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c h a p t e r
3
© Jones & Bartlett Learning,
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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC
Ethics in Professional
NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Nursing Practice
Jones & Bartlett Learning, LLC
Janie B. Butts © Jones & Bartlett Learning, LLC
Nursing is a profession that has its own code of conduct, its own philosophic views,
and its own place in the health care team. . . .Nurses work under their own license.
That means that nurses are completely responsible for their work.
—JANET &
© Jones R. K ATZ, 2007, A CAREER IN NURSING: IS IT RIGHT FOR ME?, P. 105
Bartlett Learning, LLC © Jones & Bartlett Learning,
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OBJECTIVES
After reading this chapter, the reader should be able to:

1. Distinguish between nursing ethics, medical ethics, and bioethics.
NOT FOR2.SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Delineate key historical events that led to the development of the current
American Nurses Association (ANA) and International Council of Nurses (ICN)
codes of ethics for nurses.
3. Discuss examples of professional nursing boundaries and ways that boundary
Jones & Bartlett Learning,
crossingsLLC
can occur. © Jones & Bartlett Learning, LLC
OT FOR SALE OR DISTRIBUTION
4. Examine the ethical nurse qualities NOTin FOR
discussed the ANASALE
and ICNOR
codesDISTRIBUTION
(see also
Appendices A and B).
5. Contrast moral distress from moral integrity.
6. Recall ways a nurse can discern whether another nurse’s character fits Aristotle’s
description of the truthful sort.
© Jones
7. Define & Bartlett
truthtelling Learning,
in terms of two LLC deontology and a virtue© Jones & Bartlett Learning,
ethical frameworks:
NOT
ethics FOR SALE OR DISTRIBUTION
approach. NOT FOR SALE OR DISTRIB
8. Examine the ethical implications of caring for a dying patient whose physician
exercised therapeutic privilege by not disclosing the whole truth.
9. Describe examples of scenarios that would prompt a nurse to respond with
moral courage. © Jones & Bartlett Learning, LLC
69
© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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70 CHAPTER 3: Ethics in Professional Nursing Practice
© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,

NOT FOR SALE OR
10. Compare DISTRIBUTION
patient NOT FOR SALE OR DISTRIB
advocacy and power in relation to nurses’ everyday
ethical work.
11. Formulate a plan for assessing a culturally diverse patient who is a new
admission to a hospital unit.
12. Characterize two types of relationships: the nurse–physician relationship
and the nurse–nurse relationship.
NOT FOR SALE OR13. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Weigh nurses’ use of social networking in terms of professional ethical
considerations.
Jones & Bartlett Learning, LLC © Jones

Introduction to Nursing Ethics& Bartlett Learning, LLC
Bioethical issues are relevant to nurses’ work in everyday practice, but in matters
of bioethics nurses usually are not autonomous decision makers. Nursing ethics,
as a unique field, continues to be debated. Fry, Veatch, and Taylor (2011) continue
to support the view that both nursing ethics and medical ethics are valid subcate-
© Jones
gories& of Bartlett Learning,
the larger field LLC
of bioethics. © Jones
Additional views are that everyday & Bartlett Learning,
ethical
NOT practice
FOR SALE in nursingORis DISTRIBUTION
situated within an interdisciplinary team and NOTthatFOR SALE OR DISTRIB
nursing
ethics is distinctive from other disciplines in bioethics but is not yet unique (Volker,
2003; Holm, 2006; Wright & Brajtman, 2011).
The experiences and needs of practicing nurses, along with explorations of the
meaning
© Jones & Bartlett Learning, of nursing
LLCethics, are areas of emphasis in nursing
© Jones ethics. Johnstone
& Bartlett Learning, LLC
(2008) defined nursing ethics as “the examination of all kinds of ethical and
bioethical issues from the perspective of nursing theory and practice, which, in
turn, rest on the agreed core concepts of nursing, namely: person, culture, care,
health, healing, environment and nursing itself” (p. 16).
Johnstone’s definition of nursing ethics is consistent with a common view that a
strong bond between nursing ethics & Bartlett
and nursing Learning,
theory distinguishes LLCethics
nursing
OT FOR SALE OR DISTRIBUTION from other areas of healthcareNOT FOR SALE OR DISTRIBUTION
ethics. Nurses’ professional relationships to patient
care and within the healthcare team bring about ethical issues unique to the nursing
profession. To practice nursing ethically, nurses must be sensitive enough to recog-
nize when they are facing seemingly obscure ethical issues in everyday work.
© Jones & Bartlett

Professional Learning,
Codes LLCin Nursing
of Ethics © Jones & Bartlett Learning,
Professional nursing can be traced to England in the 1800s, to the school that was
founded by Florence Nightingale, where profession-shaping ethical precepts and
values were communicated. By the end of the 1800s, modern nursing had been
established, and ethics was becoming a discussion topic in nursing. The Nightin-
© Jones & Bartlettgale
Learning, LLC
Pledge of 1893 © Jones
was written under the chairmanship & Bartlett
of a Detroit nursingLearning,
school LLC
principal, Lystra Gretter, to establish nursing as an art and a science. Six years later,
in 1899, the International Council of Nurses (ICN) was established and became
known as a pioneer in developing a code of ethics for nurses.

Professional Codes of Ethics in Nursing 71
By the©turn
Jones
of the & Bartlett
20th Learning,
century, the LLC
first book on nursing ethics, titled Nursing© Jones & Bartlett Learning,
NOT
Ethics: For FOR
Hospital andSALE OR(1900),
Private Use had been written by an American nurseNOT FOR SALE OR DISTRIB
DISTRIBUTION
leader, Isabel Hampton Robb. In Robb’s book, the titles of the chapters were
descriptive of the times and moral milieu, such as Chapter 4: The Probationer,
Chapter 7: Uniform, Chapter 8: Night-Duty, and Chapter 12: The Care of the
Patient (nurse–physician, nurse–nurse, nurse–public relationships). The focus in
the nursing code initially was on physicians, because, typically, male physicians
trained nurses in the Nightingale era. Nurses’ technical training and obedience to
physicians remained at the forefront of nursing responsibilities into the 1960s. This
emphasis was reflected in the ICN Code of Ethics for Nurses as late as 1965. How-
ever, by 1973, the ICN code reflected a shift in nursing responsibility from a focus
on obedience to © needs,
physicians to a focus on patient Jones & Bartlett
where it remains toLearning,
this day. LLC
American Nurses Association’s Code of Ethics for Nurses
“A Suggested Code” was published in the American Journal of Nursing (AJN) in 1926
by the American Nurses Association (ANA), but was never adopted; in 1940 “A Ten-
tative Code” was published
© Jones in AJN, but
& Bartlett again was never
Learning, LLC adopted (Davis, Fowler, and© Jones & Bartlett Learning,
Aroskar, 2010). The ANA adopted its first official code in 1950. Three more code revi-
sions occurred before the creation of the interpretative statements in 1976.
The word “ethics” was not added to the title until the 1985 code was replaced
with its sixth and latest revision in 2001. Within the code are nine moral provisions
that are nonnegotiable with regard to nurses’ work. Detailed guidelines for clinical
© Jones & Bartlett
practice, Learning,
education, LLC
research, administration, © Jones
and self-development & Bartlett
are found in Learning, LLC
the accompanying interpretive statements of each provision (seeNOT FOR ASALE
Appendix for OR DISTRIBUTION
the ANA Code of Ethics for Nurses with Interpretive Statements).
A clear patient focus in the 2001 code obliges nurses to remain attentive and
loyal to each patient in their care, but nurses must also be cognizant of ethical issues
and conflicts of interest that potentially have a negative effect on patient care and
relationships with patients. Other forces to be reckoned with in today’s environ-
OT FOR SALE ORmentDISTRIBUTION NOT FOR
are the politics in institutions and cost-cutting SALE
strategic ORBox
plans (see DISTRIBUTION
3.1).
In the code, the ANA (2001) emphasized the need for the habitual practice of
virtues such as wisdom, honesty, and courage, because these virtues reflect a
morally good person and promote the values of human dignity, well-being, respect,
© Jones
health, and & Bartlett
independence. Values inLearning, LLC what is important for the© Jones & Bartlett Learning,
nursing emphasize
NOT FOR SALE OR DISTRIBUTIONthe magnitude of moralNOT FOR SALE OR DISTRIB
nurse personally and for patients. The ANA emphasized
respect for all human beings, including the respect of nurses for themselves. Per-
sonal regard involves nurses extending attention and care to their own requisite
needs, as nurses who do not regard themselves as worthy of care usually cannot
fully care for others. Recognizing the dignity of oneself and of each patient is essen-
tial in moral reasoning. There are other statements in the code about wholeness of
character, which pertains to recognizing the values of the nursing NOT FOR SALE
profession and OR DISTRIBUTION
one’s own authentic moral values, integrating these belief systems, and then
expressing them appropriately.
BOX 3.1
©ETHICAL
JonesFORMATIONS:
CODE OF ETHICS APPLICATION
In the Code of Ethics for Nurses with Interpretive Statements, the ANA currently emphasizes the
word “patient” instead of the word “client” in referring to the recipients of nursing care. Do you
agree with this change? Please explain your rationale for your answer.
Take a few minutes to review the ANA Code of Ethics for Nurses with Interpretive Statements
(2001) in Appendix A. In your view, should there be additional provisions of the code? Would you
remove any of the nine provisions? Please explain your rationale forNOTyourFOR SALE OR DISTRIBUTION
answers.
After reviewing the interpretive statements in the code, discuss random brief scenarios on how
nurses can justify their actions with the following approaches or frameworks: the principles of
autonomy, beneficence, nonmaleficence, and justice; Kant’s categorical imperatives based on
deontology; a LLC © Jones
utilitarian framework; a virtue ethics & and
approach; Bartlett
an ethicLearning, LLC
of care approach.
International Council of Nurses’ Code of Ethics for Nurses
In 1953, the ICN adopted its first code of ethics for nurses. (See Appendix B for the
2006 ICN Code of Ethics for Nurses.) The multiple revisions illustrate a reaffirma-
© Jones
tion of&the
Bartlett Learning,
code as a universal globalLLC
document for ethical practice©in Jones & Bartlett Learning,
nursing. The
NOT four
FOR SALE OR DISTRIBUTION NOT FOR
major elements contained in the code involve standards related to nurses and SALE OR DISTRIB
people, practice, the profession, and coworkers. The elements in the code form a
framework that must be internalized before it can be used as a guide for nursing
conduct in practice, education, research, and leadership.
Common Thread between American Nurses Association and
NOT FOR SALE OR International Council of Nurses Codes NOT FOR SALE OR DISTRIBUTION
DISTRIBUTION
A common theme between the ANA (2001) and ICN (2006) codes is a focus on the
importance of compassionate patient care aimed at alleviating suffering. Nurses are
to support patients’ self-determination and are to protect the moral space where
patients receive care. The interests & Bartlett
of various Learning,
nursing associations and LLC
healthcare
OT FOR SALE OR DISTRIBUTION institutions must not be placedNOT FOR
above thoseSALE ORNurses
of patients. DISTRIBUTION
are to uphold the
moral agreement that they make with patients and communities when they join the
nursing profession. Nursing care includes the primary responsibilities of pro-
moting health and preventing illness, but the primacy of nursing care has always
© Jones & Bartlett
involved Learning,
caring for patients who areLLC ©physical,
experiencing varying degrees of Jonespsy- & Bartlett Learning,
chological, and spiritual suffering.
Professional Boundaries in Nursing
Professional ethical codes serve as useful, systematic, normative guidelines for pro-
viding direction and shaping behavior. The ANA and ICN codes apply to all nurses
regardless of their role, although no code can provide a complete and absolute set
NOT FOR SALE OR DISTRIBUTION NOT
of rules free of conflict and ambiguity—a rationale FOR
often citedSALE
in favorOR DISTRIBUTION
of the use
of virtue ethics as a better approach to ethics (Beauchamp & Childress, 2009).

