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Page 1 Professional Caring and Ethical Practice Study Guide for the CCRN®

General Information

About 20% of the questions on the CCRN® test cover concepts and procedures that concern professional behavior and using ethical judgment on the job. You will be asked what to do in a certain situation and you will need to rely on ethical standards and the parameters of professional nursing behavior to answer. Use this study guide to review the expected standards and professional practices to which you will be expected to adhere.

Advocacy/Moral Agency

Advocacy and moral agency in nursing are part of the core values of effective and compassionate patient care. These guidelines, written by the AACN®, help to create nursing environments that improve patient, nursing, and facility outcomes and satisfaction.

AACN® Synergy Model

The AACN® Synergy Model of nursing practice was created to identify and treat the needs of patients based on patient characteristics, nursing competencies, and healthcare environment. There are eight patient characteristics and eight nursing competencies identified in this model. These characteristics and competencies are graded on a scale of 1-5, with increased reflected numbers being related to stronger outcomes. They are as follows:

Patient Characteristics

  • Resiliency
  • Stability
  • Vulnerability
  • Complexity
  • Resource availability
  • Participation in care
  • Decision-making participation and ability
  • Predictability

Nursing Competencies

  • Clinical judgment
  • Advocacy
  • Caring practices
  • Collaboration
  • Systems thinking
  • Diversity response
  • Clinical inquiry
  • Facilitation of learning

The healthcare environment also plays into this model as a way to see how nursing and patient roles interact both successfully and unsuccessfully. Without a properly functioning healthcare environment, the synergy of patient and nursing interactions could not be achieved.

Quality outcomes are based on the previously defined characteristics/competencies. They affect interactions, patient health, and overall job performance.

The six indicators of quality outcomes are:

  • Patient and family satisfaction
  • Adverse incident rates
  • Complication rates
  • Adherence to discharge plans
  • Rate of mortality
  • Length of hospital stay

Advocacy/Moral Agency

Advocacy and moral agency are two of the many nursing competencies listed under the AACN® Synergy Model. Advocacy occurs when the nurse performs his or her best work for the benefit of the patient despite any conflicts with personal values. The nurse must also work to provide information or access to the best, most appropriate resources available to that patient.

Moral agency works in two ways. For the agency factor, the nurse must be open to recognizing issues within the system and to act on those issues. Moral agency, then, elaborates on this to include taking action to influence decisions.

Three levels of advocacy and moral agency exist.

Level 1 advocacy and moral agency focuses on the work of the nurse for the patient when the patient and nurse’s personal values align.

In Level 3, the nurse broadens his/her care to advocate for the patient and to assist them in finding resources while considering the patient’s values even if they do not align with the nurse’s values.

Level 5 is the most thorough level, where the nurse advocates to empower patients to have access to the best resources for them regardless of any differences in personal values.

Complementary Therapies

Many families will request options for therapy beyond medicine. These therapies are often classified as complementary therapies. Complementary therapies include homeopathic interventions, naturopathic medicine, herbal remedies, acupuncture, chiropractic treatment, diet changes, music/art/meditation/dance therapy, Reiki, and bioelectromagnetic-based therapies.

While many of these therapies can be accomodated to patients’ medical treatment plans, they may not always serve as a replacement for specific necessary therapies. Conversations with both the patient and healthcare team are essential to prevent unnecessary interactions between complementary therapy practices and traditional medicine practices. It is important to allow patients control in choosing additional therapies that complement their current treatment plan.

Ethical Principles

Ethics is the study of morals and right and wrong. It is the question of what people should do and what they actually do and how it impacts the outcomes of the situation. Ethical choices can be difficult to make due to personal viewpoints, political bias, environmental limitations, and other concerns.

Many critical care facilities have ethics committees consisting of employees trained in ethical decision making without personal influence. These committees usually work closely with risk management committees who can help guide healthcare providers through implications of personal and institutional liabilities based on specific decisions/events. External agencies, such as the public health department, can also provide ethical guidance and regulations to prevent patient harm and maximize beneficial/acceptable therapies.

Beneficence and Nonmaleficence

Beneficence and nonmaleficence are two factors in nursing/patient relationships. Beneficence means to act in the benefit of the patient. Nonmaleficence means to do no intentional harm to the patient. When these actions are not performed, patient care is compromised. Nurses must ensure that the acts being performed are morally neutral or good, the intent of the action is for positive outcomes, adverse events are not the cause for achieving good effects, and the benefit of therapy outweighs the risk and harm of that therapy. These guidelines should be reviewed frequently throughout patient care to ensure that the patients are receiving the best, least harmful therapies for their needs and diagnoses.

Autonomy and Justice

Autonomy and justice are also factors in ethical nursing/patient relationships. Autonomy allows a person the right to make independent decisions about his or her care. Family members may have to make decisions for incapacitated and/or critically ill patients. The nurse in this case must also ensure that the patients are provided with the information required to make confident decisions about their care.

Justice occurs when healthcare benefits and resources are distributed fairly across patients and society. In critical care units, healthcare teams must be able to critically assess their incoming patients’ needs and how to manage them if resources are limited. Ultimately, the patients’ best interests should be taken into account and healthcare teams should not allow personal biases to impact decision making.

