M5 GENERAL SYSTEMS THEORY RUBRIC: WRITTEN ASSIGNMENT (40 pts)

Last updated:3/24/2021 © 2021 School of Nursing – Ohio University Page 1 of 2

Criteria

Levels of Achievement Accomplished Needs Improvement Not Acceptable

Introduction (5 Points)

5 to 5 Points x Clearly states the purpose of the

paper. x Provides a comprehensive

overview of topic or questions. x Engages the reader. x Organized and has easy follow.

2 to 4 Points x Overview is provided, but

key points/ideas are missing.

x Purpose statement is not clear.

x Does not engage the reader.

x Somewhat disorganized but still comprehensible

0 to 1 Points x Does not provide an

overview of the paper or is absent.

x No purpose statement.

Body (24

Points)

Key Requirement 1 – Identify 2 major issues faced by rural populations

6 to 6 Points x Demonstrates evidence of

research, includes the following: Two major issues and what specific social determinants of health significantly influence these issues.

x Writing is clear and shows critical thinking.

3 to 5 Points x Includes a description of

the issues and specific social determinants of health

x Writing is disorganized and does not contain evidence of critical thinking.

0 to 2 Points x Summary of the issues

and social determinants is poorly written; at least 3 topics are missing.

x No evidence of critical thinking.

Key Requirement 2 – Identify and describe 3 (out of 10) explicit assumptions of Roy’s Adaptation Model

6 to 6 Points x Writing shows evidence of

research. x Includes how these assumptions

apply to rural health. x Evidence of critical thinking.

3 to 5 Points x Student includes a

description of assumptions, does not connect how these assumptions apply to rural health.

x Writing is disorganized.

0 to 2 Points x No description of

assumptions. x No evidence of critical

thinking. Rural Health and Nursing

Key Requirement 3 – Identify what subsystems facilitate or hinder the overall system’s ability to meet the needs of the rural population

6 to 6 Points x Clearly identifies subsystems

that facilitate or hinder the needs of the population.

x Shows evidence of critical thinking.

3 to 5 Points x Vague discussion of

subsystems. x No discussion as to the

needs of the population.

0 to 2 Point x Student does not

discuss subsystems or meeting the needs of the population.

x No evidence of critical thinking.

Key Requirement 4 – Describe a plan or legislative process (may be one currently under review or recently passed) for improving the “healthcare system” and the potential impact on the rural population

6 to 6 Points x Includes a clear plan or

legislative process. x Thorough discussion of

improving the “healthcare system” and the impact on the population.

3 to 5 Points x Discusses a plan or

legislative process. x Does mention improving

the “healthcare system” and the impact on the population.

0 to 2 Point x Does not discuss a

plan or legislative process.

x Does not mention improving the “healthcare system” or

M5 GENERAL SYSTEMS THEORY RUBRIC: WRITTEN ASSIGNMENT (40 pts)

Last updated:3/24/2021 © 2021 School of Nursing – Ohio University Page 2 of 2

Criteria

Levels of Achievement Accomplished Needs Improvement Not Acceptable x Shows critical thinking. impact on the

population. x No evidence of critical

thinking.

Conclusion (5 Points)

5 to 5 Points x Summarizes paper and reflects

on what the reader has learned from the paper.

x Demonstrates persuasive thought and is well organized.

2 to 4 Points x Merely summarizes the

introduction or contains new ideas not present in the paper contents.

x Somewhat disorganized but still comprehensible

0 to 1 Points x Simply restates the

introduction or is absent.

x Disorganized to the point of distraction.

Stylistics (6 Points)

6 to 6 Points x APA Citations are appropriate. x Formatted correctly. x Reference page is complete and

correctly formatted. x At least 4 references provided:

Two (2) references from required course materials and two (2) peer-reviewed references. *References not older than five years.

x More than 600 words excluding title and reference pages.

3 to 5 Points x APA Citations are

appropriate and formatted correctly.

x Reference page is formatted correctly.

x References are not professional or is not formatted correctly.

x Missing 1 professional reference.

x At least 600 words or more excluding title and reference pages.

0 to 2 Points x No citations are used

or citations are made but not formatted correctly

x Reference page is missing.

x Less than 600 words excluding title and reference pages.

Peer-reviewed references include professional journals (i.e. Nursing Education Perspectives, Journal of Professional Nursing, etc. –), professional organizations (NLN, CDC, AACN, ADA, etc.) applicable to population and practice area, along with clinical practice guidelines (CPGs – National Guideline Clearinghouse). References not acceptable (not inclusive) are UpToDate, Epocrates, Medscape, WebMD, hospital organizations, insurance recommendations, & secondary clinical databases. *All references must be no older than five years (unless making a specific point using a seminal piece of information) Note: You will have three (3) attempts to submit a written assignment, only the final attempt will be graded. For each attempt you will receive a SafeAssign originality report. This will give you a chance to correct the assignment based on the SafeAssign score. Click here to view instructions on how to interpret SafeAssign originality report.

