BY CHUKWUEKE V.C. (MRS) RN, RM, BSC (NURSING),MED. DEPT. OF NURSING SERVICES MINISTRY OF HEALTH. OWERRI IMO STATE. AT THE MANDATORY CONTINUING PROFESSIONAL WORKSHOP ORGANIZED BY THE NURSING DEPARTMENT MINISTRY OF HEALTH OWERRI IMO STATE. VENUE: NEWTON HOTEL OFF PORT- HARCOURT ROAD DATE: 7TH -11TH JULY 2014 TIME: 8.00AM DAILY Every society gears towards attainment of optimal health of every individual. All known societies have institutions and various category of personnel that provide health services for the prevention of diseases, promotion of health, treatment of diseases and rehabilitation of victims of chronic illnesses. The health care delivery system is made up of different health professionals who work together in a team. Each professional group is guided by internally enforced codes of practice that members of the profession must follow which are aimed at protecting the consumers of the services and preventing client exploitation as well as preserving the integrity of the profession. These codes of practice are referred to as “professional code of ethics” which are also aimed at ensuring professionalism. The code of ethics or professional ethics for nurses was developed as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession. At the end of this presentation participants will be able to . Define ethics and code of nursing ethics. Discuss the historical background of code of nursing ethics. State the types of ethics. Explain the principles of nursing ethics. Explain the purpose of professional code of ethics / nursing codes of ethics. Discuss the International Council of Nurses (ICN) ethics for nurses. Discuss the Nursing and Midwifery Council of Nigeria’s code of nursing ethics. Discuss why the revised code of nursing ethics was formulated • The free online dictionary defines ethics as a “set of principles of right conduct” a system of moral values being in accordance with the accepted principles of right and wrong that govern the conduct of a profession. • Berman and Snyder (2012) defines “code of ethics” as a formal statement of a group’s ideals and values”. It is a set of ethical principles that is shared by members of the group, reflects their moral judgments over time, and serves as a standard for their professional actions. • Ethics is the branch of philosophy concerned with the meaning of all aspects of human behavior (bomndless.com). • Berman and Snyder (2008) described code of nursing ethics as a formal statement of the ideals and values of nursing and ethical principles that serve as standards for nurses action, concerning a behavior that is normally right for a nurse in professional situations. • The need for an ethical code of nursing was perceived in the 19th century. Some religious communities prepared code of practice for their nurses in consonance with their religious orders called “Rule of life”. According to Babajide (2001), the origin of modern code of nursing ethics is closely linked with Florence Nightingale; one of the earliest nurses who perceived this need in the secular world. It was based on Hippocratic oath dubbed from the medical code. Historically, the Western medical ethics may be traced to guidelines on the duty of physicians as contained in the Hippocratic oath, the early Christian teachings, the Jewish thinkers as well as the writings of Muslim, physicians such as Ishaq, Ali Rahawi who wrote the first book dedicated medical ethics called ‘conduct of physicians’. • By 1893 all expectations from a nurse in that era were formulated in the present Nurses pledge. This has also been revised by the Nursing and Midwifery Council of Nigeria in 2001. The pledge is being recited by student nurses at the beginning and end of their training programme as a guide. • By 1950, the America Nurses Association (ANA) in agreement with this ideal, took the lead by adopting for the first time, an elaborate code of ethics for Nurses. This has been revised several times. The 1985 version is the present. In 1953, the International Council of Nurses (ICN) adopted her first code of nursing ethics. This has been revised too and the 2000 edition is the present one. The National Association of Nigerian Nurses and Midwives (NANNM) has also revised hers in 2001. Professional Nurses Associations of various countries have either adopted the ICN code of Ethics or formulated their own professional Nurses Ethics. There are two types of ethics governing an individual's life in a society. These are personal and the professional ethics. • PERSONAL ETHICS Nwonu in NOUN (2008), Kemp, Pilliteri and Brown (1989) opined that personal ethics refers to a person's moral principle and values acquired as the person develops and matures through life span. An individual code of behavior might include things he ought to do, such as: being honest, spending his time qualitatively in worthwhile activities, helping and being kind to people and things he ought not to do, such as: stealing, telling lies, cheating other people or organization or consciously causing harm to another. Personal ethics are influenced by family, religion, education, peer group and vary in individuals. The same may change or be modified as a result of age, environment, situational influence, economic affluence and religious status. NOUN (2008), Kemp, Pilliteri and Brown (1989) continues to emphasize and refers to it as the formal or informal moral responsibilities peculiar to a profession which are not shared by members of the society. The informal professional ethics are unwritten while the formal ones' are documented ethical codes. Members do not only agree to subscribe to the ethical codes to govern their conduct but also monitors other members of the profession to ensure conformity on them as well. Failure to conform may earn the individual a suspension or a dismissal from the profession. The medical profession is the first recognized