Ethics in perioperative practice—patient advocacy

AORN Journal,  May, 2002  by Kathryn Schroeter

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Perioperative nurses make ethical decisions daily, and they need to be prepared to take action based on the ethical code outlined in the American Nurses Association's (ANA's) Code of Ethics for Nurses with Interpretive Statements. This article is intended to help perioperative nurses relate the ANA code to their own area of practice, and it focuses on provision three of the 2001 ANA code, which says, "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." (1)

This provision directs perioperative nurses' role as protectors of their patients. As an offshoot of respect for people, which was discussed in the previous article in this series (AORN Journal, April 2002), nurses must apply the principles of autonomy, justice, beneficence, nonmaleficence, fidelity, and veracity when ensuring their patients' rights, health, and safety. Provision three in the ANA code conceptually addresses privacy, confidentiality, research participation, and practice standards. In terms of behavior, this provision espouses patient advocacy. The necessity for patient advocacy stems from the impact of illness on an individual's autonomy and ability to make decisions.

ADVOCACY

Many perioperative practice issues involve ethics and advocacy. Researchers have identified these issues as including lack of respect for the patient's dignity, withholding of information or blatant lying to patients, inadequate consents, incompetent health care providers, and do-not-resuscitate orders. (2)

In nursing, advocacy often is viewed as a duty or obligation that arises from nurses' rote as continual observers of their patients' conditions. Patient advocacy is part of a patient's rights in the Patient's Bill of Rights put forth by the American Hospital Association. This document includes the statement that "activities must be conducted with an overriding concern for the patient, and above all, the recognition of his dignity as a human being." (3)

Nurses act as patient advocates by protecting patients from incompetent, unethical, or illegal practices and by complying with facility policies of competent performance, federal regulations from such entities as the Occupational Safety and Health Administration, state nurse practice acts, and accrediting agency (eg, the Joint Commission on Accreditation of Healthcare Organizations) requirements. Nurses also should confirm clinicians' privileges and credentials. (4)

Advocacy in nursing has two components. The first is that advocacy in the nursing role implies that nurses support patients' autonomy or patients' rights to freely choose, regardless of whether the nurse agrees with patients' decisions. Second, advocacy in nursing includes the nurse's ability to take action on behalf of the patient. (5) The term advocacy is especially applicable to the perioperative practice environment because it is during this phase of the surgical experience that sedated or anesthetized patients are vulnerable.

Nurses have the potential to develop relationships with patients that put them in a position of trust. Patients trust that their nurses will support and follow through with any concerns or issues that have been discussed. Nurses consistently are close and accessible to patients, so they often are the first to identify a patient's ethical concerns and become mediators or messengers in relaying these concerns to other members of the health care team.

As patient advocates, perioperative nurses must ensure both the quality and continuity of care delivered to their surgical patients. In the perioperative setting, nurses continually assess the care of perioperative patients, attempting to ensure that patients' physical, emotional, and ethical needs are met. Nurses, as patients' moral agents, must be ready and able to advocate for patients' needs whenever necessary while providing perioperative care. Additionally, they should intervene to protect the patient's safety. (6) Safety issues can take many forms, from verifying patient identity and the surgical site to medication administration; however, the OR often contains other safety concerns, such as the assurance of aseptic technique and the potential for injury from lasers, electrosurgical units, chemicals, and positioning. (7) Ensuring patient safety in the perioperative environment is just one way in which nurses advocate for surgical patients.

In the perioperative setting, time often limits a nurse's ability to get to know a patient intimately. The factor of time constraints may affect the advocacy component of perioperative nursing such that a nurse may be too hurried to adequately address a patient's needs.

CONFLICTING LOYALTIES

Perioperative nurses may find that they experience conflicting loyalties to themselves, their patients, their coworkers, or their employers. These conflicting loyalties may include supporting a patient's decision that is contrary to the beliefs of the physician or the institution's philosophy and mission. This type of conflict should be brought forth via the proper channels of nursing management.