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Values and Ethics in Nursing

A. Values
I. freely chosen, enduring attitudes or beliefs about the worth of a person, object, idea, or action
a. attitudes
i. a feeling or an emotion, generally including a positive or negative judgment, toward a person, object, idea, or action
ii. three components of an attitude
a. affective component
i. the feeling associated with an attitude
b. cognitive component
i. the factual information associated with an attitude
c. behavioral component
i. the inclination to act in a certain way associated with an attitude
b. beliefs
i. a special class of attitudes based primarily on faith as opposed to fact
II. value system
a. the organization of a person's values in which each value is ranked along a continuum of relative importance which operates as a personal code of ethics
III. types of values
a. religious (obtains strength from religious beliefs)
b. theoretical (holds truth, rationality, and empiricism in high esteem)
c. political (values power)
d. economic (values usefulness and practicality)
e. aesthetic (values beauty, harmony, and form)
f. social (values human interactions, is kind, sympathetic, and unselfish)
IV. transmission of values
a. modeling
i. children learn what is of high or low value by observing parents, peers, and significant others. Thus, modeling may lead to socially acceptable or
unacceptable behavior
b. moralizing
i. children are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for children to weigh
different values
c. laissez-faire
i. children are left to explore values (no one set of values is presented as best for all) and to develop a personal value system. This approach is often
accompanied by little or no guidance and can lead to confusion or conflict
d. rewarding and punishing
i. children are rewarded when demonstrating values held by parents and punished when demonstrating unacceptable values
e. responsible choice
i. children are encouraged to explore different values and to weigh their consequences. Support and guidance are offered as children develop a personal
value system
V. values essential to the practice of professional nursing (ANA, 1976)
a. aesthetics (qualities of objects, events, and people that provide satisfaction)
i. attitudes and personal qualities that demonstrate aesthetics
a. appreciation, creativity, imagination, sensitivity
ii. example of a professional nursing behavior that demonstrates aesthetics
a. adapting the environment so that it is pleasing to the patient
b. altruism (concern for the welfare of others)
i. attitudes and personal qualities that demonstrate altruism
a. caring, commitment, compassion, generosity, perseverance
ii. example of a professional nursing behavior that demonstrates altruism
a. assisting other personnel in providing care when they are unable to do so
c. equality (having the same rights, privileges, or status)
i. attitudes and personal qualities that demonstrate equality
a. acceptance, assertiveness, fairness, self-esteem, tolerance
ii. example of a professional nursing behavior that demonstrates equality
a. providing nursing care based on the individual patient's needs irrespective of his/her personal characteristics
d. freedom (capacity to exercise choice)
i. attitudes and personal qualities that demonstrate freedom
a. confidence, hope, independence, openness, self-direction, self-discipline
ii. example of a professional nursing behavior that demonstrates freedom
a. honoring an individual patient's right to refuse treatment
e. human dignity (inherent worth and uniqueness of an individual)
i. attitudes and personal qualities that demonstrate human dignity
a. consideration, empathy, humanness, kindness, respectfulness, trust
ii. example of a professional nursing behavior that demonstrates human dignity
a. safeguards the patient's right to privacy
f. justice (upholding of moral and legal principles)
i. attitudes and personal qualities that demonstrate justice
a. courage, integrity, morality, objectivity
ii. example of a professional nursing behavior that demonstrates justice
a. allocates nursing care fairly
g. truth (faithfulness to fact and reality)
i. attitudes and personal qualities that demonstrate truth
a. accountability, authenticity, honesty, inquisitiveness, rationality, reflectiveness
ii. example of a professional nursing behavior that demonstrates truth
a. documenting nursing care accurately and honestly
VI. value neutrality as essential to the practice of professional nursing
a. a nurse should strive to be aware of his/her own and a patient's values and not assume that his/her own values are superior to those of a patient
VII. clarification of values
a. a process by which people, including both nurses and patients, identify, examine, and develop their own individual values and value system
