6.12 Describe how the ANA Code of Ethics for Nurses is adhered to across the organization.

In the Professional Practice Model, the value statement supporting the vision for the

Department of Nursing provides the framework for nurses to use ethical analysis and decision-

making in practice.

“Supporting our vision is a clearly-articulated set of values which pervade our decision-making process

and find daily expression in our policies, practices and norms of behavior. Our values combined with our

vision provide both an affirmation of work, which already exists and a foundation on which to bring about

ideas not yet realized. Each of us makes decisions every day by personal and institutional values. The values

we have chosen to be of primary importance to us as we move forward are: leadership, entrepreneurial

teamwork, caring, innovation, and scientific practice.”

The structural dimension needed to guide practice is also supported by the position of the

Chief Nurse within the organization. In her role as Senior Vice President for Patient Care, she is on

equal par with all senior hospital leaders at MGH (OOD 2.a). This immediately places nursing in a

position of professional equality in the organization that further supports ethical practice.

Within the Professional Practice Model, the ANA Code of Ethics serves as a succinct statement

of ethical obligations and duties of every individual who enters the profession, establishing the standard for

practice. The nine interpretive statements within the ANA Code of Ethics provide the framework

for understanding how to actualize ethical analysis and decision-making into practice. Gladys White

(2001) conceptualizes the ANA Code in three general categories:

1. Tenets 1 to 3 describes fundamental values and commitments of the nurse;

2. Tenets 4 to 6 describes boundaries of duty and loyalty;

3. Tenets 7 to 9 describe nursing duties beyond individual patient encounters.

Evidence of these nine statements is clearly demonstrated throughout Department of

Nursing, as nurses at all levels of the organization participate in an interdisciplinary team approach

to patient-focused care. Although not an exhaustive list, the following cases and examples provide

insight to the dedication and commitment of the nursing staff and of the organization to maintain

the tradition of outstanding clinical practice and the highest standards for ethical conduct.

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Tenet 1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of the health problems.

Patients are admitted to MGH because of their need for medical and nursing care, regardless

of one’s background or ability to pay. The QuadraMed® AcuityPlus™ Productivity, Benchmarking

and Outcomes System is used to determine the allocation of nursing staff on patient care units, as

described in Force 1.5 and Force 1.6. Nursing resources are determined for each unit according to

an unbiased formula that determines the patient’s nursing care needs. This assures that resources are

equitably distributed base on need, regardless of ethnicity, race, religious or cultural beliefs or ability

to pay as the following case illustrates.

TF was a 21-year-old male patient transferred to MGH from an outlying community

hospital, after a high-speed motor vehicle accident. The patient was expected to be ‘brain dead’

and a possible organ donor, but much to the surprise of the Surgical ICU (SICU) nursing and

medical staff, he woke up. The staff learned that TF was an undocumented person from an

economically depressed Central American country. He had no money or medical insurance. He

was diagnosed as a C-2 quadriplegic, and would be dependent upon a ventilator for the rest of

his life. It was unclear how much brain function he would recover, but as time went on, it was

clear that he had an undying spirit and a beautiful smile. Once stable, he was transferred to

Ellison 7, a General Surgical unit. Staff Nurses on both units worked with an interdisciplinary

team and the support of the Optimum Care Committee, to achieve positive outcomes for him,

despite the obstacles placed before them regarding his language barrier, economic status, and

Massachusetts Medicaid regulations that made him ineligible for long term care.

The team found a volunteer tutor through Boston University who came twice a week, to

teach TF to learn and read English, even though he was not able to read in Spanish, his native

language. His Primary Nurse and Respiratory Therapist took him on outings to the Esplanade,

across from the hospital grounds, for concerts. This required a high degree of skill and

confidence with a portable ventilator, as TF de-saturated in seconds if his ventilator tubing

became disconnected.

With no family in the area, the staff connected with members of a Spanish-speaking church

to provide TF with a support system. Church members visited him often and provided home

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cooked Spanish food. This was an important contribution to his recovery, as he could not

tolerate ‘American food’ and needed to increase his oral intake to be weaned from tube feedings.

The relationships with this church community are still in place today.

A Central American employee traveled to TF’s native country as part of the employee’s

vacation. To help him stay connected to his family, this employee brought a photo album to his

mother and family, even though it meant he had to leave his vacation route to go to a remote

village, where even telephone access is over two miles away.

Through the efforts of the team, TF was eventually transferred to Spaulding Rehabilitation

Hospital, where he resides today. This case illustrates an interdisciplinary team, with nursing

leadership, attending to the dignity, worth and uniqueness of a disenfranchised patient in the

face of great obstacles.

Tenet 2: The nurse’s primary commitment is to the patient, whether an individual, family, group or community.

As stated in the Staff Nurse position description (OOD 23.e), the nurse is responsible for

assuring competent, compassionate nursing care for specific patients and families. The position description also

articulates the need for collaboration with the team to achieve optimal patient outcomes. This

commitment to patients is as important in last stages of life, as it is when a patient is expected to

make a full recovery. In an effort to support quality care at the end of life, all health care providers at

Massachusetts General Hospital (MGH) are authorized to consult the Optimum Care Committee to

address ethical aspects of patient care, as evidenced in the following case.