Qualities of Ethical Nurses 73
Some© Jones
people & Bartlett
contend that nursesLearning, LLC
who are without a virtuous character cannot© Jones & Bartlett Learning,
NOTonFOR
be depended to act SALE OR
in good or DISTRIBUTION
moral ways, even with a professional code as aNOT FOR SALE OR DISTRIB
guide. In the 30th-anniversary issue in 2006 of the Journal of Advanced Nursing,
the editors reprinted and revisited a 1996 article by Esterhuizen titled, “Is the
Professional Code Still the Cornerstone of Clinical Nursing Practice?”, and
solicited three responses. One respondent, Tschudin, agreed with Esterhuizen
that nursing lacks opportunities for full autonomy in moral decision making.
There is abundant ground for nurses to engage in moral decisions, but they still
do not have enough opportunity to participate. In the current uncertain moral
landscape, nurses often wonder about the benefit of codes of ethics. Tschudin’s
key message was that virtuous nurses with full autonomy and accountability have
Jones & Bartlett Learning, LLCcompass to guide their practice
an internal moral © Jones and do&not
Bartlett Learning,
necessarily need a LLC
OT FOR SALE ORcodeDISTRIBUTION
of ethics. NOT FOR SALE OR DISTRIBUTION
However one perceives the value of the codes of ethics for nurses, they still serve
as mandates for accountability in practice. Professional boundary issues occur in
all settings of nursing. Professional nursing boundaries are commonly defined as
limits that protect the space between the nurse’s professional power and the
patient’s vulnerabilities. Boundaries facilitate a safe connection in a relationship,
because they give each person in the relationship a sense of legitimate control,NOT FOR SALE OR DISTRIB
whether the relationships are between the nurse and patient, the nurse and physi-
cian, the nurse and administrator, or nurse and nurse. Boundary crossings or vio-
lations are actions that do not promote the best interest of the other person(s) in a
© Jones & Bartlett
relationship; Learning,
crossings LLC risk, harm, or exploitation
pose a potential © Jones & Bartlett Learning, LLC
to the other(s)
NOT FOR in theSALE OR DISTRIBUTION
relationship. The blurring of boundaries between personsNOT FOR SALE OR DISTRIBUTION
in a relationship
is often subtle and unrecognizable at first. The ANA (2001) included numerous
boundary issues in the code. See Box 3.2 for a few examples of these boundary
topics and moral obligations.

Qualities of Ethical Nurses © Jones & Bartlett Learning, LLC
Numerous qualities, or virtues, could describe the ideal ethical nurse. The foremost
quality, often considered the fiber for all others, is moral integrity. Some people
believe that moral integrity is necessary for the individual as a whole to flourish. A
person with moral integrity usually is described as having honesty, truthfulness, trust-
© Jones
worthiness, & Bartlettand
courage, benevolence, Learning, LLC
wisdom. In this section, there is a discussion© Jones & Bartlett Learning,
NOT
of (1) moral FOR SALE OR
integrity—honesty, DISTRIBUTION
truthfulness, and moral courage; (2) concern—NOT FOR SALE OR DISTRIB
advocacy and power; and (3) culturally sensitive care. Other qualities, such as respect
for others and confidentiality, are explored in the previous chapter.
Moral
© Jones Integrity
& Bartlett Learning, LLC © Jones & Bartlett Learning, LLC
NOT FOR SALE
Moral OR
integrity DISTRIBUTION
represents NOT
a person’s wholeness of character. T. FOR(2004)
G. Plante SALE OR DISTRIBUTION
stated that although no one is mistake free, people with moral integrity follow a

BOX 3.2 ©ETHICAL

JonesFORMATIONS:
& Bartlett Learning, LLC BOUNDARIES AND MORAL
PROFESSIONAL © Jones & Bartlett Learning,
OBLIGATIONS FOR NURSES AS SPECIFIED BY THE ANA CODE OF ETHICSNOT
NOT FOR SALE OR DISTRIBUTION FOR FOR SALE OR DISTRIB
NURSES WITH INTERPRETIVE STATEMENTS (2001)
Clinical Practice Boundaries

Respecting patients’ dignity
© Jones & to
Right Bartlett Learning, LLC
self-determination © Jones & Bartlett Learning, LLC
NOT FOR SALE
Delegating OR
tasks DISTRIBUTION
appropriately NOT FOR SALE OR DISTRIBUTION
Practicing good judgment
Accepting accountability in practice
Alleviating suffering
Being attentive to patients’ interests
Working withinLLC © Jones
the nurse practice acts and nursing & of
standards Bartlett
practice Learning, LLC
Professional Practice Boundaries
Maintaining authenticity in all relationships with others, such as nurse-to-nurse relationships,
nurse–physician relationships, nurse-to-patient relationships, and multidisciplinary collaboration
Addressing and evaluating issues of impaired practice; fraternizing inappropriately with patients
or others;©accepting
Jonesinappropriate
& Bartlettgifts Learning,
from patientsLLC © privacy
and families; confidentiality and Jones & Bartlett Learning,
NOT
violations; FOR SALE
and unhealthy, unsafe,OR DISTRIBUTION
illegal, or unethical environments NOT FOR SALE OR DISTRIB
Self-Care and Self-Development Boundaries and Obligations
Participating in self-care activities to maintain and promote moral self-respect, professional
growth and competence, wholeness of character in nurses’ actions and in relationships with
© Jones & Bartlett
others, Learning,
and preservation LLC
of integrity © Jones & Bartlett Learning, LLC
Advancing knowledge and NOTeducation,
research through professionalism, practice, FOR SALE and OR DISTRIBUTION
administrative contributions
Collaborating with other healthcare professionals and the public to promote community,
national, and international efforts
Promoting healthy practices in the community through political activism or professional
organizations by addressing unsafe, unethical, © Jones
or illegal & Bartlett
health Learning,
practices that LLC
have the potential
to harm the community NOT FOR SALE OR DISTRIBUTION
moral compass and usually they do not vary by appeals to act immorally. Most of
the time, when people speak of a person’s moral integrity, they are referring to a
© Jones & quality
person’s Bartlett Learning, LLC
of character. © Jones & Bartlett Learning,
People with moral integrity pursue a moral purpose in life, NOT FOR
understand SALE OR DISTRIB
their
moral obligations in the community, and are committed to following through
without any constraints imposed on them by their moral stance. In a qualitative
study on moral integrity by Laabs (2011), nurses’ perceptions of the definition of
moral integrity were, “[A] state of being, acting like, and becoming a certain kind
© Jones & BartlettofLearning, LLC © Jones & Bartlett Learning, LLC
person. This person is honest, trustworthy, consistently doing the right thing and
NOT FOR SALE OR DISTRIBUTION NOT FOR
standing up for what is right despite the consequences” SALE OR DISTRIBUTION
(p. 433).

© Jones
Features of moral&integrity
Bartlett Learning,
include LLC intent, and performance.© Jones & Bartlett Learning,
good character,
Nurses withNOT FOR
moral SALE
integrity OR DISTRIBUTION
act consistently with personal and professional values.NOT FOR SALE OR DISTRIB
When nurses are asked or pressured to do something that conflicts with their values,
such as to falsify records, deceive patients, or accept verbal abuse from others, moral
distress may occur. In a healthcare system often burdened with constraints of poli-
tics, self-serving groups or interests, and organizational bureaucracy, threats to moral
integrity can be a serious pitfall for nurses. When nurses with moral integrity must
compromise, the compromise usually does not interfere with their personal or pro-
fessional values. To have moral integrity means that a person’s character is made of
up several virtues; three of those virtues are honesty, truthfulness, and moral courage.
Moral Distress
Moral distress occurs when nurses or other healthcare professionals have multiple
or dual expectations and cannot act according to the guidance of their moral
integrity. Jameton (1984) popularized and defined the term moral distress as
occurring “when one knows the right thing to do, but institutional constraints
make it nearly impossible to pursue the right course of action” (p. 6). Nurses’ work
involves © Jones
hard choices &
thatBartlett
sometimesLearning, LLCof patients, emotional and© Jones & Bartlett Learning,
result in avoidance
physical NOT FOR
suffering, SALE
painful OR DISTRIBUTION
ambiguity, contradiction, frustration, anger, and guilt.NOT FOR SALE OR DISTRIB
Since Jameton’s initial work, authors have continued to research and develop the
conception of moral distress.
Numerous scholars have linked moral distress to incompetent or poor care,
unsafe or inadequate staffing, overwork, cost constraints, ineffective policy, futile
care, unsuccessful advocacy, the current definition of brain death, objectification
of patients, and unrealistic hope (e.g., Corley, 2002; Corley, Minick, Elswick, &
Jacobs, 2005; Pendry, 2007; Schluter, Winch, Holzhauser, & Henderson, 2008;
McCue, 2011). Moral distress is defined in the context of institutional constraints.
Research has revealed that nurses’ work environments have a strong effect on the
degree of moralLLC © Jones
distress experienced (e.g., Redman & Fry,&2000).
Bartlett Learning, LLC
Leaders of nursing continue to search for NOT FOR SALE
strategies to reduce OR
moral DISTRIBUTION
distress and
promote healthy work environments. The American Association of Critical-Care
Nurses (AACN) published a position statement to accentuate the seriousness of
moral distress in nursing:
Moral© Jones
distress & Bartlett
is a critical, frequentlyLearning, LLC
ignored, problem in healthcare work environ- © Jones & Bartlett Learning,
ments. Unaddressed it restricts nurses’ ability to provide optimal patient care and to
NOT
find job FORAACN
satisfaction. SALE ORthatDISTRIBUTION
asserts every nurse and every employer are respon- NOT FOR SALE OR DISTRIB
sible for implementing programs to address and mitigate the harmful effects of moral
distress in the pursuit of creating a healthy work environment. (American Associa-
tion of Critical Care Nurses [AACN], 2008, p. 1)
© Jones &TheBartlett Learning,

AACN ethics LLC
work group © Jones
developed a call-to-action plan—The Four&A’sBartlett
to Learning, LLC
NOT FOR
Rise SALE ORDistress—for
above Moral DISTRIBUTION NOTmoral
use by nurses to identify and analyze FOR SALE OR DISTRIBUTION
distress
(AACN, 2004):

