Choosing the ethically right course of action has never been easy .. and seems particularly difficult to-day. In the past, the IndiVidual l1ved among people with similar religious and cultural values, wh.o P.oi.nted out right conduct and supported him in doing nght. The Individual m1ght choose to do either "right" or "wrong ," as these were defmed by those about him, but he was unlikely to be confused about which he had chosen.

In contemporary society, the mixing of cultures , diminishing religious belief, and rising materialism mean that each person is exposed to a confusing assortment of ethical commands , many of which are contradictory. As a result , each person must , to some degree, create his or her own system of values: recognize contra­dictions and choose from the values offered the ones which seem to have the most merit.

As in other areas in which the nurse is expected to be proficient , it is better if examination of ethical values and skill in their application precede nursing practice. If a nurse's beliefs, for instance, do not permit participation in some therapy, it is better to undertake nursing assignments where this therapy is not required than suddenly to find oneself unable to care for a specific client. An ethical conflict which involves a client is likely to be more distressing to the nurse (besides being potentially harmful to the client) than is an ethical question which the nurse solves in private and at leisure.

It remains true that not all the ethical dilemmas which nursing can present can be solved in advance. But the nurse who spends some time considering eth ical values together with personal resolution of hypothetical problems also sorts out personal priori­ties in these areas. How are duties to client , employer, and self to be ranked? If the nurse values the right of self and others to personal ethical choices, what ought the nurse do when a client makes an ethical decision the nurse believes wrong? Which of the nurse's values in that case- the one which concerns the client's situation or the one which concerns the client 's freedom of ethical choice­should prevail? Consideration of such questions prior to their

presentation in individual cases can only enhance the practice of nursmg .

Guidelines for Ethical Behaviour in Nursing (1980) carries out part of the College of Nurses' mandate to develop standards for nursmg pract1ce. These guidelines have been developed in terms of contmumg concern for the client, and are not based on one specific theoretical framework. Given the ethical responsibilities wh1ch are a part of nursing, this preliminary statement of standards to be used in judging ethically-acceptable acts is meant to serve as a reference point in developing and assessing the ethical component of any nurse's professional practice.

A Note on Organization of the Document Guidelines for Ethical Behaviour in Nursing begins by stating

the Assumptions upon which the guidelines are based. It then presents a sequence of eleven Statements concerning ethical behaviour in nursing practice, together with an Interpretation of .each Statement. These three elements make up the basic guidelines.

The "ethical situations " which begin the appendix to the Guide­lines describe several ethical problems in nursing. Many of these situations arose in the practice of college registrants, who kindly contributed them to the Guidelines. It is hoped that they will be useful for personal consideration as well as group discussion. Fmally, the append.ix. closes with a bibliography, for readers who w1sh to pursue the1r 1nterest in nursing ethics.

1Within the text. of these Guidelines, "nurse" refers to Registered Nurse, Reg1stered Nursmg Ass1stant, or student nurse; and "client" includes a client, a pat1ent. or a group of patients.

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Assumptions

1. The purpose of nursing is to promote human well-being .1 In this paper, nursing is considered to include: (a) Caring for individuals , families , and communities; (b) Teaching t'hose who are entering the profession or continu­

ing their preparation within it ; (c) Advancing the theoretical aspects of nursing through re­

search involving individuals or groups. 2. Nursing is a form of intervention in the lives of others . As such,

all nursing has an ethical component. Choices based on values must be made. The values upon which the choices must be based may vary from one individual to another: between two nurses, between nurse and client, and between a nurse and others who share the care of a single client. Since nurses have a particular responsibility to help others meet particularly sen­sitive human needs, a nurse needs skill in making ethical decisions.

3. The ethical decisions made in nursing -the decisions based on values - arise first from recognizing that each individual involved in the nursing interaction has a "human dimension," i.e., a unique set of biological, spiritual, psychological, and social characteristics . This is true of nurse, client , other people caring for the client, family members, etc. This "human dimension" commands respect, even as it entails rights and responsibilities.

4. The nurse's ability to fulfil ethical responsibilities is commen­surate with the professional context within which the nurse works : i.e., appropriate professional preparation , suitable con­ditions for exercising nursing activity, social respect tor the nurse as a responsible decision-maker, and social recognition of professional expertise .

. 5. Each nurse's ethical judgments flow from personal conscience. They include a weighing of alternatives (what could be done) and the resulting decision as to what should be done. lnformed ethical decision-making rests on a theoretical reason ing pro­cess in which the alternative modes of action are "matched" against the individual's personal value-system. The result of this "matching" process is applied in a particular situation to determine the best course of action in that situation . The "matching" takes into account past experience, possible con­sequences, and personal strengths and weaknesses . Once the ethical decision is made, personal inventiveness in the situation and strength of will are important in carrying out the decision.

6. Help in clarifying personal ethical values is often available to the nurse from associates and colleagues in nursing, from members ot . other health disciplines, and from employers, family , and fnends . The particular social, cultural, and religious value-systems wh1ch form the individual conscience are often helpful in resolving ethical dilemmas. Important in finding the best solut1on 1s a continuing recognition of the values of other persons and consideration tor these values . No set of guidelines can resolve the .ethical dilemmas which a

nurse may. be called upon to face. As noted, this is a personal matter, un1que to each individual and situation. Nevertheless, g1ven the nature of nursmg and the ethical responsibilities associ­ated with it, and given the requests from nurses tor "sign-posts" in th1s area, some statement of desirable ethical behaviour in selected nursing situations seems required .

Fulfi.lment of these criteria is only a beginning : the actual ~esolut1on of the continuing ethical problems presented to each 1nd1v1dual nurse remains a continuing personal challenge.

1See The Standards of Nursing Practice (p. 2) for a further statement of Beliefs about nursmg care and the scope of nursing practice.

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1. Role of the Nurse

Statement

The nurse, as one of the providers of health care, has a unique and responsible role in health promo­tion , in preventing illness, and in helping individuals attain and main­tain the highest level of health pos­sible.

Fulfilment of this role within the nurse-client reldtionship requires mutual recognition of responsibil ity for self and respect for human dignity.

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Interpretation

Nurses have a responsibility to provide the opportun ity for health care and to respect the individual's right to receive it.

The same belief - that human interactions require responsibility for one's self and respect for human dignity - may be held by different people for different philosophical or theological reasons . Consequently, though they share the same view of human relationships , these people have different value systems and may find different solutions to ethi­cal problems. They have in common, however, the desire to choose and perform "good" actions.

2. Competence

Statement

The nurse is responsible for achieving and maintaining profes­sional competence.

Interpretation

Professional nursing is directed to safe, competent care of clients. Nursing actions derive from an iden­tifiable and developing base of nurs­ing theory and skill.

The profession must ensure that opportunities for learning and for applying this knowledge are avail­able in suitable settings.

Using a variety of resources and selecting appropriate activities. each nurse is personally responsible for maintaining and expanding initial professional competence.

Each nurse has a responsibility to prevent/report incompet~nt activity.

While safe, competent care is ex­pected from all nurses at all times , it is recognized that emergencies oc­cur in which the nurse may be called upon to act without adequate re­sources (e.g. , assistance, equipment, or theoretical knowledge). In such cases , individual obligation is ful­filled when the nurse does as well as individual knowledge, individual experience, and circumstances per­mit.

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3. Expanding Knowledge

Statement

The nurse has a responsibility to contribute to expanding the body of nursing theory and its application.

Interpretation

Continuing research is the necessary basis for expanding the theoretical framework of nursing and improving specific components of nursing care.

The profession and society should provide the means by which indivi­duals can learn how to undertake research . They should also try to ensure an attitude and provide resources which encourage and permit nurses to undertake research.

Members of the profession should contribute to nursing research in ways suited to their own abilities and circumstances, whether in carry­ing out their own research projects or as learners of research methods, as subjects in research studies , or as critical users of published results .

4. Quality of Care

Statement

. The nurse has a responsibility to 1mprove the quality of care being g1ven .

Interpretation

The nursing profession estab­lishes standards for initial registra­tion and continued certification which provide general guidelines for safe, competent nursing care.

The individual nurse meets and tries to exceed these minimum stan­dards, applying them as individual situations require so as to provide ever higher quality of care.

The individual nurse who has the necessary skills contributes to the development of specific standards for the care of clients with particular (special) needs.

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5. Accountability

Statement

As a member of the profession , the individual nurse accepts res­ponsibility for certain acts and func­tions .

The nurse is respons ible and accountable for the consequences of nursing actions.

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Interpretation

The nurse is accountable for the results of individual nursing actions, to self , to the cl ient, and to the employer. These respons ib il ities may sometimes conflict : the nurse's view of individual responsibility to the client may not be shared by the client because of differing personal value systems, or the nurse's ac­countability to the employer may conflict with the nurse 's accounta­bility to the client.

In preparing to resolve such po­tential dilemmas , the nurse must recognize priorities in the realm of personal values (e.g., death, truth , confidentiality, the right of others to hold their own personal values). As already noted, it is better to recognize these personal priorities before a situation involving a cl ient arises . A nurse who is struggling to clarify personal values while caring for a client is likely to find the resolution more difficult and may give the client less than the best care poss ible.

