Module-II

Nursing Ethics

Nursing Ethics 1
 Outline
• Session 1: Introduction to Nursing Ethics

• Session 2: Ethical Principles

• Session 3: Nursing Values

• Session 4: Ethical Dilemmas and Ethical distress in

Nursing
• Session 5: Ethical Decision Making in the Nursing
Practice
• Session 6: Legal Aspects of the Nursing Practice

• Session 7: Nursing Code of Ethics

Nursing Ethics 2
 Session 1

Introduction to
Nursing Ethics

Nursing Ethics
 Session Objectives

 Define Nursing Ethics

Nursing Ethics 4
Brain Storming:

What is Ethics?

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 Nursing Ethics
 Derived from the Greek word “ethos”,
means custom or guiding beliefs.

 Rules of conduct

 Determines the characteristics of a

profession and is also called as a
“code of conduct”.
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 Nursing Ethics

 Provides the professional standards for nursing

activities, which
 protect the nurses and the patients from legal and ethical
issues.
 Concerned with fundamental principles of right and

wrong and what people ought to do

 Inform our judgments and values and help individuals

decide on how to act

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 Nursing Ethics

 According to ANA code of ethics for nurses serve

 Ethical obligations and duties of every person
who chooses to enter the profession of nursing.
 To act as the nonnegotiable standard of ethics
 To serve as an expression of the understanding
on nursing’s commitment to society.

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 Session 2

Ethical
Principles

Nursing Ethics
 Session Objectives

 Identify Principles of Nursing Ethics

 Analyze Principles of Nursing Ethics

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Activity: 5 Minutes

State Principles of
Ethics You Know

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 Ethical Principles

 Provide criteria on which to base

judgments in relation to ethical theories.
 Ethical principles include:
i. Beneficence v. Veracity
ii. Non-maleficence vi. Fidelity
iii. Respect for vii. Privacy and
Autonomy
Confidentiality
iv. Justice
viii.Paternalism

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 Ethical Principles

Beneficence - to do good
 This is done by:
 Providing health benefits to the clients.
 Balancing the benefits and risks of harm.
 Considering how a client can be best
helped.
 Example: Page 50

Nursing Ethics 13
 Ethical Principles

Non Maleficence: To do no harm

 Avoidance of harm or hurt;
 Avoiding deliberate harm, risk of harm that
occurs during the performance of nursing
actions.
 Determining whether the use of technological
advances provides benefits that outweigh risks.
 Example: Page 51

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 Ethical Principles

Autonomy:
 individuals right to self-determination
 individuals right to make decisions about their
lives without interference from others.
 Respecting a client’s rights, values and choices
 Informed consent is a method that promotes
and respects a person’s autonomy.
 Example: Page 51

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 Ethical Principles

Justice
 Equal and fair distribution of resources,

 based on analysis of benefits and

burdens of decision.

 Example: Page 52

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 Ethical Principles

Veracity: Duty to tell the truth

 Not intentionally deceive or mislead
clients.
 The nurse should be truthful to the
patient
 After decision is made, the nurse should
be truthful to the patient.
 Tell him the decision and why they chose
it.
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 Ethical Principles

Fidelity: Duty to Keep Promises

 Requires loyalty, fairness, truthfulness,
advocacy, and dedication to our
patients.
 It involves an agreement to keep our
promises.
 Keeping a commitment
 Example: Page 53
Nursing Ethics 18
 Ethical Principles

Privacy and Confidentiality

 Privacy belongs to each person and, as such, it

cannot be taken away from that person unless

he/she wishes to share it.

 Confidentiality, on the other hand, means that the

information shared with other persons will not be

spread abroad and will be used only for the

purposes intended.
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 Ethical Principles

Paternalism
 Healthcare professionals make decisions about diagnosis,
therapy, and prognosis for the patient.
 is characterized by the professional acting on behalf of and
in the best interest of the patient.
 Paternalism is commonly agreed to be the overriding of an
individual's autonomy, for the purpose of acting in his best
interests.
 is closely associated with the principles beneficence and
non-maleficence
 Its is always the desire to safeguard an individual's best
interest
 Example: Page 53
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Group Activity
• Discuss on the issue for 5
Minutes
• Come back to the larger
class and discuss ( 30
minutes)
• Discussion Questions:
• What is the ethical issue?
• What should you do?
Nursing Ethics 24
 Session 3

Nursing values and

moral values

Nursing Ethics
 Learning Objectives:

