The nursing process is more than a method that nurses use to diagnose and treat actual and potential health problems. The American Nurses Association (ANA) Standards of Nursing Practice provides a basis for practice and recognition of the patient; in addition, nurses also must adhere to the profession’s ethical code as well. “Nurses are committed to respect human beings with an unbiased approach of care to differences socially, economically, culturally, racially, and other human attributes” (Saucier, 2005, p. 80). It is the responsibility of the professional nurse to engrain ethics as an essential part of the foundation of nursing. The International Council for Nurses (ICN) identifies that the need for nursing is universal and that “nurses have four fundamental responsibilities: to promote health, prevent illness, restore health, and alleviate suffering” (Tomey, 2004, p. 75). From the beginning of nursing Florence Nightingale stated it so eloquently in the original Nightingale Pledge:

I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling (Nightingale, 1893, para. 1)

Ethical issues that are challenging for nurses in everyday practice and nurses continue to find it difficult to practice with moral integrity and as moral agents given the many difficult ethical challenges they encounter in the healthcare system.

Confidentiality

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was originally created to ensure the privacy of individuals and it holds those individuals accountable that might acquire sensitive information in regards to medical records (Garrett, Baillie, & Garrett, 2010, p. 117). However, there are also some gray areas where a nurse is often not sure whether the information that is being handed out is acceptable, or whether the person that is asking for the information is authorized to have it. When these kinds of situations take place, confusion can arise and it can make it difficult for nurses to do the job properly without fear of retaliation. Not only is confidentiality an ethical issue, but a legal requirement.

In chapter five, Principles of Confidentiality and Truthfulness, the terms obligation and secrets was used. Having the understanding and knowing the difference between the types of secrets and an awareness of harm or possible harm to the patient, family, or profession is key. This information is directly related to the Nursing Scope and Standards of Practice, Standard 12. Ethics, The registered nurse integrates ethical provisions in all areas of practice. The measurement criteria for the registered nurse state: “Maintains patient confidentiality within legal and regulatory parameters, maintains a therapeutic and professional patient-nurse relationship with appropriate professional boundaries, and uses Code of Ethics for Nurses with Interpretive Statements to guide practice” (American Nurses Association [ANA], 2004, p. 39). Specifically, ethic 3.2 Confidentiality, that is encompassed in the standard that states “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (American Nurses Association [ANA], 2001, p. 12). Trust and well-being of the patient are key in the area of confidentiality; keeping in mind, that when working within a multi-disciplinary team, the nurse must only share relevant information on a need to know bases.

As an example, the emergency room nurses’ cousin was admitted to the emergency room during the shift at the hospital. He is in critical condition. The nurses’ mother is very concerned about him, but she has not been able to reach the nurses aunt and uncle. The nurse is aware of the cousin’s condition. With the standards and ethics does she tell her mom? No, this is probably the hardest of situations, but the nurse must not tell. She must not even let on that she has any information. Instead, encourage her mother to keep calling your aunt. The nurse might even see if her aunt is at the hospital and arrange for her to call mom. Even doctors can only release information to the immediate family-in this case, the cousin’s parents. It is up to the aunt and uncle to inform the rest of the family. That way, they can determine how much information family members should have.

Maintaining confidentiality is an important aspect of professional behavior. It is essential that a nurse safeguard the patient’s right to privacy by carefully protecting information of a sensitive, private nature. Sharing personal information or gossiping about others violates nursing ethical codes and practice standards. It sends a message that the nurse cannot be trusted and damages interpersonal relationships.

Informed consent

Nurses are obligated to tell all patients, regardless of whether or not they are capable or incapable of giving consent, about the care or treatments before it is given. Nurses are obligated to assist patients understand the nature of their health problems and assist them to receive the information and support they need to make informed decisions. A key principle studied in chapter two, Principles of Autonomy and Informed Consent, that all medical care requires the consent of the patient (or someone who is authorized to consent for the patient) before the care plan is carried out. An assumption is made that informed consent recognizes that a patient needs to know about a procedure, surgery, or treatment, before they decide to have it. Standard 14.Resource Utilization in the ANA Scope and Standards of Practice explicitly denotes that nurses should “assists the patient and family in becoming informed consumers about options, costs, risks, and benefits of treatment and care. Informed consent may have a multitude of legal ramifications, but its core and most controversial function lies in the idea of patients actually participating in medical decision making. It may be at this point that the physician (or autonomist) and the nurse most tend to butt heads. Fortunately for nurses there is Ethics Code 1.4. The concept of informed consent is fundamental to the delivery of health care. The nurse’s responsibility is vital in ensuring that patients are fully informed and understand their options; “each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination” (ANA, 2001, p. 8). Informed consent is more than just signing a paper, is specific patient right.

An example case of a patient with angina who was considered for a coronary bypass surgery demonstrates the issue of informed consent. Ethical and legal aspects of achieving consent must be considered. Physicians may have personal biases, which may lead to coerced consent, or may overwhelm the patient with information on potential complications of a proposed procedure. Patient preconceived notion or misinformation may lead to misunderstood consent. The patient’s request to put back the decision to the physician raises the question of whether such requested paternalism violates patient self-determination and invalidates consent or is it an exercise of the patient’s right to have his physician decides (Garrett et al., 2010, p. 32)?

Quality and safety

Providing basic nursing care for the individual patient is an important nursing value supported by professional mandates and by codes of nursing ethics. Referring again to Standard 14.Resouce Utilization that states, “the registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services” (ANA, 2004, p. 42). It is easy to tie the concept directly from the ANA standards of performance to the nursing code of ethics 8 that states “the nursing profession is committed to promoting health, welfare, and safety of all people” (ANA, 2001, p. 23). In reading from chapter six, there was discussion that quality care can be achieved by high tech equipment, credentialing, licensing, skill, knowledge, and protocols; however, a key point in judging quality stated “professions lead the effort to enhance and protect quality in the professions” (Garrett et al., 2010, p. 134). If employment conditions, agency regulations, or hospital policies create undesirable working conditions that limit the quality of nursing care that can be provided, nurses become concerned. Since nurses value quality of patient care, they also value those conditions that allow quality patient care.

When nurses attempt to balance the value of quality of patient care with issues involving their quality of life the action of a possible strike may come into question. While the nurse’s value being able to guarantee high quality care they may realize in the short term many patients may not receive the highest of quality care while a strike is in effect. When putting ethical decisions first, nurses should work through their professional organizations and promote positive mechanisms for negotiations with employers. If nurses can gain responsibility for, and control over, the quality of care delivered, they will have gained great benefit for the health of the community.

Conclusion

If not nurses, who will advocate for the chronically ill (both young and old), the under and uninsured, and the most vulnerable with complex health needs? Who will question the rightness or wrongness of aggressive care, technological advancements, and determinations of quality of life? Who will address patient concerns related to informed consent, surrogate decision-making, and the risks and benefits of treatment or research? And who will challenge ineffective or inefficient nursing, physician, and administrative leadership standards and styles that underestimate the significance of ethical problems on patient outcomes and nurse productivity and retention? These philosophical questions are at the core of our deeply held values and beliefs about who we are as a discipline. Without adequate ethical knowledge and competence; however, it is difficult to bring together nursing on central ethical concepts in the provision of nursing care. The nurse, as a patient advocate presents difficult challenges; however, the key principles of ethics will allow all nurses to persevere in understanding the scope and limits of their professional responsibilities.