Ethics and Managing Risk

Awareness of the ethical basis and standards for managing risk in a healthcare environment is critical for practicing nurses. A fundamental assumption in the practice of nursing is the profession's ethical obligation to society and to the individual patient/client to provide high-quality nursing care (see American Nurses Association Code for Nurses, 1985, Appendix 1). Taking control of risk in practice promotes the delivery of high quality nursing care, which in turn assists in fulfilling the nurse's professional ethical obligation to society.

In this chapter the authors will discuss the ethics of managing risk from two perspectives: 1) an organization-wide view, and 2) other selected areas of focus.

Organization-wide View

Risk management is broad in scope. According to Guido (1997, pp. 290-291), "risk management is a process that identifies, analyzes, and treats potential hazards" in a circumscribed practice setting. The objective of risk management is to identify and eliminate potential hazards before anyone is harmed or disabled, and to develop and evaluate policies and procedures that provide guidelines for the institution and direct practice. These activities are, of course, helpful in protecting an institution from legal liability and potential financial disaster but more importantly, they serve to protect the public as well as healthcare personnel (See American Society for Healthcare Risk Management Code of Professional Responsibility, Appendix II).

The relationship of risk management to financial and legal liability is significant. Historically, the focus of risk management has been on financial liability awareness. According to Monagle (1985, p. 11), "the main function of the director of risk management is to ensure the financial solvency of the organization against ... risks at the least possible cost." Sullivan and Decker (1988, pp. 499-500) explained that "risk management follows the current trend of adapting business strategies to hospital management; it is the hospital parallel to product liability prevention in industry. They further described risk management as a planned program of loss prevention and liability control, but emphasized the importance of detection, education, and intervention.

It is the "self-protective" business focus of risk management that may provoke questions as to whether or not risk management is ethical. However, the issue is far broader than "simple" protection of institutions. The maintenance of viable, accountable healthcare service institutions is crucial to the health of the populace - a "greater good," in ethics terms, than not having such resources available.

The moral integrity of the risk management process and the individuals involved are critical. Integrity is broadly defined as a state of being whole. Moral integrity encompasses a coherence and consistency within a set of ethical principles and commitments so that these principles and commitments are upheld for the right reasons, even when challenged (McFall, 1987; Rushton, 1995). Ethical principles and virtues that ought to be part of a risk management process include respect for autonomy (self-determination), non-maleficence (do no harm), beneficence (act in the best interest of), justice (fairness), veracity (truthfulness, honesty), confidentiality, and fidelity (promise keeping, loyalty). Using ethical principles and virtues to maintain individual and institutional integrity will promote patient/ client well-being and will therefore be consistent and compatible with the legal needs of the healthcare facility (Haferneister & Hannaford, 1996).

The principle of veracity requires particular discussion in relation to risk management because of its association with the "duty to disclose." It is important here to emphasize that this discussion pertains to the ethics of veracity and disclosure and that legal advice ought to be sought for individual situations. Questions of meaning and scope of disclosure often arise in the practice of nursing and are more complicated when one is involved in a potential claim/suit. Beauchamp and Childress (1994) provide an in-depth discussion of veracity and the duty to disclose. In brief, veracity, or truthfulness, is based on the principle of respect for others, and it is clear that adherence to the rules of veracity is essential in fostering trust. Lying and inadequate disclosure clearly violate respect for others and impede a trusting relationship. However, veracity, like informed consent, is a concept that is not absolute because of its inherent nature: it deals with information, and the meaning and scope of information can be difficult to determine. Valid questions are frequently asked about the appropriate quantity and quality of information to be disclosed to individuals or the public-at-large in any given situation. While the intention is not to be deceptive, but rather to avoid alarming others, any withholding of information may be perceived as violating a duty to disclose. Legal advice is recommended when such questions arise, especially when risks are recognized.