profession in the health care industry and therefore, the first to develop a set of professional ethics among the professions in the health care system. This code of ethics shares many principles with other professional ethics such as the nursing and pharmacy codes of ethics. Ethics have been part of nursing practice from the early foundations of modern nursing in the late 19th century. Nursing ethics shares many principles with medical ethics because most parts of nursing ethics have been derived from the medical ethics with specific modifications in certain areas based on the peculiarities of nursing practice. The provisions of the medical ethics which are also similar to those in the other professions in the health care system include. Beneficence, non-maleficence, autonomy, justice, dignity, veracity, confidentiality and fidelity. Berman and Snyder 2012 also identified them as principles of nursing ethics. •Beneficence: This means that the practitioner (nurse, doctor, pharmacist etc.) should act in the best interest of the patient. All health care professionals are therefore, expected to act in the best interest of the patient. They are to implement actions that benefit clients and families. •Non-Maleficience: This means that the health care professional should do no harm to the patient in whatever form or way. • Autonomy: The patient has the right to refuse treatment offered. He/she has the right to self governance. This is an indicator for health and informed consent is implicated. • Justice: This is concerned with the distribution of scarce health resources and the decision of who gets what treatment i.e. the principle of fairness and equity. For example in a situation where two patients condition require much attention. She will need to weigh the facts carefully in order to divide her time justly among her clients. • Dignity: This advocates that the patient and the person treating the patient have the right to dignity the both should be respected. • Veracity: Is concerned with the principle of informed consent where the patient must be fully informed about and be made to understand the potential benefits and risks of their choice of treatment. Health care practitioners should be sincere in dealing with the clients. • Confidentiality: This refers to keeping secret; all information obtained about the patient’s state of health except to those directly involved in the care and the significant others. Confidentiality relates to the concept of privacy. Information obtained from an individual will not be disclosed to another. This has some legal implications in modern day practice of health care. On no account should the nurse divulge the patients information to outsiders. • Fidelity: This means to be faithful to agreements, promises and commitments. Nurses have responsibility to patients, employers, government and society as well as themselves. According to Mitchell (1999) and Berman and Snyder (2012) they purposes are as follows: •It sets guidelines to demonstrate levels of minimum practice required to maintain standards of conducts within the profession. •It informs members and the society of the primary goals and values of the profession. •Ethical codes provide a sign of the profession’s commitment to the public it serves. •It allows the people outside the profession to know the ways members of that profession are expected to consistently act. •Guide the profession in self-regulation •Outline the major ethical consideration of the profession. •Provide ethical standards for professional behavior •Remind nurses of the special responsibility they assume when caring for the sick. •It serves as a mark of professional maturity and professionalism •It serves as a frame work to making ethical decisions as it provides a means of evaluating alternative course of action. The nursing ethics are aimed at regulating and guiding the behavior and conduct of professional nurses in the course of practicing as nurses and in dealing with other professionals as well as the general public. It protects the client from harm and exploitation. According to Babajide (2001), the origin of modern code of nursing ethics is linked with Florence Nightingale who as early as 1857 documented points like providing selfless service to the needy, avoiding harm to the client, providing confidentiality and maintaining high level of personal standard by the nurse. According to the ICN code of ethics for nurses (2006) and Kemp et al (1989), the ICN code of ethics has four principal elements that outline the standards of ethical conduct. These elements are •Nurses and the people •Nurses and practice •Nurses and Profession •Nurses and Co-workers The international council of nursing (1973) made the following thirteen (13) declarations in its code of nursing ethics. 1. The fundamental responsibilities of the nurse are four (4) folds i.e. –A. To promote health –B. To alleviate suffering –C. To restore health –D. To prevent illness 2. Nurses at all times should ensure and maintain the highest standards of nursing care and of professional conduct. •3. The nurse must not only be prepared to practice but shall maintain skill at consistently high level. This could be achieved by continuing educational programs like the MCPDP. •4. Nurses should hold in confidence all personal information entrusted to them. Information about patient’s health should only be made available to those concerned about his/her care and those that may be affected by the health condition. •5. The religion and ethic group of the patient shall be respected. •6. The nurse shall not recommend or give medical treatment without medical prescription except on emergencies/specific cases and should report such actions as soon as possible to the appropriate individuals. •7. The nurse is under obligation to carry out physician prescriptions intelligently and to refuse to participate