Chapter 4: Creating an Ethical Environment

Personal Responsibilities

While a nurse is supposed to have respect for all the patients, colleagues and individuals he comes across in life, the nurse is supposed to show the same respect to himself. In practical terms, this means that a nurse should take care of his own physical and emotional wellbeing since both can have severe effects on the work life balance. Towards this purpose, there are three elements in the ANA code of ethics (2001) which a nurse needs to be aware of:

• Maintaining personal and professional competence
• Preserving the ethical character of a nurse
• Performing nursing duties with a high level of integrity

Personal competence has a lot to do with the capabilities of the nurse to perform her duties while remaining in a good condition both mentally and physically. Incompetence can lead to impaired judgment and can cause a nurse to make mistakes at critical junctures, therefore this ethical dictate has direct connections to the betterment of the patients as well as the health of the nurse. Similarly, maintaining and improving professional competence also has real life benefits for the nurse and the patients.

The benefits of the ethical responsibility to improve professional competence become obvious when it is understood what is affected by increased professional competence. Self-esteem, self-respect, value/satisfaction derived from work, career aims and prospects, even the financial status of a nurse can be improved if she increases her professional competence. Therefore, it is clearly for the benefit of the nurse if she decides to take steps which improve her as a nursing professional (ANA, 2001).

The source for this improvement is learning alone because learning is the tool by which the skill set of an individual can be increased and present skills can be polished to a higher level. Ethically speaking, quite a few activities can be considered a part of learning efforts to improve competence including continued education, attendance at professional seminars and discussions with colleagues who have advanced degrees or backgrounds in other medical fields. Additionally, a nurse can also improve competence with the use of self study courses, professional research, nursing certifications and full time study for higher degrees in nursing. It is required of all nurses to be up to speed on current issues in the field of nursing as well as the controversies and ethics which are connected with the profession (ANA, 2001).

The ANA code of ethics (2001) differentiates between the personal and professional aspects of the nurse but considers these elements to be integrated to a large extent. A nurse does not stop being a nurse once she has left the workplace, neither does she stop being a person once she enters it. Professionals from many different fields are given the same advice which is given to nurses i.e. personal values and professional values should be integrated to form a better, stronger and more beneficial set of values which help in more efficient manner of discharging a person's duties (Holm, 2006).

Undoubtedly, the professional code of ethics recommended for nurses would certainly have an impact on a nurse's personal life if she continues to follow the same rules in personal life. Elements like respect for human worth and treating all individuals with dignity can only be a positive force for the betterment of a person, but there are situations where personal morals could differ significantly from professionally acceptable morals (ANA, 2001). In such situations, a moral conflict can be created which may hinder the performance of a nurse's duties and if such a situation does come up, a nurse is allowed to withdraw from her assigned duties citing a moral objection.

Integrity and Nursing

The spirit of ethics can be summed up as integrity. However, the spirit is constantly under attack from the economic realities surrounding the provision of health care. A nurse can find his integrity under question when he is ordered to withhold or falsify information, knowingly deceive a client, or be placed in any situation which can cause a violation of the code of ethics. For example, even if a nurse is being abused or threatened by a patient, his integrity is threatened because he may lose respect for the human being which is the patient, or respond in a manner which is inconsistent with the high ethical standards expected of nursing professionals. An ethical nurse would do his best not to lose his temper and try to diffuse the situation in the best possible manner. On the other hand, a nurse with weak integrity may react in a negative way which might make the situation worse than it is.

In some situations, a nurse may have to compromise with the situation that he is placed in. It is very important to note that the compromise must never be on the fundamental ethics of the nursing profession but on the situation that presents itself (ANA, 2001). For example, the case mentioned above concerning the abusive patient can be handled with an ethical compromise if the nurse agrees to let others handle and administer the patient while he does his best not come into contact with the patient.

This is a compromise which preserves the integrity of the profession since the patient is left to be handled by nurses who are better equipped to deal with such a patient, and the nurse does not cause any reduction in treatment or quality of service for the patient. Situational compromises are easier to create when the hospital or the work environment comes with the acceptance that there is an open forum for debate and discussion where compromises can be brought out into the open and shared with others (Rankin, 2000).

The code of ethics also provides a way out for a nurse who feels that the compromises made at an organization have become commonplace and incompatible with the principles of integrity. In such cases, a nurse is ethically bound to present his objections to the relative board, group or committee which is responsible for maintaining an ethical environment. This report can be filed individually but collective efforts are more likely to bring about actions which can remedy the situation (Caputo, 2006). Additionally, nurses are directed to show their concern for the situation, prevent the need for the creation of such compromises and try to change the environment in order to discourage the acceptance of such situational compromises.

