Assignment PART II: Competencies of Advanced Practice Nursing

Professional Codes and Guidelines

The ANA’s Code of Ethics for Nurses (2001) describes the profession’s philosophy and general ethical obligations of the professional nurse. It describes broad guidelines that more reflect the profession’s conscience than provide specific directions for pa1ticular clinical situations. It provides a framework that delineates the nurse’s overriding moral obligations to the patient, family, community, and profession.

Professional organizations delineate standards of performance that reflect the responsibilities, obligations, duties, and rights of the members. These standards also can serve as guidelines for professional behavior and define desired conduct. Although the general principles are relatively stable, professional organizations often reflect on specific or contemporary issues and take a proactive position on pivotal concerns. For example, the American Association of Critical-Care Nurses (2008) has issued a position paper on moral distress, acknowledging that it negatively affects quality of care and influences nurses who are considering leaving the profession.

The paper then lists the responsibilities of nurses to address moral distress, some resources that can be helpful to them, and the obligations of nurses’ employers to offer support, such as employee assistance programs and ethics committees, to assist with managing moral distress. An additional example is the International Association of Forensic Nurses’ position paper (2009) supporting the use of emergency contraception for victims of sexual assault. This document provides ethical and clinical rationales for policies that permit dispensing of these medications.

Personal and Professional Values Individuals’ interpretations and positions on issues are a reflection of their underlying value system. Value systems are enduring beliefs that guide life choices and decisions in conflict resolution (Ludwick & Silva, 2000). Viens (1995) found that values were an essential feature of the everyday practice of the 10 primary care NPs she inter- viewed. Values of caring, responsibility, trust, justice, honesty, sanctity and quality of life, empathy, and religious beliefs were articulated by the study participants, often as ideals that motivated their actions. An awareness of per- sonal values generates more consistent choices and behaviors; it can also assist APNs to be aware of the boundaries of their personal and professional values so that they can recognize when their own positions may be unduly influencing patient and family decision making.

Values awareness should include an understanding of the complex interplay between cultural values and ethical decision making (Buryska, 2001; Ludwig & Silva, 2000). When patient and family decisions contradict traditional.

Western medical practice, health care providers may resort to coercive or paternalistic measures to influence patient’s choices to be more consistent with the provider’s values. APNs and other health care providers must under- stand that the assumptions they make may be based on their own cultural values and biases and understand how these assumptions may influence their recommendations of particular treatments. As health care professionals gain an understanding of factors that guide a person’s decisions, treatment plans that reflect the patient’s value preferences are more easily developed. for example, a patient from a Southeast Asian culture may show respect to authority figures by obeying the APN’s treatment suggestions, even if he or she disagrees with the plan. In this situation, the APN could assure the patient that questions about the plan of care are welcomed and are not disrespectful.

By the same token, claims made in the name of religious and cultural beliefs are not absolute. Buryska (2001) offered helpful guidelines for clinicians to assess the defensibility of patient and family claims made in the name of cultural or religious considerations. For example, he maintained that spiritual or cultural claims grounded in an identifiable and established community are more defensible than those that are idiosyncratic to the person malting the claim. Although it is critical for caregivers to respond with respectful dialogue, support, and compassionate care, patient and family demands for treatment must be considered in relation to other claims that also have ethical weight-the professional integrity of providers, legal considerations, economic realities, and issues of distributive justice.Advanced Practice Nurse Assignment Papers.

Professional Bou1utaries In their professional capacity, APNs have access to per- sonal and private patient information and may develop long-term therapeutic relationships with many of their patients. The atmosphere of intimacy in the nurse-patient relationship, coupled with the need to touch the patient during a physical examination, sets up a power differential that accentuates the patient’s vulnerability (Holder & Schenthal, 2007). Boundaries must be established that acknowledge the appropriate and necessary use of this patient information and intimacy to meet the patient’s needs and provide care. The obligation to maintain professional boundaries within a therapeutic relationship is shared with all nurses (ANA, 2001), but APNs are also in a position to observe for boundary violations by others and to intervene when they occur.

Boundary violations, in which the APN or another health care professional inadvertently or purposely breaches the limits and expectations of the relationship, may profoundly alter the foundation of a therapeutic relationship. Such transgressions may be subtle, such as the APN sharing excessive personal information, or blatant, as in sexually seductive behavior. Regardless of the magnitude of the violation, the behavior must be con- fronted immediately and the culpable individual must be removed from interaction with the patient. Other members of the health care team should strive to restore the patient’s integrity and trust, involving the help of others as necessary (National Council of State Boards of Nursing, 2009).

Phase 2: Knowledge Application

The second phase of the core competency is applying the knowledge developed in the first level to the clinical practice arena. Phase 2 continues the APN’s journey in assessing ethical problems and being actively involved in the process of resolving ethical dilemmas. As APNs acquire core ethical decision making knowledge, the responsibility to take moral action becomes more compel- ling. Rather than retrospectively analyzing ethical dilem- mas, the APN takes moral action, which implies that the APN recognizes, pursues, and responds to ethical issues. Often, the inequities toward or infringements on other persons are enough to motivate moral action and a timely response can change the course in present and future situations. 1herefore, moral action should not be under- estimated as a core APN skill and should be recognized, fostered, and valued by others. Once an advanced nursing role is assumed, the APN accepts the responsibility to be a fUll participant in the resolution of moral dilemmas rather than simply an interested observer or one of many parties in conflict.

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Although the core knowledge of ethical concepts pro- vides the foundation for moral reasoning, the application of these concepts enables the APN to develop the practical wisdom of moral reasoning. It is the experience in the practice setting and the courage of the APN to discuss sensitive issues openly that enable the APN to assume an active role in dispute resolution. The success and speed with which the APN gains these behavioral skills is related to the presence of mentors in the clinical setting and the willingness of the APN to become immersed in ethical discussions.

Institutional resources, such as ethics committees and institutional review boards, provide valuable opportunities for APNs to participate in the discussion of ethical issues. Typically, hospital ethics committees serve three functions-policy formation, case review, and education. As a member of the ethics committee, the APN exchanges ideas with colleagues and gains an understanding of ethical dilemmas from a variety of perspectives. In addition, the APN is informed of current legislation, regulations, and hospital policies that have ethical implications.