in unethical procedures. Nurses must therefore be up-to date in nursing and other health care related issues. •8. The nurse should maintain and sustain confidence in the physician and other members of the health team and where incompetence or unethical conduct is exhibited, it should be exposed but only to the appropriate authority. •9. Nurses should not permit their names to be used in connection with the advertisement of products or any other form of personal advertisement. •10. Nurses should co-operate and maintain humorous relationship with members of other professions and other nurses. They should avoid unnecessary misunderstanding, quarrels and conflicts with their professional colleagues and conflicts with their professional colleagues and other members of the health team. •11. The nurse should adhere to standard of personal ethics which reflect credit upon the profession. All forms of professional misconducts within and outside the healthcare facilities should be avoided. •12. The nurse shall always adjust to the environmental changes and patterns of behaviour of the community in which he/she lives and practice provided it is not unethical. •13.The nurse should participate and show responsibility with other citizens and other health professionals in promoting efforts to meet the health needs of the public at local, national and international levels. The Nursing and Midwifery Council of Nigeria (2012) presented a harmonized code of nursing ethics under four (4) main subheadings: 1. Nurses and people 2. Nurses and practice 3. Nurses and profession (Professionalism) 4. Nurses and co-workers. This code of nursing ethics is a statement of the ethical commitments of nurses and midwives and sets the ethical standards by which all cadres of nurses including student nurses in training to conduct their practice from frontline clinicians through to nurse educators and nurse managers. It is intended to empower the professional nurse practitioners to provide effective care to individuals, families and communities. All nurses and midwives practicing in Nigeria must abide by the provisions of the code of ethics. This section demands the followings from the nurse: 1. Decisional capacity: Consent must be obtained from legally accepted individual. The nurse must be aware of all legislations regarding mental capacity and ensure that people who lack mental capacity to decide remain at the centre of decision making and are fully safeguarded. Where a client lacks substitutes as accepted by the law. The nurse must serve as the client advocate especially where their wellbeing is being compromised by family members, community or health professionals e.g. in female genital cutting. The nurse is not obliged to comply with client's wishes when it is contrary to the law or when it unnecessarily endangers his/her life. The nurse must respect the culture, religion and decision making processes of the clients under their care. 2. Confidentiality: Nurses must respect the right of each person to informational privacy. You must ensure that the clients are informed about how and why information is shared by those providing care. The nurse must advocate for clients requesting for access to their health record subject to legal requirements. Person's health information must only be disclosed to authorized persons unless there is a substantial risk to others or as legally required. This is concerned with health care delivery and health information management. Nurses must be committed to the delivery of quality nursing and midwifery care at all times. • Nurses must practice as required by the laws and the provisions of the code of ethics. • The nurse must have the required knowledge and skills for safe and effective practice. • The nurse must continuously update his/her knowledge throughout the professional career in order to develop and maintain competence. • The nurse must recognize and practice within his/her level of competence and seek help from supervisors and other competent practitioners where necessary. • Nurses must also provide care based on available evidence of best practice. • Nurses must advocate for sufficient human and material resources to provide safe and competent care which must be properly distributed. • They must contribute to and promote safe and supportive work environment with respect for human rights, values, customs and spiritual beliefs of the people. • Nurses must maintain high standard of personal health so that the ability to provide care is not compromised. • Every nurse is personally accountable for actions and omissions in the course of practice and must always justify decisions taken. • Nurses must be committed to keeping clear and accurate records of assessments, care and treatment. Records must be completed as soon as possible after an event has occurred. •The nurse must not tamper with original records in any way. All written records must be legible, dated, timed, signed, counter-checked by nursein-charge or a senior nurse and be securely kept. • Nurses must contribute to the positive image and development of the profession. • The nurse must maintain standards of personal conduct which reflect well on the profession. • Nurses must not use their professional status to promote issues that are not related to health e.g. FGM and advertisements. • Nurses must participate in the advancement of the profession by contributing to best practice, education, administration and research. • The nurse must actively participate in determining and implementing acceptable standards of clinical practice, education, administration and research at all times. • The nurse must adhere to approved dress policy at all times. • Nurses must collaborate with colleagues, professional associations, training institutions and other groups to present nursing views in ways that are consistent with their professional roles