College of Nurses

(CNO-Compendium)

http://www.cno.org/Global/docs/prac/41034_Ethics.pdf?eps
language=en
CNO
• Nurses encounter ethical conflict,
Why an uncertainty and distress in their
Ethical everyday practice.
• Changes in the health care system,
framework in areas such as technology and in
? values, contribute to these ethical
dilemmas.

How do you help nurses prevent ethical conflicts?

• Understanding and communicating beliefs and values -
helps nurses to prevent ethical conflicts and to work
through them when they do occur
• To make decisions about ethical situations, nurses need to
be aware of their personal values
CNO:Definitions
Nursing - is the • promoting client’s health
therapeutic relationship through assessing
that enables the client to • providing care for and
attain, maintain or
regain optimal function • treating the client’s health
by; conditions.

Therapeutic
relationship -
established and
maintained by the nurse • based on trust, respect and
through the nurse’s use of
professional nursing intimacy and requires the
knowledge, skill, and appropriate use of the power
caring attitudes and
behaviours to provide
nursing services.
CNO: Definitions

Quality • Professional nursing practice,

including
practice • appropriate professional
settings: preparation
• suitable conditions for
create and nursing practice
maintain • respect for nurses as
characteristic responsible decision-makers,
and
s that • recognition of professional
support; expertise
CNO: Ethical concerns
When two or more ethical values apply to a situation, but
these values support diverging courses of action, an ethical
conflict or dilemma exists

Nurses may experience ethical uncertainty when faced

with a situation in which they are unsure of what values
apply or where the moral problem is.

They may also experience ethical distress when they know

the “right” thing to do, but various constraints make doing
the “right” thing difficult (Jameton, 1984)

Nurses need to choose ethical interventions that meet the

needs of clients.
CNO: Ethical concerns
Resolving ethical conflicts
• The best possible outcome is identified in
consultation with the client, and the health care
team works to achieve that outcome.
Document layout
• the value should be explained- to assist in
understanding how that value can conflict with
other values
• it is important to understand why the issue
presented may be an ethical problem for other
caregivers
CNO: Ethical Values
client well-being

client choice

privacy and confidentiality

respect for life

maintaining commitments

truthfulness

fairness
CNO: Client well-being

Means facilitating the client’s health

and welfare, and preventing or
removing harm.

In determining the best action, it is

necessary, as a beginning point, to
differentiate between the nurse’s and
the client’s views of what is beneficial
CNO: Client well-being
Case Scenario: The following situations
illustrate ethical conflicts related to client
well-being.
• Some of the procedures, such as debridement, that
nurses perform on children may cause the children
to experience severe pain.
• Norman, a nurse, has explained to his client the
benefits of taking medication and firmly believes
that the medication is in the client’s best interest.
The client understands Norman’s explanation, but
refuses to take the medication. The client states that
the side effects of the medication cancel out any
benefits.
CNO: Client well-being:
Nurses demonstrate a regard for client well-being by:

■ listening, understanding, and respecting clients’ values, opinions,

needs, and ethno cultural beliefs;

■ supporting clients to find the best possible solution, given clients’

personal values, beliefs and different decision-making styles;

■ using knowledge and skill to promote clients’ best interests in an

empathic manner;

■ promoting and preserving the self-esteem/self-confidence of clients;

■ maintaining the therapeutic nurse-client relationship;

■ seeking assistance when ethical conflicts arise

CNO: Client well-being:
■ to improve health care in the community by working with individuals,
groups, health care professionals, employers or government staff to advocate
for needed health policy and health resources;

■ respecting the informed, voluntary decisions of clients, including

participants in research; and

■ minimizing risks and maximizing benefits to clients (CNA, 1994).

■ means self-determination and includes the right to the information

necessary to make choices and to consent to or refuse care.

■ substitute decision-maker must always be consulted when individual

clients are incompetent to make decisions
CNO: Client choice:
Limits to choice
• clients do not have the right to choose to
endanger the safety of others for example,
restrictions on smoking

When values differ

• clients’ wishes may be difficult when their
beliefs and values differ from those of
nurses.
• the nurse needs to arrange for another
caregiver and withdraw from the situation
Nurses demonstrate regard for client choice by:
■ respecting clients even when the clients’ wishes are not the same as
theirs;
■ following clients’ wishes within obligations of the law & standards of
practice;
■ following SDM’s’ directives if clients are incompetent to make
decisions about their care, within the obligations of the law & standards
of practice

■ exploring clients’ rationales for their decisions before acceding to

wishes that the nurse disagrees with.

■ supporting informed decision-making;

■ advocating for clients to acquire information before consenting to, or

refusing, care, treatment or to be a research participant; and

■ making a reasonable effort to identify a SDM if a client is not

competent to make choices regarding health care.
Privacy and Confidentiality

Privacy - is limited
access to a person, the
person’s body, - maintains the
conversations, bodily dignity and
functions or objects privacy of clients
immediately associated
with the person.