July-August 2015 • Vol. 24/No. 4268

Jill Winland-Brown, EdD, FNP-BC, DPNAP, is Professor Emeritus, Christine E. Lynn College of Nursing, Florida Atlantic University, and member of American Nurses Association Ethics and Human Rights Advisory Board. Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a consulting and coaching firm, Avalon, NJ, and Sarasota, FL. She is Chair, American Nurses Association Ethics and Human Rights Advisory Board, and serves on a hospital ethics committee. Elizabeth O’Connor Swanson, DNP, MPH, APRN-BC, is Assistant Professor of Nursing, Mary Black School of Nursing, University of South Carolina Upstate; Nurse Practitioner/Clinical Nurse Specialist, South Carolina Department of Juvenile Justice; and member of the American Nurses Association Ethics and Human Rights Advisory Board.

The New ‘Code of Ethics for Nurses With Interpretive Statements’ (2015): Practical Clinical Application, Part I

F or the 13th year in a row, Gallup poll results indi-cate Americans rate nursing as the most honestprofession and nurses as having the highest ethi- cal standards (Gallup, 2014). In addition, the American Nurses Association (ANA) identified the focus of 2015 National Nurses Week as “Ethical Practice, Quality Care” as part of its effort for 2015 to be named “The Year of Ethics.” The new Code of Ethics for Nurses with Interpretive Statements (ANA, 2015) (Code) was released in January after a 4-year review process involving input from sever- al thousand RNs (OnCourse Learning Corporation, 2015). The second edition of the Guide to the Code of Ethics for Nurses with Interpretative Statements: Development, Interpretation, and Application (Fowler, 2015) was released in April.

This two-part series will explore the new Code and its use in every day clinical practice with a case situation for each article. Part I will introduce the Code, discuss the glossary, and use a nursing case situation to explore the first four provisions. The second part of the series will continue discussion of the last five provisions.

The Code (ANA, 2015) articulates the ethical obliga- tions of all registered nurses. The nine provisions iden- tify the responsibilities of nurses, while the interpretive statements provide guidance in their application. The introduction to the Code explains why certain terms were chosen, such as patient versus client, as well as the use of moral and ethical word choices. This introduc- tion also gives an overview of some terms, and includes links to foundational and supplemental documents on

the ANA ethics web page. Because many terms in nurs- ing ethics are used imprecisely and interchangeably with possible misconceptions, this edition of the Code includes a glossary of 49 terms, such as compassion fatigue, moral distress, and social media (ANA, 2015, pp. 35-45).

The first three provisions explain the most basic val- ues and commitments of the nurse, all of which might be helpful in exploring the following nursing case situ- ation. These provisions address the nurse’s duties to respect the patient, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. The fourth provision discuss- es the nurse’s accountability in practice.

The following nursing case situation is used to illus- trate some of the Code violations:

Keisha and Kyle are two RNs on the night shift. They have been out of school for sever- al years and are trying to move to the day shift to normalize their lives. They have got- ten very close through their years in nursing school together; he was one of her major supports as she re-entered nursing after an addiction to oxycodone due to a shoulder injury. Kyle understands Keisha has some biases against major surgical interventions for palliation and engaging patients in Phase 1 clinical trials.

Tonight, they are caring for Mrs. Williams, a 44-year-old married woman with four chil- dren ages 3-20. She was admitted with an intestinal obstruction and is scheduled for surgery tomorrow. After some imaging stud- ies, the physician suspects a massive tumor that will likely require removal for palliative purposes only. He believes the cancer has spread to all surrounding organs and lymph nodes. However, nothing is certain until sur- gery.

Leaving the unit in the morning, Keisha and Kyle are talking about the case when Mrs. Williams’s 20-year-old daughter Wendy gets on the elevator. Wendy recognizes the

Ethics, Law, and Policy

Jill Winland-Brown Vicki D. Lachman

Elizabeth O’Connor Swanson

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The New Code of Ethics for Nurses with Interpretative Statements (2015): Practical Clinical Application, Part I

nurses from her mother’s unit. She overhears them saying “What a shame with such a massive tumor and with four children at home!” Although Wendy assumes they are talking about her mother, she thought her mother only had a minor intestinal obstruc- tion. She does not know what to do as her mother is going to surgery very soon. Rural Health and Nursing

Provision 1 The nurse practices with compassion and respect for

the inherent dignity, worth, and unique attributes of every person.

This provision is more concise than the previous Provision 1, but encompasses the same concepts. Five interpretive statements are similar to the previous edi- tion, but the language is updated to articulate the con- tent more clearly. The first two statements address nurs- es’ fundamental ethical obligations for patient respect and development of trust between nurse and patient.

The first interpretive statement addresses “respect for human dignity.” Keisha and Kyle seemed to have com- passion for their patient, but they did not respect her right to confidentiality. The second interpretive state- ment identifies “relationships with patients” and the importance of trust. While Keisha and Kyle may have developed a relationship with Mrs. Williams, they vio- lated the trust by discussing her health situation in a public place. It is not clear if Mrs. Williams was aware of her diagnosis or the physician’s surgical plans. As this interpretative statement indicates, nurses do not need to agree with patient choices, but they are required to set aside any bias or prejudice (e.g., Keisha’s bias con- cerning palliative care surgeries).

