This essay is the winner of the 40th Anniversary Student Essay Competition.
By Riley Reel, School of Nursing BSN student
Although Registered Nurses (RNs) join the profession for an infinite number of reasons, the essence of all nurses’ practice is their unremitting ambition to protect the patients they care for (Canadian Nurses Association (CNA), 2007). A comprehensive document that aligns with this intention is essential for the nursing profession. The Canadian Nurses Association (CNA) strives to articulate the ethical values of Canadian RNs through the provision of an explicit Code of Ethics (CNA, 2008a). The code is developed and approved by nurses to facilitate continued compatibility with nurses’ values. Additionally, it is necessary for the code to evolve as the values of RNs, and the values of Canadian society, progress. For this to occur, the CNA must implement frequent revisions so the code reflects the issues and trends that currently plague or define society and healthcare. Since 1980, the CNA has fulfilled this expectation through their commitment to revise the code approximately every five years (CNA, 2008b). This has resulted in seven revisions since the code’s inauguration in 1954 (CNA, 2008a). Revisions of the code are supported by theoretical frameworks, which assist in preserving the code’s relevancy to practice. Recent adaptations of the code utilize ethical theories that recognize innate morality and relational complexities, such as virtue ethics, relational ethics, and feminist ethics (Burkhardt, Nathaniel, & Walton, 2013). The CNA Code of Ethics for RNs has maintained its applicability because nurses are capable of developing and reviewing the code, theoretical frameworks are utilized to guide adaptations, and periodic revisions take place in order to incorporate evolving societal trends, issues, and values (CNA, 2008a; CNA, 2008b).
“By Nurses, For Nurses”
The CNA (2008a) claims that the Code of Ethics is developed “by nurses for nurses” and it is not necessary to look far in order to detect the truth in this statement (p. 30). Many members of the CNA Board of Directors are Registered Nurses, some of whom have past experience working as staff nurses (CNA, 2016). This relevant expertise demonstrates the Board of Directors’ exceeding competence to develop appropriate ethical frameworks for nurses. As a result, the CNA authenticate their assertion that the Code of Ethics is developed and reviewed by nurses, which supports the code’s relevance and applicability to practice.
Ethical Theories Throughout the Code of Ethics’ Revisions
In 1954, the CNA adopted the International Council of Nurses’ code, which thoroughly embraced a deontological framework (CNA, 2008a). Deontology is a theory of ethics that employs a rationalist view to conclude that each act is inherently right or wrong, despite external factors (Burkhardt, Nathaniel, & Walton, 2013). Many professions adopt this rule-based structure, but the CNA recognized that it could limit nurses’ ability to develop their own ethical sensitivity (Meulenbergs, Verpeet, Schotsmans, & Gastmans, 2004). As a result, in 1980, the CNA developed its own code of ethics that minimized use of deontology, and instead, amalgamated numerous philosophies to support the development of the “caring code” (CNA, 2008a; Storch, 2007). This progressive code incorporated values of respect for human life and emphasized caring through compassion, commitment, confidence, competence, and conscience (Storch, 2007). Since the inception of the 1980 Code of Ethics, the CNA has prioritized virtue ethics, relational ethics, and feminist ethics and all have become increasingly predominant with each revision.
Virtue Ethics
Virtue ethics acknowledges the innate morality within all individuals (Burkhardt, Nathaniel, & Walton, 2013). When the CNA embraced the theoretical framework of virtue ethics, deontology was no longer applicable because of the contradiction between these two theories. Instead of supplying stringent regulations, as is common in deontology, virtue ethics recognizes nurses’ inherent moral standards. This shifts the focus from the morality of the act itself to, instead, emphasize the integrity of the individual that commits the act. This perspective promotes respect for nurses as virtuous and ethical professionals (Burkhardt, Nathaniel, & Walton, 2013).
The contemporary virtues in this theory include “honesty, compassion, caring, conscientiousness, responsibility, integrity, discernment, trustworthiness, and prudence” (Burkhardt, Nathaniel, & Walton, 2013, p. 37). These virtues thoroughly permeate the 2008 Code of Ethics; a clear example is evident within the ethical responsibility that states, “nurses engage in compassionate care…through their efforts to understand and care about others’ healthcare needs” (CNA, 2008a, p. 8). This ethical responsibility provides guidance to nurses,
but is not a deontological, rule-based structure because the elucidation distinctly respects nurses’ capability of providing compassionate care in the manner they see fit. Additionally, this ethical responsibility demonstrably fulfills one of the cardinal virtues, compassion. Therefore, it is apparent that the CNA utilizes the theory of virtue ethics to develop a more holistic code.
Relational Ethics
Relational ethics is embodied in the Code of Ethics as this philosophy acknowledges the relationships between individuals involved in ethical dilemmas. Relational ethics emphasizes the necessity of mutual respect for persons, which is expressed through conscious striving for connection and authenticity in all relationships. For nurses specifically, relational ethics promotes the provision of holistic care through intentional insight of patients’ subjective experiences and by incorporating empirical knowledge (Burkhardt, Nathaniel, & Walton, 2013). Relational ethics is emphasized in all aspects of the code. For example, the CNA states, “nurses build trustworthy relationships as the foundation of meaningful communication, recognizing that building these relationships involves a conscious effort” (CNA, 2008a, p. 8). This description exemplifies how relational ethics is used as a guiding framework to support the Code of Ethics.