and capabilities which are in the interest of the public. • The nurse must share responsibility with society for initiating and supporting actions to meet health and social needs of the public especially the vulnerable. The nurse must refuse any gifts, favours or hospitality that might be interpreted as an attempt to gain preferential treatment. The nurse must not ask for or accept any gifts, money, loan or undue favour from anyone in his/her care or any one related or associated with their clients. The nurse must clearly establish and actively maintain clear sexual boundaries at all times with people in his or her team and members of their families. • The nurse must be committed to working effectively as a member of a team. • The nurse must work co-operatively within teams and must respect the rights, skills, expertise and the contribution of every member of the team. • Nurses must be willing to share their skills and experience for the benefit of their colleagues. • The nurse must assist students and others to develop their competence. • The nurse must consult with colleagues where and when necessary and must treat colleagues fairly, with respect and without discrimination. Where delegation of duty or responsibility to another person is required, the competences, knowledge and skills of the person must be ascertained. • Nurses must ensure that the outcome of delegated task meet required professional standard. Referral must be made when it is in the best interest of the client. • The nurse must act without delay if he/she believes that he/she or a colleague or anyone else may be putting someone at risk. • The nurse must inform someone in authority if he/she experiences problems working within this code of ethics or other nationally agreed standards. • The nurse is justified in using reasonable means to protect himself/herself against threatened or actual violence in the course of providing care. • The nurse must admit mistakes and take all necessary actions to prevent or minimize harm arising from adverse event. • The nurse must explain fully and promptly to the persons involved in an adverse event what has happened and the likely effects. • The nurse must give a constructive and honest response to anyone who complains about the care they have received. Someone's complaint should not prejudice the care you render to him/her. • The nurse must seek constructive and collaborative approaches to conflict resolution and must cooperate with internal and external investigations when the need arises. The nurse must take preventive as well as corrective actions to protect persons from incompetent, unethical or unsafe care. Nurses growing awareness that ethical problems arising in their professional; practice has largely occurred due to i. Social and technological changes ii. Nurses conflicting loyalties and obligations. This is the origin so that it can help solve some ethical dilemma according to Berman and Snyder (2012). Social And Technological, Changes Social changes such as women organizations and women's movement have exposed lots of these changes such as; • Work places redesigned under managed care. • The high cost of medical care. • Issues of fairness especially in the distribution of resources whether equally or equitably. • New collegiate system, a change in status of studentship to start and come at par with other professions. • Emphasis on research for professionalism. • • • • • • • • Social And Technological, Changes Technology creates new issues that had not existed in the past E.g. Monitors. Respirators. Parenteral feeding Dialysis Scan x-ray Endoscopy etc. There was no question about whether to allow a premature baby with low birth weight to die, this was obvious. Before organ transplantation, death did not require a legal definition that might still permit viable tissues to be removed and given to other living persons. Social And Technological, Changes • Advances in the ability to decode and control the growth of tissues through gene manipulation, presents new potential ethical dilemma related to cloning organisms and altering the course of hereditary diseases and biological characteristics. • Human experimentation and behavioral control, for wholistic man were not in existence etc. • Today, with treatment that can prolong and enhance biological life, several questions arise e.g. i) Should we go ahead and do what we can? ii) Who should be sophisticatedly treated? iii) Every one or only those who can pay, or only those who have a chance to improve? • The code of ethics for nurses is a formal statement of the ideals and values of nursing and ethical principle that serve as standard to nurses actions. • It maintains the trust of the public in the profession thereby ensuring that the clients continue to enjoy quality services from the nurses. • It is designed to encourage professionalism among nurses and to establish standard of accepted behavior so that both nurse and the public will understand what is permissible from members of the profession. • It also defends the interest of the nurse in the course of her practice. • Where it is well applied quality assurance is achieved. Berman A, Snyders (2008) Kozier and Erb’s Fundamentals of Nursing, concepts, process and practice, ninth edition, New Jersey; Pearson Education Inc. Berman A, Snyders (2012) Kozier and Erb’s fundamentals of Nursing, concepts, process and practice, ninth edition, New Jersey; Pearson Education Inc. Kemp B, B, Pilliteri A, Brown P, (1989), Fundamentals of Nursing A frame work for practice second edition, USA, Scott Foreman and company. Nursing and Midwifery council of Nigeria (2012) The ICN code of ethics for Nurses (2006), International Connial of Nurses. Retrieved 27/6/09. www.freedictionary.com/ethical retrieved20th Sept 2013. www.bomdless.com , management, Ethical Business, Ethics an overview Retrieved 20th Sept.2013.