Test Bank for Essentials of Nursing Leadership and Management 7th Edition Weiss

[COMPANY NAME] [Company address] TEST BANK FOR ESSENTIALS OF NURSING LEADERSHIP AND MANAGEMENT 7TH EDITION WEISS Test Bank for Essentials of Nursing Leadership and Management 7th Edition Weiss Characteristics of a Profession OBJECTIVES After reading this chapter, the student should be able to: ■ Explain the qualities associated with a profession ■ Diff erentiate between a job, a vocation, and a profession ■ Discuss professional behaviors ■ Determine the characteristics associated with nursing as a profession ■ Explain licensure and certifi cation ■ Summarize the relationship between social change and the advancement of nursing as a profession OUTLINE Introduction Professionalism Defi nition of a Profession Professional Behaviors Evolution of Nursing as a Profession Nursing Defi ned The National Council Licensure Examination Licensure ■ Discuss some of the issues faced by the nursing profession Licensure by Endorsement ■ Explain current changes impacting nur’ssinfguture Qualifi cations for Licensure Licensure by Examination NCLEX-®RN Political Infl uences and the Advance of Nursing Professionals Nursing and Health-Care Reform Nursing Today The Future of Professional Nursing Conclusion 3 4 unit 1 ■ Professionalism Introduction Professionalism It is often said that you do not know where yoDuefi nition of a Profession are going until you know where you have beenA. vocation or calling defi nes “meaningful work” More than 40 years ago, Beletz ( 1974 w) rote depending on an individu’asl point of viewDi(k that most people thought of nurses in gender- & Duff y, 2009 ). Nursing started as a vocation or linked, task-oriented terms: “a female who per- “calling.” Until Nightingale, most nursing occurred forms unpleasant technical jobs and functions athsrough religious orders. To care for the ill and an assistant to the physician” (p. 432). Interesti -nfi rmed was a duty ( Kalisch & Kalisch, 2004 ). In ingly, physicians in the 1800s viewed nursing ae sarly years, despite the education required, nursing a complement to medicine. According tWo ar- was considered a job or vocatioCna(rdillo, 2013 ). rington ( 1839 ), “. . . the prescriptions of the best Providing a defi nition for a “profession” or “prophysician are useless unless they be timely anf dessional” is not as easy as it appears. Th e term is properly administered and attended to by thenurse” (p. iv). used all the time; however, what characteristics defi ne a professional? According to Saks ( 2012 ), In its earliest years, most nursing care occurredseveral theoretical approaches have been applied at home. Even in 1791 when the fi rst hospitalto creating a defi nition of a profession, the older opened in Philadelphia, nurses continued to caoref these looking only at knowledge and expertise, for patients in their own home settings. It tookwhereas later ones include a code of ethics, pracalmost another century before nursing moved into tice standards, licensure, and certifi cation, as well hospitals. Th ese institutions, mostly dominated byas expected behaviorPso(st, 2014 ). male physicians, promoted the idea that nurses Nurses engage in specialized education acted as the “handmaidens” to the better-educateda, nd training confi rmedby successfullypassing more capable men in the medical fi eld. the National Council Licensure Examination Th e level of care diff ered greatly in these early(NCLEX ® ) and receiving a license to practice health-care institutions. Th oseoperated by the in each state. Nurses follow a code of ethics and religious nursing orders gave high-quality care r teocognized practice standards and a body of conpatients. In others, care varied greatly from good totinuous research that forms and directs our practice. almost none at all. Although the image of nurses Nurses function autonomously within the desigand nursing has advanced considerably since thenn ,ated scope of practice, formulating and delivering some still think of nurses as helpers who carry out a plan of care for clients, applying judgments, and the physician ’ s orders. utilizing critical thinking skills in decision making It comes as no surprise that nursing and health( Cardillo, 2013 ). care have converged and reached a crossing point. Nurses face a new age for human experience; the very foundations of health practices and thera- Professional Behaviors peutic interventions continue to be dramatically According toPost( 2014 ), professional characterisaltered by signifi cantly transformed scientifi c, tics or behaviors include: technological, cultural, political, and social realities ( Porter-O’Grad,y 2003 ). Th e global environment ■ Consideration needs nurses more than ever to meet the health■ - Empathy care needs of all. Nursing sees itself as a profession rather than a job or vocation and continues with this quest for its place among the health-care disciplines. However, ■ Respect ■ Ethical and moral values ■ Accountability ■ Commitment to lifelong learning what defi nes a profession? What behaviors are ■ Honesty expected from the members of the profession? Professionalism denotes a commitment to carry Chapter 1 discusses nursing as a profession woituht specialized responsibilities and observe ethical its own identity and place within this new and principles while remaining responsive to diverse ever-changing health-care system. recipients (Al-Rubaish, 2010 ).Communicating chapter 1 ■ Characteristics of a Profession5 eff ectively and courteously within the work envi-Evolution of Nursing ronment is expected professional behavior. State boards of nursing through the nurse practice acts elaborate expected behaviors in a registered nurse ’Nsursing Defi ned professional practice and personal life (NationalTh e changes that have occurred in nursing are Council of State Boards of NursingNC[ SBN], refl ected in the defi nitions of nursing that have 2012, 2016 ). Nurses may lose their licenses f d o e r ve a loped through time. In 1859, Florence Nightvariety of actions deemed unprofessional or e defi ned the goal of nursing as putting the For example, inappropriate use of social mediac , lient “in the best possible condition for nature to posting emotionally charged statements in blogs oract upon him” (Nightingale, 1992/1859 , p. 79). In forums, driving without a license, and committing 1966, Virginia Henderson focused her defi nition felonies outside of professional practice may beon the uniqueness of nursing: cause for suspending or revoking a nursing license. Commitment to others remains central to a profession. In nursing, this entails commitmentto colleagues, lifelong learning, and accountability Th e unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or for one ’ s actions. Professionalism in the workplaceto peaceful death) that he would perform unaided means coming to work when scheduled and on if he had the necessary strength, will or knowledge. time. Coming to work late shows disrespect to your And to do this in such a way as to help him gain peers and colleagues. It also indicates to your superi -ndependence as rapidly as possible. ( Henderson, visor that this position is not important to you. Always portray a positive attitude. Although 1966 , p. 21) everyone experiences a bad day, projecting personaMl arthaRogers defi ned nursingpracticeas “the feelings and issues onto others aff ects the woprkrocess by which this body of knowledge, nursing environment. Many agencies and institutions have science, is used for the purpose of assisting human dress codes. Dress appropriately per the emplobye-ings to achievemaximum health within the er ’ s expectations. Wearing heavy makeup, colognpeost,ential of each personR”o(gers, 1988 , p. 100). or inappropriate hairstyles demonstrates a lack of Rogers emphasized that nursing is concerned with professionalism. Finally, always speak professiona-ll