The third interpretive statement for Provision 1 con- cerns the “nature of health.” To promote Mrs. Williams’s health fully, the nurses should have encour- aged an honest dialogue between the patient and sur- geon. She has the right to know what the surgeon is anticipating. Also, this statement addresses the need for support for the family and significant others, including the patient’s daughter Wendy.

The fourth interpretive statement focuses on “the right to self-determination.” Mrs. Williams has the capacity to understand her diagnosis and participate in the decision for her surgery. From the case situation, the husband should be included in discussion and Mrs. Williams may like her daughter Wendy to be involved in the decision-making process as well. As this state- ment indicates, “patients have a moral and legal right to determine what will be done with and to their person” (p. 2). The physician, patient, and family need to know the diagnosis and prognosis in order to make an informed decision for surgery. If the surgery is only for palliation, then the patient and family need to engage in an advance care planning conversation with the physician. The nurse’s obligation is to assure the patient has accurate, complete, and understandable informa- tion on which to base her decision.

The last interpretive statement for Provision 1 involves the nurse’s “relationships with colleagues and others.” Keisha and Kyle failed to demonstrate respect for persons when they had their conversation, which included identifying information about the patient, in a public place. Nurses have a responsibility to create an ethical environment, including an affirmative duty to prevent harm. Their violation of confidentiality could cause significant harm to the needed trust as Mrs. Williams and her family struggle to make the best deci- sion for her. Additionally, this interaction in the eleva- tor initiated a great deal of distress for Wendy.

Provision 2 The nurse’s primary commitment is to the patient,

whether an individual, family, group, community, or population.

This provision has retained the previous four inter- pretive statements, with added clarity in the explana- tions. It focuses on the nurse’s obligation to assure the primacy of the patient’s interests regardless of conflicts that arise between clinicians or patient and family.

The first interpretive statement is for the “primacy of the patient’s interests.” Keisha’s and Kyle’s primary com- mitment is to Mrs. Williams and her family. They need to provide opportunities for Mrs. Williams and her fam- ily to participate in her care, including honest discus- sions about available resources and treatment options. Wendy’s reactions seem to indicate she is unaware of her mother’s prognosis or the purpose of the surgery.

The second interpretive statement involves the “con- flict of interest for nurses.” This nursing case situation illustrates several possible conflicts: between physician and nurses, physician and patient, physician and family members, and nurses and family members. Nurses pro- mote Mrs. Williams’s best interests when they speak up and raise questions about her understanding of her prognosis, thus supporting interprofessional collabora- tion with physicians. Nurses must address conflicting expectations from patients, families, and physicians, as well as conflicts arising between their own professional and personal values.

The third interpretive statement relates to “collabora- tion.” “Nurses are responsible for articulating, represent- ing, and preserving the scope of nursing practice, and the unique contributions of nursing to patient care” (p. 6). This collaboration “requires mutual trust, recogni- tion, respect, transparency, shared decision-making and open communication among all who share concern and responsibility for health outcomes” (p. 6). If nurses are reluctant to open a dialogue with the physician con- cerning a patient’s possible lack of understanding of diagnosis and/or prognosis, other professionals can be used: other health care colleagues, leaders, and the hos- pital ethics committee. With collaboration, the desired outcome is always a demonstrated commitment to the patient.

The final interpretive statement for this provision illustrates the importance of “professional boundaries.”

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Keisha and Kyle committed several boundary violations. “Nurse-patient and nurse-colleague relationships have as their foundation the promotion, protection, and restoration of health” (p. 7). The nurse-patient relation- ship needs to remain therapeutic and professional. Concerns arise in this situation about the casual way in which Keisha and Kyle engaged in an end-of-shift con- versation about a patient.

Provision 3 The nurse promotes, advocates for, and protects the

rights, health, and safety of the patient. The six interpretive statements within this provision

combine two from the previous Code (ANA, 2001) (pri- vacy and confidentiality) and add a new one: “profes- sional responsibility in promoting a culture of safety.” This provision focuses on the nurse’s obligation to pro- tect patients from harm. Rural Health and Nursing

The first interpretive statement for this provision addresses “protection of the rights of privacy and confi- dentiality.” This statement was most violated in the case situation. Keisha and Kyle should have known the importance of maintaining confidentiality and should not be discussing this case on the elevator. While they did not give any specifics related to the case, how many other patients on their unit are likely to have an intes- tinal problem and four children at home? This violates the fundamental trust between patient and nurse. “Patients rights are the primary factors in any decisions concerning personal information, whether from or about the patient” (p. 10).

The second interpretive statement centers on “pro- tection of human participants in research” and is similar to the third statement in the previous edition. This addresses the importance of informed consent and the fact participants may decline to participate or withdraw from any research. Nurses have the obligation to raise questions about the individual’s capacity to consent and honor the patient’s right to withdraw from research. If Mrs. Williams chooses to engage in a Phase 1 clinical trial, nurses may have to support her withdrawal.