In this context, if the nurse recog­nizes a personal hierarchy of values sufficiently well , a conflict of values between nurse and client can be identified readily. If conflict arises , the nurse must be able to respect the client's point of view and give the necessary care or, if th is is impossible, the nurse must arrange for someone else to take over the care of the client.

The scope of responsibility and accountab ility vary according to context and should be mutually defined by the nurse and the em­ployer.

6. Truth

Statement

The nurse respects the role of truthfulness in health care.

Interpretation

Trust is essential in the relation­ship between nurse and client. It is an aspect of respect for the client's human dignity and responsibility for self .

In this connection , it may be helpful to distinguish among three areas of information. There is infor­mation the client wants to know, and asks for. There is information which the client may not want to know, and does not ask for. And there is infor­mation the client does not ask for because he does not know it exists . Truth is equally important in each of these areas, but the best way to give 11 may vary.

The simplest of these is the first. If the client asks a question, the nurse gives the information asked for, on the spot.

The nurse may be aware, however, that additional information is rele­vant: further details of the client's condition , for instance, the implica­tions of a medical finding , the future the client may face. Here the nurse's judgment is important. It may be necessary to choose a time and place and to prepare the client to receive unwanted bad news, or to point out unpleasant implications of which the client has never heard.

A direct question must be an­swered directly. In other areas, how­ever, a balance between helpful and harmful truth-telling should be sought in maintaining the trusting relation­ship between nurse and client.

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7. Consent

Statement

The nurse respects the client's right to an informed and voluntary consent regarding care, treatment, and participation in research .

As a responsible decision maker, the client has the right: o To be advised of the probable

and potential consequences of nursing and medical actions and of research activities ;

o To decide whether or not to ac­cept treatment or participate in reseQrch , without coercion or duress .

o To be involved in developing the plan of care.

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Interpretation

The nurse respects this principle in providing individual nursing care, but various factors may require dif­ferent applications of it. For example, the client may not be able to respond fully to the situation ; or uncoordi­nated efforts of the health care team members may make it hard for the nurse to provide the client with an adequate base of information for decision making.

In certain cases (e.g., the uncon­scious patient, the young child , cer­tain psychiatric patients), fully in­formed proxy consent is required as an application of the principle.

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8. Confidentiality

Statement

The nurse respects the client 's right to confidentiality within the nurse-client relationship.

Interpretation

Respect for confidentiality is es­sential in the relationship between nurse and client. It is an aspect of respect for the client's human dignity and responsibility for self . Philoso­phical and legal arguments support this view.

Since nursing care is provided by an interdisciplinary team, the nurse must explain to the client the need for sharing pertinent information about the client with other health care personnel : as long as the client knows that this will be done, it is not a violation of client trust.

The nurse must also explain that others will be given information about the client if withholding such information may cause harm to someone. In this case, the duty to prevent harm overrides the respon­sibility of confidentiality .

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9. The Health Team

Statement

The nurse as a member of the health team has a responsibility to collaborate, to share information , and to participate in joint planning for the benefit of the client and to maintain the standard of the team.

The client, being the reason the team exists , is included in discus­sions when advisable and feasible .

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Interpretation

While the people on a health team may vary in number and discipline, the health team offers the best way of providing care for clients . The team is effective when each member understands the others ' duties; when the members collaborate; and when each respects the competence of the others . In this regard , the nurse shares information about the client with other members of team as re­quired for client well -being , co­operates with others as required for client well -being , and assumes res­ponsibility for coordinating team ef­fort as indicated by the team when c lient well-being so requires .

When the competence of any team member is in question , the nurse presents / reports this in the most suitable manner, seeking to main­tain continuity of client care. If cir­cumstances require it , the nurse balances the need for truthfulness to the c lient against the client 's need for trust in the team, and against respect for the team member's repu­tation .

1 0. Professional Goals

Statement

The nurse has a responsibility to further the goals of the profession.

Interpretation

Adherence to ethical principles and standards of practice, parti­cipation in continuing education , contribution to the expansion of nurs­ing knowledge , and participation in professional activities are required for the maintenance and growth of the nursing profession . Constant review and pertinent revision of guidelines and practice are requisite to the profession 's development: the individual nurse shares in these as practicable.

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11. Nurse as Citizen

Statement

The nurse as citizen has a res ­ponsibility to serve the community by trying to improve the level of health care.

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Interpretation

The individual nurse fulfils civic responsibility in many ways : identi­fication of need in particular com­munity groups (e .g., the elderly, the handicapped); participation in ac­tivities directed toward promoting health and preventing disease; and assistance in efforts to increase communication among social agen­cies providing health care. The nurs­ing profession provides the theoreti­cal model and moral support for the individual nurse in this endeavour .

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