people, only some of whom are ill. ally to everyone in the work environment. A good rule to follow should be, “If you wou’ltdnsay it in front of your grandmother, do not say it in the workplace”M( cKay, 2017 ). In the modern nursing era, nurses are viewed as collaborative members of the health-care team. Nursing has emerged as a strong fi eld of its own in which nurses have a wide range of obligations, Work politics often create an unfavorable envi- responsibilities,and accountability.Recent polls ronment. Stay away from gossip or engaging inshow that nurses are considered the most trusted negative comments about others in the of professionals because of their knowlChange the topic or indicate a lack of interest in edge, expertise,and ability to care for diverse this type of verbal exchange. Negativity is contpao-pulations. gious and aff ects workplace morale. ProfessionalsNightingale’ s concepts of nursing care became maintain a positive attitude in the work environt-he basis of modern theory development, and in ment. If the environment aff ects this attitude, it is time to look for another position M( cKay, 2017 ). Lastly,professionalbehavior entails honesty today ’ s language, she used evidence-based practice to promote nursing. Her 1859 bookNotes on Nursing: What It Is and What It Is Not laid the founand accountability. If a day off is needed, takedaation for modern nursing education and practice. personal or vacation day; save sick days for illnessM. any nursing theorists have used Nighting’asle Own up to errors. In nursing, an error may result thoughts as a basis for constructing their view of in injury or death. Th e health-care environmenntursing. should promote a culture of safety, not one of pun- Nightingale believed that schools of nursing ishment for errors. Th is is discussed more in latermust be independent institutions and that women chapters. who were selected to attend the schools should be as a Profession 6 unit 1 ■ Professionalism from the higher levels of society. Many of Night- license in one state is recognized in another. States ingale ’ s beliefs about nursing education are stbilel longing to the compact passed legislation adoptapplicable,particularly those involved with the ing the terms of the agreement. Th e state in which progress of students, the use of diaries kept btyhe nurse resides is considered the home state, and students, and the need for integrating theory into clinical practice R( oberts,1937 ). Th eNightingale school served as a model license renewal occurs in the home staNtCeS( BN , 2018a ). Licensuremay be mandatory or permissive. for nursing education. Its graduates were soughPtermissive licensure is a voluntary arrangement worldwide. Many of them established schools and whereby an individual chooses to become licensed became matrons (superintendents)in hospitals to demonstrate competence. However, the license is in other parts of England, the British Common-not required to practice. In this situation a mandawealth, and the United States. However, very few tory license is not required to practice. Mandatory schools were able to remain fi nancially indepenlic-ensure requires a nurse to be licensed in order to dent of the hospitals and thus lost much of their practice. In the United States and Canada, licenautonomy. Th is was in contradiction to Nightins-ure is mandatory. gale ’ s philosophy that the training schools were educational institutions, not part of any service agency. The National Council Licensure Examination Professionsrequire advancededucation and an Licensure by Endorsement If a state is not a member of the compact, nurses licensed in one state may obtain a license in another state through the process of endorsement.Each application is considered independently and is granted a license based on the rules and regula-tions of the state. States diff er in the number of continuing eduadvanced area of knowledge and training. Mancyation credits required, mandatory courses, and are regulated in some way and have a licensuorteher educational requirements. Some states may or certifi cation requirement to enter practice. Th isrequire that nurses meet the current criteria for holds true for teachers, attorneys, physicians, alincdensure at the time of application, whereas others pilots, just to name a few. Th e purpose of a profesm-ay grant the license based on the criteria in eff ect sional license is to ensure public safety, by setting at the time of the original license. When applying a level of standard that indicates an individual has for a license through endorsement, a nurse should acquired the necessary knowledge and skills toalways contact the board of nursing for the state enter into the profession. Licensure and ask about the exact requirements for licensurein that state. Th is information is usually found on the state board of nursing Web site. Licensure for nurses is defi ned by the NCSBN NURSYS is a national database that houses as the process by which boards of nursing grai ftormation on licensed nurses. Nurses applypermission to an individual to engage in nursinigng for licensure by endorsement may verify their practice after determining that the applicant haslicenses through this database. Th e’ snulircseense attained the competency necessary to perform vaerifi cation is available immediately to the endorsunique scope of practice. Licensure is necessairnyg board of nursing ( NCSBN , 2016 ). Not all when the regulated activities are complex, require states belong to NURSYS. specialized knowledge and skill, and involve independent decision making ( NCSBN, 2012 ). Qualifi cations for Licensure Government agencies grant licenses allowing anTh ebasic qualifi cation for licensure requires individual to engage in a professional practice and graduation from an approved nursing program. use a specifi c title. State boards of nursing issInue the United States, each state may add nursing licenses. Th is limits practice to a specaifdi dcitional requirements, such as disclosures jurisdiction. However, as the NCLE ®Xis a nation- regarding health or medications that could aff ect ally recognizedexamination, many states have practice. Most states require disclosure of criminal joined together to form a “compact” where theconviction. Licensure by Examination chapter 1 ■ Characteristics of a Profession7 health services. Public health nursing found itself A major accomplishment in the history of nursing in an ideal position to step up and assume responlicensure was the creation of the Bureau of St sa i t be ility for providing care to dependent mothers Boards of Nurse Examiners. Th feormation of and children, the blind, and disabled children this agency led to the development of an identical ( Black, 2014 ). In 1965, under President Lyndon B. examination in all states. Th e original examinationJ , ohnson, amendments to the Social Security Act called the State Board Test Pool Examination, wasdesigned to ensure access to health care for the created by the testing department of the National elder adult, the poor, and the disabled resulted in League for Nursing (NLN). Th is was complete td he creation of Medicare and Medicaid (Centers through a collaborative contract with the state for Medicare and Medicaid Services [ CMS ], boards. Initially, each state determined its own 2017 ). Health insurance companies emerged and passing score; however, the states did eventuai l n lycreased in number during this time as well. Hosadopt a common passing score. Th e examina pti io tan ls started to rely on Medicare, Medicaid, and is called the NCLEX-RN® and is used in all states insurance reimbursement for services. Care for the and territories of the United States. Th is test s is ick and new opportunities and roles emerged for prepared and administered through a professional nurses within this environment. testing company. NCLEX-RN ® Historically, as a