© Jones Ask
& Bartlett Learning,
appropriate questions to LLC © Jones
become aware that moral distress is present.& Bartlett Learning,
NOT FORAffirm
SALEyourOR DISTRIBUTION
distress NOT
and commitment to take care of yourself FOR SALE OR DISTRIB
and address
moral distress.
Assess sources of your moral distress to prepare for an action plan.
Act to implement strategies for changes to preserve your integrity and
authenticity.
Honesty NOT FOR SALE OR DISTRIBUTION
In the 2010 Gallup poll, just as it had been over the past 11 years, nurses were rated
as the most honest and ethical health professionals (Jones, 2011). Nurses continue
to be ranked consistently as the most trusted voice among the healthcare profes-
sionals; nurses have earned this trust because of their commitment and loyalty to
their patients. According to Laabs (2011), nurses voiced that being honest was
important for three reasons: (1) honesty is a prerequisite for good care, (2) dis-
honesty is always exposed in the end, and (3) nurses are expected to be honest.
In a phenomenological study of nurses on honesty in palliative care, Erichsen,
Danielsson, and Friedrichsen (2010) stated that nurses had some difficulty defining
© Jones & Bartlett
honesty. In an attempt Learning, LLC
to clarify their © often
perception of honesty, nurses Jones & Bartlett Learning,
defined
NOT lying
FORorSALEdishonestyORasDISTRIBUTION
sharp contrasts to honesty. Nurses perceived NOT FORas SALE
honesty a OR DISTRIB
virtue related to facts, metaphors, ethics, and communication, while perceiving
truthtelling as a palpable feature in trusting relationships.
Honesty, in simple terms, can be defined as being “real, genuine, authentic, and
bona fide” (Bennett, 1993, p. 597). Honesty is more than just telling the truth: it is
the substance of human relationships. It involves people having the ability to place
emphasis on resolve and action to achieve a just society by exercising a willingness to
dig for truth in a rational, methodical, and diligent way. A person with maturity in
honesty will place bits of truths into perspective and prudently search for the missing
truths before addressing the issue. In other words, honesty is well-thought out and
rehearsed behavior that reflects©commitment
Jones & and Bartlett
integrity.Learning, LLC
OT FOR SALE OR DISTRIBUTION There are many ways that NOT FOR SALE ORFor
nurses can portray honesty. DISTRIBUTION
example, nurses must
stay committed to their promises to patients and follow through with appropriate
behaviors, such as returning to patients’ hospital rooms, as promised, to help them
with certain tasks. If nurses do not follow through with their commitments, trust
may be broken, and patients potentially will see those nurses as dishonest or
untrustworthy. © Jones & Bartlett Learning,
NOT FOR SALE
Honesty OR
is also DISTRIBUTION
about being honest with one’s self. For example, NOT FORwasSALE OR DISTRIB
if a nurse
in the process of administering medications and a pill fell on the hospital floor,
would the nurse be justified in wiping it off and placing it back in the cup if no one
was there to see the action? Nurses might be tempted to wipe off the pill and
© Jones & Bartlettadminister
Learning, LLC
it just to keep from completing a © Jones
required & Bartlett
form Learning, LLC
for a replacement
medication, but if nurses evaluate their problems NOT FORdecisions
and make SALEbased OR on DISTRIBUTION
the
thought “always be honest with myself,” it is more likely that they will make
rational, trustworthy decisions regarding the care of patients.


Truthfulness © Jones & Bartlett Learning,
AristotleNOT FORtruthfulness
recognized SALE OR as the mean between imposture (excessiveness)NOT FOR SALE OR DISTRIB
DISTRIBUTION
and self-deprecation (deficiency) and as one of the 12 excellences (virtues) that he
identified in his book Nicomachean Ethics (Aristotle, 2002, C. Row Trans.). People
accomplish their ultimate goal of happiness only by exercising rational and intel-
lectual thinking, which is known as wisdom or contemplation. Aristotle explained
his view of a truthful person as being the truthful sort (see Box 3.3).
NOT FORBased SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
on the principle of veracity, truthfulness is what we say and how we say
it. Truthfulness, translated to “truthtelling” in the healthcare environment, means
that nurses are usually ethically obligated to tell the truth and are not intentionally
to deceive or mislead patients. Because of the emphasis in the Western world on
patients’ rightLLC
to know about their personal© Jones
health care, & BartletthasLearning,
truthtelling become LLC
OT FOR SALE ORthe DISTRIBUTION NOTprofessionals
basis for most relationships between healthcare FOR SALE andOR
their DISTRIBUTION
patients
(Beauchamp & Childress, 2009). In the older, traditional approach, disclosure or
truthtelling was done with more of a beneficent or paternalistic approach and
involved basing actions on answers to the questions such as, “What is best for my
patient to know?”
The ethical question to ask is: Are there ever circumstances when nurses should
be ethically excused from telling the truth to their patients? The levels of disclosure
in health care and the cultural viewpoints on truthtelling create too much foggi-
ness for a clear line of distinction to be drawn between nurses telling or not telling
the truth. The ANA Code of Ethics for Nurses (2001) obligates nurses to be honest
© Jones & Bartlett
in matters Learning,
involving patients andLLC © Jones
themselves, and to express a moral &view
point of Bartlett Learning, LLC
NOT FOR whenSALE OR DISTRIBUTION
they become aware of unethical practices. NOT FOR SALE OR DISTRIBUTION
In some Western cultures, such as the United States, autonomy is so valued that
withholding information is unacceptable. Under this same autonomy principle, it
is assumed that patients also have a right not to know their medical history if they
so desire. Some cultures, such as those in several Eastern countries, do not prize
autonomy in thisLLC ©the
way; the head of the family or Jones & Bartlett
elders usually Learning,
decide how much LLC
OT FOR SALE ORand DISTRIBUTION
what information needs to be disclosed to NOT FORmember
the family SALEasOR DISTRIBUTION
patient.
BOX 3.3 ETHICAL FORMATIONS: ARISTOTLE’S “THE TRUTHFUL SORT”

“We are not here talking about the person who tells the truth in the context of agreements, or any-
thing of that sort . . . but about contexts in which . . . a person is truthful both in the way he talks and
in the way he lives, by virtue of being such by disposition. Someone like this would seem to be a decent
person. For the lover of truth, since he also tells the truth where it makes no difference, will tell the
truth even more where it does make a difference; for there he will be guarding against falsehood as
© Jones & Bartlett
something Learning,
shameful, when heLLC
was already guarding against it © Jones
in itself. Such& Bartlett
a person Learning,
is to be praised.” LLC
NOT FORSource:
SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Quotation from Aristotle. (2002). Nichomachean ethics. (C. Rowe, Trans.) New York, NY: Oxford University Press.

© Jones & Bartlett

Therapeutic Learning, LLC
Privilege © Jones & Bartlett Learning,
NOT The
FOR SALEMedical
American OR DISTRIBUTION NOTonFOR
Association (AMA, 2006) published a statement SALE OR DISTRIB
the def-
inition of therapeutic privilege and offered an explanation of its moral meaning.
The following excerpt spotlights this opinion:
[T]he practice of withholding patient medical information from patients in the belief
that disclosure is © Jones
medically contraindicated is known & Bartlett
as therapeutic privilege. It Learning,
cre- LLC
ates a conflict between the physician’s obligations to promote patients’ welfare and
NOT FOR SALE ORrespectDISTRIBUTION NOT FOR SALE OR
for their autonomy by communicating truthfully. Therapeutic privilege does DISTRIBUTION
not refer to withholding medical information in emergency situations, or reporting
medical errors.
Withholding medical information from patients without their knowledge or con-
sent is ethically unacceptable. Physicians should encourage patients to specify their
Jones & Bartlett Learning, LLCpreferences regarding communication
© Jonesof &their Bartlett
medical Learning, LLC
information, preferably
OT FOR SALE OR DISTRIBUTION before the information becomes NOT FOR[but]
available SALE OR DISTRIBUTION
physicians should honor patient
requests not to be informed of certain medical information or to convey the infor-
mation to a designated proxy . . .
All information need not be communicated to the patient immediately or all at
once; physicians should assess the amount of information a patient is capable of
© Jones & Bartlett
receiving at a givenLearning, LLC
time, delaying the © Jones
remainder to a later, more suitable time, and& Bartlett Learning,
should tailor disclosure to meet patients’ needs. (para. 1, 2, 3)
When physicians exercise this privilege, they base their opinion on facts gathered
from the patient’s records and their interactions with the patient, family, and other
healthcare professionals. There are several reasons nurses or physicians might avoid
telling the full truth: (1) they are trying to protect patients from sad and heart-
breaking news, (2) they do not know the facts, or (3) they state what they know to
be untrue about the situation rather than admit everything they know to be true.
There are advantages for physicians and nurses to tell the truth, especially when
patients are in advanced stages of a diagnosis (Loprinzi et al., 2010). With the full
knowledge of the disease process, patients will make fully informed decisions, be
prepared for the outcomes, have © Jones & Bartlett
more meaningful Learning,
dialogue with familyLLC
members,
OT FOR SALE OR DISTRIBUTION and make the most of meaningful NOTevents
FORduringSALE OR
their DISTRIBUTION
remaining life. Physicians
and nurses are left with a difficult decision to make, especially when a patient wants
to know the full truth and physicians have decided to disclose only part of the
truth—or none of it—to the patient. No matter how disappointing the news will
be to patients and families, nurses must evaluate each situation carefully with
© Jones
wisdom & and
Bartlett Learning,
contemplation beforeLLC
making any decision on the degree© Jones & Bartlett Learning,
of disclo-
NOT sure.
FOR SALE
A clear OR DISTRIBUTION
understanding of the communication that has transpired NOT FORtheSALE OR DISTRIB
between
physician and patient and family members contributes to the nurse’s decision on
the degree of shared disclosure (see Box 3.4).
An excellent example of truthtelling is from the play Wit by Margaret Edson,
winner LLC
of the 1998 Pulitzer Prize; the play was © Jonesas&a book,
published Bartlett Learning,
then in 2001 LLC
was made into an HBO Home Movie and is NOT FOR SALE OR DISTRIBUTION
available for purchase. Susie Monahan,
R.N., decided to tell the truth to and be forthright with a patient despite a few physi-
cians who chose not to do so (see Box 3.5).