The third interpretive statement, which focuses on “performance standards and review mechanisms,” is clearer and more concise than the previous edition. The statement addresses the need for nurses to continue their professional development to maintain their com- petence because nurses “are responsible and account- able for nursing practice and professional behaviors” (p. 11). Maintenance of confidentiality is considered a basic performance standard in nursing. Rural Health and Nursing

Interpretive statement four is entirely new: “profes- sional responsibility in promoting a culture of safety.” This statement addresses the importance of the nurse’s role in patient safety. The nurse is responsible for report- ing any errors or near misses to the appropriate author- ity, ensuring disclosure of the errors to patients, and establishing processes to investigate these errors to pre- vent recurrence. The nurse also must not remain silent in the event of an error. If a colleague would overhear

Ethics, Law, and Policy

Keisha’s and Kyle’s conversation, he or she would be required to address this violation with them. Not addressing their error could be seen as condoning their conversation.

The fifth statement in Provision 3 centers on the “protection of patient health and safety by acting on questionable practice.” This is similar to the previous edition, addressing the need to support nurses who become whistleblowers. As mentioned previously, the nurse overhearing Keisha and Kyle’s conversation has an obligation to confront them and organizational lead- ers have an obligation to protect the confronting nurse from any retaliation. “Reporting questionable practice, even when done appropriately, may present substantial risk to the nurse; however, such risk does not eliminate the obligation to address threats to patient safety” (p. 13).

The sixth and final interpretative statement focuses on “patient protection and impaired practice” and is similar to the previous version. The definition of impaired practice is broadened in this revision to include “mental or physical illness, fatigue, substance abuse, or personal circumstances” (p. 13). This state- ment not only addresses reporting the impaired nurse but also ensures the nurse receives assistance. This advo- cacy includes supporting the return of the individual to practice after recovery, as Kyle did for Keisha. Rural Health and Nursing

Provision 4 The nurse has authority, accountability, and

responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to pro- mote health and to provide optimal care.

Provision 4 has four interpretive statements empha- sizing responsibilities and obligations of the profession- al nurse to his or her patients. These statements remain essentially unchanged in this revised Code. Patients are seen as individuals, families, or populations. “Nursing practice includes independent direct nursing care activ- ities; care as ordered by an authorized healthcare provider, care coordination; evaluation of interventions and delegation of nursing interventions…” (p. 15).

Emphasis of the first interpretative statement is on “authority, accountability, and responsibility.” Nurses have authority in every role, and are accountable and responsible for the quality of the care they provide and in meeting nurse practice acts, regulations, and the Code. Advanced practice registered nurses (APRNs) are included in Provision 4, specifically APRNs with pre- scribing privileges; the revised Code states both the ARPN who orders a treatment and the nurse who accepts the order are responsible for the judgments each makes and accountable for the actions each takes. The issuance of a prescriptive order by an APRN is not an act of delegation.

The second interpretative statement reviews “accountability for nursing judgments, decisions, and actions.” The revised Code recognizes technology that assists nurses in the clinical arena but identifies these

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The New Code of Ethics for Nurses with Interpretative Statements (2015): Practical Clinical Application, Part I

systems and technologies are aids, rather than a substi- tute for the nurse’s skill and judgment. This statement reminds the professional nurse of two important issues in accountability. First, nurses are accountable for all decisions and actions in the course of practice. Second, system or technology failure does not relieve the nurse of practice accountability because these are seen as adjuncts to nursing knowledge and skill rather than replacements for them. Nurses are always accountable for their actions, decisions, and judgments, just as Keisha and Kyle are for their failure in judgment to honor patient confidentiality. Rural Health and Nursing

The third interpretative statement focuses on “responsibility for nursing judgments, decisions, and actions.” Keisha and Kyle exhibited poor nursing judg- ment by speaking about a patient in the elevator. This statement emphasizes the need to provide safeguards for patients, nurses, colleagues, and the environment, and nurses’ responsibility to “bring forward difficult issues related to patient care and/or institutional con- straints upon ethical practice for discussion and review” (p. 16). This revised Code places a duty on nurse execu- tives for safeguarding nurses’ access to organizational committees and institutional boards, as well as inclu- sion in decision-making processes that touch patient care ethics, quality, and safety. Nurses who participate on these committees and boards “are obligated to actively engage in, and contribute to, the decisions that are made” (p. 16). Inclusion of Keisha and/or Kyle on the hospital’s Ethics Committee may have sensitized them to the issues surrounding confidentiality. Rural Health and Nursing

Interpretative statement four addresses the “assign- ment and delegation of nursing activities or tasks.” The revised Code specifically indicates nurses may not dele- gate nursing process duties of assessment and evalua- tion, and “employer policies do not relieve the nurse of responsibility for making assignment or delegation deci- sions” (p. 17). This statement also focuses specifically on the importance of managers in facilitating appropriate assignment and delegation. In addition, this statement expands on the obligations of nurses functioning in educator or preceptor roles. As the revised Code states, “It is imperative that the knowledge and skill of the nurse or nursing student be sufficient to provide the assigned nursing care under appropriate supervision” (p. 17). There is nothing in this interpretative statement relevant to the case situation.