profession, nursing has mademost of its advances during times of social change. Th e1960s through the 1980s brought many changes for both women and nursing. In 1964, Th e NCLEX-R ®N is administered through com-President Johnson signed the Civil Rights Act, puterized adaptive testing (CAT). Candidates which guaranteed equal treatment for all individneed to register to take the examination at anuals and prohibited gender discrimination in the approved testing center in the state in which they workplace. However, the law lacked enforcement. intend to practice. Because of a large test banDku, ring this time, the feminist movement gained CAT permits a variety of questions to be adminis- momentum, and the National Organization for tered to a group of candidates. Candidates taking Women was founded to help women achieve the examination at the same time may not neces- equality and give women a voice. Nursing moved sarily receive the same questions. Once a candidaftoerward as well. Specialty care disciplines develanswersa question, the computer analyzesthe oped. Advances in technology gave way to the response and then chooses an appropriate questiomnore complex medical–surgical treatments such to ask next. If the candidate answers the question as cardiothoracic surgery, complex neurosurgical correctly, the following question may be more dif- techniques, and the emergence of intensive care fi cult; if the candidate answers incorrectly, the nexet nvironmentsto care for these patients. Th ese question may be easier. In April 2016, the NCSBN releasedthe changes fostered the development of specializa-tion for nurses and physicians, creating a shortage updated test plan. Th e new test plan redistributedof primary care physicians. Th e public demanded the percentages for each content area and updatedincreased access to health care, and nursing again the question format with increased use of technol- stepped forward by developing an advanced pracogy that better simulated patient care role for nurses to meet the primary health-care More updated information on the NCLE ®Xtest plans may be found on the NCSBN Web site( .o)r.g needs of the public. Th roughout the years, wars created situations that facilitated changes in nursing and its role within society. Wars increased the na’tsion eed for nurses and the public ’ s awareness of’ snursing Political Infl uences and the AdrovleainncsoecietyK(alisch & Kalisch, 2004 ). Nurses of Nursing Professionals Nursing made many advances during the time of served in the military during both world wars and the Korean confl ict and changed nursing practice during the time of war. For the fi rst time, nurses social upheaval and change. Th e passing of twhere close to the front and worked in mobile hosSocial Security Act in 1935 strengthened publicpital units. Often they lacked necessary supplies 8 unit 1 ■ Professionalism and equipment K(alisch & Kalisch, 2004 ). Th etoy recognized standards of nursing practice” found themselves in situations where they needed(American Nurses AssociationA[NA ], 2006 ). to function independently and make immediate Nursing has recognized the need for the decisions, often assuming roles normally associatepdrofession to understand and function during with the physicians and surgeons. human-caused and natural disasters such as 9/11 Th e Vietnam War aff orded nurses opportunitieasnd hurricanes. Th e profession has answered the to push beyond the boundaries as they functioned call by increasing disaster preparedness training for in mobile hospital units in the war theater, oftennurses. without direct supervisionof physicians. Th ese nurses performed emergency procedures such as tracheostomies and chest tube insertions in order to preserve the lives of the wounded soldiers ( TexaF s Tech University, 2017 ). After functioning inde- or more than 40 years,Florence Nightingale played an infl uential part in most of the important pendently in the fi eld, many nurses felt restricted health-care reforms of her time. Her accomplishby the practice limits placed on them when the m y ents went beyond the scope of nursing and returned home. nursing education, aff ecting all aspects of health Challenges for society and nurses continued care and social reform. from the 1980s through 2000. Th e 1980s were Nightingale contributed to health-care reform marked by the emergence of the HIV virus ant d hrough her work during the Crimean War, where AIDS. Although we know more about HIV and she greatly improved the health and well-being of AIDs today than we knew more than 30 years ago,the British soldiers. She kept accurate records and society’ s fear of the disease stigmatized groups of accountings of her interventions and outcomes, individuals and created fear among global popu a - lations and health-care providers. Nurses becam nd on her return to England she continued this w e instrumental in educating the public and working ork and reformed the conditions in hospitals and directly with infected individuals. health care. Th e 21st century brings both challenges and Th e increase in available technology allowe o d pportunities for nursing. It is estimated that for the widespread use of life-support than 434,000 nurses will be needed by the Nurses working in critical care areas often face y d ear 2024 (Bureau of Labor Statistics [BLS ], ethical dilemmas involving the use of these tech- 2017 ). Th e severe nursing shortage has increased nologies. During this time period, nurses voicedthe demand for more nurses, whereas the passing their opinions and concerns and helped in formu- of the Aff ordable Care Act (ACA) off ers opporlating policies addressing these issues within their tunities for nurses to take the lead in providing communities and institutions. Th e fi eld of hospice nursing received a renewed interest and suppoprimary health care to those who need it. More a rt dvanced practice nurses will be needed to address (National Hospice and Palliative Care Organi- the needs of the diverse population in this country. zation [NHPCO ], 2012 ); therefore, the numberHealth-care reform is discussed in more detail in opportunities for nurses. Th e fi rst part of the 21st century introduced nurses to situations beyond anyone ’ ismagina- tion. Nursing’ s responseto the terrorist attack on the World Trade Center and during the onset Nursing Today Issues specifi c to nursing refl ect the problems and and aftermath of Hurricane Katrina raised mul-concerns of the health-care system as a whole. tiple questions regarding nurses’ abilities to reaTcht e average age of nurses in the United States is to major disasters. Nurses, physicians, and oth4e6r.8 years, and approximately 50% of the nursing health-care providers attempted to care for andworkforce is older than 50 ( NCSBN, 2015 ). protect patients under horrifi c conditions. NurseBsecause of changes in the economy, many nurses found themselves trying to function “during unfa- who planned to retire have instead found it necmiliar and unusual conditions with the health essary to remain in the workforce. However, the care environment that may necessitate adaptationsrecent data collected also noted an increase in men Nursing and Health-Care Reform Chapter 1.6 of hospice care providers grew and opened new chapter 1 ■ Characteristics of a Profession9 entering the fi eld as well as an increase in younger Advanced practice nurses (APRNs) are qualand more diverse populations seeking nursing ifi ed to diagnose and treat certain conditions. careers. Th ese highly educated nurses are more than phyConcerns about the supply of registered nursessician extenders as they sit for board certifi cation (RNs) and staffi ng shortages persist in both theexaminations and are licensed by the states in United States and abroad. For the fi rst time, multi-which they practice. Educational requirements for ple generations of nurses fi nd themselves workingAPRNs