At the Intersections of Law, Ethics, and Nursing

From Nursing Ethics, 1880s to the Present (p. 393-396)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes

I often reflect on how our past has shaped us and how different the world looks through eyes that have seen and studied multiple iterations of the Code of Ethics for Nursing. Most of the time, I have been in search of an ethical environment where nurses learn, grow professionally, and practice in a resilient and joyful manner. Even in trying to create such an environment in my own space, I have faced constraints, but I still ask us to be nurses, remain nurses, and recruit nurses—we need nurses now more than ever in our history. We, collectively, are truly the pathway to health. Why nursing? For me it was a strong desire to be helpful in a meaningful way. An opportunity to care for those most vulnerable as part of a profession that is viewed as the most trusted year after year, a profession that requires both individual and collective relationships to “do good.”

Recently, I had cause to talk with students—the next generation of nurse leaders—about nursing ethics and the importance of our ANA Code of Ethics for Nurses. I shared with them my experience in developing not one, but two versions of the Code. Now, enough time has passed, and enough changes have occurred—a pandemic, greater social networking, a more global and nurse-traveled world—that the time has come, once again, to reexamine our Code and what changes are necessary for our ethical code to match and guide our ever-changing practice.

The state of our lives is evolving. Life is not static, problems are not static, and health, information, and technology are changing by the minute as we age. As I reflect back to my start in nursing, as a much younger me, the changes were less ap- parent than they are today. It is hard to imagine a bed you crank or drips you count without the help of a monitor or an IV pump. Often, I wonder how my patients survived in a world where health care and nursing care was so different, lacking in cell phones, MRIs, and assistive technologies.

But then I ask, was it really that different? Even almost a half century ago the focus was on the patient and the family and was inclusive of the community for those of us who served the needs of patients beyond the walls of the hospital or clinic. We valued the needs of those in our care beyond the physical care to encompass something more. As nurses, we considered safety, human rights, dignity, individual uniqueness, and vulnerability as key components of our primary commitments as nurses.

I recall the stress of caring for those for whom we had no answers, a dying group, whose disease we feared was contagious. We dressed as if our lives depended on it, with gowns and gloves and masks. We later called the illness HIV/ AIDS. I watched in wonder the parallels of the COVID‑19 pandemic with my own experiences years prior. The similarities were uncanny, but the remarkable care of others prevailed even when the fears were great. I think how proud those nurses from earlier pandemics and illnesses must be, recognizing the persistence and re- silience that brought us through yet another challenge.

I never remember even thinking that I would resign my position because the fear was too great or the risk to carry out needed nursing care was beyond my capacity. I do remember reflecting on my own mortality and the possibility that it could be transmitted to me and to my family. I do remember working together with other nurses within my workspace and at clinical specific meetings throughout nursing in general to create an environment where we would feel most protected. Whether it was use of PPE for TB, HIV, or to avoid the consequences of toxic chemothera- peutic agents, we made new policies to push our profession forward in a manner that kept us as safe as possible while minimizing risk to ourselves and our patients. All of us, together, pushed to create new paths that focused on better outcomes, and together felt the sadness when despite our efforts the outcome was an inevitable part of the life cycle. Many of these experiences came full circle as we again faced something bigger, something unknown in my lifetime, an unparalleled pandemic, and an all-embracing social crisis.

We learned and acknowledged the importance of self-care for ourselves and our profession, thus increasing our life spans as individuals and as a profession. We also learned that there were distinct differences among us, and that I am privileged to live a life with a skin color and postal zip code that places me inside a world where my personal outcomes in life and health would be favored. I also came to know that my profession and I needed to acknowledge and apologize to others for the dispari- ties and injustices that exist in our history, but more so I needed to work toward equity, inclusion, and belonging to change the path of our profession moving forward. Additionally, my early research in advance directives and shared decision mak- ing strengthened my focus on why clinical ethics are so central to our work as nurses engaged with patient’s lives that extend beyond the clinical setting. Recent work using gaming for selection of decision makers with cell phones shows how little we have moved the mark in the world of advance directives and how far we have come in thinking about health-care surrogates.

Thankfully, I, with other nurses, focused on our practice as a profession. We focused on the impact and interconnectedness of our work with the work of others in providing responsible and accountable care within the boundaries of our profession. Often, we were pushing up against the wave of technology that was both a gift and a curse as we aspired to be better. And now innovative technology, a global social network, and the genomic revolution are creating a future for self-care and care of others that is the new reality. However, we continue to see vast disparities and recognize our need for a deepened commitment to fostering dialogue and mak- ing real change in order to achieve justice.

My innate abilities and perhaps more than a bit of stubbornness have allowed me to focus on nursing in unique ways. My interest in ethics and the boundaries of nursing practice were amplified by my pursuit of a law degree, followed quickly by graduate study in health policy and ethics as I completed a nursing master’s with a focus on education. My love of mentoring and sharing knowledge moved me to a path in nursing education and ultimately to academic administrative leadership. While working at ANA on the Code of Ethics for Nurses, multiple ethics position statements and even improvements in how the Center for Ethics and Human Rights operates are experiences I had the privilege to lead. We worked to make applicable and practical the ever-evolving guides and guardrails for our professional practice. Years of involvement in groundbreaking work in genomics health education and, more recently, work to encourage assessment of our ability to use and translate genomics in nursing practice across the world is creating change and forging new paths.

On this winding nursing path, my desire to help others placed me at the bedside, studying the narratives in order to find ethical solutions to the difficult challenges and conflicts in health care. For me, leadership was about people and helping each individual or group find the niche where who they are and what they say and do is in harmony with their passion. This is defined as “happiness” by Gandhi and by me as “joy.” When your work and your passion collide—that is joy. Law, ethics, and nursing for me created this collision and this intersection was always a place where I could do my best work.

And now back to our beginning. The words of Nightingale, Notes on Nursing, resound, especially the part about using data to create changes! Mary Seacole, Harriet Tubman, Clara Barton, Mary Eliza Mahoney, Lillian Wald, Annie Goodrich, Virginia Henderson, and so many more pathfinders and innovators on whose shoulders we stand have created for us a professional moral compass. Their works provide many practical lessons on pathways for change. More recent colleagues, living legends, and living inductees to the ANA Hall of Fame, many of whom I had the distinct pleasure of knowing, have similarly shaped my practice, teaching, and leadership as they have shared their stories of improvement and change. Both groups challenged me, challenge us to move nursing in a direction that both honors our profession and those we serve. We seek to optimize health and well-being as we provide care for all others. Opportunities abound for nurses to be innovators and change agents. As I reflect on my own contributions to the profession, they pale in comparison to the giants who have enabled me to forge a new side path or two that have expanded nursing.

As an education leader and dean, I am honored each day to mentor the nursing workforce of the future and share visions about the future. I appreciate my col- leagues and hold dear those moments of their recognition that humble and delight, yet also confront the fear of the imposter syndrome. Those occasions are always a bold reminder that our work is rarely individual, but is the result of our powerful, collaborative connections.

So again, I reflect on ethics in nursing. Nursing has no boundaries in the good that we can do, through our practice, research, education, or administration. Often, we experience these in combination influenced by our art and science, working to create ethical environments and exerting ourselves together, as one, to advance health for all. All of society and the next generation of nurses is trusting us to pro- vide care as only we can. Be well.