Conclusion When the Code (ANA, 2001) was written, few contrib-

utors could have envisioned the current health care envi- ronment. These revised provisions and interpretive state- ments were developed with an eye toward the future and a foot well-grounded in knowledge gained from the past. This updated version provides nurses with clarity on terms through a glossary, links to foundational docu- ments on the ANA website, and improved clarity through editing of the first four provisions. Through the

addition of interpretative statement 3.6, “protection of patient health and safety by acting on questionable prac- tice,” the importance of the role of the professional nurse in the patient safety is expressed. Rural Health and Nursing

REFERENCES American Nurses Association (ANA). (2001). Code of ethics for nurses

with interpretive statements. Silver Spring, MD: Author. American Nurses Association (ANA). (2015). Code of ethics for nurses

with interpretive statements. Silver Spring, MD: Author. Gallup. (2014). Americans rate nurses highest on honesty, ethical stan-

dards. Retrieved from http://www.gallup.com/poll/180260/ americans-rate-nurses-highest-honesty-ethical-standards.aspx

Fowler, M. (2015). Guide to the code of ethics for nurses with interpreta- tive statements: Development, interpretation, and application. Silver Spring, MD: American Nurses Association.

OnCourse Learning Corporation. (2015). The ANA’s “year of ethics” kicks off with the release of revised code of ethics. Retrieved from http://news.nurse.com/article/20150121/NATIONAL06/150121003 #.VRb80sYtGUk

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Vicki D. Lachman, PhD, APRN, MBE, FAAN, is President, V.L. Associates, a consulting and coaching firm, Avalon, NJ, and Sarasota, FL. She is Chair, American Nurses Association Ethics and Human Rights Advisory Board, and serves on a hospital ethics committee. Elizabeth O’Connor Swanson, DNP, MPH, APRN-BC, is Assistant Professor of Nursing, Mary Black School of Nursing, University of South Carolina Upstate; Nurse Practitioner/Clinical Nurse Specialist, South Carolina Department of Juvenile Justice; and member of the American Nurses Association Ethics and Human Rights Advisory Board. Jill Winland-Brown, EdD, FNP-BC, DPNAP, is Professor Emeritus, Christine E. Lynn College of Nursing, Florida Atlantic University, and member of American Nurses Association Ethics and Human Rights Advisory Board. Rural Health and Nursing

The New ‘Code of Ethics for Nurses with Interpretative Statements’

(2015): Practical Clinical Application, Part II

I n June 2015, over 300 registered nurses (RNs) gath-ered in Baltimore, MD, to examine the newlyrevised Code of Ethics for Nurses with Interpretive Statements (Code) (American Nurses Association [ANA], 2015a). Participants represented all nursing specialties and ranged from new graduates to nurses with more than 40 years of practice experience. All had one thing in common: a need to learn more about this revised Code.

Part I of this series introduced the reader to the revised Code, discussed the glossary, and used a nursing case scenario to illustrate Provisions 1 through 4 (Winland-Brown, Lachman, & Swanson, 2015). This article will complete the discussion of the Code, concen- trating on Provisions 5 through 9 and including the interpretative statements for each provision. A nursing case scenario will be used to illustrate ethical dilemmas nurses may encounter. Rural Health and Nursing

Provisions 5 and 6 focus on ethical issues related to boundaries of duty and loyalty. The language used in the revised Code makes these provisions more precise and the interpretive statements supporting the provi- sions are organized more logically. As a result, the intent of Provisions 5 and 6 is easier to understand. Provisions 7 through 9 concentrate on the nurse’s ethical duties beyond individual patient encounters. These provisions had the most significant changes. They focus on the nurse’s obligation to address social justice issues through direct action and involvement in health policy, as well as a responsibility to contribute to nursing knowledge through scholarly inquiry and research. A

case scenario illustrating ethical issues addressed in Provisions 5 through 9 follows.

Keisha and Kyle are two RNs working the night shift. They have been out of school for several years and have remained close friends. Kyle was one of Keisha’s major supporters when she re-entered nursing. Keisha suffered an addiction to oxycodone after a shoulder injury. This forced Keisha to leave nursing until her successful completion of the recovering profes- sional program administered by the Board of Nursing. Keisha continues to see a counselor on an as-needed basis.

Kyle has heard some rude comments about Keisha from co-workers. He heard Lindsey, a co- worker, describe Keisha as “that bleeding heart liberal woman I have to work with every shift.” Keisha earned this name after she was over- heard discussing the death penalty with a patient one night. Lindsey has worked on the unit for many years. Keisha is uncomfortable when she has to interact with Lindsey.