Medical Errors

Medical errors are a common source of recognized risks, and concern about them is evident in current literature. According to Leape (1997), most medical errors (95%) go unreported. It is widely believed that the situation of underreporting (or failure to disclose) is because of the professional's fear of punishment, be it in the form of legal sanctions (civil or criminal), the loss of one's job, or disapproval of colleagues. Leape suggested that the healthcare industry's relaxed approach to error reduction (as compared with aviation and the space industry) is a result of an ineffective and counterproductive "train and blame" approach: the belief that mistakes can be avoided if everyone is trained not to make them and punished when they do (1994,1997). According to Leape, research has shown that while "errors are almost always made by individuals, error results from defects in the systems in which we work" (1997, p. 1). Unfortunately, as a result of underreporting, institutions have no reliable indicator of the severity of error problems. Thus, underreporting hinders the process of system improvement for system failures and is an issue of importance for nurses as they take control of risk in their practice.

For example, a nurse in an emergency situation gives the patient ten times the ordered dose of lidocaine IV push (bolus) to treat an arrhythrnia. The patient's heart stops; resuscitation procedures are necessary; and the patient incurs charges for the treatment and an increased length of stay in the hospital. If this had not been reported, the facility would have lost the opportunity to discover that the lidocaine for IV bolus administration and the lidocaine for dilution in an IV drip were stored next to each other in a drawer both in similar syringe-type containers. The individual nurse made the error, but the storage "system" made the effort more likely to occur.

Issues of veracity and disclosure in the case include many unanswered questions. Should the patient and/or family be told about the error? Who should tell them? How much information should they be given? It is generally agreed that when errors require treatment modifications to reverse or prevent adverse outcomes, the patient must be told. Patients have a right to be involved in treatment decisions (autonomy) and to know that they will not incur charges associated with treatment caused by error (justice). Usually the professional who can discuss treatment options with the patient should be involved in disclosing the error. Risk management staff or legal counsel should be consulted for assistance with the disclosure.

A more difficult situation arises when no harm comes from the error. Friedson (1997) addressed whether patients should always be informed, or if there are situations where nondisclosure may be therapeutically beneficial and, therefore, morally justified. One must consider whose needs are being served by non-disclosure-the needs of the professional or the patient ? Making a decision between worrying families needlessly and enriching caregiver and patient relationships by using full disclosure requires professional judgment. The literature includes reports that patients tend to respect and forgive healthcare professionals who are honest with them about mistakes (Christensen, Levinson, & Dunn, 1992; Finkelstein, Wu, Holtzman, & Smith, 1997) as well as reports that some might be more likely to take punitive action if they find out about an error that has not been previously disclosed (Witman, Park, & Hardin, 1996). Thus, when one chooses to limit or avoid disclosure, one must make that decision based on the benefit or harm to the individual, as well as on the issue of maintaining societal trust which is important in minimizing liability.

Clearly, the issue is far from settled. While it may be that the only way to ensure accurate reporting of errors is to provide protection from disclosure such as through peer-review activities, instead of by embracing the "train and blame" paradigm, this approach invokes questions about full-disclosure. Thus, we have a conflict where physic ian/nurse-patient integrity and the ethics of improving organizational integrity may stand in opposition to one another (Ross, 1997). But in the interest of improving organizational integrity and subsequently patient care, risk management must strive to address an error as a system failure versus a personal failure and support efforts to track, establish trends, and reduce error.

Regulations, Standards, Policies, and Procedures Regulations

Standards, policies, and procedures that influence the individual practice of nursing, as well as institutions, are often designed to uphold ethics-based precepts. Nurses whose relationships with patients/clients are in a direct care, one-on-one setting, as well as those who have professional managerial responsibilities (e.g., nursing management, quality assurance, or risk management positions) must ensure that mandates and guidelines are maintained. Several of the planks in the American Nurses Association Code for Nurses (1985) (Appendix 1) support nurses' responsibilities for understanding and interpreting regulations that have an impact on their practice (and therefore the health and safety of the public). However, it is essential that nurses distinguish between regulations and standards that are legally binding and policies and procedures that are recognized as being guidelines that allow for professional interpretation in individual situations.

