Chapter 3: Patient's Rights/Safety and Handling Ethical Concerns

The Importance of Patient Rights

A nurse can come across varied situations and several different patients in the course of an ordinary day and every patient has certain rights which must be respected in both ethical and legal terms. While the legal rules concerning the rights of the patient are often limited by the local laws, the ethical rules concerning patient rights go as far as asking the nurses to advocate and promote the rights of the patient as much as they can (ANA, 2001). Of the various rights which a patient has access to, privacy comes first since it is tied to one of the fundamentals of nursing i.e. confidentiality (Horan, 2006).

Privacy for a patient means both the opportunity to remain unseen and unheard as much as it is feasible. For example, a nurse can go to great lengths in order to ensure that the patient is protected from prying eyes as he disrobes for an examination, but ethics demand that the patient should also be given privacy and be kept away from curios ears (ANA, 2001). For example, a patient has a right to be listened to in private if they wish to discuss some issue concerning their health. Of course, it is up to the patient to decide what discussion can be had in public and what requires a private audience with the nurse (DoBias, 2006).

Confidentiality is another right of the patient which is linked to the concept of privacy, but it covers a rather broader spectrum since there are cases where confidentiality needs to be broken (ANA, 2001). The ethical need for confidentiality in nursing comes with the need to establish a relationship of mutual trust between the nurse and the patient. Patients would be more comfortable in discussing things like their sex life, recreational drug use and other things considered to be taboo if they know that their information would remain confidential. There is also the consideration of patient safety when this information is to be shared with other individuals including doctors, social workers or law enforcement officers since information should only be shared on a need to know basis (Rogers, 2006).

The need for confidentiality is not an overriding ethical principle because in some cases it is more ethical to break the seal of privacy and confidentiality where legal requirements make such breaches mandatory (ANA, 2001). For example, if a patient confesses to being a sexual predator of children or tells a nurse that he molested a child, the nurse may come under a legal obligation to inform social organizations or law enforcement agencies in her region. In such situations, the protection of a third party is a more important ethical consideration than the demands of confidentiality.

Protection for Research Subjects

The basic principles of nursing ethics lay the guidelines for the right to accept and deny treatment based on individual wishes. Similarly, the more advanced principles follow the same guidelines and allow individuals complete freedom in choosing to participate in research or not. The ethical nurse will make sure that the information given to the subjects about the research being conducted is sufficient for them to understand the consequences and allows them to make an informed decision regarding their participation. They must also be told about the ways in which they can discontinue their participation in any research project without incurring any negative penalties (ANA, 2001).

In fact, withdrawal from a research study at any point is a right for the patient/subject which a nurse must protect as per the ethical guidelines for research. If a nurse is conducting a study or an experiment herself, she must first obtain permission from a qualified body and the ethics of the study need to be approved by a review board. There are protected groups which may have certain legal privileges and protections offered by the law depending on the legal structure of the state or county where research is being conducted.

For example, young children, prison inmates, university or college students and the elderly may have restrictions as a group as to what research can be conducted using these subjects. In case a nurse spots something he thinks is illegal or against the principles of ethics followed in the nursing profession, it becomes his duty to report this to higher authorities and if he has moral objections, to refuse to participate in the research (ANA, 2001). Moral objections to participation in research are permitted as a good enough reason for not being a part of a certain line of research if the research line is ethically questionable.

Handling a Breach of Ethics

In case a research line or a nursing practice comes across as ethically questionable, then a nurse must play his role as a caretaker for ethics and the nursing field. The role of the caretaker according to the ANA code of ethics (2001) means that a nurse has to look out for and act on any information that shows:

• Incompetence in patient care
• Unethical medical practices
• Illegal activities
• Performance impairment

This examination is not limited to the person of the nurse or other nurses working in the same hospital since it applies to all medical professionals who provide health care services. Of course, to be fully functional in this capacity as a caretaker for ethical principles, a nurse must be very well aware of the guidelines concerning ethics and the standards followed in the field (ANA, 2001). Additionally, to fulfill this particular role, a nurse should also be knowledgeable about local laws and rules, employment policies, as well as broader federal laws which apply to medical practice.
If a nurse finds out about an unethical practice, the first person who the nurse should talk to is the individual who is responsible for the practice and quite often this should be enough to remedy the situation and prevent further lapses in ethics. If the unethical situation is being caused by outside influences like the healthcare system or an HMO then the case should be brought to the attention of the administrative bodies in the workplace. In fact, the code of ethics recommends that external bodies should be contacted if there are ethical breaches which can not be handled by one person alone (Harrison, 2003).
While the code does not lay out an exact process by which reports can be made for unethical, illegal or deficient practices observed by the nurse, it does suggest that nurses should group together to establish such processes given the needs of their work environment. Clearly a nurse working in the areas of education or research would come across slightly different situations compared to nurses working in the emergency room of a metropolitan hospital. Therefore, a general process is given by the code of ethics which begins with a discussion and a report of the unethical activity (ANA, 2001). This report should be made through official channels whenever possible since it would lessen the chance of any personal conflict between nurses working together (Harrison, 2003).

