ANA Code of Ethics provision 1 examples

Patients trust that by virtue of being a patient, a nurse is providing unconditional care to them. This is especially true for incapacitated patients who are unable to self-advocate for appropriate and empathetic care. However, ethical conflicts can arise for nurses caring for incapacitated patients because these patients cannot make their wishes known or participate in their own care. Nurses find themselves in positions to make decisions for patients that often challenge the ability of the nurse to maintain patient dignity while protecting the patient from harm.
One example of this is the decision to use sedation as restraint for incapacitated patients with agitation. While this makes sense clinically, it can challenge the ethical framework of nursing care. This case study illustrates the importance of knowing how to apply the Code of Ethics for Nurses to these difficult situations.

As professional nurses, we make decisions that may affect the very human “being” of the patients for whom we provide care. Being human is inherent; it just “is.” The Code of Ethics for Nurses begins by informing nurses that human dignity is inherent also. “All persons should be treated with respect simply because they are persons” (ANA American Nurses Association, 2015, p. 45).

Provision 1 states, “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).

Provision 1 establishes the fundamental premise for the ethical delivery of all nursing care and is based on human rights, the fundamental freedoms that all persons are entitled to because they are human (ANA American Nurses Association, 2015, p. 45). Delivering ethical nursing care in a complex health care environment is not always clear. Situations occur that result in ethical conflict when it is difficult to determine or perform the right course of action. Nurses must be aware of the significance of human rights in order to provide ethical nursing care and advocate for the rights of patients in these situations. The risk of ethical conflict exists when patients cannot make their own decisions or assert their rights. They are vulnerable to violations of these rights (Center for Ethics and Human Rights, 2010). A study that explored nurse leaders’ identification of risk factors that lead to complex ethical situations included patients with altered capacity as a contributing risk factor to nurses’ ethical conflicts (Pavlish, Brown-Saltzman, So, Heers, & Iorillo, 2015).

The purpose of this article is to examine an example of a complex situation that involves the use of sedation as a restraint in an incapacitated patient, identify the ethical conflicts, and show how the code of nurses guides the nurse in everyday practice. The case is a compilation of events and patients experienced over years of nursing in diverse environments. Many nurses can relate to similar situations in their practice.

Case Study
Mrs. Smith is an incapacitated patient admitted to the hospital with confusion and weakness. Her diagnosis is pneumonia, complicated by end stage cirrhosis and an elevated ammonia level. During the previous shift, Mrs. Smith became physically aggressive, confused, and uncooperative. She fell but had no injury. Staff was not able to console or manage her behavior and obtained orders to sedate her. After multiple doses of sedation, Mrs. Smith is resting but heavily sedated. Now some nurses’ advocate for continued sedation throughout the night for behavioral control. Others advocate for continued sedation to prevent another fall. What is the dilemma? The Code of Ethics asserts the need to balance patient dignity with sedation.

Conflict with Provision 1
“The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (ANA American Nurses Association, 2015, p. 1).

According to the ANA position statement on restraints, “Restraining or secluding patients either directly or indirectly is viewed as contrary to the fundamental goals and ethical traditions of the nursing profession, which upholds the autonomy and inherent dignity of each patient or resident” (Center for Ethics and Human Rights, 2012).

It is important to understand that sedation is a chemical restraint when it used to restrict or manage the patient’s behavior or to restrict their freedom of movement, and when it is not a standard medication or dose for care of the patient’s condition. Chemical or (physical restraints) can lead to incontinence, pressure ulcers, pneumonia, muscle weakness, and other health issues (Center for Ethics and Human Rights, 2012). This is not in the patient’s best interest and will lead to other health declines over time.

Conflict with Provision 2
“The nurses primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA American Nurses Association, 2015, p. 5).

Administering sedation as a restraint to control behavior is in conflict with nurses’ ethical responsibility of beneficence and nonmaleficence to the patient. In its position statement on restraints, the ANA recognizes that nurses may face pressure from peers to use restraints (Center for Ethics and Human Rights, 2012). However, these intentions may not be in the interest of the patient. The nurse’s primary focus is the patient. Provision 2 states this and reflects upon Provision 1 as it explains that each plan of care must reflect the fundamental commitment of nursing to the uniqueness, worth, and dignity of the patient (ANA American Nurses Association, 2015).

How the Code Directs Nursing Care
Nurses assume a great amount of responsibility when providing care to incapacitated patients. There can be conflict between doing what is right and good for the patient while avoiding harm. It is not appropriate to administer sedation for convenience.

However, should nurses sedate a patient to prevent another fall? In this case, study falls prevention interventions are in place as per policy, except for an option of assigning one to one observation to this patient because staff is not available. The conflict is now between the responsibility to keep the patient safe or using a practice such as sedation that is not safe. How should a nurse make the decision and know they have done the right thing? Follow the guidance provided in Code of Ethics for Nurses Provision 2, begin to think of the care plan for the patient who is confused, agitated, and at risk for falls.