Ethical Assessment

Frequent evaluation of patient care includes intensive ethical assessment. Nurses must be able to act upon what is right, even if it contraindicates previously defined orders or practices. Nurses must also recognize their own biases and how they impact patient care. Ultimately, care for the patient should be in the patient’s best interest regardless of personal views or opinions.

Bioethics

Bioethics focuses on the medical aspect of patient care. Patients must be treated in a fashion that is most morally correct among all the treatment options available to that patient. This is easy to accomplish when all viewpoints align between the healthcare team, patient, and family members.

However, when different opinions and treatment options threaten the cohesiveness of the team, the dilemma must be addressed in a professional manner. If the disagreement cannot be solved with therapeutic communication and discussion of all treatment options, utilization of a facility’s ethics committee should be implemented.

Terminally Ill Patients

Terminally ill patients are at higher risk for ethical dilemmas due to the potentially complicated nature of their long-term care. These patient cases will need extra care and consideration throughout their ethical assessments to ensure that treatment options are in the best interest of the patient. Providing a thorough explanation of care to the family is critical to helping them make the most informed decisions about their loved one’s care.

In cases of terminal conditions, options regarding care vary. Some patients may require or request analgesic measures. These measures can provide comfort but can also decrease patient sensations and awareness, leading to decreased interactions with others and result in possible acceleration of death. Active treatments, on the other hand, may promote a longer lifeline and improve quality of life but ultimately do not cure the conditions. The active treatments may prolong the inevitable death and cause severe side effects that may worsen a patient’s quality of life.

Nutrition and supplemental nutrition can be a priority for some family members. Nutrition, while it can prolong life, may also accelerate tumor growth, cause nausea or vomiting, and increase discomfort. When possible, allow the patient to help decide how nutrition is implemented into their plan of care. IV fluids and increased fluid intake also fall under this category. While administration of these medications may help families feel that thirst is not a concern, increased fluid volume may cause edema and worsen conditions such as congestive heart failure and pulmonary fluid overload. Patients may also experience skin breakdown from fluid overload and potential incontinence. Encourage family members to keep the mouth moist with swabs if thirst is a concern and IV fluids are contraindicated.

Resuscitation efforts can also be a delicate subject. Patients with a terminal illness may struggle to come to terms with imminent death. Family members, when presented with the tough decisions of life-saving measures, are prone to emotional decision making when facing the loss of the patient. When a terminally ill patient reaches the end of life, ensure that thorough and clear discussions and plans are created with the family to reduce the ill effects of extensive resuscitation measures that prolong the outcome of death.

Patient and Family Rights

Knowing and teaching patient and family rights helps to promote ethical decision making and comprehensive treatment. Patients and their families must be treated with dignity and respect and all care must be performed in the best interest of the patient.

Hospital-wide measures and committees with patient and parent team members can be extremely useful in advocating for patient rights. Patient and family satisfaction surveys, feedback cards, follow-up interviews, and post-care assessment appointments can also be utilized to improve patient care and identify advocacy issues.

Patients and their families have the right to obtain their medical records, receive competent and non-discriminatory care, and participate in the care decisions being made. They should be given complete, understandable information regarding their care and be allowed to ask questions regarding these conversations. They should be supplied with and guided through information to create advanced directives. Patients and families should be treated with respect.

Patients and their families are also responsible for their participation in medical care. They should respect the staff and other patients. They should ask questions when they need more clarification. They should participate in the care plans developed or voice their concern/explanation as to why they are unable to participate. Also importantly, they should be honest and open regarding their health histories and previous therapies to ensure that the most accurate and appropriate treatment options are developed for their needs.

Informed consent is one of the most important documents that must be completed before performing invasive procedures or treatments on a patient. Informed consent is a legal document that is signed by the patient (or family member if patient is incapacited), performing provider, and a witness to ensure that appropriate education and understanding has been had between the parties regarding an invasive medical procedure. During this process, all risks, benefits, and alternate options to the treatment must be discussed. Patients and/or their family members must be given adequate opportunity to ask questions regarding the treatment and object, if necessary.

The American Medical Association® (AMA) created a strict guideline of what informed consent must entail. These objectives include:

  • Explanation of diagnosis
  • Risks and benefits of treatment or procedure
  • Alternative options; risks and benefits of alternative options
  • Nature and reason for treatment or procedure
  • Risks and benefits of not having the treatment or procedure

The AMA also mandated that all states be required to obtain this formal agreement among healthcare providers and patients/families. If patients waive their right to informed consent, a thorough documentation of the refusal must be included in the patient’s chart. In the event of emergency medical procedures, such as the need to save a life or limb, informed consent is not necessary if the patient and/or family is not able to provide that consent.

Confidentiality

Confidentiality is another part of patient/family rights. All patients and their care should be confident in their professional-patient relationship with healthcare staff. This means that all health information must be kept confidential. As a healthcare provider, maintaining confidentiality is an obligation, not an option. Patient information should be safeguarded and only shared with people in direct care of that patient. Rarely, confidentiality may be broken to save a life. Otherwise, breaks in confidentiality are often terms for severe reprimand, legal action, and/or termination.