Vol. 1 Number 2
Fall, 2001 Past Issues of Update
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Vol. 1 Number 2 Fall, 2001 Past Issues of Update |
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Letter From The Editor
Empowered Caring and the Code of Ethics
Toward an Ethical Defense of Whistleblowing
Reflections - Ethical Implications of the Nursing Manpower Crisis, Shortage and Staffing
Clinical Case Study
Welcome to the second issue of our new online newsletter, Ethics and Human Rights Issues Update! This spring and summer has been an auspicious time for ethics issues in nursing and healthcare. In June, the ANA House of Delegates voted to accept the nine major provisions of our new Code of Ethics for Nurses. In mid July, the ANA Congress on Nursing Practice and Economics voted to accept the text of the Interpretive Statements that accompany the Code and we now have a completely approved document in print! This is the first time in more than 25 years that our Code of Ethics has undergone a complete revision and you can place an advance order for the complete document by telephoning 800-637-0323. You may also access the nine major provisions of the new Code online .
This summer we also conducted our second annual summer intern program. We were fortunate to have Kevin Hook, a critical care nurse with a background in journalism, religious studies and nursing, here with us at the ANA office for five weeks. Kevin received his Bachelor of Science in Nursing Degree from Columbia University, and his master of arts degree in Religious Studies and Ethics from Indiana University. You will see the fine fruits of Kevin's efforts in two articles and a case study in this issue of
The Update . Please read and enjoy the features that follow and let us hear from you. Comments and suggestions are always welcome!
Gladys B. White, Ph.D., R.N.
Editor
What makes a code of ethics an important document for nurses? Nurses' historical "ethic of
care" is deeply ingrained throughout their educational and socialization process. However, when
providing patient care, it is doubtful that nurses are overtly conscious of a code of ethics as they
go about their work. Interestingly, but not surprising to nurses, respondents in a recent Gallup
poll ranked nurses above medical doctors, teachers and clergy when asked which profession they
regarded "as the most honest and ethical." (Revolution). Generally, a code of ethics works as a tool for professional self-definition. As nursing continues to struggle towards a model of professionalism, the relationship between that model and a code of ethics must be seriously considered. Among scholars and older professional groups, the
absence of a code of ethics is detrimental to professional self-definition and professional
legitimacy. The mere existence of a code provides a positive argument that a group self-identifies as "professional," not just as occupational. In fact, the formulation of "a code of ethics
itself is commonly taken to be one of the defining marks of a profession." (Alexandra). As nurses continue to argue their case as professionals, then certainly "acceptance of a code seems likely to influence both the social and legal status of nursing." (ibid, p. 226). Professionals recognize that they must embrace specific responsibilities and obligations to those
they serve to legitimately call themselves professionals. A code, then, functions as a reminder of
these duties to both the practitioner and the public. As Alexandra and Woodruff write,
"..membership in a profession... entails duties, but also rights and privileges of a distinctive
kind."(Alexandra, p. 226). A Code of Ethics outlines these "distinctive" duties. Although a profession's obligations may have been recognized implicitly, the formal nature of a code of ethics brings another level of commitment to the professional endeavor. "A group's adoption of
a code of ethics, whatever its reasons, means it has explicitly avowed certain obligations...Perhaps it would have had these obligations whether it avowed them or not, but the explicit recognition that it has them gives another layer of responsibility to members of the group." (Lichtenberg). Ultimately, a code serves as the written word, or the public document, about how professionals
think of themselves, individually and collectively, and the serious responsibilities they have
embraced. Indeed, the written word can "have a striking influence on our attitudes,
understandings, and sometimes our behavior. (Fitzpatrick). Without a codification of duties and behaviors, the risk of losing professional clarity is high, especially for health care providers who practice in the midst of an ethically challenging environment. The written word provides that clarity and the moral power that flows from that. As the Code of Ethics "defines the core ethical tenets, describes the normative behaviors desired, and reflects the ethical aspirations of the profession," (Scanlon), it also reflects the actual work of nurses. It reveals nursing to be, at its core, a "morally significant" relationship based on trust between nurse and patient, writes Pyne. (Pyne). Nurses are acting as autonomous moral agents when they build these relationships and are reminded by the Code of Ethics that they do not leave their moral agency at the front door of the hospital. Unfortunately, nurses find their moral agency increasingly tested by their work environments.