b. includes cognitive, affective, behavioral components
i. cognitive component (choosing)
a. freely, without outside pressure
b. from among alternatives
c. after reflecting and considering consequences
ii. affective component (prizing)
a. chosen beliefs are prized and cherished
iii. behavioral component (acting)
a. affirmed to others
b. incorporated into one's behavior
c. repeated consistently in one's life
B. Ethics
I. systematic inquiry into the principles of right or wrong conduct, of virtue or vice, and of good and evil as they relate to conduct
a. morals, although similar in meaning to ethics, usually refer to personal standards of right and wrong in conduct, character, or attitude
II. ethical conduct essential to the practice of professional nursing
a. described in the nursing code of ethics
i. formal statement that determines the standards of conduct of a professional nurse
b. the nursing code of ethics reflects the following underlying moral principles:
i. autonomy (the right to make one’s own decisions)
ii. nonmaleficence (duty to do no harm)
iii. beneficence (doing good)
iv. justice (fairness)
v. fidelity (faithfulness to agreements and responsibilities one has undertaken)
vi. veracity (telling the truth)
c. functions of the nursing code of ethics
i. inform the public about the minimum standards of the profession and to help them understand professional nursing conduct
ii. to provide a sign of the profession’s commitment to the public it serves
iii. to outline the major ethical considerations of the profession
iv. to provide general guidelines for professional behavior
v. to guide the profession in self-regulation
vi. to remind nurses of the special responsibility they assume when caring for the sick
III. ethical theories and frameworks
a. teleology
i. teleology views the rightness or wrongness of an action as being dependent upon the consequences the action produces
a. emphasizes happiness, pleasure, and absence of pain
ii. e.g., Utilitarianism:
a. emphasizes the utility or inutility of an action, or its instrumental value
b. utile act:
i. brings the greatest amount of good into existence for the greatest number of people
ii. thus the end justifies the means utilized to obtain it
c. inutile act
i. produces harmful effects
d. Utilitarianism applied to euthanasia:
i. "euthanasia, which ends unbearable suffering, is not murder, and morally right"
b. deontology
i. deontology views an action as right or wrong independent of the consequences it produces
a. emphasizes duty, rationality, and obedience to rules
ii. e.g., Kantian theory:
a. emphasizes that respect for persons is the primary test of one's duties with three components to this imperative:
i. that all persons must be respected as persons
ii. that all persons must respect their own humanity
a. e.g., people on suicidal missions, such as Kamikaze pilots, do not respect their own humanity
iii. that all persons must never be treated as the means to an end
a. e.g., prostitutes should not use "Johns" as the means to an end, such as to make money, and "Johns" should not use
prostitutes as a means to and, such as only to satisfy sexual desires
b. Kantian theory applied to euthanasia:
i. "euthanasia, even if it ends unbearable suffering, is murder, and morally wrong"
c. institutionism
i. the notion that people inherently know what is right or wrong
ii. as such, right or wrong actions do not need to be taught
d. caring
i. based on relationships
ii. emphasizes courage, generosity, commitment, and responsibility
iii. force for protecting and enhancing patient dignity
iv. uses touch and truth-telling to affirm patients as persons rather than objects and to assist them to make choices and find meaning in their illness
IV. types of ethical problems
a. decision-focused ethical problems
i. difficulty lies in what to do
ii. typically, two or more moral principles can apply
iii. results in a moral dilemma
iv. can be resolved by improving one’s decision-making skills
v. to deal successfully with these problems, the nurse must shift attention to "making the right decision" by improving his/her decision-making skills
b. action-focused ethical problems
i. difficulty lies not in what to do, but in implementing it
ii. typically, the nurse feels secure in the decision about what is right, but to act on his/her decision puts him/her at personal risk
iii. results in moral distress
iv. cannot be resolved by improving one’s decision-making skills
v. to deal successfully with these problems, the nurse must shift attention from "making the right decision" and focus on factors that are preventing the
"right action"
V. steps to resolve ethical problems by use of a decision-making model
a. identify the moral aspects of nursing care
b. gather relevant facts related to the case