Implementation of Ethical Nursing Care
Recognizing uncertainty in a course of action is the first step in providing ethical nursing care. Imagine yourself as the nurse caring for Mrs. Smith. Begin by following the nursing process. Your nursing assessment finds her asleep, vital signs are with in parameters, and she has loud snoring respirations. She arouses to gentle shaking and answers simple questions. She is agitated during the assessment but cannot keep her eyes open. She intermittently follows commands with heavy limbs. She remains sedated, and you wonder about the prolonged effects of all the medications she received because of her extensive medical problems. You review her records and see that she was articulate and oriented a few days ago, and wonder how much the elevated serum ammonia level affects her behavior. You also note that her dose of lactulose was increased, and that she did not receive it earlier due to her behavior, but she does take it now.

Mrs. Smith does not exhibit the same behavior that she did earlier. You are not sure that she needs sedation. A sitter would be beneficial, but none is available. If you sedate her and she cannot take her medication, the condition will worsen and the incapacitation will increase. As her nurse, you feel the appropriate goal is to keep her safe from falls, harm, and her symptoms. This demonstrates respect for patient dignity and human rights by exhibiting a caring ethic. Nurses’ ethical responsibilities are to promote health, prevent illness, restore health and alleviate suffering (Center for Ethics and Human Rights, 2010). The Code of Ethics for Nurses guides nurses in this situation by instilling the nurse with the fundamental elements of respect for the human being under care.

The ANA position statement on restraints provides valuable guidance in making an ethical decision in this situation and tells nurses what to do.
1.    All behavior has meaning.
2.    Patient needs are best met when behavior is understood.
3.    A systemic approach of assessment, intervention, and evaluation is the best means to respond to behavior (Center for Ethics and Human Rights, 2012, p. 9).

During the shift, Mrs. Smith intermittently tries to get out of bed and causes the bed alarms to sound. However, she is still unable to keep her eyes open and still seems sedated. Now the reason for her agitation is that she needs to void and attempts to get to the bedside commode, has abdominal discomfort related to the lactulose, and is simply trying to reposition herself in bed and secure her blankets and pillows. These are all needs that nurses should address. The nursing process does not identify a diagnosis that supports sedation for this patient. You now can plan and implement care according to the unique needs of Mrs. Smith. She is still agitated but sleeps for long periods between episodes. Each time she awakens, she is more appropriate. By morning, the disruptions are less frequent, she is more awake, and she is able to converse. This is a more desirable outcome.

Conflict Provision 4
“The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care” (ANA American Nurses Association, 2015, p. 15).

This provision directs nurses to take action and accountability for situations that prevent or interfere with delivery of ethical care for a patient. In this case, refer to Provision 4.3, “Nurses must bring forth for review difficult issues related to patient and/or institutional constraints upon ethical practice for discussion and review” (ANA American Nurses Association, 2015, p. 16). The implications of this case are apparent when reviewed in an ethical context. In this case, because of staffing issues, a one on one sitter was not available. This caused some nurses to consider sedation as a likely treatment to manage behavior and prevent falls. The institution does have a responsibility to support an environment and provide resources that are conducive to the delivery of ethical nursing care. Nurses have an ethical obligation to inform nurse leaders of these implications and offer ethically informed suggestions to improve care. Nurse leaders also have an obligation to promote ethical care by influencing changes to make this happen. The Nursing Code of Ethics provides the ways and means by which to learn from and improve nursing care.

Conclusion
The Nursing Code of Ethics Provision 1 provides unwavering position in this case study. The use of sedation for the purpose of restraint or behavior management is not ethical and does not respect the inherent dignity of the person receiving nursing care. Provision 2 provides guidance because it directs nurses’ primary focus to the patient. It is not appropriate to use sedation for nurse convenience. Provision 4 guides nurses in taking action to change practice in difficult situations in which ethical conflicts occur.
In this case, continued sedation would prohibit this vulnerable patient’s ability to express basic human needs, accept care and treatment, and may cause negative health outcomes. The nursing profession has a responsibility to uphold an unwavering trust that an incapacitated patient receives dignified nursing care that is his or hers by inherent rights. Through knowing and applying the Code of Ethics, nurses are better prepared to provide patient-centered care and uphold social trust in the nursing profession.

References
ANA American Nurses Association. (2015). Code of Ethics for Nurses with Interpretitive Statements. Silverspring, Maryland: nursebooks.org. Retrieved October 18, 2015 from www.nursingworld.org.
Center for Ethics and Human Rights. (2010, June 14). ANA Position Statement: The Nurses Role in Ethics and Human Rights: Protecting and Promoting Individual Worth, Dignity and Human Rights in Practice Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements
Center for Ethics and Human Rights. (2012, March 12). ANA Position Statement: Reduction of Patient Restraint and Seclusion in Health Care Settings. Retrieved October 18, 2015, from nursingworld.org: http://nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Position-Statements
Pavlish, C., Brown-Saltzman, K., So, L., Heers, A., & Iorillo, N. (2015). Avenues of Action in Ethically Complex Situations: A Critical Incident Study. JONA: The Journal of Nursing Administration, 45(6), 311-318.

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