include a minimum of a ma’ssterdegree together within the health-care environment. Th e in nursing with a clinical focus, and a designated oldest of the generations, the early baby boomers,number of clinical hours. Many nurse practitionplanned to retire during the last severalyears; ers are obtaining the Doctor of Nursing Practice however, economics have forced many to rema(DinNP) degree. Th e American Association of Critin the workplace. Th ey presently work alongsiidceal Care Nurses (AACN) and the NLN both Generation X (born between 1965 and 1979) and promote this as the terminal degreefor nurse the generation known as the millennials (born in practitioners. Areas of advanced practice include 1980 and later). Nurses from the baby boomerfamily nurse practitioner, acute care nurse pracgeneration and Generation X provide the majort-itioner, pediatric nurse practitioner, and certifi ed ity of bedside care. Where the millennials fi ndnurse midwife. themselves comfortable with technology, the baby boomers feel the “old ways” worked well. Conclusion Generational issues in the nursing workforce present potential confl icts in the work environ- Professional behavior is an important component ment as these generations come with diff eringof nursing practice. It is outlined and guided by viewpoints as they attempt to work together within state nurse practice acts, the ethical codes, and the health-care communityBr(agg, 2014 ; Moores,tandards of practice. Acting professionally both Everly, & Bauer,2016 ). Each generation brings its while in the workplace and in on’es personal life is own set of core values to the workplace. In order toalso an expectation. As nursing moves forward in be successful and work together as cohesive teamtsh,e 21st century, the need for committed profeseach generation needs to value the others’ skisllsionals and innovative nurse leaders is greater than and perspectives. Th is requires active and asserteivveer. Societ’ys demand for high-quality health care communication, recognizing the individual skill sets of the generations, and placing individuals in positions that fi t their specifi c characteristics. at an aff ordable cost is now law and an impetus for change in how nurses function in the new environment. Th e related issues of excessive workload, maEn-mployers,colleagues,and peers depend on datory overtime, scheduling, abuse, workplace new nurses to act professionally and provide safe, violence, and lack of professional autonomy coqnu-ality patient care. Taking advantage of expandtribute to the concerns regarding the nursing ing educational opportunities, engaging in lifelong shortage C( larke, 2015 ; Wheatley, 2017 ). Thleaersneing, and seeking certifi cation in a specialty issues impact the workplace environment and oftendemonstrate professional commitment. place patients at risk. Professional behavior requires Nursing has its roots as a calling and vocation. respect and integrity, as well as safe practice. It originated in the community, moved to hospitals, returned to the community, and is now seen The Future of Professional Nurinsminulgtiple practice settings. Th e ACA has opened doors for more opportunities for nurses, and the Th e changes in health care and the increased neIeOdM report on theFuture of Nursing states that for primary care providers has opened the door fornurses need to be permitted to use their educanursing. Th e Institute of Medicine (,IOM2010 ) tional skills in the health-care environment. report specifi callystated that nursesshould be Often students ask the question: “So what can permitted to practice to the full extent of their I do? I am a new graduate.” Get involved in your education. Nurses are educated to care for individ-profession by joining organizations and becoming uals who have chronic illnesses and need heapltholitically active. Continue pursuing excellence and teaching and monitoring. set the stage for those who will come after you. 10 unit 1 ■ Professionalism 1. RNeoatdes on Nursing: What It Is and What It Is Not by Florence Nightingale. How much of its content is still true today? 2. What is your defi nition of nursing? How does it compare or contrast with Virginia He’nsderson defi nition? 3. Review the mission and purpose of the ANA or another national nursing organization online. Do you believe that nurses should belong to these organizations? Explain your answer. 4. Professional behaviors include a commitment to lifelong learning. What does “lifelong learning” mean beyond mandatory continuing education? 5. Formulate your plan to prepare for the N ®C.LEX Case I Th omas went to nursing school on a U.S. Public Health Service scholarship. He has been directed to go to a rural village in a small Central American country to work in a local health center. Several other nurses have been sent to this village, and the residents forced them to leave. Th e village lacks electricity and plumbing; water comes from in-ground wells. Th e villagers and children suff er from frequent episodes of gastrointestinal disorders. 1. How do you think Florence Nightingale would have approached these issues? 2. What do you think Th omas should do fi rst to gain the trust of the residents of the village? 3. Explain how APRNs would contribute to the health and welfare of the residents of the village. Case II Th e younger nurses in your health-care institution have created a petition to change the dress code policy. Th ey feel it is antiquated and rigid. Rather than wearing uniforms or scrubs on the nursing units, they would prefer to wear more contemporary clothing such as khakis and nice shirts with the agency logo along with laboratory coats. Th e older-generation nurses feel that this will detract from the nursing image, as patients expect nurses to dress in uniforms or scrubs and this is what defi nes them as a “profession.” 1. What are your thoughts regarding the image of nursing and uniforms? 2. Do you feel that uniforms defi ne nurses? Explain your reasoning. 3. Explain the reasons certain generations may see this as a threat to their professionalism. 4. Which side would you support? Explain your answer with current research. Case Studies to Promote Critical Reasoning chapter 1 ■ Characteristics of a Profession11 1. Nursing has its origins with 1. Florence Nightingale 2. Th e Knights of Columbus 3. Religious orders 4. Wars and battles 2. Who stated that the “function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death)”? 1. Henderson 2. Rogers 3. Robb 4. Nightingale 3. You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A non-nursing colleague asks about this code. Which of the following statements best describes this code? 1. Improves communication between the nurse and the patient 2. Protects the pa’ stiernigtht of autonomy 3. Ensures identical care to all patients 4. Acts as a guide for professional behaviors in giving patient care 4. Th e NC ®LfoErXnurses is exactly the same in every state in the United States. Th e examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Ensures that honest and ethical care is provided 4. Provides a minimal standard of knowledge for a registered nurse in practice 5. APRNs generally: Select all that apply. 1. Function independently 2. Function as unit directors 3. Work in acute care settings 4. Work in the university setting 5. Hold advanced degrees 6. Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. Th is is which type of education? 1. Continuing education 2. Graduate education 3. In-service education 4. Professional registered nurse education 7. Which of the following is unique to a professional standard of decision making? Select all that apply. 