Persevering as morally independent professionals is challenging as the nurse practices within a
matrix of several competing interests in complex hierarchical institutions that continue to try to
control nursing practice. It is this busy intersection that makes nursing unique when it
participates in moral or ethical reflection and action. To act effectively, then, nurses may need assistance in articulating their ethical obligations to
each other and to others with whom they work. The Code, then, serves as "educational armor"
which should encourage nurses to exercise their moral power in pursuing ethical reflection and
action when needed. The Code of Ethics becomes power-giving as it reminds nurses that,
despite their complicated position in the hierarchy, their status as independent moral agents
remains unchanged. Indeed, the Code helps nurses reclaim their rightful place as health care
collaborators, not followers. Nurses are not isolated professionals. To provide optimum care for patients, nurses are bound to
each other since bedside nursing is a 24-hour responsibility. More broadly, creating a health care
delivery system responsive to patients' and society's needs will not be achieved by one nurse
alone. The Code provides strength to nurses as it reminds them of their membership in the larger
professional nursing community. "The efficacy of the role of nurses envisioned in the Code
largely depends on group action. It is often only within appropriately structured institutions that
individual nurses can act as autonomous and collaborative workers. Given institutional inertia
and conservatism, such structures are unlikely to be erected without concerted action by nurses as
a group." (Alexandra, p. 243). The recently revised Code of Ethics for Nurses with Interpretive Statements reflects nurses
expanded professional roles in today's health care environment. (ANA, 2001). Nurses today are
faced with multiple challenges, including cost-conscious hospitals, managed care payment plans,
nursing staffing problems, the looming nursing shortage, and complex medical conditions that
affect not just individuals, but whole communities. Since new situations require new
responsibilities, the revised Code now expresses expanded ethical obligations.
So, although the Code reflects enduring precepts "that undergird the profession, it remains a
dynamic and living document in the face of changes within health care and professional life."
(Scanlon, p. 263). Managed care has altered relationships in all spheres of health care, so much so that it has
"generated a parallel moral paradigm shift that fundamentally challenges medical ethics and the
patient-physician relationship, as they have traditionally been understood." (Baker). The relationship between nurses and patients has been challenged as well and nurses face "ethical issues and stresses in intra-professional and inter-professional relationships not envisioned in years past." (Walleck). The revised Code is now available to help nurses navigate this new "moral paradigm" in an era "when hospitals have become marketplaces..." (Curtin). The revised Code of Ethics challenges the nursing profession to assume a new mantle of
leadership and relocate the patient to the center of health care. Many feel that nurses now have a
significant opportunity to challenge the loss of the patient-centered ethic and step into more
highly visible roles as public advocates. Bemoaning the lack of leadership in health care today,
Rambur writes nurses have "an unusually pronounced leadership responsibility: to publically
champion reform toward more ethical health care financing and delivery." (Rambur). She argues that true leadership exists when the best interest of the patient it kept center stage. With nursing's patient-centered history, she concludes that nursing "is the profession poised to take this leader/advocate role." (ibid, p. 70). By making nursing's professional duties and commitments explicit to society, the Code serves to
increase the trust between professional nurses and those they serve. With this trust secure, nurses
will be in an ever better position of power and leadership "to bring about the social change
necessary to enhance" health care. (Fowler). Increased knowledge of the Code and its interpretations should inspire nurses to find ways to
become comfortable with increasingly higher levels of ethical deliberation. As Walleck states,
"No longer can the nurse simply react in ethical discussions; he or she must be able to state a
position clearly and accept the responsibility for the decision." (Walleck, p. 366). Erlen agrees: "one factor that will facilitate an atmosphere of mutual respect and collegiately is the demonstration of competence. Nurses need to possess knowledge and skill related to ethical decision making so that they can articulate their positions clearly. Nurses need to provide a sound rationale for their views." (Erlen). And although nurses are still deeply committed to caring, they can no longer "care" at the expense of being disempowered in relationships and systems. The Code of Ethics should contribute to what Rankin refers to as "empowered caring." (Rankin). The Code is the promise that nurses are doing their best to provide care for their patients and
their communities, supporting each other in the process so that all nurses can fulfill their ethical
and professional obligations, as well as increase their goals of professionalization. In the midst
of these challenges, the Code of Ethics will be there as concrete evidence of nursing's thoughtful
and deliberate ethical posture. References (Alexandra) Alexandra, A., and Woodruff, A., Ethics and the Professions, D. Appelbaum and S. Lauton, ed., Prentice-Hall, 1990. American Nurses Association,
Code of Ethics for Nurses with Interpretive Statements .