Keisha admits to Kyle that working nights have been taking a toll on her health. She is beginning to feel “down” and has had difficulty finding time to go on any bicycle rides. Keisha is a passionate cyclist and was a member of a local cycling team known for its community work with the homeless. She also admits to Kyle she has not been motivated to complete contin- uing education requirements needed to finish her recertification. Furthermore, she has not been participating actively in the unit research council and has not met the deadline for an article about recovering nurses she had agreed to submit to a journal. Rural Health and Nursing

Kyle is concerned his friend is suffering from burnout. Keisha has used inappropriate jargon when describing patients in shift report and her grooming is not as neat and profession- al as when they began working together. Moreover, Keisha stated this is the first time in her professional career she feels uncomfortable going to work.

Ethics, Law, and Policy

Vicki D. Lachman Elizabeth O’Connor Swanson

Jill Winland-Brown

September-October 2015 • Vol. 24/No. 5364

Provision 5 The nurse owes the same duties to self as to others,

including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and pro- fessional growth.

This provision delineates personal behaviors in which the nurse must engage to achieve the expecta- tions of the Code. These self-regarding behaviors include maintaining personal health, personal safety, and over- all well-being. The nurse also must remain a competent nursing professional, growing in his or her professional and personal life.

The first interpretive statement addresses “duty to self and others.” The virtue of respect encompasses respect for self as well as for patients. Keisha is having difficulty engaging in self-regarding behaviors; her behaviors indicate she is not caring for her physical, emotional, and spiritual self. Keisha is talking to patients about personal opinions (e.g., capital punish- ment), is not attending to her grooming, and has made derogatory statements about patients during shift change. These behaviors do not demonstrate respect for self or others. Rural Health and Nursing

The second interpretive statement focuses on “promo- tion of personal health, safety, and well-being.” This interpretive statement centers on the importance of the nurse’s care of self to mitigate burnout, fatigue, and com- passion fatigue. This statement recommends “nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs” (ANA, 2015a, p. 19). Keisha is complaining of feeling “down” and admits to an inability to schedule leisure activities for exercise. Her change in grooming indicates a lack of attention to her role as a pro- fessional, and she is having difficulty working with at least one member of her team. These signs suggest a nurse suffering from burnout. However, because Keisha does not recognize the signs, she is not seeking advice and treatment from an appropriate source (Krischke, 2013). Kyle should discuss his concerns with her.

The third interpretive statement considers the “preservation of wholeness of character,” and addresses the nurse’s dual identity — professional and personal. It was appropriate for Keisha to discuss the capital punish- ment issue with a patient as long as she was speaking as an individual on the issue, as “authentic expression of one’s own moral viewpoint is a duty to self” (p. 20). Nurses are free to express a personal opinion, as long as they preserve proper professional or personal bound- aries. Interpretive statement 3 asserts, “Nurses must be aware of the potential for undue influence attached to their professional role” (p. 20). Because nurses will encounter situations with patients that test their per- sonal beliefs, giving compassionate and respectful care thus can be challenging at times. Rural Health and Nursing

Interpretive statement 4 upholds “preservation of integrity.” “Personal integrity is an aspect of wholeness

Ethics, Law, and Policy

of character that requires reflection and discernment: its maintenance is a self-regarding duty” (p. 20). Nurses face threats to their integrity in any health care setting. These threats can include demands for falsification of records, requests to deceive patients or families, and physical or verbal abuse from anyone in the setting. Lindsey has violated the Code by verbally abusing Keisha, and a manager needs to intervene and assure Keisha will not be bullied (Rocker, 2012). If the unit administrator fails to respond, Keisha has an obligation to take the next step up the chain of command to resolve this problem of bullying. Interpretive statement 4 maintains nurse administrators “must respond to con- cerns and act to resolve the concern in a way that pre- serves the integrity of the nurses” (p. 21).

This fourth interpretative statement also addresses the concept of conscientious objection. This means refusing to participate in a decision or action the nurse believes may endanger a patient, family, or community, or nursing practice itself because it violates the nurse’s moral stan- dards. Nurses must understand these acts of moral courage do not insulate them from formal or informal consequences (Lachman, 2014). Any eroding of the ethi- cal environment could result in moral distress for nurses. Therefore, they have an obligation to express their con- scientious objection to the appropriate authority.

Interpretive statement 5 focuses on “maintenance of competence and continuation of personal growth.” Maintaining competence is not only important to pro- fessional growth, but also is a necessary lifelong duty. Keisha has violated this through her unwillingness to complete required necessary education to maintain cer- tification. She has not participated in the nursing research council, and has failed to submit an article on recovering professionals to a journal. Kyle has a duty to encourage Keisha to complete her certification require- ments and other professional commitments.

Interpretive statement 6 reflects on the necessity of “the continuation of personal growth.” “Professional and personal growth reciprocate and interact” (p. 22). Nurses are encouraged to engage in activities that increase their knowledge and understanding of the world in which they live. This interpretive statement urges nurses to participate in activities, such as social advocacy, civic activities, and recreational activities. Keisha stopped going on team rides; these were not only recreational, but also a way to participate in community service. While these outside activities cannot be required of nurses, nurses are encouraged to participate. Rural Health and Nursing

Provision 6 The nurse, through individual and collective effort,

establishes, maintains, and improves the ethical envi- ronment of the work setting and conditions of employ- ment that are conducive to safe, quality health care.

