Chapter 5 : Nursing and Ethics
Section 2. Social Context
Nursing is as much a profession as is that of medicine. Nursing is also regarded as a vocation and therein is the origin of a problem for how nurses consider themselves, their relationships to others and how they will approach ethical problems.
As professionals nurses have the same sets of relationships as do physicians. They can and do set their own standards for care and conduct. They have their oaths and codes and peer review systems. They have as professionals an opportunity to develop a set of moral guidelines that would be distinct from those developed in the vocational model.
They have a "code" that presents a set of responsibilities including:
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the recipient of care.
4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum care for recipients of service.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving healthcare environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
Nurses who are organized as a trade union and think of themselves as having a job which is a source of income and little more than that are more likely to employ a contractual model for their relationship to the recipients of care.
Nurses using the professional model are more likely to stop work in protest of conditions of care for those they serve than are those nurses organized with the vocational model and operating under a union contract. Their concerns are more likely to focus on conditions of employment.
Nurses have a variety of relationships that often conflict with one another and are sometimes a source of moral dilemmas.
Should a nurse be more responsible to the physician ? Fellow Nurse? Recipient of care?
A nurse is instructed by a physician to give an amount of a medication that is ten times the appropriate dosage according to the PDR (Physicians Desk Reference). When the nurse questions the physician's order , the nurse is reprimanded for challenging the doctor and told to follow instructions. Should the nurse administer the dose as written? What should the nurse do and why? To whom is the nurse responsible?
As with the physician there exists a variety of models for the relationship of the nurse to those for whom the nurse is responsible to care. among the many models the principle models include:
1. Maternal Model or Parent Surrogate
From the Nursing perspective the Maternal Model is one where the Nurse and patient are viewed as 'mother and child'. While the Nurse may be the protectorate, one must be concerned about the possibility of the patient's dignity and autonomy being reduced.
2. Physician Surrogate
The nurse acts in the capacity of the physician. This is a model not well accepted by those physicans who control most health care institutions.
3. Soldier Model
The Soldier Model removes all autonomy from the Nurse, reducing her role to that of a non-questioning soldier who simply obeys and carries out the General's (Physician's) orders.
4. Contract Model Contracted Clinician(health care provider)
The Contract Model is one in which various parties work together and share the burdens and benefits of such a relationship. The Nurse may see her role as that of forming a contract with thepersons served by the nurse, the physician, the institution and society in general. The Contract Model thus stresses autonomy as well as authority as developed via a team-work approach to medicine.
5. Advocate Model
The Advocate Model is such that the Nurse tries to promote the best interests of the patient. In serving as an advocate the nurse would be involved in assisting those for whom nurses provide care in a number of ways , including:
Informing persons served by the nurse of their rights
Supporting persons served by the nurse in the exercise of their rights
Defending the rights of those served by the nurse
This advocacy goes against the culture of all bureaucratic systems, e.g., the hospital system.
Here too, one must be concerned that the true interests of the persons served by the nurse are respected and that there is no conflict between the Nurse and Physician who may sometimes be seen as pursuing different goals (e.g., one 'cares', the other 'cures'). Nancy Jecker and Donnie Self report (in "Separating Care and Cure: An Analysis of Historical and Contemporary Images of Nursing and Medicine", Journal of Medicine and Philosophy 16, 1991) http://www.cariboo.bc.ca/ae/php/phil/mclaughl/students/phil433/jecker.html that this potential conflict may be resolved if one recognizes that the individuals are not pursuing 'care' versus 'cure' visions but that the parties may 'care for' and 'care about' the persons served by the nurse in different ways.
6. Covenant Model
As with physicians those who provide nursing care undergo an ontological transformation and carry a set of obligations towards all in society due to a debt they have incurred through their training and practice. This model provides a basis for establishing rights and duties.
While these models are not all mutually exclusive, some are. Some models may serve as the base for autonomous decision making that is a requisite for morality and ethical conduct and some do not. The covenant and advocate models are the most supportive of an ethical basis for behavior.
Applying these models to actual cases for analysis will be the object of exercises associated with the decision scenarios in this chapter.
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