1. Weighs benefi ts and risks when making a decision 2. Analyzes and examines choices more independently 3. Concrete thinking 4. Anticipates when to make choices without others' assistance NCLE ® -XStyle Review Questions 12 unit 1 ■ Professionalism 8. Nursing practice in the 21st century is an art and science that focuses on: 1. Th e client 2. Th e nursing process 3. Cultural diversity 4. Th e health-care facility 9. Which of the following represent the knowledge and skills expected of the professional nurse? Select all that apply. 1. Accountability 2. Advocacy 3. Autonomy 4. Social networking 5. Participation in nursing blogs 10. Professional accountability serves the following pSuerpleoscet:all that apply. 1. To provide a basis for ethical decision making 2. To respect the decision of the client 3. To maintain standards of health 4. To evaluate new professional practices and reassess existing ones 5. To belong to a professional organization. Professional Ethics and Values OBJECTIVES After reading this chapter, the student should be able to: ■ Discuss ways individuals form values ■ Diff erentiate between laws and ethics ■ Explain the relationship between personal ethics and professional ethics ■ Examine various ethical theories ■ Explore the concept of virtue ethics ■ Apply ethical principles to an ethical issue ■ Evaluate the infl uence organizational ethics exerts on nursing practice ■ Identify an ethical dilemma in the clinical setting ■ Discuss current ethical issues in health care and possible solutions OUTLINE Values Morals Values and Moral Reasoning Value Systems How Values Are Developed Values Clarifi cation Belief Systems Ethics and Morals Ethics Ethical Theories Ethical Principles Autonomy Nonmalefi cence Benefi cence Justice Fidelity Confi dentiality Veracity Accountability Ethical Codes Virtue Ethics Nursing Ethics Organizational Ethics Ethical Issues on the Nursing Unit Moral Distress in Nursing Practice Ethical Dilemmas Resolving Ethical Dilemmas Faced by Nurses Assessment Planning Implementation Evaluation Current Ethical Issues Practice Issues Related to Technology Technology and Treatment Technology and Genetics DNA Use and Protection Stem Cell Use and Research Professional Dilemmas Conclusion 13 14 unit 1 ■ Professionalism Doctors at the Massachusetts General Hospital “iron lung”). During this period, Danish physifor Children faced an ethical challenge when a cians invented a method of manual ventilation by pair of conjoined twins born in Africa arrived placing a tube into the trachea of polio patients. last year seeking surgery that could saveone of them. Th e twins were connected only Th is initiated the creation of mechanical ventiat th la e tion as we know it today. Th e development of abdomen and pelvis, sharing a liver and bladder, mechanical ventilation required more intensive and had three legs. An examination by doctorsat the hospital determined that only one of thegirls was likely to survive the surgery, but that if doctors did not act, both would die. Th e case had posed the hospital with the challenge bothof ensuring that the parents understood the nursing care and patient observation. Th e care and monitoring of patients proved to be more effi cient when nurses kept patients in a single care area, hence the term intensive care. Th e late 1960s brought greater technological advances. Open heart surgery, in its infancy at the risks of the procedure and that the hundreds time, became available for patients who were seriof medical professionalsneeded to perform ously ill with cardiovascular disease. Th ese patients the complex series of operations to separate required specialized nursing care and nurses the children were comfortable with the ethics specifi cally educated in the use of advancing techof the situation M( alone, 2017 ). Which child should live, and which child should die? nologies. Th esenew therapies and monitoring methods provided the impetus for the creation of intensive care units and the critical care nursingspecialty V( incent, 2013 ). In the past, the vast majority of individuals Th is is only one of many modern ethical dilermec-eiving critical care services would have died. mas faced by health-care personnel. If you weHreowever, the development of new drugs and a member of the ethics committee, what decision advancesin biomechanical technology permit might you make? How would you come to thaht ealth-care personnel to challenge nature. Th ese decision? Which twin would live and which would advances have enabled providers to off er patients die? treatments that in many cases increase their In previous centuries, health-care practitionerlisfe expectancy and enhance their quality of life. had neither the knowledge nor the technology to make determinations regarding prolonging life, sustaining life, or even creating life. Th emain However, this progress is not without its shortcomings as it also presents new perplexing questions. Th e ability to prolong life has created some function of nurses and physicians was to supphoertart-wrenching situations for families and patients and families through times of illness, help complex ethical dilemmas for health-care prothem toward recovery, or provide comfort until fessionals.Decisions regarding terminating life death. Th ere were very few complicated decisisounpsport on an adolescentinvolved in a motor such as “Who shall live and who shall die?” Duringvehicle accident, instituting life support on a the latter part of the 20th century and through the 65-year-old productive father, or a mother becomfi rst part of the 21st century, technological advanceinsg pregnant in order to provide stem cells for such as multiple-organ transplantation, use of stemher older child who has a terminally ill disease cells, new biologically based pharmaceuticals, aanrde just a few examples. At what point do parents sophisticated life-support systems created uniquseay good-bye to their neonate who was born far situations stimulating serious conversationsand too early to survive outside the womb? Families debates. Th e costs of these life-saving treatmeantds professionals face some of the most diffi cult and technologies presented new dilemmas as teothical decisions at times such as these. How is who should provide and pay for them, as welldaesath defi ned? When does it occur? Perhaps these who should receive them. questions need to be asked: “What is life? Is there Health care saw its fi rst technological advancesa diff erence between life and living?” during 1947 and 1948 as the polio epidemic raged To fi nd answers to these questions, health-care through Europe and the United States. Th is dev- professionalslook to philosophy, especiallythe astating disease initiated the development of units branch that deals with human behavior. Th rough for patients who required manual ventilation (the time, to assist in dealing with these issues, the fi eld chapter2 ■ Professional Ethics and Values15 of biomedical ethics (or simply bioethics) evolved. Way, 2018 ). Reasoning allows individuals to think Th issubdiscipline of ethics, the philosophical study of morality, is the study of medical morality, which concerns the moral and social implications for themselves and not to take the beliefs and judgments of others at face value. Moral reasoning relates to the process of forming conclusions and of health care and science in human life ( Nummi- creating action plans centered on moral or ethical nen, Repo, & Leino-Kilpi, 2017 ). In order to understand biomedical ethics, it is important to appreciate the basic concepts of values,belief systems,ethical theories, and issues. Values,viewpoints, and methods of moral reasoning have developedthrough time. Older worldviews have now emerged in modern history, morality. Th e following sections will defi ne thesuech as the emphasis on virtue ethics or a focus on concepts and then discuss ways nurses can help thwehat type of person one would prefer to become interprofessional team and families resolve ethical ( McLeod-Sordjan, 2014 ). Virtue ethics are disdilemmas. Values cussed later in this chapter. Value Systems A value system is a set of