Staff Nurses caring for a 100-year old woman with dementia were struggling to provide a

comfort care for her, as her son was insisting on providing life-sustaining treatment, and her

Attending Physician was unwilling to disagree with her son’s decision. Focused on the quality of

life for this patient, the unit’s Nursing Director and the Staff Nurse caring for the patient

consulted the Clinical Nurse Specialist in Ethics to explore ways to help her son and the

Physician achieve a better outcome for the patient.

A team meeting with the Physician, Nursing Director, unit-based Clinical Nurse Specialist,

Ethics Clinical Nurse Specialist, the Staff Nurse primarily responsible for the patient’s care, the

Social Worker, Chaplain, Speech Language Pathologist, Dietician and Physical Therapist was

organized. The Nursing Director, supported by the two Clinical Nurse Specialists, facilitated the

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meeting by outlining the goals for the patient’s interdisciplinary team. Clinicians caring for the

patient needed to:

♦ Recognize the patient’s suffering and evaluate treatments by weighing benefits verses

burdens;

♦ Establish a code status for this patient, as it was critical to her care;

♦ Review the current medical recommendation for a gastrostomy tube for tube feedings;

♦ Establish a plan to manage the patient’s pain, as she was unable to advocate for herself.

As a result of the meeting, the following outcomes were achieved:

♦ The team developed a pain and symptom management plan for the patient to make her

more comfortable. They agreed that the patient’s son could not demand interventions

for his mother that promote suffering, as the Massachusetts Health Care Proxy statute

states that ‘pain management is within the purview of the medical team, not the proxy.’

♦ A ‘limitation in life-sustaining treatment order for CPR’ (DNR) was established, as the

MGH Life Sustaining Treatment policy requires Physicians to take responsibility in not

offering CPR as a life-sustaining treatment when it will be harmful to the patient.

♦ After discussion with the Speech Language Pathologist and Dietician, the Physician

agreed to reconsider the use of a feeding tube for this very elderly woman with

advanced dementia and a history of multiple pneumonias.

♦ The team developed a planned approach to the address the son’s concerns without

alienating him, while implementing the established plan of care for his mother.

As a result of this team’s efforts, the patient died peacefully one week later, without

having to incur the burdens of CPR. This case provides an example of how nurses were able to

keep their ‘primary commitment to the patient’. The Staff Nurse, with the support of the nursing

leadership on the patient care unit, was the patient’s advocate.

Tenet 3: The nurse promotes, advocates for and strives to protect the health, safety, and rights of the patient.

This case illustrates how the nurse advocates for the health, safety and rights of the patients

and how the organization supports clinicians in their role as patient advocates.

A woman in her seventies with necrotic leg ulcers was transferred from a community

hospital to Bigelow 11, a General Medical unit at MGH, at her son’s request. The patient was

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assigned to Medical Team 5, the interdisciplinary team of clinicians led by a Nurse Practitioner

that will be described in Force 8.6. The patient had severe, infected and necrotic leg ulcers from

arterial vascular disease, and the only treatment option was an above the knee amputation.

Although a Psychiatrist had determined that she lacked the capacity to make decisions about her

care, she was able to articulate that she was in extreme pain and wanted the amputations. Her

son was his mother’s health proxy, and would not consent to the surgery. Prior to her transfer,

proceedings had begun to seek court guardianship, but guardianship had not been established

prior to her transfer to MGH.

Nurses and physicians at the MGH value patient autonomy and in most cases, when patients

cannot speak for themselves, family members are usually believed to be good advocates.

However, her care team did not feel that her son was making decisions that were in her best

interest. This patient had been septic and was in pain, with no reasonable hope of the ulcers

healing. Working with the unit-based Clinical Nurse Specialist, Social Worker, Chaplain and the

hospital’s Legal Counsel, the Nurse Practitioner managing her care consulted the Optimum Care

Committee to help guide the plan of care for this patient.

With support from the Optimal Care Committee, the team proceeded to obtain legal

support to perform the amputations. The court appointed guardian assigned to the patient,

visited the hospital and reviewed the facts with the nurses caring for her. The Nurse Practitioner

explained the patient’s condition, and described the leg ulcers. The guardian returned to the

court, and shortly afterward, a court order to perform the amputations was issued.

Tenet 4: The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.

As described in Force 4.14 and Force 4.18, Massachusetts General Hospital complies with

the Massachusetts Nurse Practice Act and the guidelines for delegation and supervision as

determined by the Massachusetts Board of Registration in Nursing, as well as the intent of the

ANA/NCSBN Joint Statement on Delegation. The specific roles and responsibilities of the

Registered Nurse are clearly described in the Staff Nurse Position Description (OOD 23.e).

Additionally, the Statement of Accountability policy addresses the scope of practice of the

Department of Nursing, as well as, delegation and supervisory responsibilities of the Registered

Nurse.

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Education on delegation is included in orientation for both Registered Nurses and Patient

Care Associates. The orientation manual for Registered Nurses contains information on delegation

including a summary of the Massachusetts Nurse Practice Act statements on delegation and how it

relates to the role of the Staff Nurse. It also describes the “Five Rights” for delegation and delineates

the nurse’s accountability for care that is delegated, using case scenarios to reinforce the key points.

Tenet 5: The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.

The Department of Nursing holds professional expertise in high esteem and believes that all

nurses should be recognized for their professional achievements. This commitment to professional

development is supported throughout the organization. Each position description identifies the

nurse’s own responsibility for professional development, as demonstrated in the position

descriptions provided in OOD 23. The Norman Knight Center for Clinical & Professional

Development supports professional development through the numerous continuing educational

offerings made available to all nurses, as described in Force 11.3. The professional development

activity of nursing leaders at MGH is well substantiated in Force 14.3. Programs, such as the Clinical

Recognition Program (Force 11.3) and awards established to recognize Staff Nurses for their clinical

and professional expertise (Force 12.3) are just two ways in which the Department of Nursing

support this commitment to professional growth and development.

Tenet 6: The nurse participates in establishing, maintaining, and improving the health care environments and conditions of employment and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession of individual and collective actions.

At MGH, nursing involvement in the Collaborative Governance committee structure

described in Force 2.3 clearly demonstrates the role that nurses have to create, maintain and

contribute to environments that “enable nurses to fulfill their ethical obligations.” Staff Nurse

leadership and participation on all the Collaborative Governance committees provides an

environment that places the nurse in decision-making role to impact patient care. The Collaborative

Governance Annual Report (OOD 22) outlines the accomplishments of each committee for the

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past year and the goals for 2007, as they continue to focus on providing the highest quality of care to

all patients at MGH.

Tenet 7: The nurse participates in the advancement of the profession through contributions to practice, education, administration and the knowledge of development.

The Chief Nurse and the Executive Nursing Team advocates for all activities that advance

MGH nursing practice and the profession, by supporting the numerous partnerships that involve,

promote and support ethics, nursing leadership, healthcare advocacy and research. As described in

Force 10, the Department of Nursing and the organization provide facilities, structures,

consultation, staff support and expertise for many nursing affiliations and outreach programs on the

local, national and international level. Force 10.1 describes the way in which MGH nurses contribute

to the profession through: the development of ethics programs; the establishment of Nurse Scientist

or Senior Nurse Scientist appointments to the Munn Center for Research; and partnerships with the

Institute for Nursing Healthcare Leadership to mentor and develop future nursing leaders.

Force 1.4 identifies the depth of MGH nurses’ participation in national nursing organizations.

MGH nurses are members of, and have assumed leadership roles in, 59 different professional

nursing organizations on the local, national and international level. In addition, Force 11.7 describes

the role of MGH nurses in supporting nursing education, with over 85 Staff Nurses, Clinical Nurse

Specialists, Nursing Directors, Nurse Researchers and Nurse Practitioners assuming faculty

positions in area nursing programs.

Nurses at all levels lead efforts to advance practice through their work in departmental, service

and unit-based collaborative governance committees. In many instances, this work advances practice

beyond the walls of MGH, through publication. For example, the Emergency Department Ethics

Committee identified the stress and grief of family members whose loved one entered the MGH

Emergency Department (ED) in cardiopulmonary arrest. A Clinical Nurse Specialist partnered with

a Physician, and the Staff Nurse Chair of the committee to study the problem. After study, they

instituted a practice change allowing ‘family presence’ during resuscitation. Attachment 6.12.a is the

first page of the article, Impact of Multifaceted Interventions on Nurses’ and Physicians’ Attitudes and Behaviors

Towards Family Presence During Resuscitation, published in the February 2007 edition of Critical Care

Nurse.

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Tenet 8: The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.

Force 10.2 provides examples of MGH nurses working to meet the health needs of the

community. Whether it is through local collaborations to support activities, such as flu clinics or

health screening events or through international efforts, such as the Durant Fellowship, that sends

nurses to areas of need in Africa and Asia, nurses at all levels of the organization are committed to

caring for those in need.

Tenet 9: The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Force 1.4 and Force 10.8 describe the role that MGH nurses have had in shaping policy

through their participation in professional organizations at local, national and international level. A

few examples include:

• The Clinical Nurse Specialist in Obstetrics is working with hospitals in Zambia to promote safer

maternity care for women in order to reduce the country's maternal and infant mortality and

morbidity rates.

• The Massachusetts Board of Registration in Nursing invited the Clinical Nurse Specialist in the

Surgical ICU to sit on the Advanced Practice Registered Nurse task force to resolve the policy

issue of title protection and licensing in Massachusetts.

• As a delegate to the American Nurses Association’s 109th Congress, a Staff Nurse had the

opportunity to vote on issues such as, the nursing shortage, workplace rights and patient

Advocacy. Attachment 6.12.b is the Caring Headlines article describing the nurse’s experience.

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