The Ethical Environment

The code of ethics recommends the creation of an ethical environment and gives some very good reasons for why such an environment is necessary. The most important reason of all is that the creation of an environment which is conducive to ethical behavior allows individuals to express their virtues as well as high standard of personal character. Virtues are defined as character traits which make a person more likely to do the right thing. For example, qualities such as emotional intelligence, sincerity, courage and wisdom are virtues. Similarly, personal characteristics are the good habits of a person which promote ethical behavior and these include things such as; empathy, tolerance, patience and other qualities attributed to a person with good morals (ANA, 2001).

When it comes to nursing, the field for virtues and personal characteristics which help a professional can be defined as traits which reaffirm and support the ideals of respect for human dignity, seeking improvements in the well being of all individuals, promoting better healthcare services and following ethical principles which form the basics of the nursing profession. Without exception, the environment can either cause these things to come out in full force, or the environment can have a negative impact on the things mentioned above. The reason behind this effect comes from the way in which the working environment is defined by the code of ethics (2001) which includes things such as:

• The structure of the Organization
• Working conditions, hours and situations
• Written policies and rules
• Unwritten informal guidelines
• Expectations of supervisors or other administrators
• Practices created by peer pressure
• Health and safety regulations enforced at the workplace
• Methods of communicating and acting on grievances
• Protocols for disciplinary actions
• Payment and compensation methods
• Lack or presence of personal fulfillment.

For example, if the environment of a hospital is such that every grievance is given a fair and honest hearing, and the decisions made based on the hearing are acted upon quickly, then nurses would have little fear of bringing up any ethical or moral issues which they face in their line of work (Walleck, 1989). This would lead to the overall environment becoming more pleasant and ethical as opposed to a work environment where grievances are dismissed without adequate attention, or where the implementation of decisions and rules is comparatively weaker (Foo, 2006).

While every nurse has a general duty to ensure that the environment does not degrade but rather improves with time, nurses who have an administrative or supervisory role are given special mention in the code of ethics since they are the ones who guide others in the creation of the environment (ANA, 2001). The culture of an office, a hospital or any other place a nurse might have to work can differ significantly but by taking responsibility for improving the environment of a place, a nurse can have a positive effect on all of her colleagues.

If a nurse is working as an administrative authority, she is given a further responsibility by the code of ethics to ensure that all employees or colleagues of the nurse are treated in a fair and equitable manner (ANA, 2001). When it comes to matters which pertain to the performance of nursing duties, input from the frontlines is extremely important. At the same time, this input must be weighed against the ethical guidelines and acceptable practice protocols of the profession. Accepting unethical practices for the sake of convenience or expediency can have far reaching negative effects, not only for the health facility where such practices are taking place, but also for the entire field of nursing.

It must be remembered by all nurses that ignoring unethical practices or taking them in stride is as bad as engaging in the practice. As a matter of fact, the code of ethics recommends that nurses should quit their positions at organizations which regularly violate the ethics concerning patient rights and leave such organizations which frequently ask nurses to compromise their professional standards or personal moral rules (ANA, 2001). This is certainly a drastic recommendation, but it can serve to prove a point and can even galvanize the administration into taking real action against the practice at once.

However, common sense and an understanding of the medical field shows quite clearly that change is often difficult to accomplish without persistence and continued work towards a goal (Caputo, 2006). Therefore, to bring about the required change, nurses should consider their actions in a collective form rather than individual objections or complaints. The nurse is not only trying to change the environment of the organization or the health facility for the better, she is also continually working towards an improved environment for the entire profession (ANA, 2001).

For this reason, collective bargaining is an accepted part of the ethical means in which change can be brought to a work environment. It is perfectly ethical to involve state or federal bodies in the change being sought by the nurses at a facility and it does not create an implication of disloyalty to the profession or the place of work. In fact, to improve the working conditions or the working environment for fellow nurses that results in the improved delivery of healthcare services is a moral good for the profession. Keeping this in mind, professional associations of nurses are also reminded by the code of ethics of their ethical duty to help nurses who require their assistance (ANA, 2001).

In some cases, nurses could even ask the professional organization to present their case to the health facility where they work and to engage the organization as a mediator and collective bargaining representative. Of course in such situations, the organizations have to balance the needs, wants and wishes of nurses who wish to see a change in the health facility against the best interests of the patients who seek optimal health care. Justice must be done by the collective bargaining representatives between what is good for the patients and what is good for the nurses involved in providing care services to the patients.