© Jones
BOX 3.4
& Bartlett Learning, LLC © Jones & Bartlett Learning,
ETHICAL FORMATIONS: A WOMAN WITH UTERINE CANCER
You are caring for a woman scheduled for a hysterectomy because of uterine cancer. Her surgeon is
known to have a bad surgical record in general, but especially in performing hysterectomies. The
woman has heard gossip to this effect and asks you about it before her surgery because she is appre-
hensive about using that surgeon. You know for a fact that at least one legal suit has been filed against
him because you personally know the woman involved in the case—a botched hysterectomy.
Your choices are: you could be brutally honest and truthful NOT
with FOR SALE OR
your preoperative DISTRIBUTION
patient, you
could give her part of the truth by giving her information that you know to be untrue about certain
gossip or not confirming the truth about certain gossip, or you could be totally untruthful by remaining
silent or by telling her that you have heard nothing.
Jones & Bartlett Learning, LLCoptions and any other ideas©that
Discuss these Jones & have
you may Bartlett Learning,
in regard to this case. LLC
As a nurse
who wants to be committed to an ethicalNOT FOR
nursing SALE
practice, whatOR DISTRIBUTION
actions might you consider in
this difficult circumstance? Be as objective as possible.
Now that you have determined possible actions, please justify these actions by applying either
Kant’s deontological theory or a virtue ethics approach.
Describe the major differences, or any similarities, between these two frameworks (deontology
versus virtue ethics).
Other than simply verbally telling the truth to patients and others, how else can FOR SALE OR DISTRIB
you display
honesty in ethical nursing practice? Think of how you would portray honesty in different settings
and situations—bedside nursing of patients, documentation, dealing with coworkers, and
administration—while taking into consideration the ANA Code of Ethics for Nurses with
© Jones & InterpretiveLearning,
Bartlett Statements. LLC © Jones & Bartlett Learning, LLC
Moral Courage
Without moral courage, our brightest virtues rust from lack of use. With it, we
build piece LLC
by piece a more ethical world. © Jones & Bartlett Learning, LLC
—RUSHWORTH M. KIDDER, “A WHITE PAPER NOT ,” IFOR SALE
NSTITUTE OREDISTRIBUTION
OF GLOBAL THICS
Moral courage is having the courage to be moral (Kidder, 2005). Although defined in
several ways, Kidder associated five core values with moral courage: honesty, respect,
responsibility, fairness, and compassion. In a hermeneutical analysis of nurses in
advanced©practice,
Jones & Bartlett
Spence and Smythe Learning,
(2007) foundLLCthat courage is an individual and© Jones & Bartlett Learning,
NOT
a collective FOR SALE
phenomenon ORinDISTRIBUTION
that occurs everyday practice. From the findings, SpenceNOT FOR SALE OR DISTRIB
and Smyth stated that courage “can be seen as a response to threat or challenge, real
in the present, recognized in the past, and/or anticipated in the future” (p. 52).
Having moral courage means that a nurse overcomes fear by confronting an
© Jones & head
issue Bartlett Learning,
on, especially LLC
when the © Jones
issue is a conflict of the nurse’s & and
core values Bartlett Learning, LLC
beliefs. Moral courage is having the will to speak out and do NOT FOR SALE
the right thing even OR DISTRIBUTION
when constraints or forces to do otherwise are present. Moral courage turns prin-
ciples into actions. When nurses have the courage to do what they believe is the

BOX 3.5
©ETHICAL
JonesFORMATIONS:
SUSIE MONAHAN, R.N.: WIT—TRUTHTELLING
Susie Monahan was a registered nurse who was caring for Vivian Bearing, a dying patient with cancer,
at a large research hospital. Vivian was getting large doses of cancer chemotherapy without any suc-
cess of remission—in fact, the cancer was progressing at an alarming rate. She was near death but the
research physicians wanted to challenge her body with chemotherapy for as long as possible to observe
outcome effects. Everyone on the medical staff had been cold and technically minded, and no one had
NOT shown
FORany SALE OR DISTRIBUTION NOT about
concern for her except for Susie. Vivian had not been informed FORthe SALE OR DISTRIBUTION
chemotherapy
failure, her prognosis, or that she was dying. One night, Susie found Vivian crying and in a state of panic.
Susie first helped to calm her, then shared a popsicle with Vivian at the bedside while she disclosed the
full truth to Vivian about her chemotherapy, her prognosis, her choices about Code Blue or DNR, and
Jones & BartlettherLearning, LLC
imminent death. © Jones & Bartlett Learning, LLC
Susie affectionately explained:
OT FOR SALE ORYou
DISTRIBUTION
can be “full code,” which means that if yourNOT FORthey’ll
heart stops, SALE call aOR
CodeDISTRIBUTION
Blue and the code
team will come and resuscitate you and take you to Intensive Care until you stabilize again. Or
you can be “Do Not Resuscitate,” so if your heart stops we’ll . . . well, we’ll just let it. You’ll be
“DNR.” You can think about it, but I wanted to present both choices . . . ” (p. 67).
Susie felt an urge to be truthful and honest. By giving human respect to Vivian, Susie was
showing her capacity to be human.
Source: Edson, M. (1999). Wit. New York, NY: Faber & Faber.
right thing in a particular situation, they make a personal sacrifice by possibly

© Jones & Bartlettstanding
Learning, LLC
alone, but © Jones
will feel a sense of peace in their &When
decision. Bartlett
nursesLearning,
are in LLC
a potential risk of danger, they need moral courageNOTto FOR SALEtoOR
act according theirDISTRIBUTION
core
values, beliefs, or their moral conscience. Nurses are susceptible to experiences of
apprehension and fear because of the uncertainty in outcomes, even when they
have a high degree of certitude that they are doing the right thing.
Even though physical harm could be a potential threat, it is more likely that
threats will materialize in the form & Bartlett
of “humiliation, Learning,
rejection, LLC
ridicule, unemploy-
OT FOR SALE OR DISTRIBUTION NOT(Lachman,
ment, and loss of social standing” FOR SALE 2007,OR DISTRIBUTION
p. 131). A few examples of
having moral courage are (1) confronting or reporting a peer who is stealing and
using drugs at work, (2) confronting a physician who ordered questionable treat-
ments that are not within the reasonable standard of care, (3) confronting an
© Jones & Bartlett
administrator Learning,
regarding LLC or staffing patterns, (4) standing
unsafe practices © Jones & Bartlett Learning,
against
peers who are planning
NOT FOR SALE OR DISTRIBUTION an emotionally hurtful action toward another
NOT FOR(5)SALE OR DISTRIB
peer, and
reporting another nurse for exploitation of a patient or family member, such as
when a nurse posts a picture or story of a patient on a social networking site.
Lachman (2007) offered two strategies to help nurses to exhibit moral courage
in threatening situations. Nurses would probably regret any careless and hasty reac-
© Jones & Bartletttions,
Learning, LLC
or even nonreaction © Jones
or silence, on their part, & Bartlett
so they must first try toLearning,
soothe LLC
NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR
inner feelings that could trigger these behaviors. Self-talk, relaxation techniques, DISTRIBUTION
and moral reasoning to process information, while pushing out negative thoughts,

are ways©forJones &keep

nurses to Bartlett
calm inLearning,
the face of a LLC
confrontation involving moral© Jones & Bartlett Learning,
courage.NOT
Second,FOR
nursesSALE OR the
must assess whole scenario while identifying the risksNOT FOR SALE OR DISTRIB
DISTRIBUTION
and benefits involved in standing alone.
Concern
Advocacy
A general definition of advocacy is pleading in favor of or supporting a case,
person, group, or cause, but many variations on the definition of advocacy exist.
Related to professional nursing ethics, Bu and Jezewski (2006) found in their con-
cept analysis that patient advocacy is defined as having three central features:
Safeguarding
Jones & Bartlett Learning, LLCpatients’ autonomy © Jones & Bartlett Learning, LLC
Acting on behalf of patients
Championing social justice in the provision of health care (p. 104)
Patient advocacy, an essential element of ethical nursing practice, requires that
nurses embrace the promotion of well-being and uphold the rights and interests of
their patients (Vaartio,&Leino-Kilpi,
© Jones Bartlett Salanterä,
Learning, & Suominen,
LLC 2006). The ANA (2001)© Jones & Bartlett Learning,
did not define the terms advocacy or patient advocacy in the Code of Ethics for Nurses
with Interpretive Statements, although advocating for the patient is implied in some
places in the code and is also explicit in others, such as in the interpretive statements:
“Nurses are leaders and vigilant advocates for the delivery of dignified and humane
care” (p. 8) and in Provision 3 of the code: “The nurse promotes, advocates for, and
© Jones & Bartlett
strives Learning,
to protect the LLC
health, safety, and rights of the patient” (p.©12).
NOT FORNurses SALE areOR DISTRIBUTION
in ideal NOT
positions for a patient advocacy role. Nurses canFOR
clarifySALE
and OR DISTRIBUTION
discuss patient rights, health goals, treatment issues, and potential outcomes with
patients, but barriers to advocacy often become a nursing reality. These barriers are
shadows that remain as unresolved issues. Refer to Box 3.6.
Hamric (2000) offered excellent ways for nurses to boost their patient advocacy
skills: (1) nursing educators need to convert the basic ethics education to real-life action;
OT FOR SALE OR(2) DISTRIBUTION NOT FOR
practicing nurses need to continue their education on theSALE OR DISTRIBUTION
ethical imperatives of
advocacy; and (3) institutions need to review their incentives, if any, to promote patient
advocacy. Butts (2011) created an acronym labeled PRISMS as a reminder of strategies
to promote patient advocacy (see Box 3.7).
Power
Power, by definition, means that a person or group has influence in an effective way
over others—power results in action. Nurses with power have the ability to influ-
ence persons, groups, or communities. Nurses ingrained with the ideals of social-
ized power seek goals to benefit others with intent to avoid harm or negative
© Jones & Bartlett
effects—an Learning,
indication LLC of beneficience, nonmaleficence,
of the principles © Jones and & Bartlett Learning, LLC
justice
NOT FOR SALE
at work. OR
Goals of DISTRIBUTION NOT through
social benefit to others are usually accomplished FOR SALE the OR DISTRIBUTION
efforts of members of large service organizations, and individual volunteer work by

BOX 3.6
©ETHICAL
JonesFORMATIONS:
BARRIERS TO NURSING ADVOCACY
Barriers to nursing advocacy were identified by Hanks (2007) based on findings from existing literature.
Conflicts of interest between the nurse’s moral obligation to the patient and nurse’s sense of
duty to the institution
© Jones & Bartlett
Institutional Learning, LLC
constraints © Jones & Bartlett Learning, LLC
A lack of education and time NOT FOR SALE OR DISTRIBUTION
Threats of punishment
A gender-specific, historical, critical social barrier related to nurses’ expectations of a subservient
duty to medical doctors
Source: Adapted from Hanks, R. G. (2007). Barriers to nursing advocacy: A concept analysis. Nursing Forum, 42(4), 171–177.
BOX 3.7 ETHICAL FORMATIONS: PRISMS—AN ACRONYM FOR KEY ACTION VERBS
FOR STRATEGIES TO PROMOTE PATIENT ADVOCACY
P Persuade© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,
R Respect NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
I Intercede
S Safeguard
M Monitor
S Support
Source: Butts, J. B. (2011). PRISMS—An Acronym for key action verbs for strategies to promote patient advocacy. Personal Col-
NOT lection.
FOREllisville,
SALE OR DISTRIBUTION
MS, copyright 2011. NOT FOR SALE OR DISTRIBUTION
nurses and others at service organizations contributes to the efforts and shared goals
of the larger organization and also© Jones & Bartlett
can contribute to effortsLearning, LLC
of smaller goals for indi-
OT FOR SALE OR DISTRIBUTION viduals, small groups, and small areas of the community.
NOT FOR SALE OR DISTRIBUTION Nurses continue to take
advantage of their empowerment as a profession in order to control the content of
their practice, the context of their practice, and their competence in practice.
Hakesley-Brown and Malone (2007) found in their research that nurses and
patients are a powerful entity evolving over time because of paradigm shifts in clin-
© Jones & Bartlett
ical, political, Learning,
and organizational LLCNurses have facilitated patients’
power. © Jones
emancipa-& Bartlett Learning,
NOT tion
FOR fromSALE
a paternalistic form of care to today’s autonomous decisionNOT
OR DISTRIBUTION makersFORseekingSALE OR DISTRIB
quality care. With nurses being directly involved in quality of care, they are in a prime
position to use power to benefit patients and the professional practice of nursing.
Ponte et al. (2007) interviewed nursing leaders from six organizations to under-
stand, LLC perspectives on the concept
from the leaders’ © Jones
of power,&ways
Bartlett Learning,
that nurses can LLC
acquire
NOT FOR SALE OR DISTRIBUTION power and ways that these leaders demonstrate power in their practice
NOT FOR SALE OR DISTRIBUTION and
work. Refer to more detail on sources of leadership power in Chapter 12. According

