Chapter 7: Current Topics in Nursing Ethics

Additional Nursing Roles

Ledbetter (2006) reports quite clearly that there is an acute shortage of teachers and faculty who can serve as qualified individuals to train future nurses in America. The American Association of Colleges of Nursing (AACN) requires teachers to have at least one doctorate degree in nursing to be considered a part of the faculty, but finding qualified faculty is a problem for many nursing colleges. It has got to the point where colleges are turning away many qualified students simply because they do not have the faculty to handle so many students.

In 2003, colleges rejected eighteen thousand applicants for nursing programs while in 2004 the number of rejections had climbed to thirty-three thousand. The situation is steadily getting worse since the number of rejections due to insufficient faculty numbers climbed to forty-one thousand (Ledbetter, 2006). This is quite an ethical dilemma for the nursing community since the nursing field already faces a shortage of qualified nurses. If the trend continues then the statistics from the labor department show that America would face a shortage of more than one million nurses by 2020.

Similarly, the nursing field also faces a shortage of individuals engaged in active research because positions for senior clinical nursing staff provide much higher benefits and salaries for nurses. Ledbetter (2006) explains that nurses with up to date training and good experience can ask for as much as $100,000 per annum in a hospital setting while nurses who choose to work in academia would make less than $70,000 per annum. The code of ethics for nurses has surprisingly little to say on this issue and makes very few references to this topic. However, the code does recommend that nurses who are engaged in teaching positions must ensure that only those students graduate who have the essential skills necessary for application in the field.

The situation has got to the point that the Congress has responded by allowing more foreign nationals to work as nurses in America. However, as in many other places where Congress makes legislative changes, this is also riddled with ethical questions regarding the import of human capital. There are some who strongly support this method of satisfying America's need for more nurses in the field, and there are others who oppose the recruiting of nurses from developing countries due to their objections based on ethical grounds.

The Ethics of Recruiting Nurses from Abroad

For example, Robert Rosseter from the AACN says that by bringing nurses from other countries, America is simply depriving developing nations of qualified nurses who are in short supply around the world (Ledbetter, 2006). Singh et. al. (2003) go as far as suggesting that such activities can be considered nothing more than poaching, and the practice should be stopped before it has more negative consequences for health services in developing nations.

It is further reported by the same writers that the trend is showing an increase even though some nations amongst the developed countries have made moves towards slowing down the recruitment of foreign nurses. The ethical debate comes into action from many different angles since there are a lot of implications of transferring nurses from one country to another. For instance, it is ethically true to say that in the age of a global economy, a person should be able to legally work wherever they receive the highest reward for their services. On the other hand, removing nurses from underdeveloped countries means that people who previously had access to low-cost health care services could find themselves being unable to purchase the same services anymore since a lack of nurses would drive up the prices for healthcare (Singh et. al., 2003).

The nursing profession has an ethical code which respects autonomy, values individual as well as collective efforts to improve the field and suggests that nurses should discharge duties towards themselves as much as they have duties towards those in their care. All of these provisions would make it perfectly ethical, if not a recommendation for a nurse to move from a third world country to a place where he is paid significantly higher amounts for his skills.

Such a move would be perfectly inline with the idea of personal autonomy. Moreover, the nurse could bring his valuable cultural experience and to improve the field and finally, he would discharge the duty towards herself by getting a higher salary with a possibly improved environmental setting. However, considering the opinion of doctors and nursing professionals coming from developing countries like Pakistan and India, the poaching of nursing is having a net effect that is strongly negative (Singh et. al., 2003). It seems that the practice is hurting more people than it is helping and ethical alternative need to be discovered before a final solution to the problem can be implemented.

Miscellaneous Ethical Issues

Coming back to the nature of nursing as an individual, there are three important issues which nurses can come across in a modern hospital, and they deserve a special understanding because such issues are quite common. The first amongst these is the issue of giving personal opinions whenever the nurse is asked to provide one by the patient. For example, a patient may ask a nurse pointed questions about end-of-life decisions, or ask about the nurse's personal opinion on certain types of treatment. In both these cases, the patient may ignore the professional opinion of the nurse and insist on getting a personal opinion.

The code of ethics suggests that nurses are free to give out their personal opinions but they must be based on informed assessments of the situation. The code also recognizes that the nurse is an accepted authority figure and her opinions can have an effect on the decision making of the patient; therefore, the nurse should be very careful not to suggest anything which decreases the personal autonomy of the patient (ANA, 2001). In most cases, such opinions can be used as invitations to open up a discussion and help the patient understand her own ideas about the subject being discussed.

While giving personal opinions all nurses are ethically guided not to pressure the patient into acting one way or the other, even if such pressure comes without any negative intentions. It must be understood that patients, as well as nurses, can have very diverse backgrounds which are reflected in their opinions about choices which a person can make. For example, a nurse with a strongly liberal background could have a very different approach from a patient who has extremely conservative viewpoint. However, since the nurse holds a position of power and influence over the patient, any personal opinions shared with the patient by the nurse should be carefully considered before they are given.