Feminist Ethics
Feminist ethics emphasizes the importance of recognizing how relationships are impacted by power imbalances (Burkhardt, Nathaniel, & Walton, 2013). The incorporation of feminist ethics may be one of the most significant adaptations to the code. This change has been prompted by the change of women’s role in society (Esterhuizen, 2006). The 1954 code stated, “the nurse is under an obligation to carry out physician’s orders intelligently and loyally” (Storch, 2007, p. 31). This perception of nurses’ primary responsibilities has transformed drastically and the Code of Ethics has evolved appropriately. This is evident as the current code states, “nurses question and intervene to address unsafe, non-compassionate, unethical, or incompetent practice or conditions” (CNA, 2008a, p. 9). This responsibility has the potential to improve patient care and safety and reflects the modern role of nurses as autonomous professionals. Through utilizing feminist ethics to support development of the code, the CNA corroborates its ability to adapt the code to reflect the current values of society. As a result, the applicability of the code is maintained.
Applicability of the CNA Code of Ethics for Registered Nurses
Applicability of the Code of Ethics is supported through the systematic manner in which it is developed and reviewed. This includes the establishment and appraisal of the code by RNs, periodic revisions, and the integration of theoretical frameworks to preserve the high ethical integrity of the code. Additionally, the importance of the Code of Ethics is undeniable because it provides guidance for ethical decision-making and promotes necessary self-reflection and evaluation (Storch, 2007). Unfortunately, the current Code of Ethics is still not used within practice to its full potential. In fact, nurse ethicist, Storch (2007) explains that, despite the code’s seemingly applicable nature, nurses still do not refer to it in practice and some nurses do not even know it exists. This awareness may change in future generations, as the code now specifies that nurses, as well as educational institutions, are responsible for ensuring that nursing students are well-informed of the code (CNA, 2008a). A subsidiary benefit to frequent revisions is that this action draws attention to the code and promotes nurses’ interest. Unfortunately, this has not been sufficient (Storch, 2007).
Conclusion
The Code of Ethics demonstrates that it is a foundation for ethical practice, developed “by nurses, for nurses” (CNA, 2008a, p. 30). The CNA incorporates current societal values and issues through frequent revisions in order to maintain the code’s pertinence to nursing practice. The code utilizes diverse theoretical frameworks to support its relevance and its compatibility with the values of nurses and Canadian society as a whole. Because nurses still underutilize the code, it is crucial that the CNA continues to prioritize improving the code’s practicality in future revisions.
Society and healthcare progress at a nearly inconceivable rate, so it is essential for the CNA to continually assess for changes in trends and issues. For example, the increasing prevalence of social media is a societal trend that currently defines Canadian society (CNA, 2012). Consequently, in the next revision, guidance for nurses in relation to social media will be necessary to continue to support nurses’ ethical practice. Additionally, diversity in the needs of patients and the complexity of the healthcare system continues to increase. Limited resources, increased nursing shortages, and excessive workload are issues that nurses now struggle with on a daily basis (Anonymous, 2008). Nurses would benefit from additional support to identify appropriate ethical responsibilities and endeavors to manage these situations. In conclusion, the CNA Code of Ethics demonstrates its theoretical diversity and practical application for practice. However, because of the new emerging trends and issues in healthcare and Canadian society, a new revision is essential for nurses to continue to be supported in practice.
References
Anonymous. (2008). A revised code: The foundation for ethical practice. The Canadian Nurse, 104(6), 20. Retrieved from http://search.proquest.com.ezproxy.library.uvic.ca/docview/232078013?accountid=14846
Burkhardt, M. A., Nathaniel, A. K., & Walton, N. A. (2013). Ethics and issues in contemporary nursing (2nd Canadian ed.). Toronto, ON: Nelson Education Ltd.
Canadian Nurses Association. (2007). Understanding self-regulation. Nursing Now: Issues and Trends in Canadian Nursing 21, 1-5. Retrieved from https://www.nurseone.ca/~/media/nurseone/files/en/nn_understanding_self_regulation_e.pdf?la=en
Canadian Nurses Association. (2008a). Code of ethics for Registered Nurses: 2008 centennial edition. Ottawa, ON: CNA. Retrieved from https://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf
Canadian Nurses Association. (2008b). Position statement: Ethical practice: The Code of Ethics for Registered Nurses. Retrieved from https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ps95_code_of_ethics_2008_e.pdf?la=en
Canadian Nurses Association. (2012). Ethics in practice for Registered Nurses. Retrieved from https://cna-aiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_feb_2012_e.pdf?la=en
Canadian Nurses Association. (2016). Board of directors. Retrieved from https://www.cna-aiic.ca/en/about-cna/our-leadership/board-of-directors
Esterhuizen, P. (2006). Is the professional code still the cornerstone of clinical nursing practice? Journal of Advanced Nursing 53(1), 104-113. doi:10.1111/j.1365-2648.2006.03684.x
Meulenbergs, T., Verpeet, E., Schotsmans, P., & Gastmans, C. (2004). Professional codes in a changing nursing context: Literature review. Journal of Advanced Nursing, 46(3), 331-336. doi:10.1111/j.1365-2648.2004.02992.x
Storch, J. L. (2007). Enduring values in changing times: The CNA Code of Ethics. The Canadian Nurse, 103(4), 29-37. Retrieved from http://search.proquest.com.ezproxy.library.uvic.ca/docview/232069385/fulltext/112474305F5B4007PQ/1?accountid=14846
From the 2016 Fall Communiqué — 40th Anniversary Issue
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