related values. For Individuals talk about value and values all theexample,one person may value (believe to be time. Th e term value refers to the worth of iamnportant) societal aspects of life, such as money, object or thing. However, the tervmalues refers objects,and status.Another person may value to how individuals feel about ideas,situations, more abstract concepts such as kindness, charity, and conceptsM. erriam-Webster's Collegiate Dictioa-nd caring. Values may vary signifi cantly, based on nary defi nes value as the “estimated or appraaniseinddividual ’ s culture, family teachings, and reliworth of something, or that quality of a thing that gious upbringing. An individua’ls system of values makes it more or less desirable, useful” ( Merriam-frequently aff ects how he or she makes decisions. Webster Dictionary,2017 ). Values, then, are judg- For example, one person may base a decision on ments about the importance or unimportance ocf ost, whereas another person placed in the same objects, ideas, attitudes, and attributes. Individualssituation may base the decision on a more abstract incorporate values as part of their conscience and quality, such as kindness. Values fall into diff erent worldview. Values provide a frame of reference andcategories: act as pilots to guide behaviors and assist people inmaking choices. Morals Morals arise from an individu’asl conscience. Th eyact as a guide for individual behavior and are learned through family systems, instruction, and ■ Intrinsic values are those related to sustaining life, such as food and water ( Zimmerman & Zalta, 2014 ). ■ Extrinsic values are not essential to life. Th ey include the value of objects, both physical and abstract. Extrinsic values are not an end socialization. Morals fi nd their basis within indiin themselves but off er a means of achieving vidual values and have a larger social componen s t omething else. Th ings, people, and material than valuesM( a, 2013 ). Th ey focus more on “good i ” tems are extrinsically valuablZeim( merman & versus “bad” behaviors. For example, if you valuZ e alta, 2014 ). fairness and integrity, then your morals include ■ Personal values are qualities that people those values, and you judge others based on yo c u o r nsider important in their private lives. concept of morality M( axwell & Narvaez, 2013 ). Values and Moral Reasoning Reasoningis the processof making inferences from a body of information and entails forming conclusions, making judgments, or making inferencesfrom knowledge for the purpose of Concepts such as strong family ties and acceptance by others are personal values. ■ Professional values are qualities considered important by a professional group. Autonomy, integrity, and commitment are examples of professional values. People ’ s behaviors are motivated by values. Indi- answering questions, solving problems, and formu-viduals take risks, relinquish their own comfort lating a plan that determines actionsM(cHugh & and security,and generateextraordinaryeff orts 16 unit 1 ■ Professionalism becauseof their values (Zimmerman & Zalta, 2014 ). Patients who have traumatic brain injuries may overcome tremendous barriers because thvalue independence.Race car drivers may risk death or other serious injury because they valcompetition and winning. skills in order to get him into the “best private school” in the area. As he moved through theprogram, his grades did not refl ect his mot’hser great eff ort, and he felt that he had disap- pointed his mother as well as himself. By the time Dino reached 9 years of age, he had devel- Values also generate the standards by whic oped a variety of somatic complaints such as people judge others. For example, someone w values work more than leisure activities will lo unfavorably on a coworker who refuses to work stomach ailments and headaches. throughout the weekend. A person who believes that health is more important than wealth would approve of spending money on a relaxing vacation Values change with experience and maturity. or perhaps joining a health club rather than invest-For example, young children often value objects, ing the money. such as a favorite blanket or toy. Older children Often people adopt the values of individu- are more likely to value a specifi c event, such as als they admire. For example, a nursing studenat family vacation. As children enter adolescence, may begin to value humor after observing it used they place more value on peer opinions than those eff ectively with patients. Values provide a guidoef their parents. Young adults often place value on for decision making and give additional meanincgertain ideals such as heroism. Th e values of adults to life. Individuals develop a sense of satisfactiaorne formed from all these experiences as well as when they work toward achieving values they believe are importantT(uckett, 2015 ). How Values Are Developed from learning and thought. Th e number of values that people hold is not as important as what values they consider important. Choices are infl uenced by values. Th e way people Values are learned ( Taylor, 2012 ). Ethicists uastteri-their own time and money, choose friends, and bute the basic question of whether values are taught, inherited, or passedon by some other mechanism to Plato, who lived more than pursue a career are all infl uenced by values. Values Clarifi cation 2,000 years ago. A recent theory suggests thatValues clarifi cation is deciding what one believes values and moral knowledge are acquired mucihs important. It is the process that helps people in the same manner as other forms of knowledge, become aware of their values.Values play an through real-world experience. Valuescan be taught directly, incorporated through societal norms, and modeled through important role in everyday decision making. Forthis reason, nurses need to be aware of what they do and do not value. Th is process helps them to behavior. Children learn by watching their parents,behave in a manner that is consistent with their friends, teachers, and religious leaders. Th rougvahlues. continuous reinforcement, children eventually Both personaland professionalvaluesinfl ulearn about and then adopt values as their owenn. ce nurses’ decisionMs c(Leod-Sordjan, 2014 ). Because of the values they hold dear, people oftenUnderstanding on’es own values simplifi es solving make great demands on themselves and othersp,roblems, making decisions, and developing better ignoring the personal cost. For example: relationships with others when one begins torealize how others develop their valueKnbaum ( 2011 ) suggested using a three-step model Niesa grew up in a family where educationa o l f choosing, prizing, and acting with seven subachievement was highly valued. Not surprisingly, she adopted this as one of her own values. steps to identify on’es own valuesBo( x 2-1 ). You may have used this method when making Niesa became a physician, married, and had the decision to go to nursing school. For some ey ue h ho ok a son, Dino. She placed a great deal of eff o p r e t ople, nursing is a fi rst career; for others, a second on teaching her son the necessary educationa c l areer. Using the model Binox 2-1, the valuing process is analyzed: box 2-1 Values Clarifi cation chapter2 ■ Professional Ethics and Values17 of weather, for example, early civilizations believed these events to be under the control of someone or something that needed to be appeased. Th ereChoosing 1. Choosing freely 2. Choosing from alternatives 3.Deciding after giving consideration to the consequences of each alternative Prizing 4. Being satisfi ed about the choice 5. Being willing to declare the choice to others Acting 6. Making the choice a part of’ osnweorldview and incorporating it into behavior 7. Repeating the choice Source: Adapted from Raths, L. E., Harmon, M., & Simmons, S. B.