The second important ethical issue faced by nurses today is the confidential treatment of electronic records. While electronic records have the same confidentiality requirements as paper based records, there are additional security concerns which must be addressed. The assurance of confidentiality concerning electronic records encourages and strengthens the integrity of the patient-nurse relationship and thus promotes patient care and recovery. The principle of respect for patient's autonomy furthers the right of a patient to have control over his own life, and this would include the right to decide who should have access to personal information which is stored on computer systems. That is why, confidentiality is seen as a fundamental ethical principal in health care and a breach of confidentiality by any health care professional could be a reason for disciplinary action (Horan, 2006).

Confidentiality has been given such importance that even if a patient does not know that her information has been disclosed by a nurse to someone else, it can be considered as a breach of the patient's confidence. Fundamentally, the relationship between the nurse and the patient can be seen as having elements of an implied contract, and this includes a promise from the side of the nurse which ensures that any confidential information about their patients will be kept secure (Stuttle, 2006).

The primary means of using digital information in a secure manner are:

1. Restriction of access to computer systems

2. Feasible anonymity with electronically stored records

If either of the two means is not employed, the results for any nurse can lead to hearings, disciplinary actions and even dismissal from service. Castledine (2006) discusses in detail exactly such a case where a nurse's inability to handle information securely led to her eventual dismissal. In the case described by Castledine (2006) the nurse had a habit of leaving patients records screen open on her computer terminal when she went for a break or went away from her computer terminal to perform other activities. Additionally, she was found to have left patient records in her car which allowed anyone to peer through the windows of the car and look at those records. The result of these indiscretions was dismissal from clinical duties.

While digital information sharing with the patient might be important for diagnostic purposes or for discussing treatment, Norwell (2006) suggest that even the arrangement of the consulting room computer screens can be taken as a confidentiality hazard. There were reported cases where people could see through large glass windows in a clinic and observe display screens where some patients' records were clearly visible to them. When this situation was brought to the notice of other practitioners, the arrangements of the screens was changed and the large glass windows were given a dark tint to reduce their opacity.

In case the digital information is to be used for research concerning a disease or a particular accident the patient was involved in, a research ethics committee should clear any research proposals involving access to a patient's records. The committee must be satisfied that arrangements to safeguard disclosure of patient information in research can only be justified with patient consent, and such consent is essential before publication of any individually identifiable personal information. It must be understood that no information system (electronic or paper-based) can ever be considered as foolproof and one hundred percent secure, but nurses are ethically bound to show that they have taken all reasonable steps in order to improve and maintain the security of patient records.

To minimize the remaining chance of unauthorized information disclosure, nurses should not leave patients records in any form, i.e. paper or electronic records anywhere that allows them to be seen by others. The "others" in this statement includes other patients, unauthorized staff personnel and the general public who have come to the health service facility (Norwell, 2006). Civil groups and privacy advocates are continually fighting for more privacy rights for the patients and to make the rules concerning privacy more stringent as technology and the means for security improve (DoBias, 2006).

The times we live in certainly have an effect on how much privacy can be given to individuals and the rude awakening given to us with the terrorist strikes means that the battle for privacy is rather difficult to sustain. Rogers (2006) mentions that the right to keep information secure and the right to privacy are certainly being threatened with a loss of liberties that were previously taken for granted around the world, and nurses have to do their part to make sure the situation is not taken to the extreme.

Finally, whistle blowing is encouraged by the code of ethics and there is an ethical obligation for other nurses to be supportive and understanding when it comes to whistle blowers. This ethical requirement for understanding and support is present because whistle blowers can face negative consequences for their actions (ANA, 2001). This is a problem because whistle blowers are acting perfectly within their rights and are often quite ethically correct when they speak up against illegal or unethical practices yet, they often face resentment from their colleagues and superiors. This is certainly an international problem because nurses around the world face issues while becoming whistle blowers depending on the general culture of the workplace (Harrison, 2003). At the same time, the code of ethics does not ensure any ethical requirement for the social, economic or career based protection of the whistle blower (Caputo, 2006).

Whistle blowing must be differentiated from ordinary complaints against the management, or against other nurses, since whistle blowing activities might even point towards financial fraud and malpractice. These not only hurt the clinic/facility where such practices occur, but also cast a negative light on the nursing profession (Foo, 2006). There is a bright light at the end of the tunnel because in San Antonio, TX, a group of nurses are trying to bring about protection for nurses who act as whistle blowers through legislative and political means. A survey of 600 nurses in Texas shows that over 97% are in favor of whistle blower protection and such laws could improve working conditions as well as the nursing field for all nurses in America (Caputo, 2006).

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