Washington, DC, ANA Publications, 2001. Fitzpatrick, J., (1990). The power of the written word. Applied Nursing Research, 3(1): 1. Fowler, M., (2000). A new code of ethics for nurses. American Journal of Nursing, 100(7): 69-72. Revolution, Jan-Feb 2000, 1(1): 15. Toward an Ethical Defense of Whistleblowing
You're one of a group of nurses noticing, with increasing alarm, the negligence and
incompetence of a physician who practices in your hospital. You've reported what you think to
nursing administration and certain physicians, but nothing has happened. As a result of some
conversations with other nurses, you eventually decide to document what you see and report this
to the proper authorities. If you decide to "blow the whistle," how do you ethically defend your
position? A recent court case in New Mexico centered on such a situation. However,
in this scenario, what six nurses did was to agree to testify in support of two people bringing a
lawsuit against a physician, alleging negligence and incompetence. One of the two had been a
patient and the other was the husband of patient who had died. The nurses in question had
apparently voiced concerns to nurse managers about the physician for several years. In fact,
several nurses had not only spoken with nurse managers, but with other physicians regarding
their concerns. (ANA, Press Release). At issue for the nurses was the hospital's assertion that New Mexico state regulations prohibit the
sharing of patient information, regardless of the reasons. The nurses began to experience some
retaliation by the hospital when they went ahead and agreed to testify. The ANA filed an amicus
curiae ("friend of the court") brief in support of the nurses' actions. Ultimately, the Court ruled
in favor of protecting the nurses' right to testify. (ANA, Press Release, 7/20/2001). What is whistleblowing? Whistleblowing "is going public or speaking out to one's professional
organization or to the media in order to protect the welfare of patients because of a perceived
wrongdoing on the part of others"... (Erlen,). More generally, "Whistleblowing is the
public exposure of organizational wrongdoing." (Wilmot). While the average patient's
immediate response to whistleblowing would probably be a resounding hurrah!, for nurses,
whistleblowing can create considerable moral distress as we weigh the consequences of our
actions against the duties of our profession. The consequences will not only affect patients, but
the nurse as well. "Nurses must carefully decide whether or not to blow the whistle. Advocating
for improved patient care and exposing unethical and incompetent health care providers is not
without risk." (Erlen, p. 70). The risk can take many forms, including negative reactions from
co-workers, losing one's job, and, in the extreme, legal retaliation. Does the nurse have a convincing ethical argument if he or she decides to become a
whistleblower? Once we become nurses, we have the Code of Ethics as our guide. According
to the Code of Ethics for Nurses with Interpretive Statements, there is justification for becoming
a whistleblower:
Section 3.5: As an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal or impaired practice by a member of the health care team or the health care system or any action on the part of others that places the rights or best interest of the patient in jeopardy." (ANA Code of Ethics with Interpretive Statements, 2001). Blowing the whistle is, in fact, a form of advocacy! So what tools might a nurse use as he or she engages in the task of deciding whether to pursue such an extreme course of action? In his thoughtful article on the subject, Wilmot offers an ethical analysis of whistleblowing as he outlines the particulars of the decision, reminding us that whistleblowing must be understood in "relation to its moral purpose." (Wilmot, p. 1051). He examines the dilemma in light of two ethical theories: consequentalist versus deontological. The consequentalist argument, expressed in its utilitarian model, is essentially a cost/benefit analysis. Consequentialism requires that we first calculate both the good and bad consequences of an action and then determine whether the total good consequences outweigh the total bad consequences. If the good consequences are greater, then the action is morally proper. If the bad consequences are greater, then the action is morally improper. In the consequentialist theory of ethics, it is the end result of the action that is the sole determining factor of its moral worth. The deficiency in this position is that it assumes that good and bad consequences are measurable. All one need do is the "cost/benefit analysis" and one will come to the correct moral decision. Unfortunately, the byproduct of this may be an unacceptable level of harm inflicted on a few people in order to