c. determine ownership of the decision
d. clarify and apply personal values
e. identify ethical theories and principles
f. identify applicable laws or agency policies
g. utilize competent interdisciplinary resources
h. develop alternative actions and project their outcomes on the patient and family
i. apply the nursing code of ethics to help guide actions
j. for each alternative action, identify the risk and seriousness of consequences for the nurse
k. participate actively in resolving the issue
l. implement the action
m. evaluate the action taken
VI. common ethical problems faced by nurses
a. between nurses and patients
i. paternalism
a. e.g., a nurse decides to obtain an order to restrain an elderly patient who is at risk for falling because she believes it to be in the patient's best
interest even though the patient does not feel the same way
ii. deception
a. e.g., a student nurse does not tell a patient that this is his first injection in order to decrease the patient's anxiety
iii. confidentiality
a. e.g., a patient tells you in confidence that she doesn't know how she will pay for the hospital bill because she is an illegal alien
i. ANA statement "the nurse safeguards the patient's right to privacy by judiciously protecting information of a confidential manner"
iv. allocation of scarce nursing resources
a. e.g., a nurse working in labor and delivery has two mothers in active labor who are fully dilated and ready to be moved into the delivery room at
the same time
v. informed consent
a. e.g., an intern wants a nurse to assist him while he "practices" inserting a central venous pressure (CVP) line in a patient who has just died to
get experience in the procedure
vi. conflicts between the patients' and nurses' interests
a. e.g., a nurse refuses to take care of a HIV-positive patient because she is afraid of passing on the virus to her infant whom she is nursing
i. ANA statement, "the moral obligation to care for a HIV-positive patient cannot be set aside unless the risk exceeds the responsibility"
b. e.g., a nurse refuses to care for a patient who is to have an abortion because of her Catholic faith
i. conscience clauses permit individual physicians, nurses, and institutions to refuse to assist with an abortion if doing so violates their
religious or moral principles
b. between nurses and physicians
i. disagreements about the proposed medical regimen
a. e.g., a physician orders a nurse to insert a feeding tube and start tube feedings in a patient; a nurse disagrees because the patient has made
it clear to both the physician and the nurse her opposition to the procedure
i. ANA statement, "it is morally as well as legally permissible for nurses to honor the refusal of food and fluids by competent patients in
their care"
ii. conflicts regarding the scope of the nurse's role
a. e.g., a nurse, who assesses that a patient's bladder is distended, calls the patient's physician with this information to which he responds, "a
nurse wouldn't know how to assess a distended from an undistended bladder"
iii. physician incompetence
a. e.g., a nurse notices that a particular general surgeon's patients seem to have a higher than to be expected rate of surgical wound infections
c. between nurses and nurses
i. claims of loyalty
a. e.g., a nurse forgets to give a patient his antibiotic and, when the nurse on the following shift her tells her of this fact, the first nurse signs the
medication adminstration record as if she gave the antibiotic and tells the other nurse not to report her action
ii. nurse incompetence
a. e.g., a nurse and patient smell alcohol on the breath of another nurse on the unit
VII. advocacy
a. protecting and supporting of another's rights by pleading the case of another
b. pat ient advocate
i. an individual who protects and supports the rights of a patient by pleading the case of the patient
c. actions of patient advocates
i. informing patients
a. about their rights in a situation and providing them with the information they need to make an informed decision, e.g.:
i. determining if the patient agrees to receiving the information
ii. either having the necessary information or knowing how to get it
iii. wanting the patient to have the information
iv. presenting the information in a way that is meaningful to the patient
v. dealing with the fact that there are those who do not wish the patient to be informed
ii. supporting patients
a. in their decisions in an objective manner that conveys neither approval or disapproval, even if the nurse believes it is wrong
VIII. ethics committees
a. review cases ensuring that relevant facts are brought out
b. write guidelines and policies
c. provide education and counseling
d. provide a forum in which diverse views can be expressed
e. reduce stress for caregivers
f. reduce legal risks