At the end of this session, participants

will be able to:
 Explain nursing values

 Explain ideal nurse ethical

competencies

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Activity: 5 Minutes
 Why do you think being a nurse is
important, worthwhile and worth
striving for?
 What do you think the nurse should
value most and why?
 Have you ever felt you are maintaining
these values?
 If not why and what should be done to
maintain these values?
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 Definition Nursing Value

Values
“What is important, worthwhile
and worth striving for and made
who we are as individuals.”
• Values are also beliefs that are
considered to be socially and
personally desirable
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 Values

• Are unwritten standards, ideals, or concepts

• Give meaning to a person’s life and
• Serve as a guide for making decisions and
setting priorities in daily life.
• Are impacted by the society, culture, morals
and beliefs
• Are related and overlapping.

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Professional nursing values

• The term refers to the attitudes, beliefs,

and priorities of nurses
• Ultimately functions as a guide and
motivation in nurses interactions
• They are the guiding beliefs and principles
that influence nurses work behaviour.
• Individually held and shared among nurses

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Ideal Nursing Ethical
Competencies
Activity 3 Minutes
1. What are the characteristics
of an ideal nurse?
2. To what extent nurses are
applying these
characteristics?

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 10 Ideal Nurse
Competencies
2. Communication:
1. Moral integrity:
i. Honesty vi. Mindfulness and

ii. Truthfulness and vii. Effective listening; and

3. Concern:
truth telling,
viii.Advocacy
iii. Benevolence
ix. Power and
iv. Wisdom and

v. Moral courage; x. Culturally sensitive care

Nursing Ethics 32
 1. Moral Integrity

“State of being, acting like, and

becoming a certain kind of person. This
person is honest, trustworthy, consistently
doing the right thing and standing up for
what is right despite the consequences”
(Laabs’s, 2011).

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 1. Moral Integrity
People with moral integrity:
 Pursue a moral purpose in life,
 Understand their moral obligations in the
community
 Committed to execute good and right actions
using rational application

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 i. Honesty
 It is being real, genuine, authentic, and
bona fide
 Nurses must
 Stay true to their word.
 Stay committed to their promises to
patients and
 Follow through with appropriate behaviours,
 Such as returning to patients’ hospital rooms
as promised to help them with certain tasks.
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 ii. Truthfulness and truth
telling
 It is the intermediate state between imposture
(excessiveness) and self-depreciation
(deficiency).
 Being genuine in all words and deeds and is
never false or phony.
• Nurses
 Are usually ethically obligated to tell the truth and
 Are not intentionally to deceive or mislead
patients
Case study ( Page 62)
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 iii. Benevolence
 “morally valuable character trait, or
virtue, of being disposed to act to
benefit others”
 Characterizations of a benevolent
person
 Altruistic, kind-hearted, caring, courteous, and warm-
hearted
 Common descriptors
 compassionate care, kindness

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 iii. Benevolence

 Benevolence is a central motivating factor

 Nurses has to seek out ways to perform

acts of kindness rather than only
recognizing ways to do good

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 iv. Wisdom
• Requires calculated intellectual ability,
contemplation, deliberation, and efforts to
achieve a worthy goal.

• Develops with intellectual accomplishment,

and practical expertise

• Nurses must have the feature of intellectual

accomplishment and the proclivity to seek the
right and the good
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 v. Moral Courage

Nurses with moral courage

• Stand up for or act upon ethical principles to do what is
right
• Make a personal sacrifice for what they believe is the
right
• Choose ethically right decision, even when under intense
pressure
• Act according to their core values, beliefs, or moral
conscience.

• Examples: Page 63-63

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 2. Communication

• Effective communication nurtures

relationships and is fundamental to
nursing

• To be effective, nurses must reside in

a state of mindfulness and be an
effective listener.

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 vi. Mindfulness

• Mindful nurses
– Are engaged and attentive in their activities
or roles by continuously analysing,
categorizing, and distinguishing data
– Pay close attention to their attitudes and
find ethical ways to interact and behave.

• Mindlessness
– State of unawareness and not focusing,
similar to functioning in autopilot mode
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 vi. Mindfulness
• Examples of the benefits of mindfulness
– Reduces stress, negative emotions, and
depression
– Enhances attention skills and focusing
– Enhances communication skills
– Promotes more positive relationships
– Increases memory and learning capacity
– Increases the ability for a deeper type of
empathy, compassion, serenity, and altruism

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 vii. Effective Listening

Without effective listening nurses

– Cannot respond appropriately no matter how
well-meaning a person’s intention of listening
is.
– Will not give competent care and
– Misinterpret facts, physician’s orders, or
patient interactions.