© Jones
to the leaders & Bartlett
in the study, power liesLearning, LLCwho engages in patient care© Jones & Bartlett Learning,
within each nurse
NOT
and in other FOR
roles, suchSALE OR DISTRIBUTION
as in organizations, with colleagues, and within the nursingNOT FOR SALE OR DISTRIB
profession as a whole. As nurses develop knowledge and expertise in practice from
multiple domains, they integrate and use their power in a “collaborative, interdisci-
plinary effort focused solely on the patients and families that the nurse and care team
serve and with whom they partner” (Ponte et al., 2007, Characteristics of Nursing
Power section, para. 1). Ponte et al. found eight properties of a powerful professional
practice, which could serve as a basis for current and future power in nursing. Refer
to Boxes 3.8 and 3.9.
Culturally Sensitive Care

Culture refers to “integrated patterns of human behavior that include the language,
thoughts, communications, actions, customs, beliefs, values, and/or institutions of
racial, ethnic, religious, and/or social groups” (Lipson & Dibble, 2005, p. xi). Giving
culturally sensitive care is a core element in closing the gap on health disparities.
Spector (2004) explained that providing culturally sensitive care means that
nurses must first have a basic knowledge of culturally diverse customs and then
© Jones
demonstrate & Bartlett
constructive attitudes Learning, LLC
based on that knowledge. A culturally compe-© Jones & Bartlett Learning,
tent nurseNOT FOR SALE
or healthcare OR DISTRIBUTION
provider NOT FOR SALE OR DISTRIB
BOX 3.8 ETHICAL FORMATIONS: PONTE ET AL.’S PROPERTIES OF A POWERFUL

PROFESSIONAL NURSINGLLC
PRACTICE © Jones & Bartlett Learning, LLC
Nurses who have developed a powerful nursing practice:
Acknowledge their unique role in the provision of patient- and family-centered care.
Commit to continuous learning through education, skill development, and evidence-based practice.
Demonstrate professional comportment [manner in which one conducts oneself] and recognize
the critical nature of presence. © Jones & Bartlett Learning, LLC
Value
OT FOR SALE OR DISTRIBUTION collaboration and partner effectively
NOT withFOR
colleagues
SALEin nursing and other disciplines.
OR DISTRIBUTION
Actively position themselves to influence decisions and resource allocation.
Strive to develop an impeccable character: to be inspirational, compassionate, and have a
credible, sought-after perspective (the antithesis of power as a coercive strategy).
Recognize that the role of a nurse leader is to pave the way for nurses’ voices to be heard and to
©novice
help Jones & Bartlett
nurses develop intoLearning, LLC
powerful professionals. © Jones & Bartlett Learning,
Evaluate the power of nursing and the nursing department in organizations NOT
they enterFOR
by SALE OR DISTRIB
assessing the organization’s mission and values and its commitment to enhancing the power of
diverse perspectives.
Source: Quoted from Ponte, P. R., Glazer, G., Dann, E., McCollum, K., Gross, A., Tyrell, R., . . . Washington, D. (2007). The power of
professional nursing practice—An essential element of patient and family centered care. The Online Journal of Issues in Nursing,
© Jones & Bartlett
12(1). Learning,
Retrieved from LLC © Jones & Bartlett Learning, LLC
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/
NOT FORVolume122007/No1Jan07/tpc32_316092.aspx

BOX 3.9
©ETHICAL
JonesFORMATIONS:
TWO LEVELS OF POWER
There are a variety of ways that power can be abusive, coercive, or not used at all. Nurses who do not
use their power for the good of a situation are ineffective. There are two examples of power presented
here, one on a smaller scale and one on a larger scale.
Power on a Smaller Scale: Ms. Gomez’s diagnosis is an inoperable and incurable cancer of the liver.
She is unaware of her diagnosis but realizes that she is experiencing abdominal pain that she described
NOT asFOR8 on a 10-point scale. Everyone in the oncology unit is involved inNOT
SALE OR DISTRIBUTION her careFOR SALE
and aware OR
of her DISTRIBUTION
diag-
nosis, except for her. The nurses had been observing Ms. Gomez’s continued edginess and irritability as
they interacted with her. Ms. Gomez senses something is terribly wrong and begins to panic when
physicians gather in her room for clinical rounds and talk medical jargon about her “case” in front of
Jones & Bartletther.Learning, LLC
Ms. Gomez experienced © Jones
an acute anxiety reaction. & Bartlett
Her outcome Learning,
could have been better LLC
had her
nurse beforehand discussed the situation with the physicians and tried convincing them to discuss her
case somewhere else and/or asked them politely to tell her the truth about her diagnosis and prognosis.
Had the nurse exerted a noncoercive power over this situation, the outcome potentially could have
been averted. What specific actions could this nurse have taken on a small-scale or unit level in terms
of unit policies regarding clinical rounds or disclosure to patients?
Power on©a Larger
Jones & Bartlett
Scale: Nurse Mary Learning, LLC located in a coastal region
is a nurse at a hospice © and
Jones
has six& Bartlett Learning,
patients in her care. The national weather center forecasted several potential NOT FOR
life-threatening hurri- SALE OR DISTRIB
canes for her region during the next two weeks. Most of her patients are financially challenged. Mary
has choices to make: (1) she could do nothing and let nature take its course; (2) she could educate her
patients and families on ways to prepare for disaster; or (3) she could educate her patients and fami-
lies on disaster preparedness as well as use her power to help poor, homebound patients—not just her
© Jones & Bartlett
patients—in Learning,
the community LLC
to prepare for disaster. One way for Mary ©toJones
exercise & herBartlett Learning, LLC
power immedi-
NOT ately
FOR onSALE OR DISTRIBUTION
a large, community-wide NOT
scale is to have a fundraiser and supply FOR
drive, thenSALE OR
work with DISTRIBUTION
agen-
cies such as the American Red Cross to recruit community or nurse volunteers for distributing the
supplies, handing out disaster preparedness information, and verbally educating the families. What are
other strategies that Mary could implement?
OT FOR SALE OR DISTRIBUTION develops an awareness of his NOT
or FOR sensations,
her existence, SALE OR DISTRIBUTION
thoughts, and environment
without letting these factors have an undue effect on those for whom care is provided.
Cultural competence is the adaptation of care in a manner that is consistent with the
culture of the client and is therefore a conscious process and nonlinear. (Purnell,
2002, p. 193)
© Jones & Bartlett
Purnell Learning,
(2011) explained that theLLC © Jones
process of nurses getting to know & Bartlett Learning,
themselves
NOT and
FOR SALE
their values, OR DISTRIBUTION
beliefs, NOT FOR
and moral compass is fundamental to providing SALE OR DISTRIB
cultur-
ally competent care. Without some degree of cultural knowledge, nurses cannot
possibly provide ethical care; one example is that relationships with others cannot
develop into a trusting, respectful exchange.
© Jones & Bartlett Learning, LLC (2005) trademark name,
Lipson and Dibble’s © ASK,
Jones &asBartlett
serves an acronym Learning,
that LLC
nurses can
NOT FOR SALE OR DISTRIBUTION use when approaching patients of various cultures; it refers to
NOT FOR SALE OR DISTRIBUTION aware-
ness, sensitivity, and knowledge. There are many cultural views in the United

Nursing Professional Relationships 85
© Jones
States, and & Bartlett
these are based on each Learning,
culture’s beliefLLC
system on health, illness, pain,© Jones & Bartlett Learning,
suffering,NOT
birth,FOR SALE
parenting, OR
death, dying, health care, communication, and truth,NOT FOR SALE OR DISTRIB
DISTRIBUTION
among others. Lipson and Dibble (2005) emphasized that nurses need to conduct
a quick assessment on cultural diversity needs. The following basic cultural assess-
ment questions are based on ASK:
© Jones &
1. Bartlett
What is theLearning, LLC
patient’s ethnic affiliation? © Jones & Bartlett Learning, LLC
Who are the patient’s
2. major support persons and where do
NOTtheyFOR
live? SALE OR DISTRIBUTION
3. With whom should we speak about the patient’s health or illness?
4. What are the patient’s primary and secondary languages, and speaking and
reading abilities?
5. What is the patient’s economic situation? Is income adequate to meet the
patient’sLLC
and family’s need? (Lipson & © Jones
Dibble, 2005,&p.Bartlett
xiii) Learning,
LLC
Nurses’ authentic attention to cultural diversity and the diversity within each
culture promotes ethically competent care, which is essential in everyday nursing
practice. Nurses must be open-minded to increasing their knowledge and aware-
ness to the needs of culturally diverse patients. The Code of Ethics for Nurses with
© Jones
Interpretive Statements&(ANA,
Bartlett
2001)Learning, LLC
contains explicit guidelines for giving care to© Jones & Bartlett Learning,
NOT
individuals FOR of
regardless SALE OR
social or DISTRIBUTION
economic status, personal attributes, or natureNOT FOR SALE OR DISTRIB
of health problems. Nursing care based on the code includes giving care with cul-
tural sensitivity.
Refer to Boxes 3.10 and 3.11 to test your moral grounding. In this section on
qualities of ethical nurses, you have read about selected qualities that make up eth-
ical nurses—moral integrity, honesty, truthtelling, advocacy, power, and culturally
NOT FOR SALE
sensitive care.
OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Nursing Professional Relationships

Nurse–Physician Relationships
Women endured many centuries of oppression from male-dominated hierarchies,
such as religious institutions. Women healers, accused of being witches, were
burned at the stake from the 1300s to the 1600s (Ehrenreich & English, 1973), and
other events also gave rise to oppression of women during that time. By the early
20th century, Florence Nightingale’s work from the 1800s had achieved some
© Jones
respect for the role of&nurses,
Bartlettbut Learning,
nurses and otherLLC mostly female occupations© Jones & Bartlett Learning,
NOT FOR
“were presented SALE
as simple OR DISTRIBUTION
extensions of women’s ‘natural’ domestic role” (Ehren-NOT FOR SALE OR DISTRIB
reich & English, 1973, p. 38). Nurses, to varying degrees, have been working since
that time to overcome this perception.
Stein (1967), a physician, characterized a type of relationship between physicians
and&nurses
© Jones that he
Bartlett called the doctor–nurse
Learning, LLC game. The game is©based on a hierar-
chical relationship with doctors being in the position of the superior. The hallmark
of the game is that open disagreement between the disciplines is to be avoided, and