As managed care expands and the potential for computer-based statistical tracking is realized, standards of practice are rapidly evolving. Some are based on sound research, while others evolve from less credible sources, but they are increasingly used as benchmarks to measure provider failure (Furrow, 1993). To control their own risk, nurses must remain alert and aware of the legitimacy of practice guidelines and standards that are being thrust upon them. Professional judgment is essential to protect the best interests of individual patients as well as the general public.

One source of widening and increasingly explicit formal expectations for ethical conduct within a healthcare service environment is the Joint Cornmission on Accreditation of Healthcare Organizations (JCAHO). JCAHO has recently incorporated standards for ethical considerations associated with managerial and business aspects of organizations, in addition to existing specific standards related to ethical issues in direct patient care (Spencer, 1997). Nurses across the country are currently involved in interpreting how these new regulations influence their practice, especially in light of the burgeoning number of managed care organizations.

Institutions are beginning to hire compliance officers to ensure that regulations and standards are being followed. Compliance officers are well known to the defense industry and evolved amid stories of the federal government paying hundreds of dollars for a hammer. They became a necessity for the healthcare industry when the Department of Justice announced that stopping fraud and abuse would be one of its main goals. The federal government committed billions of dollars to the effort. Compliance officers, however, will not only be occupied with Medicare billing requirements. They will undoubtedly be responsible for assuring compliance with the myriad of regulations and standards affecting health care.

Compliance officers will not be able to work in a vacuum. Compliance committees with institution-wide representation will often be one method used to ensure that the compliance plan is followed. Staff will need to be educated regarding the plan and encouraged to report suspected violations. Institutions would be better served having no plan than a plan that is not followed. Lockheed Martin Corporation adopted a code of ethics that included the following questions that may provide guidance for nurses: "When in doubt, ask yourself? What would I tell my child to do? How will it look in the newspaper? Will I sleep soundly tonight?" (Maintaining ethical conduct.... 1997).

For nurses seeking ethics-related information, the ANA provides more than 50 position statements, in addition to the ANA Code for Nurses (1985). The ANA position statements are available on the ANA Web site (American Nurses Association, http://www.nursingworld.org/readroom/position/index.htm). Specialty organizations are also potential information sources, as are institutional ethics committees.

Selected Areas of Focus

Managed Care With the increase in managed care organizations, nurses are finding themselves exposed to goals and regulations that appear to be business-focused rather than patient-focused. Concern has been expressed that the quality of nursing care is being jeopardized to save costs. The ethical principle of justice and how we can best allocate our scarce resources is the underlying ethical issue of concern as managed care grows. There are opportunities as well as challenges and concerns as we as a society restructure the healthcare delivery system, ideally in a manner that will promote a "greater good."

Within the issue of allocating resources, nurses encounter several other ethical issues as well. Quality of nursing care is related to the ethical principles of beneficence and nonmaleficence: acting in the best interest of the patient/client and doing no harm. Reduction in professional nurse staffing, substituting unlicensed assistive personnel (UAP) for professional nurses, and requiring nurses to provide patient care in specialty areas with which they are not familiar are some of the concerns expressed by nurses across the country. Balancing the benefits and burdens of such demands can be difficult for individual nurses and institutions alike; good communication, effective reasoning skills, and professional judgment are needed to reach solutions that uphold the ethical responsibilities of all involved. Various professional organizations provide information and guidelines for dealing with issues of quality of care. Informational topics addressed by the ANA include use of unlicensed assistive personnel, maintenance of professional and legal standards during a shortage of nursing personnel, quality indicators and the ANA's Safety and Quality Initiative, as well as background and suggestions related to practicing nursing in the era of managed care (See ANA Web site).

Issues of veracity have arisen related to managed care organizations limiting of information (e.g., treatment choices) that healthcare professionals can disclose to patients. Additionally, a conflict of interest can occur if healthcare professionals have a financial stake in the profit a company might make (limiting treatment options might save money and increase company profit). Legislation and policies are being developed and implemented to prevent "gag" orders and protect against conflict of interest, and managed care organizations and consortiums are developing their own codes of ethics.

An understanding of professional integrity and moral compromise is of value when a nurse encounters ethical dilemmas related to managed care or other practice issues and wishes to take control of his or her own risk. Winslow and Winslow (1991) suggested that compromise is compatible with moral integrity if a number of conditions are met and that nurses are in a position uniquely suited to leadership in fostering an environment that makes compromise with integrity possible. The conditions delineated by Winslow and Winslow include sharing a moral language, mutual respect on the part of those who differ, acknowledgment of factual and moral complexities, and recognition of limits to compromise. In short, when faced with a situation where one is asked to violate one's own sense of morality, dialogue that encompasses the listed conditions may allow moral integrity-preserving negotiation and compromise. Rushton (1995) expanded upon these conditions and applied them to a clinical situation.

Electronic Information

As healthcare service organizations store a greater proportion of their information electronically, new concerns arise for an individual's constitutional right to privacy, as well as a healthcare professional's obligation to uphold confidentiality. Information storage purposes include individual patient record-keeping processes, as well as data collection for organization-wide tracking of trends and establishment of benchmarks, private and governmental healthcare providers' payment calculations, societal health protection, and research investigations.

There are ethical and legal concerns related to the protection of this information. Accrediting organizations such as the JCAHO hold nurses and others in leadership positions accountable for the integrity of stored information, and healthcare organizations are required to demonstrate a balance between security levels and ease of access to electronic information (Styffe, 1997). Thus, it is possible to have an ethical conflict between an individual's right to privacy, a healthcare professional's obligation to protect patient confidentiality, and a third party's right to know certain information. Styffe differentiated between the functions of privacy, confidentiality, and security in protecting electronic information. Privacy refers to the right of individuals to determine when, how, and to what extent information is transmitted (the patient is the primary stakeholder). Confidentiality refers to trust that the information shared will be respected and used only for the purpose disclosed (all healthcare providers and organizations are responsible for confidentiality). Security refers to the protection of information from accidental or intentional access by unauthorized people, including change or destruction of the information, and is a part of the system itself.

Gostin and colleagues (1996) reviewed and commented on the law of health information privacy. State and federal legislation is being developed and revised as information technology evolves and needs for protection are recognized. Nurses need to maintain an awareness of potential changes and rely on the workplace and other professional resources to keep abreast of specific evolving guidelines.

Woodward (1997), Bates (1997), and others (Symposium: Medical Confidentiality & Research, 1997) commented on the use of patient data for research as well as for quality and cost control purposes. According to Bates (p. 112), "Better information systems can make healthcare safer and more efficient, something that is badly needed as the market demands unprecedented improvements in efficiency." He also commented that major changes in policies regarding electronic records and confidentiality are desperately needed, both legislatively and administratively, and at national and local levels. Nurses are likely to be involved (and should be) at all levels, but their input is especially needed at the individual institutional level as integrated delivery systems are initiated. Their sensitivity to privacy and confidentiality as it directly affects individual patients is a vital perspective.

The ANA has developed three position statements related to electronic information: Computer-based Patient Record Standards, Authentication in a Computer-Based Patient Record, and Access to Patient Data. These papers provide background and guidelines related to patient data collection and dispersion. Nurses need to avail themselves of the multiple sources of information related to protection of patient privacy and maintenance of confidentiality as they take control of risk related to the use of electronic data in their practice environments.

Environmental/Occupational Hazards

Nurses may be exposed to a variety of environmental or occupational hazards in their practice. Workplace violence, environmental hazards such as exposure to latex, and the existence of a number of life-threatening communicable diseases stimulate healthcare professionals to consider just how much risk they are obligated to accept as an ethical duty. Sugarman and colleagues (1996) addressed issues of communicable disease in treating patients with multi-drug-resistant tuberculosis, and Smolkin (1997) discussed the risk and duty-to-treat issue in relation to HIV and hepatitis B infections.

Plank I of the ANA Code for Nurses (1985) supports the responsibility of the nurse to provide services with respect for human dignity, unrestricted by a variety of considerations, thus creating a special relationship between the nurse and the client. The nurse is not free to abandon those in need of nursing care. However, the ANA does recognize that there may be limits to the personal risk of harm the nurse can be expected to accept as an ethical duty and has developed a policy on risk versus responsibility in providing nursing care (Position on Risk Versus Responsibility, see ANA Web site). The position provides background information and states, "For assistance in resolving the question of risk versus responsibility, nurses must turn to the field of ethics for guidance. In ethics, the differentiation between benefiting another as a moral duty and benefiting another as a moral option is found in four fundamental criteria. As applied to nursing, a moral obligation exists for the nurse if all four of the following criteria are present:

1. The client is at significant risk of harm, loss, or damage if the nurse does not assist.

2. The nurse's intervention or care is directly relevant to preventing harm.

3. The nurse's care will probably prevent harm, loss, or damage to the client.

4. The benefit the client will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse." Familiarity with these guidelines should help the nurse in decision-making when personal safety is an issue.

Organizations also hold varying degrees of responsibility for workplace safety to their customers and employees. Major ethical principles to consider in managing organizational risk include the best interests of customers and employees and rights to be protected from harm. Information is available in the literature as well as from professional organizations relevant to particular hazards of interest.

Restraints

The underlying ethical issue related to use of physical patient restraints in managing risk is the conflict between an individual patient's autonomy and the healthcare professional's concern for patient safety (best interest, nonmaleficence). For years the justification for the use of restraining devices has been for patient safety; that is, to prevent falls or removal of medical devices such as IVs, endotracheal and nasogastric tubes, and Foley catheters. Additionally, from an institutional viewpoint, there has been a fear that should an unrestrained patient fall and sustain an injury, the institution and/or care provider would be liable for negligence. However, issues of who, when, where, how and, most importantly (from an ethics standpoint) whether to restrain, are extremely complex.

First of all, evidence is not clear that restraint use protects patients from harm. Thus, the use of restraints may not satisfy the ethical principle of acting in the patient's best interest (beneficence, nonmaleficence). While the intention behind the use of restraints historically was for the benefit of the patient, there is ample evidence that indicates more risk of injury from the use of restraints than there are benefits (Marks, 1992). Physical complications associated with the use of restraints include "physical de-conditioning; sensory deprivation; decreased muscle mass, tone and strength; increased osteoporosis; nosocomial infection; urinary and fecal incontinence; skin abrasions; and pressure ulcers" (Marks, p. 2204). Psychological effects of restraint must also be considered.

Capezuti, Evans, Strumpf, and Maislin's (1996) study in long-term care settings likewise revealed that restraint use was not associated with a significantly lower risk of falls. They suggested that researchers and clinicians should focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

In their essay on the ethical and legal aspects of patient restraints, Moss and LaPuma (1991, p. 24) stated, "The Fourteenth Amendment guarantees freedom from harm and unnecessary restraint. The less likely a patient is to cause harm to himself or others, the more significant is the infringement on the patient's legal rights by restraints." Thus, in deciding whether restraints are warranted, professional judgment and knowledge are required. "The issue is not whether to protect the patient; the issue is how to effectively protect the patient in a way that respects the patient's dignity" (What about the Ethics.... 1997, p.9). Informed consent discussion with patients and/or surrogate decision makers are well accepted for other treatment options and should be incorporated into decisions about the use of restraints and other alternatives.

Notice that Moss and LaPuma mentioned the potential for a patient harming others. That can be another legitimate reason to restrain a patient. While restraining an individual may not reduce aggressive or agitated behavior, it can be ethically justifiable when another identifiable individual is at risk of serious morbidity or mortality or the public welfare appears in jeopardy. The ethical principle of preventing harm to identifiable others may supersede the patient's right to refuse. During the last 10 years, efforts have been underway to minimize the use of restraints (Bryant, & Fernald, 1997). The 1987 Omnibus Budget Reconciliation Act (OBRA) and its Interpretive Guidelines, which applied to long-term care, declared that when alternatives to restraints were unsuccessful, then the resident or surrogate must be informed about and consent to the use of restraints. JCAHO has developed standards for restraint practices that have accounted for a high percentage of Type I citations in 1996 and 1997.

It is important to note that rationale for restraint use differs in hospitals as compared with long-term care settings. Mion and colleagues (1996) studied the use of physical restraint in hospital settings, concluding that "the ethical dilemma of autonomy versus beneficence has not been resolved satisfactorily for patients in this setting. The lack of large-scale studies ... makes it difficult for policy makers to determine whether it is necessary to address hospital physical restraint practices through additional regulation" (p. 411). As information accumulates, nurses must continue to update their knowledge base and consider the ethical implications of restraining patients in order to minimize their risk related to this practice.

Summary

Taking control of risk lies squarely within the obligation of ethical conduct for nurses: to provide high-quality nursing care to society and to the individual patient/client. Using moral principles and virtues as a foundation for professional judgment and moral decision making promotes high-quality nursing care and maintains professional and moral integrity while managing risk encourages trust between society and the profession.

References

American Nurses Association. (1985). Code for nurses with interpretive statements. Kansas City, MO: author

American Nurses Association. [Web site]. Home page, reading room, position statements. http://www.nursingworld.org.

American Society for Healthcare Risk Management Code of Professional Responsibility. (1997). ASHRMForum, January/February, 9. Chicago, IL: author.

Bates, D. W. (1997). Commentary: Quality, costs, privacy, and electronic medical data. Journal of Law, Medicine, and Ethics, 25(2&3),111-112.

Beauchamp, I L., & Childress, J. F. (1994). Principles of biomedical ethics, (4th ed.). New York: Oxford University Press.

Bryant, H., & Fernald, L. (1997). Nursing knowledge and use of restraint alternatives: acute and chronic care. Geriatric Nursing, 18(2), 57-60.

Capezuti, E., Evans, L., Strumpf, N., & Maislin, G. (1996). Physical restraint use and falls in nursing home residents. Journal of the American Geriatrics Society, 44(6), 627633.

Christensen, J. R, Levinson, W., & Dunn, P.M. (1992). The heart of darkness: The impact of perceived mistakes. Journal of General Internal Medicine, 7(4), 424-43 1.

Finkelstein, D., Wu, A. W., Holtzman, N. A., & Smith, M. K. (1997). When a physician harms a patient by a medical error: Ethical, legal, and risk-management considerations. The Journal of Clinical Ethics, 8(4), 330-340.

Friedson, J. B. (1997). Must we tell the truth about medical errors? Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 2-4.

Furrow, B. R. (1993). Quality control in healthcare: Developments in the law of medical malpractice. Journal of Law, Medicine, and Ethics,'21(2), 173-192.

Gostin, L. 0., Lazzarini, Z., Neslund, V S., & Osterholm, M. T. (1996). The public health information infrastructure: A national review of the law on health information privacy. Journal of the American Medical Association, 275(24), 1921-1927.

Guido, G. W. (1997). Legal issues in nursing, (2nd ed.). Stamford, CT: Appleton & Lange.

Hafemeister, T. L., & Hannaford, P. L. (1996). Resolving disputes over life-sustaining treatment; A health care provider's guide. Williamsburg, VA: National Center for State Courts.