(1979). Values and teaching. New York, NY: Charles E. Merrill. fore, they developedrituals and ceremoniesto pacify these unknown entities. Th ey called theseentities “gods” and believed that certain behaviors either pleased or angered the gods. Because these societies associated certain behaviors with specifi c outcomes, they created a belief system that enabled them to function as a group. As higher civilizations evolved, belief systems became more complex. Archeology has provided evidence of the religious practices of ancient civ-ilizations that support the evolution of belief systems B(all, 2015 ). Th e Aztec, Mayan, Incan, and Polynesian cultures had a religious belief system composed of many gods and goddesses for the same functions. Th e Greek, Roman, Egyptian, 1. Choosing After researching alternative a c n a d re S e c r andinavian societies believed in a hierarchal options, you freely choose nursing school. Th issystem of gods and goddesses. Although given choice was most likely infl uenced by such various names by the diff erent cultures, it is very factors as educational achievement and abilities,interesting that most of the deities had similar fi nances, support and encouragement from others, time, and feelings about people. purposes. For example, the Greeks looked at Zeusas the king of the Greek gods, whereas Jupiter was 2. Prizing Once the choice was made, you h w is e R re oman counterpart. Th or was the king of the satisfi ed with it and told your friends about it. Norse gods. All three used a thunderbolt as their 3. Acting You entered school and started t s h y e mbol. Sociologists believe that these religions journey toward your new career. Later in your developed to explain what was then unexplainable. career, you may decide to return to school for a Human beings have a deep need to create order bachelo’rs or maste’ sr degree in nursing. As you progressedthrough school, you probafrom chaos and to have logical explanations for events. Religion off ers theological explanations to answer questions that cannot be explained by “pure bly started to develop a new set of values—yosucrience.” professional values. Professional values are those Along with the creation of rites and rituals, reliestablished as being important in your also developed codes of behaviors or ethical Th e values include caring, quality of care, andcodes. Th ese codes contribute to the social order ethical behaviorsM( cLeod-Sordjan, 2014 ). Belief Systems and provide rules regarding how to treat family members, neighbors, and the young and the old.Many religions also developed rules regarding marriage, sexual practices, business practices, propBelief systems are an organized way of think-erty ownership, and inheritance. ing about why people exist in the universe. Th e For some individuals, the advancementof purpose of belief systems is to explain issues suchscience has minimized their need for belief as life and death, good and evil, and health asnydstems, as science can now provide explanations illness. Usually these systems include an ethicafol r many previously unexplainablephenomena. code that specifi es appropriate behaviors. PeopInle fact, the technology explosion has created an may have a personal belief system, participate eivnen greater need for belief systems. Technologia religion that provides such a system, or follow a cal advances often place people in situations where combination of the two. they may welcome rather than oppose religious Members of primitive societies worshipped convictions to guide diffi cult decisions. Many relievents in nature. Unable to understand the sciencegions, particularly Christianity, focus on the will of 18 unit 1 ■ Professionalism a supreme being; technology, for example, is considered a gift that allows health-care personnel to Teleological theories take their norms or rules for behaviors from the consequences of the action. maintain the life of a loved one. Other religionsT,h is theory is also called utilitarianism. Accordsuch as certain branches of Judaism, focus on freeing to this concept, what makes an action right choice or free will, leaving such decisions in thoer wrong is its utility, or usefulness. Usefulness is hands of humankind. For example, many Jewischonsidered to be the right amount of “happiness” leadersbelieve that if genetic testing indicates the action carries. “Right”encompassesactions that an infant will be born with a disease such as that result in good outcomes, whereas “wrong” Tay-Sachs that causes severe suff ering and ualtic-tions end in bad outcomes. Th is theory origimately death, terminating the pregnancy may bneated with David Hume, a Scottish philosopher. an acceptable option. According to Hume, “Reason is and ought to be Belief systems often help survivors in makintghe slave of passions” (Hume, 1978, p. 212). Based decisions and living with them afterward. So faor,n this idea, ethics depends on what people want technological advances have created more queas-nd desire. Th e passions determine what is right tions than answers. As science explains more and or wrong. However, individuals who follow telemore previously unexplainable phenomena, peopleological theory disagree on how to decide on the need beliefs and values to guide their use of t“hriigshtness” or “wrongness” of an action because new knowledge. Ethics and Morals individual passions diff er. Principalism is an arising theory receiving a great deal of attention in the biomedical ethics community. Th is theory integrates existing ethical Although the termsmorals and ethics are often usperdinciples and tries to resolve confl icts by relating interchangeablye,thics usually refers to a standard-one or more of these principles to a given situation ized code as a guide to behaviors, whereas morals( Hine, 2011 ; Varelius, 2013 ). Ethical principles usually refers to an individual ’ s personal codeacfoturally infl uenceprofessionaldecision making acceptable behavior. Ethics more than ethical theories. Ethical Principles Ethics is the part of philosophy that deals witEhthical codes are based on principles that can be the rightness or wrongness of human to judge behavior. Ethical principles assist It is also concerned with the motives behind that decision making because they are a standard for behavior.Bioethics , specifi cally, is the application omf easuring actions. Th ey may be the basis for laws, ethics to issues that pertain to life and death. Th ebut they themselves are not laws. Laws are rules implication is that judgments can be made abocurteated by governing bodies. Laws operate because the rightness or goodness of health-care government holds the power to enforce them. Th ey are usually quite specifi c, as are the conseEthical Theories quences for disobeying them. Ethical principles Several ethical theories have emerged to justifayre not confi ned to specifi c behaviors. Th ey act as moral principles ( Baumane-Vitolina,Cals, & guides for appropriate behaviors. Th ey also conSumilo, 2016 ).Deontologicatlheoriestake their sider the situation in which a decision must be norms and rules from the duties that individualms ade. Ethical principles speak to the essence of owe each other by the goodness of the commtiht-e law rather than to the exactness of the law. ments they make and the roles they take uponHere is an example: themselves. Th e term deontological comes from the Greek worddeon (duty). Th is theory is attributed to the 18th-century philosopher Immanuel Kant Mrs. Gustav, 88 years old, was admitted to the hospital in acute respiratory distress. She was ( Kant, 1949 ). Deontological ethics considers diagnosed with aspiration pneumonia and soon intention of the action. In other words, it is th became septic, developing acute respiratory disindividual ’ sgood intentions or goodwill (Kant, tress syndrome (ARDS). She had a living will, 1949 ) that determines the worthiness or goodnes and her attorney was her designated health-care the