achieve a good end for others. Since nurses are responsible for the safe care of each patient, the nurse runs the risk of causing an unacceptable level of "harm" to a few to benefit the majority. What if a patient suffers an unbearable loss of privacy brought on by a whistleblowing incident? What if finding another provider becomes difficult because the physicians fear undue scrutiny? What if the ensuing publicity affects the institution's ability to carry on its mission as physicians and nurses find work elsewhere in order to distance themselves from this incident? Worse, what if nothing positive comes as a result of our whistleblowing, but several people (staff and patients) suffer because of it? As Wilmot reminds us, "Exposure of abuse or poor care does not necessarily lead straight to the achievement of good care." (Wilmot, p. 1053). How do we logically defend our desire to achieve a positive consequence, knowing there may be some short term negative consequences? Wilmot suggests that the consequentialist theory be balanced by the second one: deontology. Based on Kant's view of individual autonomy and responsibility, deontological ethics views the individual as having general moral duties such as treating persons as ends in themselves, keeping promises and truth-telling. In deontological ethics, "we replace the idea of the consequences of a persons' actions with the idea of actions for which that persons is responsible." (Wilmot, p. 1053). In the end, deontology requires an acknowledgment of one's duty and taking responsibility for only those actions for which one is responsible. In other words, the actions of others are not my responsibility, but theirs, even if their actions are a response to something I have done. Nurses have multiple duties and competing roles, which makes whistleblowing a wrenching decision. In this case, the nurse has a duty to the patient and a duty to the employer. After debating the merits of duty to patient versus duty to the organization, Wilmot offers a compelling argument in favor of duty to the patient. This even includes situations where a nurse has signed a "contract" of employment. He questions the moral status of an organization and, consequently, duties to organizations. He specifically questions the morality of being duty-bound to an organization that is no longer carrying out its intended goals and objectives, i.e. allowing an impaired practitioner to continue practicing. He concludes that while the "nurse is well-placed in terms of information to blow the whistle, she (he) is badly placed in terms of the balance of her (his) duties." (Wilmot, p. 1053). Why does it matter whether the nurse understands the ethical framework in which this decision is made? Because understanding the ethical framework that goes into serious deliberation ultimately gives the nurse's decision increased legitimacy. The nurse puts him or herself at great risk by becoming a whistleblower and when that nurse can more clearly understand the underlying theories and principles at work in such a decision, then that nurse can more adequately defend his or her decision. As nurses are increasingly confronted with ethical dilemmas, bringing reasoned principles and sophisticated ethical thinking to the process only increases our moral autonomy, making us more powerful advocates for our patients while maintaining the integrity of our profession. Nurses don't always know how to begin a process of reporting incompetent or negligent practice. For this reason, writes Erlen, "A mechanism needs to be in place that enables staff to speak freely and to bring inconsistent and/or potentially harmful situations to the attention of others...Policies need to be developed that clearly delineate the procedure for reporting unethical, illegal, or incompetent practice." (Erlen, p. 69). Only after all the avenues have been exhausted, with no response, does the nurse go public with his or her accusations. Not surprisingly, even the most ethically sophisticated nurse may suffer unpleasant consequences brought about by whistleblowing. Most everyone agrees that, ultimately, legislation is needed to protect nurse whistleblowers and nurses themselves need to actively support such efforts. At the very least, nurses should not have to worry about legal retaliation when, after serious and careful consideration, they take the ultimate step in patient advocacy, and decide to blow the whistle. References American Nurses Association Press Release, 6/19/2001. American Nurses Association Press Release, 7/10/2001. American Nurses Association, Code of Ethics for Nurses with Interpretive Statements, Washington, DC, ANA Publications, 2001). Erlen, J., (1999). What does it mean to blow the whistle?, Orthopaedic Nursing, 18(6): 67-70.
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