Howe, E. G. (1997). Possible mistakes. 77ie Journal of Clinical Ethics, 8(4), 323-328.

Leape, L. L. (1997). Can we reduce medical errors? Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 1-2.

Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.

Maintaining ethical conduct throughout an organization. (1997, April). Health System Leader, 26-27.

Marks, W. (1992). Physical restraints in the practice of medicine. Archives of Internal Medicine, 152 (11), 2203-2206.

McFall, L. (1986). Integrity. Ethics, 98, 5-20.

Mion, L. C., Minnick, A., Palmer, R., Kapp, M. B., & Lamb, K. (1996). Physical restraint use in the hospital setting: unresolved issues and directions for research. Milbank Quarterly, 74(3),411-433.

Monagle, J. R (1985). Risk management.- A guide for health care professionals. Rockville, MD: Aspen Systems Corp.

Moss, R. J., & La Puma, J. (1991). The ethics of mechanical restraints. Hastings Center Report, 21(l), 22-25.

Ross, J. W. (1997). Error, ethics, systems, and conflicts. Ethical Currents, A publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 5 1 (Fall), 4-5,9.

Rushton, C.H. (1995). The Baby K case: Ethical challenges of preserving professional integrity. Pediatric Nursing, 21(4), 367-372.

Smolkin, D. (1997). HIV infection, risk taking, and the duty to treat. The Journal of Medicine and Philosophy, 22(l), 5574.

Spencer, E. M. (1997). A new role for institutional ethics committees: Organizational ethics. The Journal of Clinical Ethics, 8(4), 372-376.

Styffe, E. J. (1997). Privacy, confidentiality, and security in clinical information systems: Dilemmas and opportunities for the nurse executive. Nursing Administration Quarterly, 21(3), 21-28.

Sugarman, J., Terry, R, Faden, R. R., Holmes, D. E., Fogarty, L., &Pyeritz, R. E. (1996). Professional healthcare workers' attitudes toward treating patients with multidrug-resistant tuberculosis. The Journal of Clinical Ethics, 7(3), 222227.

Sullivan, E. J., & Decker, P. J. (1988). Effective management in nursing (2nd ed.). Menlo Park, CA: Addison-Wesley.

Sweet, M. P., & Bernat, J. L. (1997). A study of the ethical duty of physicians to disclose effors. The Journal of Clinical Ethics, 8(4), 341-348.

Symposium: medical confidentiality &research. (1997). The Journal of Law, Medicine, and Ethics, 25(2&3),85-138.

What about the ethics of restraint use?(1997). Ethical Currents, A Publication of the Center for Healthcare Ethics, St. Joseph Health System, Orange, CA, 50 (Summer), 8-9.

Winslow, B. J., & Winslow, G. R. (199 1). Integrity and compromise in nursing ethics. The Journal of Medicine and Philosophy, 16,307-323.

Witman, A. B., Park, D. M., & Hardin, S. B. (1996). How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. Archives of Internal Medicine, 156(22), 2565-2569.

Woodward, B. (1997). Medical record confidentiality and data collection. The Journal of Law, Medicine, and Ethics, 25(2&3), 88-97.

JoAnn B. Reckling, PhD, RN is an ethics consultant in Fort Collins, Colorado. Robin Welsh, JD, RN is Patient Representative/Risk Management Assistant, Poudre Valley Hospital, Fort Collins, Colorado.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

American Nurses Association (2001). The code of ethics for nurses with interpretive statements. Washington, D.C., American Nurses Publishing.

Kopala, B., Kondratowicz, D.M., Goldberg, A.L., Panek, D.M. (October 1999). Home health care professionals at risk of harm. Home Care Provider, 4 (5), 193-7.

Wysoker, A. (October 1999). Legal and ethical considerations. Suicide: risk management strategies. Journal of American Psychiatric Nurses Association, 5 (5), 164-6.