e s of the action. chapter2 ■ Professional Ethics and Values19 surrogate. Her competence to make decisionsthat a patient received insuffi cient information to remained uncertain because of her illness. Thm e ake an appropriate choice, is being coerced into physician presented the situation to the attora decision, or lacks an understanding of the conseney, indicating that without a feeding tube and tracheostomy, Mrs. Gustav would die. According to the laws governing living wills and health-care surrogates, the attorney could have made the decision to withhold all treatments. However, he believed he had an ethical obligation to discuss the situation with his client. Th e quences of the choice, then the nurse may act as a patient advocate to ensure the principle of autonomy (Rahmani, Ghahramanian, & Alahbakhshian, 2010 ). Sometimesnurses have diffi culty with the principle of autonomy becauseit also requires respecting another person’ s choice, even when client requested the tracheostomy be performed the nurse disagrees. According to the principle and the feeding tube inserted, which was done. of autonomy, nurses may not replace a p’astient decision with their own, even when the nurses deeply believe that the patient made the wrong Following are several of the ethical principles that choice. Nurses may, however,discuss concerns are most important to nursing practice: autonomy, with patients and ensure that patients considered nonmalefi cence, benefi cence, justice, fi delity, cthoen-consequences of the decision before making it fi dentiality, veracity, and accountability. In some( Rahmani et al.,2010 ). situations, two or more ethical principles may confl ict with each other, leading to an ethical dilemma.Making a decision under these circumstances Nonmalefi cence Th e ethical principle of nonmalefi cence requires causes diffi culty and often results in extreme stresthsat no harm be done, either deliberately or uninfor those who need to make the decision. Autonomy tentionally. Th is rather complicated word comes from Latin roots, non, which means not; male (pronouncedmah-leh), which means bad; and Autonomy is the freedom to make decisions fofracere, which means to do. oneself. Th is ethical principle requires that nursesTh e principle of nonmalefi cence also requires respect patients’ rights to make their own choices nurses to protect individuals who lack the ability about treatments. Informed consent before treat-o protect themselves because of their physical ment, surgery, or participation in research providesor mental condition. An infant, a person under an example of autonomy. To be able to makeanesthesia, and a person suff ering from dementia an autonomouschoice, individuals need to be are examples of individuals with limited ability to informed of the purpose, benefi ts, and risks of theprotect themselves from danger or those who may procedures. Nurses accomplish this by assessincgause them harm. Nurses are ethically obligated to the individuals’ understanding of the informationprotect their patients when the patients are unable provided to them and supporting their choices. to protect themselves. Closely linked to the ethical principle of auton- Often, treatments meant to improve patient omy is the legal issue of competence. A patienhtealth lead to harm. Th is is not the intention of the needs to be deemed competent in order to mankuerse or of other health-care personnel, but it is a a decision regarding treatment options. When direct result of treatment. Nosocomial infections patients refuse treatment, health-carepersonnel because of hospitalization are harmful to patients. and family members who think diff erently oftenTh e nurses, however, did not deliberately cause the question the patient’ s “competenceto” make a infection. Th e side eff ects of chemotherapy or radidecision. Of note is the fact that when patientsation may also result in harm. Chemotherapeutic agree with health providers’ treatment decisionsa,gents cause a decrease in immunity that may rarely is their competence questionSedha(hriari, result in a severe infection, and radiation may burn Mohammadi, Abbaszadeh, & Bahram2i,013 ). or damage the skin. For this reason, many choose Nurses often fi nd themselves in a position nt t to pursue treatments. protect a patien’ts autonomy. Th ey do this by pre- Th e obligation to do no harm extends to the venting others from interfering with the pa’tisent nurse who for some reason is not functioning at an right to proceed with a decision. If a nurse observeosptimal level. For example, a nurse who is impaired 20 unit 1 ■ Professionalism by alcohol or drugs knowingly places patients autnderstand your role as a patient advocate. Conrisk. According to the principle of nonmalefi cence,sider the following questions: other nurses who observe such behavior have a 1 n . To whom do you owe your duty: to the patient ethical obligation to protect patients. Benefi cence Th e worbdenefi cence also comes from bLeantein,: or the family? 2. How do you think you may be able to be apatient advocate in this situation? which means well, and facere, which means to do.3. What information would you communicate to Th e principle of benefi cence demands that goodthe family members, and how could you assist be done for the benefi t of others. For nurses, this them in dealing with their mothe’r s concerns? means more than delivering competent physical or technical care. It requires helping patients meet all their needs, whether physical, social, or emoT-h e principle of justice obliges nurses and other tional. Benefi cence is caring in the truest senshee,alth-care professionalsto treat every person and caring fuses thought, feeling, and action. Iet qually regardlessof gender,sexualorientation, requires knowing and being truly understandingreligion, ethnicity, disease, or social standJinoghn(- of the situation and the thoughts and ideas of the individual (Benner & Wruble, 1989 ). Sometimesphysicians, nurses, and families stone, 2011 ). Th is principle also applies in the workand educational settings. Based on this principle, all individuals should be treated and judged by the withhold information from patients for the sake same criteria. Th e following example illustrates this: of benefi cence. Th e problem with doing this is that it does not allow competent individuals to make their own decisions based on all available informa- Mr.Laury was found on the street by the tion. In an attempt to be benefi cent, the principle police, who brought him to the emergency of autonomy is violated. Th is is just one example department. He was assessed and admitted to a the ethical dilemmas encountered in nursing prac- medical unit. Mr. Laury was in deplorable contice. For instance: Mrs. Liu was admitted to the oncology unit with ovarian cancer. She is scheduled to begin chemotherapy treatments. Her two children and her husband have requested that the physician ensure that Mrs. Liu not be told her diagnosis dition: His clothes were dirty and ragged, he was unshaven, and he was covered with blood. His diagnosis was chronic alcoholism, complicated by esophageal varices and end-stage liver disease. Several nursing students overheard the staff discussing Mr. Laury. Th e essence of the conversation was that no one wanted to care for because they believe she would not be able him because he was “dirty and smelly,” and he cope with it. Th e physician communicated this information to the nursing staff and placed an order in the patient’ s electronic medical record (EMR). After the fi rst treatment, Mrs. Liu brought this condition on himself. Th e students, upset by what they heard, went to the clinical faculty to discussthe situation. Th eclinical faculty explained that based on the ethical prinbecame very ill. She refused the next treatment, ciple of justice, every individual has a right to stating she did not feel sick until s