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Discrimination and the code of ethics for nurses

In the mid 1980's, in an effort to curtail rapidly rising health care costs, the federal government began to change the way in which it reimbursed health care providers for their services. The goals of this change were to encourage efficiency and reduce health costs. As the average length of stay has been reduced by half under these reforms, it has been a challenge for the nursing profession to maintain its standards. The "Code of Ethics for Nurses" serves as a guide for the delivery of care by nurses. Because of these changes, it is useful to examine the code's ability to guide nurses. Analysis of the code reveals that although it is written an appropriate level, it can be improved by adding clauses pertaining to discrimination and by making it more available to nurses and the public.

Article 1 of the code states: "The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems."1 Although the interpretive statement addresses considerations of race, the article itself does not. Discrimination in health care based on race has been observed in professional literature and in the press as an ethical problem. For instance, an article by Carlisle et. al., a study of invasive cardiac intervention in California found that, "[a]fter adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance."2 But examples of discrimination in health care are not limited to California. Carol Stevens of The Detroit News writes, "At a time when many African Americans are enjoying historic gains in education, income and employment, blacks at every income and social level are sicker and die earlier than whites.". 3

In order to offset the effects of discrimination in our society, guidance from nursing's leaders is needed. Nursing's leaders could provide this guidance by adding specific language to the code forbidding discrimination based on race or ethnicity. Article 1 of the code might be changed to read, "The nurse provides services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, ethnicity, or the nature of health problems." Where Article 1 addresses individual actions of nursing,, Article 11 of the code addresses nursing's interaction with other care provider organizations and the community. According to article 11, "The nurse collaborates with members of the health professions and other citizens in promoting community goals and national efforts to meet the health needs of the public."4 The interpretive statement goes on to detail the nurse's "responsibility to the public . . . to assure a just distribution of health care and nursing services."5 The American Nurses Association could meet with representatives of the NAACP and other African American organizations to modify article 11 to read something like this: "The nurse collaborates with members of the health professions and other citizens in promoting community goals and national efforts to meet the health needs of the public, including efforts to end health discrimination based on race."

Despite the lack of guidance regarding ending health care discrimination, analysis of "The Code for Nurses, utilizing the guidelines presented in Goree's "Quality Codes of Ethics,"6 reveals that it is written at a theoretical level. It is vaguely worded in order to give the nurse flexibility in meeting patient needs. Nursing as a profession requires moderate to high educational standards and provides complex services to clients whose lives may literally be in the nurse's hands. Although she usually performs under the direction and supervision of an independent practitioner, the nature of her practice requires the that she posses the ability to make a wide range of critical decisions about her client's care. Because of this, nursing requires a high quality professional code of ethics that both protects the rights of clients and the nurse's ability to function with minimal supervision. Because it is written at a theoretical level, the code makes no mention of sanctions for misconduct It relies instead on the individual states to write laws governing nursing practice.

But the mere wording of the Code may not be its greatest defect. Rather, the greatest defect may lie in the lack of attention the code receives. Although written at an appropriate level, the code remains practically unread. Five nurses were asked when they had last read the "Code of Ethics for Nurses." While it is encouraging that all had read it, none had done so since graduating from nursing school. The ANA itself does nothing to encourage reading and discussion of the Code. In fact, anyone wishing to read it must either find a library copy or send money to the ANA. The picture is further complicated by the reliance on standards of practice and other documents apart from the code. Like the code, these adjuncts are available from ANA at a price. It would be a helpful to nurses and their patients if the ANA would change its policy allow the code to be freely provided. The code would be strengthened by including the directives now contained in separate standards of care. Certainly, if the code is meant to serve as a guide for nurses, it must be more easily accessed, and nurses must be encouraged to read it.

That nursing leaders are not prepared to deal with the issue of discrimination in health care can be seen in an interview of the nurse manager at a local hospital. Even where knowledge of a lack of service to minority patients exists, no effort has been made to remedy this lack. In the words of Mr. Monti: "I know of none [outreach pro-grams] we have done aimed at minorities. Considering increased risk of atherosclerosis and related health complications and our prominence as a 'Heart Institute'......well...this is kind of self indictment, prima facia."7 Changes in the code strengthening anti discrimination language would increase nurses' awareness of the needs of minority patients. Active collaboration of nursing with the community has long been recognized in other areas, and must to be encouraged in meeting the needs of minority patients by changing the code. Distributing the code and making nurses and the public aware of its contents is essential in making it an effective guide for nurses.

Works Cited

1. American Nurses Association. Article 1, "Code of Ethics for Nurses With Interpretive Statements". 1985.

2. Carlisle, David M., Leake, Barbara D. and Shapiro, Martin F. Authors Abstract. "Racial and Ethnic Disparities in the Use of Cardiovascular Procedures: Associations With Type of Health Insurance." The American Journal of Public Health, Feb 1997 v87 n2 p263(5). Online. Infotrac. 10/30/97

3. Stevens, Carol. "System, Race and Suspicion Promote Medical Disparities", The Detroit News.December 10, 1995. . 11/4/97.

4. ANA. Article 11

5. IBID

6. Goree, