Nursing Ethics: Codes, Whistleblowing, and Patient Safety

Introduction: Workplace Ethics and Patient Safety

Regardless of the institution or department, workplace violations of professional standards are a persistent concern in healthcare. Healthy workplaces fundamentally contribute to the job satisfaction of all staff members, and—crucially—they directly affect patient safety (Browne, 2009). Many scholars and experts are now investigating workplace ethics and how they affect both workers and patients. In the simplest terms, patient safety is the primary goal every hospital aims to achieve. If a nurse or doctor is dissatisfied with their work environment, their output will suffer, which can ultimately harm patients and contribute to poor outcomes. Workplace ethics are therefore essential to the eventual quality of care provided (Browne, 2009). The central dilemma is this: how can an organization create a healing and therapeutic environment for patients and their families when that same organization is proving harmful to the health staff working within it (Jackson & Daly, 2010)?

Nursing Codes of Ethics and the Duty to Act

The International Council of Nurses Code of Ethics states that all nurses have an important responsibility to take appropriate action to protect patients when their care is being hindered by a co-worker or any other person. Other international and local nursing codes of ethics similarly instruct nurses to act when someone's conduct puts a patient at risk. A patient's life can be endangered by illegal, unethical, or incompetent acts—acts that may be committed by other nurses, doctors, or surgeons.

A code of ethics is founded on the principles of beneficence, non-maleficence, veracity, justice, honesty, autonomy, and respect. These codes are developed with a full understanding of the healthcare system and the situations in which guidelines will be needed. The Australian Association of Occupational Therapists Code of Conduct (2001) stated that a person should be loyal to their organization and should show a proper degree of respect and dignity. However, it was also firmly stated that a person's responsibility as a member of society—on moral and legal grounds—overrides their loyalty to the organization at all times. This means that if a therapist ever doubts the conduct of a colleague, they may report it to the National Office of OT Australia or the relevant territory Member Association.

Although this may appear to be the straightforward moral course of action, it is far from easy in practice. Speaking out at one's workplace against a colleague—or even a senior—takes considerable courage. According to the literature, when nurses take a moral stand to protect patient safety and the quality of care, it can hurt them professionally and personally to a significant degree (Ahern & McDonald, 2002).

When a violation occurs, nurses are expected to report to an authority. However, authorities frequently fail to respond or take action, which leaves reporting nurses in doubt about whether the effort was worthwhile (Johnstone, 1999). Nurses are then left with three choices: remain silent, leave their position, or take the last resort of whistleblowing.

Research from various North American studies on peer reporting of co-worker violations suggests that most nurses are reluctant to report misconduct (Lawton & Parker, 2002). Johnstone (2002), however, found that when nurses are pushed beyond a certain limit, they ultimately decide to act against whatever wrong is occurring.

Several factors influence a nurse's decision to report risks or wrongdoing. First, individual characteristics—particularly professional and personal ethics—play a pivotal role. Situational factors also matter greatly. For instance, a nurse who is merely looking to create conflict might report minor negligence, whereas most nurses would overlook small lapses. When the wrongdoing is serious and deliberately concealed, there is little choice but to report. Finally, organizational dynamics come into play: whether the institution receiving the report will actually take meaningful action.

Key Ethical Principles: Non-Maleficence and Beneficence

The term non-maleficence derives from the Latin phrase meaning "above all, do no harm." It obliges healthcare professionals not to harm or injure anyone—preventing wrongful harm to patients or the prescription of inappropriate treatments. This principle differs from beneficence, which means "to do good." Both principles are directly applicable to nursing, since the primary moral duty of healthcare workers is to help patients without causing harm (Johnstone, 1999). Beauchamp and Childress (1994) argue that the obligations of non-maleficence override those of beneficence. Applied to nursing, non-maleficence makes it not only permissible but necessary for a nurse to speak out against any avoidable action that causes harm to a patient (Johnstone, 1999). Since nurses often directly supervise patients or are positioned to observe negligent behavior, the principle of non-maleficence compels them to report such conduct to prevent future incidents.

Beneficence in Latin means "above all, do good," obliging healthcare personnel to act solely in the interest of benefiting others. Empathy, sympathy, care, compassion, and kindness are all expressions of beneficence (Johnstone, 1999). There is, however, a recognized limit to this principle: although a person should do good and speak up for what is right, they are not strictly obliged to do so if acting in good faith would ultimately cause serious harm to themselves. In other words, if a nurse's own moral or professional interests are severely compromised, the obligation to act diminishes (Johnstone, 1999). That said, there is a form of obligatory beneficence that creates controversy: certain moral and social obligations may make it imperative for a person to pursue the good, regardless of personal cost.

To illustrate this tension in a nursing context, Johnstone (1999) presents the following case. A patient is in the late stages of a terminal illness and is expected to die soon. She has clearly expressed a wish not to receive a blood transfusion. Regardless of the basis for this wish, it represents an exercise of patient autonomy. A doctor arrives and orders a unit of blood—one that is not medically indicated and will not benefit the patient. The nurse refuses to administer it and directs the doctor to do so if he insists. In refusing, the nurse exercised beneficence toward the patient by honoring her wishes and protected the patient from an unwanted, unnecessary procedure. This act also illustrates the next major ethical concept: conscientious objection.

Conclusion: Nurses as Ethical Watchdogs

All of this demonstrates that nurses must be very careful when speaking against the system. Despite the importance of the nursing profession, their reports and claims are not always treated with the weight they deserve. Nevertheless, nurses remain a vital mechanism for providing checks and balances across the entire hospital system. Ethical codes provide a framework, legal protections offer some measure of safety, but meaningful institutional accountability is ultimately what determines whether a nurse's ethical courage produces lasting change.

References

Ahern, K., and McDonald, S. (2002). The beliefs of nurses who were involved in a whistleblowing event. Journal of Advanced Nursing, 38, pp. 303–309.

Ashley, B., Deblois, J., et al. (2006). Health care ethics. Washington, D.C.: Georgetown University Press.

Beauchamp, T., and Childress, J. (2001). Principles of biomedical ethics. New York, N.Y.: Oxford University Press.

Browne, J. (2013). Healthy workplaces and ethical environments: a staff nurse's perspective. Critical Care Nursing Quarterly, 32(3), pp. 253–261.

Jackson, D., and Daly, J. (2010). Improving the workplace: the pivotal role of nurse leaders. Contemporary Nurse: A Journal for the Australian Nursing Profession, 36(1/2).

Johnstone, M. (1999). Bioethics: A nursing perspective. Sydney, N.S.W.: Harcourt Saunders.

Johnstone, M. (2002). Poor working conditions and the capacity of nurses to provide moral care. Contemporary Nurse, 12, pp. 7–15.

Johnstone, M. (2004). Patient safety, ethics and whistleblowing: a nursing response to the events at the Campbelltown and Camden Hospitals. Australian Health Review, 28(1).

Lawton, R., and Parker, D. (2002). Barriers to incident reporting in a healthcare system. Quality & Safety in Health Care, 11, pp. 15–18.

Unknown. (2011). Conscientious objection [Policy document]. Australian Nursing Federation.

Unknown. (2001). Code of ethics [Policy document]. Australian Association of Occupational Therapists.