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 3. Concern
• Sense of responsibility about scope of care
important for patients
• Often it prompts nurses to action.
• composes
i. Being an advocate,
ii. Using power, and
iii. Giving culturally sensitive care

Nursing Ethics 45
 viii. Advocacy

• Is pleading in favour of or supporting a

case, person, group, or cause,
• Three central characteristics :
– Safeguarding patients’ autonomy

– Acting on behalf of patients

– Championing social justice in the provision of

health care (Jezewski, 2006)
Nursing Ethics 46
 vii. Advocacy
Barriers to nursing advocacy (Hanks, 2007)

• Conflicts of interest between the nurse’s moral

obligation to the patient and the nurse’s sense of
duty to the institution

• Institutional constraints

• Lack of education and time

• Threats of punishment

• Barrier related to nurses’ expectations of a

subservient duty to medical doctors
Nursing Ethics 47
 ix. Power

• Nurses with power have the ability to

influence persons, groups, or
communities.
• Nurses are in powerful positions to
– improve quality of inpatient care and
– oversee professional nursing practice
standards.
• Properties of a powerful professional
nursing practice : Page 65
Nursing Ethics 48
 x. Culturally Sensitive
Care
• Cultural competence is the
adaptation of care in a manner that
is consistent with the culture of the
client

• Nurses must first have a basic

knowledge of culturally diverse
customs and act accordingly

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 The Most Important Qualities of a
Professional Nurse
They will be the nurse that patients
want
• To be on shift to look after them:

• To take care of them, speak up for

them, soothe them, monitor them
and
• Make sure they are getting the best
possible care in the circumstances.
 10 Ideal Nurse
Competencies
2. Communication:
1. Moral integrity:
i. Honesty vi. Mindfulness and

ii. Truthfulness and vii. Effective listening; and

3. Concern:
truth telling,
viii.Advocacy
iii. Benevolence
ix. Power and
iv. Wisdom and

v. Moral courage; x. Culturally sensitive care

Nursing Ethics 51
 Session 4

Ethical dilemma and distress

in nursing practice

Nursing Ethics
 Session objectives

 Describe elements of ethical dilemma and

distress
 Apply Ethical decision-making models to
solve ethical dilemmas and distress

Nursing Ethics 53
 Ethical dilemmas
Activity (5 Minutes)
• Have you ever felt difficulty to
choose between two or more options
that will affect the outcome of the
patient you care for?
• Have you ever felt frustration
because all possible options have
both positive and negative
consequences?
Nursing Ethics 54
 Ethical dilemmas

• Is situations when
– Equally compelling ethical reasons both
for and against a particular course of
action are recognized,
– Appropriate choice in the situation is
unclear
– And a decision must be made
• Although each option can be justified
as “good,” both have pros and cons
Nursing Ethics 55
 Ethical dilemmas

• It creates uncertainty in the outcome

• May or may not be the same decision

that others believe is the right
decision.

• The DECIDE model to achieve morally

and ethically sound decisions (page
69)
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 Ethical dilemmas

• Activity (page 70)

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 Ethical/Moral distress

• Activity (page 70)

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 Ethical/Moral distress

Moral/ethical distress is an emotion

that occurs when nurses have identified and
know what right response is called for, but
institutional or other constraints make it
almost impossible to pursue the right course
of action (Jameton, 1984).

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 Ethical/Moral distress

• Has situational, cognitive, action, and feeling

dimensions,
• Has short- and long-term effects
• Result in significant physical and emotional
stress,
• Contributes to nurses’ feelings of loss of integrity
and dissatisfaction
• Affects relationships with patients and others
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• Affect the quality, quantity, and cost of nursing
 Ethical/Moral distress

• Groups of people who work together in situations

that cause distress may experience
– Poor communication,
– Lack of trust,
– High turnover rates,
– Defensiveness, and

– Lack of collaboration across disciplines.

Nursing Ethics 61
 Ethical/Moral distress
Moral distress is
• Ineffective policy,
linked to
• Incompetent or poor
• Futile care,
care, • Unsuccessful
• Unsafe or inadequate advocacy,
staffing, • The current
• Overwork, definition of brain
• Cost constraints, death,
• Low job satisfaction • Objectification of
• Nurses turnover patients, and
• Unrealistic hope
Nursing Ethics 62
 Ethical/Moral distress

Four A’s to Rise Above Moral Distress (2004)

1. Ask appropriate questions to become aware that moral

distress is present.