The code of ethics does differentiate between impairment and incompetence because a nurse can be very competent but still be impaired by unethical acts like self medication or substance abuse. On the other hand, it is also possible for a nurse to be incompetent as far as nursing skills are concerned due to a lack of training or inexperience in dealing with certain situations (ANA, 2001). Impairment can be cured with support and help from the nurses' circle but incompetence can only be overcome with training and education in which the greater role must be played by the nurse himself.

There are also guidelines for nurses who have been told of their own unethical practices and the first step for them is not to become defensive or react in a manner which is against the principles of nursing. They should listen to the report made against them and provide full assistance to identify and remove any issues which may have caused them to behave unethically. Since a breach of ethics is a serious matter, the evidence given for unethical behavior has to be based on factual instances, hard data or eyewitness accounts. The evidence can not be based on opinions or feelings alone, even though a nurse may have strong suspicions or doubts about someone in the workplace. Finally, the code recognizes that certain risks are posed to the reporting nurse himself when he reports a breach of ethics, but this does not reduce his obligation to make the report (ANA, 2001).

In fact, a nurse is asked to report a lot more than ethical issues since reporting also needs to be done for impaired medical practice (ANA, 2001). For example, Nurse Lansing sees one of her fellow nurses behave in an odd manner after she had returned to the hospital from lunch. Upon inquiry, Lansing discovers that her fellow nurse had too much to drink and seems to be unable to fully respond to her duties. Even though she is not handling any patients and only doing paper work, Nurse Lansing makes a strong recommendation to her coworker that she go home and rest. In this case, Nurse Lansing acted ethically because she took steps to remove an impaired healthcare provider from the hospital. It could also be recommended to Nurse Lansing that she make an official report of this incident to ensure that it is not repeated in the future.

The first duty of a nurse in the case described above is towards the patient and that duty was fulfilled by removing an impaired nurse from the scene. However, there is also a duty a nurse has towards his fellow colleagues and that comes in the shape of support and guidance which can help other people through difficult times. For example, a nurse could be recovering from a mental or physical illness which is impairing her performance or she could be facing some other difficulties in her personal life which are having a negative effect. In all of the cases, support and assistance from the nursing fellowship is not only an ethical requirement, it is also the humane thing to do. Once again, the individual standards followed at the particular work environment can come quite handy when dealing with such situations.

Of course all breaches in ethics or law can be reduced significantly if there is an established system for evaluating and reviewing the performance of nurses (Harrison, 2003). While the nurses involved with education and training might find it easy to review the performance of others, nurses who actively work with patients can have a more difficult time in such situations. Ethically speaking, peer review bodies, nurse evaluation committees and other groups within a hospital can be a great method for creating and drafting rules by which ethics and legal issues can be solved for nurses (ANA, 2001).

Responsibility and Accountability

While the nursing profession comes with an understanding that a nurse will have to cooperate and work with other professionals in the field, provision four of the code of ethics clarifies to all nurses that they are also individuals who are accountable for their actions and bear full responsibility for their actions (ANA, 2001). The differentiation between accountability and responsibility is clarified by the code of ethics in the following way:

Accountability: To answer for and justify workplace actions regardless of the orders or procedures defined by the working environment.

Responsibility: The conscientious delivery of the duties given to a nurse depending on the role she is placed in.

The role of the nurse can change on a day to day basis; in some situations a nurse can be responsible for the actions of other health care professionals of which some may not even be licensed practitioners. For example, a nurse may have to supervise other nurses or even cleaning staff where the actions of the people being supervised become the responsibility of the nurse. On the other hand, a nurse may have to administer an injection to a patient or to assist a patient in taking his medication in which case the concept of accountability is more applicable.

A nurse is also responsible for his own supervision and adding to the competence of his person (ANA, 2001). Education, collaboration and seeking outside assistance can all be useful in discharging this responsibility, but knowing the competence of others is a different matter altogether. A nurse can accurately give an account of his own competence in a certain field, but it would be difficult to expect that the nurse would know the exact competencies all those she works with. The ANA code of ethics (2001) recognizes this difficulty and makes the recommendation that all nurses should try to reasonably assess the people they works with in order to understand their individual abilities and skill levels.

Ethically, such assessments must be made by the supervising nurse alone and this task should not be given over to others. Nurses are also responsible for maintaining adequate staffing levels when they are placed in a supervisory role since a lack of sufficient personnel can lead to some nurses being overworked. This creates an unsafe situation for both nurses as well as patients and reduces the quality of health care service (Caputo, 2006). The code of ethics demands that nurses should refuse any unsafe assignments and should work with the administrative arm of the workplace to remedy the situation (ANA, 2001).