South Florida Hospital News
Tuesday September 29, 2020

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July 2008 - Volume 5 - Issue 1


Ethics In Nursing

Every nurse, at one time or another, has confronted ethical dilemmas in their practice. Generally, we consider ethical responsibility issues to involve practice issues like end-of-life care, resources for poor or indigent clients, the withdrawal of life support, the withholding of nutrients to terminal clients, religious issues(eg.-LDS parents refusing blood products for their children) and cultural variations (eg.- female circumcision), etc. Few of us recognize the importance of ethical responsibility at the nursing "field" level.

Relevant sections of the ANA (American Nursing Association) Code of Ethics are outlined below:

  1. The nurse’s primary commitment is to the patient, whether an individual, family, group or community.
  2. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.
  3. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
  4. The nurse participates in establishing, maintaining and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action.
  5. The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.
  6. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
In 2005, the President of the AACN (American Association of Critical Care Nurses), Connie Barden, called for nurses to use their "bold voices" to make their work environments safer. In particular, she challenged nurses to:
  1. identify the most pressing challenge(s) in their work environments,
  2. initiate discussions with their colleagues to find solutions to these challenges, and
  3. to remain actively involved in the solutions until they are working.
It appears that only one States’ nurses have heard and responded to this challenge: California. In 2005, California formally started enforcing the mandatory staffing ratios passed under the direct efforts of the California Nurses Association, overcoming the persistent obstructionism of Governor Swarzennegger and the Hospital Association. To their credit, Kaiser Permanente was proactive on this and instituted the measures without being forced to do it by law. Perhaps they recognized not only the inevitability of the law but also the consistency of this law with safe patient care. 94 studies have shown a strong correlation with safe patient care and safe staffing ratios, and the IOM (Institute of Medicine) report stating that up to 90,000 patients a year are prematurely killed in U.S. hospitals has placed tremendous national pressure on delivery systems to focus on improving patient safety…well, focus on everything BUT safer staffing ratios. The Massachusetts State Nurses Association (MSNA) has also been increasingly proactive for set ratios, as has the United American Nurse (UAN).

In particular, the AACN Standards for Establishing and Sustaining Health Work Environments were defined. 3 of the 6 essential standards are listed below:

  1. Effective Decision Making: Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations.
  2. Appropriate Staffing: staffing must ensure the effective match between patient needs and nurse competencies.
  3. Authentic Leadership: Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.
For more than 20 years now, bedside nurses HAVE articulated their concerns in institutional survey after survey, in anecdotal complaints to each other, and in national surveys. Unfortunately, these persistent complaints have done little but result in "action plans" for mid-level nurse managers who are essentially powerless to correct them. "Do the best you can" has become the mantra for many nursing administration systems. Many nurses are now realizing that the best way to protect their patients is to organize and protect themselves.

Perhaps the recent CMS (Medicare) regulations dealing with non-payment for many hospital acquired infections and complications will be the final stimulus for hospital systems to recognize the importance of truly "safe" nursing practice. CMS will no longer reimburse healthcare facilities for:

  1. Certain catheter associated UTI’s
  2. Vascular associated infections
  3. Mediastinitis after CABG
  4. Bed sores
  5. Blood incompatibility
  6. Air embolism
  7. Falls
Interestingly, the results of many nursing studies have shown that inadequate staffing ratios play an important role in:
  1. Failure to rescue
  2. Medication errors
  3. Fall prevention
  4. Infections
  5. Delays in discharges
As the evidence mounts , CMS may well move on to mandate set ratios.

The healthcare system faces increasing regulation, stimulated by public demand, unless the system can reduce complications associated with health care. The AHRQ released a study in 2004 showing that hospital profits did not decrease due to increased staffing, although operating costs did rise. It appears the savings outweigh the expenditure. What should be paramount is that the benefit to patient safety is what really matters.

John Silver, Fellow of the Institute of Nursing Leadership, Assistant Professor of Nursing, NOVA Southeastern University, can be reached at (954) 262-1995 or
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