2. Affirm your distress and commitment to take care of yourself

and address moral distress.

3. Assess sources of your moral distress to prepare for an action

plan.

4. Act to implement strategies for changes to preserve your

integrity and authenticity

Activity (page72)
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 Ethical/Moral distress

• Activity (page 70)

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Ethical dilemma and
distress

Case studies (page 71 to

73)

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 Session 5

Ethical Decision Making

in the Nursing Practice

Nursing Ethics
 Session Objectives

• Identify appropriate ethical decision

making procedures
• Demonstrate sound ethical decision
making ability

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Brain Storming

What is ethically
sound decision?

Nursing Ethics 68
 Introduction

• Ethical questions are a challenge to navigate

• Consider the following issues:

• multiple clinical facts

• Patient values & preferences

• Concerns and values of family

• Contextual features including law

• In some cases quick decision may be required

Nursing Ethics 69
 The Four Quadrant
Approach
• Provides a framework for sorting
through and focusing on specific
aspects of clinical ethics cases
• Connects the circumstances of a case
to their underlying ethical principles

Nursing Ethics 70
 The Four Quadrant
Approach
The quadrants:
1. Medical indications
2. Patient preferences
3. Quality of life
4. Contextual features
• Page 75

Nursing Ethics 71
The Four Quadrant
Approach

• Case study
participants manual
page 76

Nursing Ethics 72
 Session Summary

• What are the things you need to

consider in order to reach into sound
ethical decision?

Nursing Ethics 73
 Session 6

Legal Aspects of the

Nursing Practice

Nursing Ethics
 Session Objectives

• describe general legal concepts of

nursing
• discuss legal issues in relation to the
nursing practice

Nursing Ethics 75
Activity

• Case scenario:
participant’s
manual page 77

Nursing Ethics 76
 Functions of law in nursing
• Establishes legal ground for patient care

• Differentiates the nurses’ responsibilities

• Shows the boundaries of independent

nursing action
• Maintains standard of care (accountability)

Nursing Ethics 77
Activity

Cases scenario:
participant’s
manual page 79

Nursing Ethics 78
Negligence and malpractice

Malpractice
– wrongful conduct
– improper discharge of
professional duties
– failure to meet the standards of
acceptable care

Nursing Ethics 79
Negligence and malpractice
…
Negligence (breach of duty)
• is the failure of an individual to provide
care that a reasonable person would
ordinarily use in a similar circumstance.

Nursing Ethics 80
 Assault and Battery

• Assault: is the intentional & unlawful offer

to touch a person in an offensive, insulting
or physically intimidating manner.
• Battery: is the touching of another person
without the person’s consent

Nursing Ethics 81
 Selected Legal Aspects of
Nursing Practice
• Informed consent
• Delegation
• Violence, Abuse, and Neglect

Nursing Ethics 82
 Informed Consent
Major elements:
– The consent must be voluntary
– The consent must be given by a client
who is capable and competent to
understand
– The client must be given enough
information to be the ultimate decision
maker
– It is the responsibility of the person who
performs the procedure
Nursing Ethics 83
 Informed Consent …
Information to be given:
– Diagnosis or condition that requires
treatment
– Purpose of treatment
– What the client can expect to feel or
experience
– The intended benefits of the procedure
– Possible risks
– Advantages and disadvantages of
alternatives to treatment (including no
treatment)
Nursing Ethics 84
 Delegation

• Does the Nurse Practice Act (if any)

permit delegation?
• Is there a list of procedure a nurse
can delegate?
• Are there guidelines explaining the
nurse’s responsibilities when
delegating?

Nursing Ethics 85
 Violence, Abuse, and
Neglect
• the nurse must report the situation to
the appropriate authority.

Nursing Ethics 86
 Legal Responsibilities in
Nursing

• Common-sense precautions
Follow accepted procedures
• Be competent in practice
• Ask for assistance
• Document well
• Do not give legal advice to clients
• Do not accept gifts
Nursing Ethics 87
 Federal Ministry of
Health

Session-7
Nursing Code of Ethics

Nursing Ethics CH-

III-3
 Session objectives

At the end of this session, participants

will be able to:

•Explain the nursing code of ethics

Nursing Ethics 89
Brain Storming:

What is nursing
code of ethics?

Nursing Ethics 90
Nurses’ professional code of Ethics

• Modular

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Nursing Ethics 92
Nursing Ethics 93
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