This provision describes the nurse’s responsibility for creating a moral environment and expands the defini- tions of the virtues of nursing. The provision states “cer-

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The New ‘Code of Ethics for Nurses with Interpretative Statements’ (2015): Practical Clinical Application, Part II

tain particular attributes of moral character might not be expected of everyone, but are expected of nurses” (p. 23). Nurses in all roles are responsible for instituting, sustaining, and cultivating an ethical work environ- ment. Nurse managers/executives must involve nurses in decisions related to workplace conditions and profes- sional practice. Nurse executives also need to advocate for appropriate organizational change to create a moral- ly good environment.

Interpretive statement 1 focuses on expanding the definitions of the virtues of nursing and states nurses are expected to have specific attributes of moral character. Keisha has violated the Code by making derogatory comments about patients, thereby failing to demon- strate respect and compassion for those in her care. Keisha also is not caring for herself, placing her physical well-being at risk. The interpersonal communication between Lindsey and Keisha is hostile, leading both nurses to be in violation of the Code. Neither is practic- ing the expected nurse virtues of compassion, patience, or respect. Rural Health and Nursing

Interpretative statement 2 focuses on “the environ- ment and ethical obligation.” This statement asserts, “Nurses in all roles must create a culture of excellence and maintain practice environments that support nurs- es and others in the fulfillment of their ethical obliga- tions” (p. 24). This means each nurse has a responsibil- ity to address Lindsey’s bullying to help ensure Keisha does not continue to be a target. Peer pressure may influence the team’s response, but if members continue to allow the bullying through their silence, they are in violation of the Code. Understanding the Code and other ethical position statements will provide nurses the knowledge necessary to construct an environment needed for professional nursing practice.

Interpretative statement 3 addresses the “responsibil- ity for the healthcare environment.” This statement emphasizes, “nurses are responsible for contributing to a moral environment that demands respectful interac- tions among colleagues, mutual peer support, and open identification of difficult issues…” (p. 24). Nurses on the team have a collective responsibility to confront Keisha regarding her unprofessional remarks about patients, her lack of involvement in team professional activities, and the hostile relationship between Keisha and Lindsey. “The workplace must be a morally good envi- ronment to ensure safe, quality patient care and profes- sional satisfaction for nurses and to minimize and address moral distress, strain, and dissonance” (p. 24).

Provision 7 The nurse, in all roles and settings, advances the

profession through research and scholarly inquiry, pro- fessional standards development, and the generation of both nursing and health policy. Rural Health and Nursing

This provision first focuses on the nurse’s role in knowledge development through research and scholarly inquiry. The second emphasis is on the importance of

developing practice standards consistent with the Code and other foundational documents. The third focus underscores the nurse’s responsibility to lead or serve on institution, local, state, regional, or global civic or orga- nizational policymaking committees.

The first interpretative statement focuses on “contri- butions through research and scholarly inquiry.” Knowledge development, whether through research or scholarly inquiry, is necessary to advance the theory and practice of nursing. Clinical nurses have the ethical obligation to know and disseminate the most recent research findings to support best practices. They also have the obligation to protect patient rights in research. Kiesha had demonstrated an initial interest in research and joined the unit research council. Now she is disen- gaged and is not meeting scholarly publication obliga- tions. While this level of involvement is not a require- ment, all nurses must remember clinical questions developed at the bedside often generate research ques- tions. “All nurses must participate in the advancement of the profession…” (p. 27).

The second interpretative statement addresses “con- tributions through developing, maintaining, and imple- menting professional practice standards.” Professional nurses have an obligation to develop practice standards that support ethical practice and nursing’s body of knowledge. Because of her compassion fatigue or burnout, Keisha appears to be doing little and is not meeting the obligations of professional nurses. Nurse managers and executives must support the autonomy of nurses in executing these standards to maintain quality patient care.

The third interpretative statement centers on “contri- butions through nursing and health policy develop- ment.” Nurses can meet their ethical obligations by par- ticipating in a variety of local, state, national, or global initiatives. Keisha could use her addiction recovery experience to help change nursing regulations in her state and present at state and national conferences on needed policy changes. Rural Health and Nursing

Provision 8 The nurse collaborates with other health profession-

als and the public to protect human rights, promote health diplomacy, and reduce health disparities.

First, in comparison to the previous Code (ANA, 2001), this provision adds health as a universal right and significantly increases the focus of the nurse on human rights and health disparities. Second, it increases the nurse’s obligation to take action on social injustice. For the first time, it also addresses nurse’s moral obliga- tions in extreme and extraordinary practice settings (e.g., Ebola, Hurricane Sandy).