Appendix I

ANA Code For Nurses

(reprinted with permission of the American Nurses Association)

1. The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

2. The nurse safeguards the client's right to privacy by judiciously protecting information of a confidential nature.

3. The nurse acts to safeguard the client and the public when health care and safety are affected by the incompetent, unethical, or illegal practice of any person.

4. The nurse assumes responsibility and accountability for individual nursing judgments and actions.

5. The nurse maintains competence in nursing.

6. The nurse exercises informed judgment and uses individual competence and qualifications as criteria in seeking consultation, accepting responsibilities, and delegating nursing activities to others.

7. The nurse participates in activities that contribute to the ongoing development of the profession's body of knowledge.

8. The nurse participates in the profession's efforts to implement and improve standards of nursing.

9. The nurse participates in the profession's efforts to establish and maintain conditions of employment conducive to high quality nursing care.

10. The nurse participates in the profession's effort to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.

11. The nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.

Appendix II

(reprinted with permission of the American Society for Healthcare Risk Management)

Preamble Healthcare risk management professionals must acknowledge and address multiple and potentially conflicting responsibilities on a daily basis. This involves balancing the needs of employers or clients; patients and visitors; employees, independent contractors and volunteers serving their employers or clients, vendors; fellow healthcare risk management professionals; local, regional, national, and international communities; with their own needs. The healthcare risk management professional must maintain standards of professional conduct which will withstand the scrutiny of all constituencies served.

The American Society for Healthcare Risk Management (ASHRM) issues this Code of Professional Responsibility to assist its members in determining ethically appropriate professional conduct and avoiding conduct which does not meet this standard.

Confidentiality The healthcare risk management professional continually encounters information of a highly confidential nature relating to the business of the employer or client as well as to patients and others served. The healthcare risk management professional must maintain the confidentiality of that information by:

• disclosing confidential information only when such disclosure is required by law; and,

• verifying the appropriate protocols exist or supporting the development of protocols to protect the confidentiality and privacy of patients, employers, clients, and others served, within the scope of the healthcare risk management professional's authority.

Conflict of Interest

A conflict of interest exists when the healthcare risk management professional is called upon to serve competing interests. Some conflicts of interest, such as transactions with a former employer or dealings with past business associates, may be acceptable as long as disclosure of the conflict is made to all involved parties. Other conflicts, such as business transactions which inure to the benefit of the healthcare risk management professional or his/her family members at the expense of others, are unacceptable even if disclosure to all involved parties is made. In order to avoid conflict of interest, the healthcare risk management professional must:

• exercise good faith in all transactions;

• act always for the benefit of the employer or client and avoid any interests, investments or activities which conflict or appear to conflict with the interests of the employer or client;

• make full disclosure of all facts of any transaction which involves possible conflict of interest to all parties involved; and, avoid accepting gifts or other considerations which might unduly influence the healthcare risk management professional's judgment.

Professional Integrity

The healthcare risk management professional must maintain professional integrity at all times by:

• practicing the profession with honesty, fairness, integrity, respect and good faith,
• avoiding conduct which would result in unjust harm to others;
• discharging all professional duties competently and consistently;
• maintaining loyalty to the employer or client and the profession;
• obeying all laws and regulations relating to professional activities, and supporting the development and enforcement of all laws and regulations which enhance the competent and ethical practice of the healthcare risk management profession;
• maintaining and improving professional skills, knowledge and competence through a program of on-going self-assessment and continuing professional education;
• enhancing public understanding of the healthcare risk manage profession;
• assisting in maintaining and raising professional standards in the healthcare risk management profession by supporting research, fostering the professional development of other healthcare risk management professionals, and refraining from participating in any activity that demeans the credibility an dignity of the healthcare risk management profession;
• upholding the mission of the American Society for Healthcare Risk Management; and,
• upholding the integrity of this code of Professional Responsibility by agreeing to abide by all rules of conduct prescribed by this Code and by ASHRM's Bylaws.