BOX 3.10
© ETHICAL
FORMATIONS: TEST YOUR MORAL GROUNDING!
Thus far, you have learned about the qualities that define ethical nursing. The codes of ethics and the
qualities of ethical nurses assist nurses in developing moral grounding for professional practice, edu-
cation, research, and leadership.
Test your personal moral grounding! List the ethical qualities of a nurse on a piece of paper and
write down how they might relate to your ethical nursing practice. Briefly summarize an ethical situ-
NOT ation
FORor SALE OR DISTRIBUTION NOT FOR
conflict that could arise with each ethical quality and a corresponding SALE OR DISTRIBUTION
resolution.
Moral integrity
Honesty
Truthfulness
Moral courageLLC © Jones & Bartlett Learning, LLC
OT FOR SALE ORAdvocacy
DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
Power
Culturally sensitive care
© Jones & Bartlett

avoidance of conflictLearning, LLC
is achieved when an experienced nurse, who is©ableJones & Bartlett Learning,
to provide
NOT helpful
FOR suggestions
SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
to a doctor regarding patient care, cautiously offers the sugges-
tions in such a way so that the physician does not directly perceive that consultative
advice is coming from a nurse. In the past, student nurses were educated about the
rules of the game while attending nursing school. Over the years, others have given
© Jones & Bartlettcredence
Learning, LLC accuracy of Stein’s characterization
to the historical © Jones & of Bartlett
doctor–nurseLearning,
rela- LLC
tionships (Fry & Johnstone, 2002; Jameton, 1984; Kelly, 2000).
Stein, Watts, and Howell (1990) revisited the doctor–nurse game concept 23
years after Stein first coined the phrase. They proposed that nurses unilaterally had
decided to stop playing the game; some of the reasons for this change and ways the
change was accomplished have involved nurses’ increased use of dialogue rather
than gamesmanship, the profession’s goal&ofBartlett Learning,
equal partnership LLCother
status with
OT FOR SALE OR DISTRIBUTION healthcare professionals, the NOT FOR SALE OR DISTRIBUTION
alignment of nurses with the civil rights and women’s
movements, the increased percentage of nurses who are receiving higher educa-
tion, and collaboration between nurses and physicians on projects. In the process
of the dismantling of the game, many nurses took a less than communitarian stance
with physicians.
There are nurses who believe that an adversarial fight needs to continue in order
NOT toFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIB
establish nursing as an autonomous profession. Nurses’ reports and opinions of
strained relationships between nurses and physicians have steadily appeared in the
literature across many countries of the world despite efforts by some nurses to have
friendlier relationships with physicians. Reported reasons for the strained rela-
© Jones & Bartletttionships
Learning, LLC
include: (1) the hierarchical way that©ethical
Jones care&decisions
Bartlett areLearning,
made, LLC
NOT FOR SALE OR bothDISTRIBUTION
institutional system decisions and physician NOT FOR (2)
decisions; SALE OR DISTRIBUTION
competency and
quality of care conflicts; and (3) the lack of communication.

BOX © Jones
3.11 & Bartlett
ETHICAL Learning,
FORMATIONS: TESTLLC © Jones
YOUR MORAL GROUNDING! SHOULD&I Bartlett Learning,
NOT FOR SALE
BUY THIS PAPER? OR DISTRIBUTION NOT FOR SALE OR DISTRIB
Megan, a nursing student, found a site on the Internet advertising a company that, for a fee, would
customize a nursing school paper on any topic. She needed a paper in APA format on the concept of
compassion in nursing practice and realized that she was overloaded with assignments from school, so
© Jones &
sheBartlett Learning,
asked herself, “Should I buyLLC © Jones
this paper?” Without further thought, &she
however, Bartlett Learning,
completed the form LLC
NOT FORandSALE
orderedOR
the DISTRIBUTION NOT
paper. The company sent the paper to her within FOR
3 days. SALE
Megan then OR DISTRIBUTION
submitted the
paper electronically to the professor as her own work.
Who is the rightful owner of the paper?
Is buying the paper unethical, illegal, or both? Please explain your rationale.
Jones & Bartlett Learning, LLCcheating, plagiarism, or both,
Is this action © by
Jones
common &university
Bartlettor Learning, LLC
college standards of
academic honesty? Please explain your NOT FOR SALE OR DISTRIBUTION
rationale.
What are some ethical implications that Megan needed to consider before buying the paper?
What was an alternative action for Megan, based on Kant’s deontology framework or a virtue
ethics approach?
What is a creative strategy that Megan’s professor could use instead of the paper assignment to
© Jones
reduce & Bartlett
the chance of students Learning,
buying a paperLLC
on the Internet? © Jones & Bartlett Learning,
NOT
What FORexamples
are some SALEofOR otherDISTRIBUTION NOT
similar Internet incidents considered illegal or FOR SALE OR DISTRIB
unethical?
(The story continues.)
The professor required that electronic versions of the paper be submitted, and Megan did not realize
that the professor opened each document to review the name appearing in the properties of the doc-
© Jones & Bartlett
ument. Learning,
The property name onLLC Megan’s document was National ©Nursing
JonesPapers.
& Bartlett
Megan was Learning,
shocked LLC
when the professor questioned her about the name in the NOT FOR SALE OR DISTRIBUTION
properties. She did not realize that a prop-
erty name even existed. She could not give an adequate explanation for the existing name and finally
admitted to buying the paper. She failed the course. Megan was not dismissed from the program for
this one academic honesty violation, but the dean and professor gave her a one-time warning notice
that if she cheated or plagiarized in any form in the future, she would be dismissed from the school of
nursing andLLC ©university’s
the university as instructed in the Jones & Bartlett
handbook. MeganLearning, LLC notice.
signed the warning
She had no other choice if she wanted to NOT FOR SALE OR DISTRIBUTION
remain in the nursing program.
Do you believe, based on your analysis of the deontology framework, that Megan deserved
another opportunity to remain in the nursing program? Please explain your rationale.

One example of research of an organizational culture is a qualitative focus group
study byNOT
MalloyFOR SALEForty-two
et al. (2009). nurses from a variety of settings in fourNOT FOR SALE OR DISTRIB
OR DISTRIBUTION
nations (Canada, Ireland, Australia, and Korea) participated to identify ethical
dilemmas and decisions in the everyday care of elders with dementia, as well as to
identify how end-of-life decisions are made. The researchers extracted four themes
© Jones
in & Bartlettwith
conjunction Learning, LLCfinding that nurses from all
the unexpected © countries
Jones consis-
NOT FOR SALE
tently voiced OR DISTRIBUTION
strained and powerless hierarchical relationshipsNOT FORphysi-
with some SALE OR DISTRIBUTION
cians. The first theme arose as a result of two different philosophies: Care (nurses)

© Jones
versus& Bartlett
treatment Learning,
(physicians) LLC of tension between nurses©and
was a source Jones & Bartlett Learning,
physicians
NOT on
FOR SALE
end-of-life OR DISTRIBUTION
decisions. NOTinFOR
The second theme was a constrained obligation SALE OR DISTRIB
terms of
the nurse–physician hierarchy, established protocol, and the way that decisions were
made. Third, nurses perceived that physicians, patients, families, and the system
silenced the nurse’s voice; they also believed themselves to be unequal participants
in the care of patients, largely because of the system. The fourth theme was a lack of
respect for the profession of nursing from other professionals.
NOT FOR SALE ORPullon’s DISTRIBUTION NOT FOR SALE OR DISTRIBUTION
(2008) qualitative study of 18 nurses and physicians in primary care
settings from New Zealand is an example of research of the features that build an
interprofessional nurse–physician relationship. Pullon identified certain extrinsic
and intrinsic factors of this relationship, but focused the article only on the intrinsic
nature of individual interprofessional & Bartlett
relationships. Learning,
A key LLC
feature of interprofes-
OT FOR SALE OR DISTRIBUTION NOTprofessional
sional relationships, demonstrated FOR SALE OR DISTRIBUTION
competence, served as the foun-
dation for respect for each other and, in turn, formed trust calculated over time
with reliable and consistent behavior.
Pullon found that nurses and physicians identified their professional groups as
distinct but complementary to each other. Nurses described the formation and
maintenance of quality professional relationships with patients and others as the
NOT heart
FORofSALE their professional work and described teamwork as NOT
OR DISTRIBUTION FORfor
one means SALE OR DISTRIB
achieving those relationships. Physicians depicted the physician–patient relation-
ship as the crux of their practice, but only in the context of consultation. Nurses
and physicians both unveiled several shared values and attitudes, such as the pro-
© Jones & Bartlettvision
Learning, LLC
of continuity © Jones
of care; the ability to cope with & Bartlett
unpredictable Learning, LLC
and demanding
NOT FOR SALE OR care;DISTRIBUTION
the importance of working together and buildingNOT FOR SALEand
a relationship; ORtheDISTRIBUTION
sig-
nificance of professional competence, mutual respect for each other, and trust in
an ongoing relationship, but with the realization that trust could be broken quickly
in the early stages of a trustworthy relationship.
Other studies have reflected findings similar to these highlighted studies. Nurses’
perceptions of inequality with© Jonesreveal
physicians & Bartlett Learning,
that the solutions LLC and
are complex
OT FOR SALE OR DISTRIBUTION NOT
currently do not exist universally. FOR SALE
Churchman OR(2010)
and Doherty DISTRIBUTION
found that certain
factors contribute to the challenge of finding answers: nurses are discouraged from
confronting physicians in everyday practice, fear of conflict and aggression by physi-
cians, and fear of having their views disregarded. The institutional hierarchy continues
© Jones
to be a& Bartlett
source Learning,
for unequal LLC
rewards and © Jones & Bartlett Learning,
power between nurses and physicians.
Nurse–Nurse Relationships
In the provisions of the code, the ANA (2001) characterized various ways that nurses
demonstrate their primary responsibility to their patients (families and communi-
ties). Some key indicators found in the code that reflect this responsibility include
having compassion for patients, showing respect to patients and to each other, col-
NOT FOR SALE OR laborating with other healthcare professionals, NOT
DISTRIBUTION FOR
protecting theSALE OR
rights and DISTRIBUTION
safety of
patients, advocating for the patient and family, and caring for and preserving the