The first interpretative statement, “health is a univer- sal right,” is new in this Code revision. This assertion is held in common with many human rights treaties; it includes many public health measures (e.g., sanitation, potable water, immunizations), basic access to preven-

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tion, and treatment of illness and injury. The Code lists 16 different entitlements included in this right (e.g., access to care, emergency care, prevention education). Keisha could take an active role in educating nurses and public in the prevention and treatment of drug abuse. Rural Health and Nursing

The second interpretative statement is “collaboration for health, human rights, and health diplomacy.” Though nurses have a personal obligation to address human rights and health disparities, only through col- laboration with other health care professionals can they make significant needed impact on these social justice issues. Practicing nurses see on a daily basis how a social problem becomes a health problem, as they view the effects of poverty, drug-infested neighborhoods, and food deserts (“urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food”) (U.S. Department of Agriculture, 2015, para. 1). Keisha has seen health disparities among homeless per- sons through previous work via her cycling.

Interpretative statement 3 addresses the “obligation to advance health and human rights and reduce dispar- ities.” Individually or through community organiza- tions, nurses can educate the public and join in legisla- tive efforts to promote health. Again, nurses know first- hand the barriers to health; homelessness, abuse and violence, and lack of cultural sensitivity are a few of the obstacles to quality health care. Keisha has experienced personally how drug addiction stops the outward focus on others, and she could be a good addition to any team that addresses addiction leading to homelessness.

Interpretative statement 4 focuses on “collaboration for human rights in complex, extreme, or extraordinary practice settings.” Nurses can face competing moral claims, for example, in caring for victims of natural dis- aster while needing to care for family. Nurses have a moral obligation to both groups, and only the individ- ual nurse can determine which moral option to address (ANA, 2006). “Only in extreme emergencies and under exceptional conditions, whether due to forces of nature or human action, may nurses subordinate human rights concerns to other considerations” (p. 33). In such cir- cumstance, the Code suggests a utilitarian framework could guide actions (greatest good for the greatest num- ber) (ANA, 2011). Rural Health and Nursing

Provision 9 The profession of nursing, collectively through its

professional organizations, must articulate nursing values, maintain integrity of the profession, and inte- grate principles of social justice into nursing and health policy.

In comparison to the previous Code (ANA, 2001), this Code (ANA, 2015a) addresses more in depth nurses’ responsibilities to engage in rectifying social injustices and health disparities in the community and beyond. The interpretative statements address issues impacting nursing practice now (e.g., climate change, human traf- ficking).

The first interpretative statement about “articulation and assertion of values” identifies the need for profes- sional nursing organizations to provide a unified voice for the profession. The various professional organiza- tions of nursing “communicate to the public the values that nursing considers central to the promotion or restoration of health, the prevention of illness or injury, and the alleviation of suffering” (p. 35). By acting in unity, nurses can have a noteworthy impact on social justice and global health policies. Rural Health and Nursing

The “integrity of the profession” is the second inter- pretative statement and is based on the knowledge and observance of essential documents, such as the Code (ANA, 2015a) and Nursing: Scope and Standards of Practice (ANA, 2015b). These documents support the covenant between the nursing profession and society. This prom- ise also is supported by defined educational require- ments for entry into practice, augmented utilization of advanced practice nurses, increased focus on certifica- tion, and nursing’s commitment to evidence-based practice. Keisha is not doing the needed work for recer- tification, which could be seen as a violation of this pro- vision.

The focus of the third interpretative statement is “integrating social justice,” with examples of the multi- ple ways this can be accomplished. This interpretative statement recognizes the responsibility of nursing organizations to advocate for changes in health policies on local, national, and international stages. Because social determinants of health continuously foster social injustice, nurses must take action with governmental and nongovernmental bodies related to health affairs. The statement also identifies the nurse’s responsibility to “firmly anchor students in nursing’s professional responsibility to address unjust systems and struc- tures…” (p. 36). Keisha could address the issue of social justice for recovering individuals by volunteering to speak to nursing classes. Through content education, staff development, or clinical experience, nurses can help students and practicing professional nurses model a commitment to eradication of social injustice. Rural Health and Nursing

“Social justice in nursing and health policy” is the final interpretative statement in the new Code (ANA, 2015a). This final statement fittingly focuses on global health and the need for voices of U.S. nurses to be heard around the world. In this reiteration of the Code, the health of the natural world is first addressed. Though Florence Nightingale demonstrated concern for the effects of environment on health, the profession today must extend its advocacy as the “environmental assaults disproportionately affect the health of the poor” (p. 37). The “Laudato Si” statement by Pope Francis (2015) starkly ties the effects of climate change to devastating effects on the poor.

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Conclusion This article elaborates on Keisha’s and Kyle’s obliga-

tions as professional nurses to meet the Code (ANA, 2015a). In preparing this article, the authors were con- fronted with what they could be doing to advance the profession and assist other nurses to do the same. Hopefully, nurses reading this article will look inward, find ways to promote this new Code, and improve the ethical practice of nursing. This revised Code provides nurses with the guidance to continue to earn the pub- lic’s trust. Rural Health and Nursing

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Krischke, M.M. (2013). Suffering from compassion fatigue, burnout of both? What a nurse can do. Retrieved from http://www.nursezone. com/Nursing-News-Events/more-news/Suffering-from- Compassion-Fatigue-Burnout-or-Both-What-a-Nurse-Can- Do_41375.aspx

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Ethics, Law, and Policy