Ethics in nursing

Over the past two years, the American Nurses Association (ANA) has been monitoring a situation at Guantanamo Bay involving the Navy’s use of registered nurses to force-feed detainees.

One of the nurses, also a member of the Navy, refused to continue the practice, saying it was a violation of ethics. The Navy planned to discharge the nurse from active duty until the ANA stepped in, pointing out the nurse was bound to a code of ethics required of all registered nurses. The Navy backed down.

The story could have run the opposite way—the nurse could have insisted on force-feeding the detainees while the Navy wanted to discontinue, and the ANA response would have been the same. Why? Because ethics is sometimes a crystal-clear issue, and sometimes an individual response. In one case, there was a nurse who felt that force-feeding was unethical because the patient in question didn’t want it; in the other case, the nurse might have said that feeding to continue life was the ethical route.

How are nurses supposed to manage ethical behavior, and what resources do they have? The ANA’s senior director for nursing programs, Cheryl Peterson, provided insight into ethical nursing and the ANA’s Code of Ethics for Nurses, which was updated and reissued in January 2015.

Q. Who’s responsible for creating and nurturing an ethical nursing/work environment?

A. We all are. We as nurses must practice ethically, and we all need to talk about the code. The ultimate obligation is to the patient first, and any ethical organization will recognize that. Yet occasionally we may find that our obligation to the patient is at cross purposes with the guidelines of the facility in which we work. Those cases can lead to moral distress. Ideally there should be an Ethics Committee at every facility, a safe place for a nurse to turn to when an ethical situation arises or the nurse is in moral distress. The Ethics Committee should be a third party arbiter, independent of the hospital or clinic. But if that doesn’t exist, the nurse needs to practice to the code and then raise issues with the chain of command.

Q. How does an ethical environment contribute to patient care?

A. It’s a matter of safety and high-quality care. Nurses have a responsibility to promote safety and to report errors or near-misses. If we want nurses to use community processes, such as ethics committees, they must be in an environment with a framework of just culture—nurses should not have to fear retaliation for speaking up. If the working environment is ethically toxic, and the nurse has tried to change it, then the next obligation is to leave that environment. It might seem like the nurse should stay, but only if it’s possible change can be accomplished—otherwise, the nurse becomes part of the problem.

Q. What are some tips for building and maintaining an ethical environment?

A. Nurses are introduced to the Code of Ethics during their initial education, and they need to understand that they’re accountable to it. It’s a document that can be used before a board of nursing or in a court of law. It has meaning, like a contract—it has applicability. It can’t be overstated how important it is for nurses to know and understand this code. But simply knowing the code isn’t enough. Nurses should also talk about it with their colleagues, asking questions like, “What could I have done differently?” I can’t emphasize this enough. This way they can build an ethical colleague community and talk about situations that cause moral distress. And it’s not just the front-line nurses—all nurses are obligated to the code, from entry level to the chief nursing officer. There needs to be much more conversation about ethics at every level of nursing. All levels need to talk about how to do risk-benefit analysis: if we go on this path, is the risk too great, or does the benefit outweigh the risk?

Q. How does advanced education help promote nursing ethics?

A. When nursing ethics infuses all coursework and education is deliberate about ethical curricula, new nurses will take that into the workplace. They’ll understand how to talk about it, how to think about it, and how to take the code seriously. Some schools don’t understand this; they say, “We don’t have time.” Well, you have to make the time. This is the nurse’s obligation. If they’re going to practice ethically and provide high levels of care for people, they need to understand what’s involved, not just in terms of procedures, but in terms of ethics.

Capella University is committed to providing students with an ethics-based education by:

• Using the Code of Ethics for Nurses in all core courses in its online nursing programs.
• Offering several courses dedicated to ethics, ranging from entry-level nursing to executive leadership.
• Providing a virtual lab within all nursing programs to provide a fail-safe environment for nurses to not only practice hands-on skills but also face ethical dilemmas.