All information relating to

the physical, psychological
Confidentiality - involves and social health of clients
keeping personal is confidential, as is any
information private information collected
during the course of
providing nursing services.
Respect for life
means that human life is precious and needs to be
respected, protected and treated with consideration
(Keyserlingk, 1979). This includes considerations of the
quality of life.
Nurses demonstrate regard for respect for life by:
• identifying, when possible, clients’ values about respect for
life and quality of life;
• respecting clients’ values and following their wishes within
the obligations of the law and standards of practice;
• following substitute decision-makers’ directives if clients are
incompetent to make decisions about their care
• advocating for palliative measures when active treatment is
withheld; and
• providing dignified, comfortable care for a dying client
Maintaining Commitments

Nurses have an obligation to maintain the

commitments they assumed as regulated
health professionals

Means keeping promises, being honest and

meeting implicit or explicit obligations toward
their clients, themselves, each other, the
nursing profession, other members of the
health care team and quality practice settings.
Maintaining Commitments

Maintaining commitments to clients

Maintaining commitments to oneself

Maintaining commitments to nursing colleagues

Maintaining commitments to the nursing profession

Maintaining commitments to team members/colleagues

Maintaining commitments to quality practice settings

Maintaining Commitments to clients
Nurses try to act in the best interest of clients
according to clients’ wishes and the standards of
practice

Nurses are obliged to refrain from abandoning,

abusing or neglecting clients, and to provide
empathic and knowledgeable care

The commitment to clients also includes a

commitment to respect family members and/or
significant other(s), some of whose needs may
conflict with those of clients
Nurses maintains commitments to clients:

■ putting the needs and wishes of clients first;

■ identifying when a client’s needs and wishes conflict with
those of the family or others and encouraging further
discussion about client needs;
■ identifying needed resources and support to enable
clients to follow their wishes;
■ identifying when their own values and beliefs conflict
with the ability to keep implicit and explicit promises and
taking appropriate action;
■ providing knowledgeable and client-centred nursing care;
■ advocating for maintaining quality client care; and
■ making all reasonable efforts to ensure that client safety
and well-being is maintained during any job action.
Nurses maintains commitments to oneself:

Nurses need to recognize and function within their value system and be
true to themselves.
Nurses’ values sometimes differ from those of other health care
professionals, employers and clients, causing ethical conflict

Nurses demonstrate a regard for maintaining commitments to

themselves by:
■ clarifying their own values in client situations;
■ identifying situations in which a conflict of their own values interferes
with the care of clients;
■ exploring alternative options for treatment and seeking consultation
when values conflict;
■ determining and communicating their values pertinent to a position
before accepting it; and
■ recognizing their physical and mental limitations, and the impact their
own health has on their ability to provide safe, effective and ethical care.
Maintaining commitments to nursing colleagues
Nurses have a commitment to each other.
- Ethical nurses are concerned about the well-being of nursing
colleagues and therefore are respectful toward each other.

Nurses demonstrate maintaining commitments to

nursing colleagues by:

■ showing a caring attitude;

■ knowing and respecting each others’ roles between RNs, NPs

and RPNs;

■ contributing to positive team functioning and supporting

one another;
Maintaining commitments to nursing colleagues
■ introducing themselves to colleagues and addressing
colleagues by the name or title that their colleagues
prefer;

■ listening to colleagues without immediately giving

advice or diminishing colleagues’ feelings;

■ giving colleagues the time and opportunity to explain

themselves and to ask questions;

■ understanding and respecting colleagues’ values,

opinions and needs;
Maintaining commitments to nursing colleagues

■ exploring colleagues’ unusual comments, attitudes or

behaviours to discover the underlying meaning;

■ discussing and working through ethical conflicts and

concerns with one another;

■ knowing the expertise of colleagues and accessing it

when clients would benefit from that expertise;

■ sharing nursing knowledge and expertise with others,

including nursing students;
Maintaining commitments to nursing colleagues
■ learning and practising effective communication with
colleagues;

■ providing peer feedback in a respectful manner;

■ recognizing that substance abuse by colleagues is a health

problem requiring prompt assistance, support and
treatment;

■ intervening in situations in which the safety and well-

being of clients are compromised; and
■ reporting to the appropriate authority any nursing
colleague whose actions or behaviours toward clients are
unsafe or unprofessional, including any physical, verbal,
emotional, financial and/or sexual abuse.
Maintaining commitments to the
nursing profession
nurses have a duty to uphold the standards of the profession,
conduct themselves in a manner that reflects well on the
profession, and to participate in and promote the growth of
the profession.

