July/August 2013

Ethical Ambiguities: Nursing Ethics Explored in New Textbook



Elaine Larson

A local bodega is discovered to be selling unprescribed antibiotics over the counter.

A doctoral nursing student is asked by a collaborating physician to collect clinical information before IRB and HIPAA forms were obtained.

Parents of a child who has been declared dead refuse to allow the ventilator to be shut down.

To help prepare nurses and nurse researchers for the kinds of ethical and legal dilemmas awaiting them as DNPs and PhDs, a new textbook provides a valuable ethical roadmap.

“Ethical and Legal Issues for Doctoral Nursing Students, a Textbook for Students and Reference for Nurse Leaders” is the first textbook to address the potential issues that doctoral level nurses could face as their scope of practice enlarges in the wake of healthcare reform.

Traditional bioethics often doesn’t address the medical, research, legal and business ethics relevant to advanced practice nurses working in today’s healthcare workplace. The legal definition of death, assisted suicide and euthanasia may affect DNP medication prescription and decisions about care sites. Laws regulating physician referrals and under-and over-coding insurance claims can affect DNP and PhD practices. And it has been argued that nurse researchers face distinct ethical considerations due to their role as patient advocate and status as a developing academic science.

Jennifer Smith, DNP, MBA, MPH, former senior associate dean at Columbia Nursing, co-edited and authored chapters in the book with Anne Peirce, PhD, also a former CU Nursing associate dean. “Doctorally prepared nurses and nurse researchers are now in positions of greater responsibility which may create more ethical and legal issues,” said Smith. “Nurse researchers are increasingly involved in the IRB approval process and some even head IRB committees at major medical centers. Advanced practice nurses with DNP degrees can now serve on ethics boards, manage more complex patients and deal with the legal issues involved with managed care and insurance companies.”

Drs. Smith and Peirce, who both taught doctoral ethics at Columbia Nursing, recognized the need for such a book after they co-authored a 2008 article in The Journal of Professional Nursing proposing a new curricular framework addressing clinical, research, business, and legal ethics for DNP students. An editor from DEStech Publications, Inc. read the article and invited them to edit a book on the subject for both PhD and DNP students.

Fast forward four years later, and the published book is now being ordered by instructors of doctoral ethics across the country.

“This book will be helpful to students and faculty because it recognizes the new ethical responsibilities inherent in doctoral level nursing,” said Smith who authored the chapter on business ethics. “Most advanced practice nurses will interact with insurance and managed care companies and work in a healthcare setting that uses conventional business models, even if they don’t set up their own practice. This book provides them with a basic understanding of these practices and their ethical and legal framework.”

Smith also points out that advanced practice nurses will face increasing regulatory oversight and legal risk given their increasing autonomy and therefore must stay current with legal and regulatory changes. The textbook provides information on regulation, specialization, licensure requirements and an appendix with charts for each state’s scope of practice for nurse practitioners.

The book also features other Columbia Nursing-connected authors: Professor Nancy Reame, PhD, wrote the chapter on research ethics, and Pediatric Primary Care NP Program Director Rita John, DNP, authored the chapter on ethical considerations for pediatric patients. Two alumni also wrote chapters: Courtney Reinisch ’07, DNP on ethical guidelines for practice and Joan Valas ’90 ’91, BS/MS on ethical considerations for vulnerable and adult populations. Former faculty member Caroline Hewitt, DNS, authored the chapter on Ethics and Women’s Health.

Reame, a nurse-researcher who has studied the bioethics of assisted reproduction, often tells her students about the ethical issues that surfaced for her when she worked as a patient advocate for some of the first surrogate mothers in the 1980s before legal and ethical frameworks were established for them.

“This was a new way of making babies that had huge ethical implications,” said Reame, who is a faculty affiliate to the Master of Science in Bioethics program. “As a nurse, I was trained to be supportive. I was concerned about the healthcare of the surrogate mothers, who were often highly stressed, and I wondered what would happen if they became attached to the children they would later give up.”

Reame believes there is a steep learning curve for dealing with ethical issues.

“When it comes to ethical dilemmas, there is no right or wrong answer but there is a process where you do a systematic analysis of the pros and cons of each decision so you can resolve them,” said Reame. “If you can pass that on to students, then you’re doing your job.”