integrity© Jones
of self & Bartlett
and others. Learning,
Patient and LLC are important, but good© Jones & Bartlett Learning,
family relationships
NOTwith
relationships FORotherSALE ORwith
nurses and other healthcare professionals are neces-NOT FOR SALE OR DISTRIB
DISTRIBUTION
sary for the successful follow-through of that responsibility to patients.
Unfortunately, nurses often treat other nurses in hurtful ways through what
some people have called lateral or horizontal violence (Kelly, 2000; McKenna,
Smith, Poole, & Coverdale, 2003; Thomas, 2009). Horizontal violence involves
interpersonal conflict, harassment, intimidation, harsh criticism, sabotage, and
abuse among nurses, and may occur because nurses feel oppressed by other dom-
inant groups, such as physicians or institutional administrators. Kelly (2000)
reported that some nurses have characterized the violence perpetrated by nurses
against other nurses who excel and succeed as the tall poppy syndrome. This per-
petration creates © Jones
an ostracizing nursing culture & Bartlett
that discourages success.Learning, LLC
Thomas and her research team (2009) studied NOTtheFOR causesSALE OR DISTRIBUTION
and consequences of
nurses’ stress and anger. In their interviews, nurses voiced horizontal and vertical
violence as common sources of stress. Thomas (2009) stated, “One of the most dis-
turbing aspects of our research data on nurses’ anger is the vehemence of their
anger at each other” (p. 98). Thomas (2009) identified common characteristics of
horizontal violence as:
Subtle nonverbal behaviors, such as rolling eyes, raising eyebrows, or giving
a cold shoulder
Sarcasm, snide remarks, rudeness
Undermining or sabotaging
© Jones & Withholding
Bartlett Learning, LLC
needed information or assistance
Passive-aggressive (behind the back) actions NOT FOR SALE OR DISTRIBUTION
Spreading rumors and destructive gossip
False accusations, scapegoating, blaming (p. 98)
Horizontal violence in nursing is counterproductive for the profession. Nurses
can strengthenLLC
a sense of community among © Jones
nurses & Bartlett
by working Learning,
to heal the dishar- LLC
OT FOR SALE ORmony.
DISTRIBUTION NOT
Nurses need to support other nurses’ FORrather
successes SALE thanOR DISTRIBUTION
treating col-
leagues as tall poppies that must be cut down.
There are occasions when unpleasant but nonmalicious action must be taken
with regard to nursing colleagues. In addition to advocating for patients’ unmet
© Jones
needs, nurses & Bartlett
are advocates Learning,
when they LLC action to protect patients© Jones & Bartlett Learning,
take appropriate
from theNOT
unethical, illegal, incompetent,
FOR SALE OR DISTRIBUTION or impaired practice of other nurses (ANA,NOT FOR SALE OR DISTRIB
2001). When nurses are aware of these situations, they need to obtain appropriate
guidance from supervisory personnel and institutional policies; then, they need to
confront the offending nurses in a constructive, compassionate way. Though action
needs to be taken to safeguard patients’ care, the manner in which a nurse handles
© Jones & Bartlett
situations Learning,
involving LLC
unethical, incompetent, © Jones
or impaired colleagues must not& be
Bartlett
a Learning, LLC
matter of gossip, condescension, or unproductive derogatory talk. NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett

Thomas Learning,
(2009) suggested LLC nurses need to self-reflect
that individual © Jones & Bartlett Learning,
at the end
NOT of
FOR SALEby
the workday OR DISTRIBUTION
examining NOT
their actions and the dialogue they had FOR
with SALE OR DISTRIB
others.
All nurses, those who follow through with daily self-reflection and those who do
not, need to “make a commitment to supportive colleagueship” and “refuse to get
caught up in workplace negativism” (p. 109).
Nurses on the ‘Net
Many people who use the Internet have already experienced, to some degree, the
consequences of unethical or illegal behavior, such as being the target of someone
else’s devious actions. There is no doubt that computers influence our personal and
professional lives on an everyday basis, and so nurses and nursing students need to
understand the potential for unethical and illegal behaviors.
Matters in Moral Spaces
The potential for professional boundary crossings exist as lines and moral spaces
become blurred. Moral space is defined as “what we live in . . . any space formed
© Jones & Bartlett
from the Learning,
relationships LLCand social objects, agents ©
between natural andJones & Bartlett Learning,
events that
NOT protect
FOR SALE OReither
or establish the conditions for, or the realization of,NOT
DISTRIBUTION some FOR SALE OR DISTRIB
vision of
the good life, or the good, in life” (Turnbull, 2003, p. 4). Respect for one another’s
moral spaces takes a serious commitment by those who use the Internet. Dozens
of ethical codes of conduct exist for users of the Internet, but no matter how many
© Jones & Bartlettcodes exist or what
Learning, LLC population they serve, the codes are of no
© Jones use if they are
& Bartlett not
Learning, LLC
practiced or if people are lacking in moral integrity. Nurses and nursing students
must remain devoted to respecting human beings in all interactions and actions,
even social networking. Some of the issues that can violate the principle of
autonomy are matters of respect for human beings, self-determination, trustwor-
thiness, confidentiality, and privacy.
OT FOR SALE OR DISTRIBUTION Social Networking and Cellular
NOT FOR Phones
Nurses are increasingly using social networks to befriend others who have common
interests or to keep in touch with long-time friends. Facebook, Twitter, YouTube,
and cellular phones have become highly important as communication methods for
healthcare
© Jones professionals,
& Bartlett as they have
Learning, LLC for everyone. Two broad views exist on the
degree of value and use of social networking, cell phones, and other media.
On the positive side, nurses and physicians have found value in sharing profes-
sional information and knowledge with patients or other nurses and physicians.
Some nurses and physicians see social networking as unavoidable, but also as a
means of providing minute-by-minute information and updates about healthcare
© Jones & Bartletttrends
Learning, LLC In 2011, the American©Nurses
and treatments. Jones & Bartlett
Association Learning,
published a LLC
booklet on the principles of social networking for nurses. The ANA highlighted how
these social networking principles fit with the ANA’s three foundational documents,

Nurses on the ‘Net 91
© Jones
one of which & Bartlett
is the Code of Ethics for Learning, LLC Statements (2001). The© Jones & Bartlett Learning,
Nurses with Interpretive
ANA (2011)NOT FOR
stated thatSALE OR DISTRIBUTION
social networks “provide unparalled opportunities for rapidNOT FOR SALE OR DISTRIB
knowledge exchange and dissemination among many people” (p. 3).
Physicians also see value in the use of social networks to take care of routine
work, such refilling prescriptions, answering questions, and sharing informational
websites. In 2011, the American Medical Association (AMA) issued a policy state-
ment on professionalism in the use of social media. The AMA stated that social
media support “personal expression, enable individual physicians to have a pro-
fessional presence online, foster collegiality and camaraderie within the profession,
[and] provide opportunity to widely disseminate public health messages” (para. 1).
On the negative side, questions of confidentiality and privacy arise when nurses,
physicians, and LLCpatients share information with© Jones & on
each other Bartlett Learning,
social networks or LLC
OT FOR SALE ORcellular
DISTRIBUTION
phones. The public nature of any social NOT FOR SALE
communication OR
poses DISTRIBUTION
ethical and
legal problems, and solutions are usually labeled by employers and other leaders as
unclear, gray, complicated, and uncertain.
The growing number of employee violations is driving employers to initiate dis-
ciplinary courses of action against personnel who engage in inappropriate behav-
iors on social network sites and cellular phones and to reenforce old policies or
enforce new ones. If the codes of ethics and current hospital policies were followed,NOT FOR SALE OR DISTRIB
new policies on social networking and cellular phone use would not be required.
Lee Thomas, Federal Secretary of the Australian Nursing Federation, acknowl-
edged her concern by saying, “Social networking is instant and fun (so I’m told)
© Jones but&people
Bartlett Learning,
are increasingly LLC
using these mediums to complain©about Jones & Bartlett Learning, LLC
employers,
NOT FOR fellowSALE OR DISTRIBUTION
staff members and among our colleagues [and] even patients” NOT(2011,
FORp.SALE23). OR DISTRIBUTION
In two horror stories, nurses were suspected of patient exploitation and violations
of confidentiality and privacy. One occurred in 2010 at Tri-City Medical Center in
Oceanside, California. Five nurses were fired and a sixth nurse was disciplined for
violating confidentiality. According to a spokesperson at the medical center, there
Jones & Bartlett Learning, LLC information to warrant
was enough substantial © the
Jones
firings&of Bartlett Learning,
the five nurses, as the LLC
OT FOR SALE ORfired
DISTRIBUTION
nurses discussed patient cases on Facebook NOT FOR
(“Five SALE
nurses fired,” OR
2010).DISTRIBUTION
In an even more repulsive story in Louisiana, Lee Zurik, Investigator for Fox 8
Live WVUE-TV, stated that St. Tammany Parish Hospital emergency room (ER)
nurses were reported by Reba Campbell, ER technician, for allegedly exploiting,
making fun© Jones & Bartlett
of, and taking cell phone Learning, LLC
pictures of unconscious patients on at least© Jones & Bartlett Learning,
two different occasions. The most
NOT FOR SALE OR DISTRIBUTION recent case involved an overweight man whoNOT FOR SALE OR DISTRIB
overdosed on pain and anxiety medications. According to Zurik, Campbell stated:
Clancy [one of the three reported nurses] and the other nurse walks in and puts these
glasses on the patient and starts to make fun of him. That wasn’t funny enough, so
they took charcoal that we dumped down his throat and painted his face like a foot-
© Jones &
ballBartlett Learning,
player and said, “Welcome to LLC ©This
St. Tammany Parish Hospital ER. Jones
is your &
ini-Bartlett Learning, LLC
NOT FORtiation
SALE OR to
for trying DISTRIBUTION
kill yourself.” (Zurik, 2011, para. 10) NOT FOR SALE OR DISTRIBUTION

© Jones & two

Then Bartlett Learning,
other nurses pulled outLLC
their phones. Campbell stated© theJones & Bartlett Learning,
nurses were
NOT “taking
FOR SALE ORtheir
pictures with DISTRIBUTION NOT
two cell phones of this patient, unconscious, FORlike
painted SALE OR DISTRIB
a clown with charcoal and glasses on his face” (Zurik, 2011, para. 12). The nurses evi-
dently had taken pictures of unconscious patients before, because the co-workers had
been observed sitting at a desk and ranking the best pictures of different patients. One
of the nurses even texted the photos on her cellular phone to a physician who named
one patient picture as best in a text reply to the nurse. The attorney representing the
unconscious charcoaled patient named the hospital and three nurses in the lawsuit.
Of the three nurses and the physician, only one nurse has been fired.
Not related to and before those two incidents occurred, Thomas and her
research team (2009) had interviewed nurses across the United States to find
meaning in their layers of stress© and
Jones
anger & Bartlett
over unethical,Learning,
harmful, and LLC
dehuman-
OT FOR SALE OR DISTRIBUTION izing treatment of patients as NOT
part ofFOR
a largerSALE
study toOR DISTRIBUTION
uncover reasons for nurses’
stress and anger. One of the themes that she discovered was “I feel morally sick.”
Nurses described situations they had observed as repugnant; they felt physically
sick, disgusted, and nauseated, and believed they were powerless to do anything
about those abhorrent situations. Thomas’s interpretation of the narratives was
that the nurses were experiencing moral distress as a result of their stress and anger.
NOT Moral
FORdistress
SALEis OR DISTRIBUTION
defined in a previous section of this chapter. NOT FOR SALE OR DISTRIB
The nurses’ narratives in Thomas’s study were depictions of their terrible real-
life experiences and feelings regarding stories not related necessarily to social net-
working. Unethical and illegal events have always been described and exposed by
© Jones & Bartlettconcerned
Learning, LLCpersonnel, but the digital age
healthcare © Jones & Bartlett
has brought Learning,
many incidents to LLC
NOT FOR SALE OR newDISTRIBUTION NOT FORpotentially
levels of public exploitation. Sadly, social networking SALE OR couldDISTRIBUTION
be a
means for nurses to express frustrations in relation to their workplace, coworkers,
and patients, but no matter what reasons exist for sharing and divulging informa-
tion, nurses who do so violate their professional boundaries and most likely will
have their license suspended or revoked. Information-sharing of any privileged
information amounts to illegal, © Jones & Bartlett
inappropriate, Learning,
and unethical LLCMany
violations.
OT FOR SALE OR DISTRIBUTION nurses and physicians are seeing NOT FOR
these SALE
concerns as a OR
validDISTRIBUTION
worry and accordingly
are taking action collectively through professional organizations. The American
Nurses Association (2011) published six principles of social networking for nurses.
Where patients and nurses and all surrounding issues are concerned in health care,
© Jones & BartlettofLearning,
the commitments LLC
privacy and confidentiality © Jones
serve as the foundation & Bartlett Learning,
for these
six principles of social
NOT FOR SALE OR DISTRIBUTION networking. NOT FOR SALE OR DISTRIB
The Association of Pediatric Hematology/Oncology Nurses (APHON) recently
issued a position statement on ethical guidelines for social networking (“Associa-
tion of Pediatric Hematology/Oncology Nurses,” 2011). In their social media
policy, the AMA (2011) advised that physicians should weigh all of the issues of
© Jones & Bartlettonline
Learning,
presence,LLC
such as violations of patient © Jones & Bartlett
confidentiality, Learning,
privacy, and rela- LLC
tionships. Other professional nursing organizations are already following suit as DISTRIBUTION
more issues of confidentiality, privacy, and exploitation have surfaced.

Nurses on the ‘Net 93
© Jones
BOX 3.12
ETHICAL FORMATIONS: DOS AND DON’TS OF SOCIAL NETWORKING
Do
Know your professional and legal responsibilities to maintain privacy and confidentiality.
Know and follow your employer’s policies on social networking.
Educate yourself
© Jones & Bartlett about privacy
Learning, LLCsettings on the sites you use.© Jones & Bartlett Learning, LLC
Keep in mind that colleagues, as well as current and future employers, could access your posts,
photos, and other activity.
Remember, your employer has the right to access your online activity on work computers.
Don’t
DiscloseLLC
Jones & Bartlett Learning, any information about patients © in your
Jonescare. & Bartlett Learning, LLC
Upload photos or video of you, patients, or coworkers in a clinical setting.
Make disparaging comments about patients, your employer, or coworkers.
Discuss or post stories of clinical events, even if they are shocking or would be of interest to
friends.
Source: Quoted from College and Association of Registered Nurses in Alberta. (2010). Dos and don’ts of social networking . . .
avoid a© Jones
social &nightmare.
networking Bartlett Learning,
Alberta RN, 66(6), 22–23.LLC © Jones & Bartlett
Learning,
Employers and professional organizations worldwide are taking measures to

prevent ethical and legal violations in patient care. The College and Association of
Registered Nurses of Alberta (CARNA, 2010) offered some “Dos and Don’ts” of
social networking. These guidelines serve as an excellent reminder to nurses every-
where to observe their code of ethics. Refer to Box 3.12 for these NOT FOR SALE OR DISTRIBUTION
guidelines.
Nurses and physicians serve as role models, whether or not they want this role.
The newcomers to the healthcare professions emulate the conduct of the role mod-
elers, both the positive and negative behaviors. It is imperative that existing nurses
influence newLLC nurses and other personnel in ©aJones
positive & Bartlett
manner. Learning,
In most of the LLC
codes of
OT FOR SALE OR DISTRIBUTION ethics for nurses, including the ANA code, there is explicit
NOT FOR SALE OR DISTRIBUTION discussion
about nurses maintaining respect, confidentiality, and privacy; those same con-
cepts are applicable to social networking and cellular phone use.
KEY©POINTS
Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,
Nursing ethics is defined as the examination of all kinds of ethical and
bioethical issues from the perspectives of nursing theory and practice.
To practice nursing ethically, nurses must be sensitive enough to recognize
when they are facing seemingly obscure ethical issues in their everyday work.
© Jones & Bartlett
Within theLearning,
2001 ANA code LLCare nine moral provisions that©areJones
nonnego- & Bartlett Learning, LLC
NOT FOR SALE
tiable OR DISTRIBUTION
with regard to nurses’ work. Detailed guidelines areNOT
found FOR
in the SALE OR DISTRIBUTION
accompanying interpretive statements of each provision.


KEY POINTS (continued)
A clear patient focus in the code obliges nurses to remain attentive and
loyal to each patient in their care.
A theme common to the ANA (2001) and ICN (2006) codes is a focus on the
importance of compassionate patient care aimed at alleviating suffering.
Boundaries facilitate a safe space in a relationship, because they give each
NOT FOR SALE OR DISTRIBUTION NOTcontrol,
person in the relationship a sense of legitimate FORwhether
SALEthe OR DISTRIBUTION
rela-
tionships are between the nurse and patient, the nurse and physician, the
nurse and administrator, or nurse and nurse.
Nurses with moral integrity act consistently with their personal and pro-
Jones & Bartlett Learning, LLC fessional values. © Jones & Bartlett Learning, LLC
OT FOR SALE OR DISTRIBUTION Nurses’ moral distress occursNOT when FORinstitutional
SALE OR constraints prevent them
DISTRIBUTION
from acting in a way consistent with their personal and professional values
that make up their moral integrity.
Nurses’ work involves hard choices that sometimes result in avoidance of
patients, emotional and physical suffering, painful ambiguity, contradic-
© Jones &tion,
Bartlett Learning,
frustration, LLC
anger, and guilt. © Jones & Bartlett Learning,
Research reveals a link between moral distress and the concepts NOT of FOR
incom- SALE OR DISTRIB
petent or poor care, unsafe or inadequate staffing, overwork, cost con-
straints, ineffective policy, futile care, unsuccessful advocacy, the current
definition of brain death, objectification of patients, and unrealistic hope.
Truthtelling means that nurses should not intentionally deceive or mislead
patients. LLC © Jones & Bartlett Learning, LLC
No matter how disappointing the news will NOTbe toFOR
patientsSALE OR DISTRIBUTION
and families,
nurses must evaluate the situation carefully with wisdom and contempla-
tion before making any decision on the degree of information disclosure.
When nurses have the moral courage to do what they believe is the right
thing in a particular situation, they make a personal sacrifice of possibly
Jones & Bartlett Learning, LLC standing alone but will©feelJones & peace
a sense of Bartlett
in theirLearning,
decision. LLC
OT FOR SALE OR DISTRIBUTION Patient advocacy, an essential
NOT FOR elementSALE OR
of ethical DISTRIBUTION
nursing practice, requires
that nurses embrace the ideals of the promotion of well-being and uphold
the rights and interests of their patients.
Nurses ingrained with the ideals of socialized power seek goals to benefit
© Jones &others with the intent to avoid harm or negative effects.
Bartlett Learning, LLC © Jones & Bartlett Learning,
Nurses’ genuine attention to cultural diversity and the diversity within
NOT FOR each
SALE ORpromotes
culture DISTRIBUTION NOTinFOR SALE OR DISTRIB
ethically competent care, which is essential
everyday nursing practice.
For a successful nurse–physician relationship, three essential features need
to be present: competence, respect, and trust.
Nurses often treat other nurses in hurtful© Jones
ways. & Bartlett
Many refer Learning, LLC
to this treat-
ment as horizontal violence. NOT FOR SALE OR DISTRIBUTION

Key Points 95
KEY© Jones & Bartlett Learning, LLC

POINTS (continued)
Social networking invokes questions of confidentiality and privacy when
nurses, physicians, and patients share information with each other. The
public nature of social communication poses ethical and legal problems,
and solutions are usually unclear.
The growing number of employee violations arising in social network sites
worldwide is driving employers to initiate disciplinary courses FOR SALE OR DISTRIBUTION
of action
against their personnel and to enforce new policies to prevent inappro-
priate behaviors.
CASE STUDY: JILL BECOMES DISHEARTENED
ill is a 28-year-old, attractive, intelligent, is an “air of unhappiness” among all of the
unit of
J
and technically competent RN who has nurses throughout the hospital. Jill says working
worked for 5 years in a medical–surgical at this hospital is like no other situation that she
©aJones & Bartlett
small hospital. Learning,
She has been well likedLLC
has been involved with since©becoming
Jonesa & Bartlett Learning,
nurse.
by herNOT FOR colleagues,
professional SALE OR andDISTRIBUTION
she habitu- NOT FOR SALE OR DISTRIB
1. What do you believe are the underlying
ally makes concerted attempts to deliver com-
causes of the ICU nurses’ treatment of Jill?
passionate care to her patients. Recently, she
Do you believe that it is likely that Jill’s
left her job and began working in the busy sur-
treatment has anything to do with her
gical intensive care unit (ICU) at a local county
hospital. Jill changed her job because she
© Jones
personal & Bartlett Learning, LLC
characteristics?
NOT FORwanted
to gain more-varied nursing experience.
2. What NOTcouldFOR SALE
Jill do to OR DISTRIBUTION
try to improve her
situation?
She was very excited and enthusiastic about her
3. What are the possible implications in Jill’s
new job, but shortly after Jill began working in
delivery of care that could arise because
the ICU, she began to question her career deci-
of the treatment that she is experiencing?
sion. The more experienced nurses in the ICU are
Jones & Bartlett Learning, LLC © Jones4.&DoBartlett Learning,
you believe LLC
that the “air of unhappi-
what Jill describes as “abrupt” and “exasper-
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© Jones & Bartlett Learning, LLC

After reading this chapter, the reader should be able to:

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,

Jones & Bartlett Learning, LLC © Jones

© Jones & Bartlett

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION.

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Jones & Bartlett Learning, LLC

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BOX 3.2 ©ETHICAL

Clinical Practice Boundaries

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© Jones &TheBartlett Learning,

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© Jones & Bartlett Learning, LLC

BOX 3.3 ETHICAL FORMATIONS: ARISTOTLE’S “THE TRUTHFUL SORT”

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© Jones & Bartlett

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right thing in a particular situation, they make a personal sacrifice by possibly

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are ways©forJones &keep

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Culturally Sensitive Care

BOX 3.8 ETHICAL FORMATIONS: PONTE ET AL.’S PROPERTIES OF A POWERFUL

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Nursing Professional Relationships

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© Jones & Bartlett

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© Jones & Bartlett Learning, LLC

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© Jones & Bartlett

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© Jones & two

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Employers and professional organizations worldwide are taking measures to

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,

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KEY© Jones & Bartlett Learning, LLC

ill is a 28-year-old, attractive, intelligent, is an “air of unhappiness” among all of the

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© Jones & Bartlett Learning, LLC

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Fry, S., & © Jones

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