Nurses also have a commitment to help regulate nursing to

protect the public’s right to quality nursing services

Nurses have an obligation to participate in the effective

evolution of self-regulation.
Maintaining commitments to team
members/colleagues
Nurses need to respect all health care
professionals and their roles, and are
expected to collaborate and
coordinate care with team members

In situations in which client safety

and well-being are compromised,
however, nurses’ primary
responsibility is to their clients.
Maintaining commitments to quality
practice settings
CNO has identified key attributes or characteristics that
support quality professional practice

professional development systems,

leadership, organizational supports

response systems facilities and equipment,

Communication systems and

Care delivery processes

Maintaining commitments to quality practice settings
Nurses demonstrate maintaining commitments to quality
practice settings by:
■ continually evaluating the workplace environment to
identify opportunities for improving the quality of care;
■ respecting the philosophy and policies of the practice
setting;
■ making those in authority aware of concerns within the
setting;
■ exploring solutions within the setting that will meet the
needs of clients and those of the setting;
■ advocating for nursing input into policies relating to client
care; and
■ determining and communicating personal values they
may bring to a position before accepting employment.
Maintaining commitments to quality practice settings
Nurse leaders also demonstrate their commitment to quality
practice settings by:
■ determining and communicating values to staff;
■ being informed about the scopes of practice of all health care
team members;
■ providing clear role expectations for nurses (Freiburger, 1996);
■ assigning responsibilities to staff according to their scope of
practice and individual abilities;
■ providing, and/or advocating for, needed resources for safe,
effective and ethical nursing care;
■ promoting positive collegial relationships;
■ showing sincere appreciation for staff contributions (Hansen,
1995); and
■ looking into and following up on concerns of staff.
Truthfulness

means speaking or acting without intending to

deceive.

also refers to providing enough information to ensure

the client is informed

Health care professionals now believe that clients

have the right to and will benefit from full disclosure.

Honesty builds trust, which is essential to the

therapeutic relationship between nurses and clients.
Nurses demonstrate a regard for truthfulness by:
■ discussing clients’ direct questions about their diagnosis with
the health care team and advocating for the clients’ right to
receive the information;

■ assessing the clients’ readiness for information;

■ answering the clients’ direct questions if nurses have the

information, or seeking the answer for clients;

■ using professional judgment and consulting with the health

care team if further information is relevant to clients, but is not
asked for because clients do not know the information exists;
Nurses demonstrate a regard for truthfulness by:

■ explaining to clients their right to information;

■ assisting clients in understanding information when there are

cultural, language or literacy concerns;

■ assessing the whole situation when clients indicate that they do

not want to know something; and

■ giving consideration to families’ and/or significant other(s)’

points of view when they do not want clients to be told about
their health condition.
Fairness
means allocating health care resources on the basis of
objective health-related factors.

The Canada Health Act provides access to health care for all
Canadians

Nurses could consider that all clients should have equal

attention, regardless of needs.

Nurses might also prioritize an individual client’s needs

according to the critical nature of that need.

Nurses could also look at who will benefit most from the
care they can give.
Nurses demonstrate regard for fairness by:
■ being clear about how their own values relate to the demands of
fairness;
■ discussing resource allocation issues with the appropriate
authority and the health care team so that all can be involved in
resolving a problem;
■ advocating for input into policies and procedures about the use of
resources;

■ advocating for adequate resources to provide safe, effective and

ethical nursing care;
■ working with other health care professionals to advocate for social
changes that promote quality practice settings and client well-being;
and
■ demonstrating a willingness to explore alternative ways of
providing care that continue to value clients’ well-being.
 Working Through Ethical Situations
in Nursing Practice
The nursing process provides a viable approach for
examining situations involving ethical values:

Assessment/description of situation
Plan/approach
Implementation/action
Evaluation/outcome
Assessment/description of situation

Pay close attention to all aspects of the situation

Examine not only your beliefs, values and knowledge

Consider policies and guidelines, professional

codes of ethics and relevant legislation

• Hold a discussion with all involved to clarify the process.
• Clearly state the ethical concern, issue, problem or dilemma
• Identify a broad range of options and their consequences
Plan/approach

Develop an action plan that takes into account

factors drawn from the assessment, options and
consequences

Decide which is the best course of action. Sometimes

a completely good outcome is impossible; the best
possible outcome may be the one that is least bad

Consult with anyone who disagrees and consider

her/his position. Further assessment needed.
Implementation/action

Carry out the agreed upon actions.

Sensitivity, good communication
and interpersonal skills are
necessary
Provide information and emotional
support for the client, the family,
friends and caregivers
Evaluation/outcome

Determine if the result is satisfactory.

Involve those who were part of the initial assessment and

planning, including the client

Reassess and re-plan if others are concerned with the

outcome

Consider policies and guidelines for subsequent situations

and decisions, and revise them as necessary.

Assess the time allowed for ethical decision making.

Conclusion: Ethical Framework

This ethical framework is designed to provide nurses with

direction in identifying and resolving ethical situations.

Continuing education about ethical issues and Conflicts

Reading and discussing this compendium

Ongoing self-reflection and further discussion with peers

 CNO
CNO- Ethical framework
http://www.cno.org/Global/docs/pr
ac/41034_Ethics.pdf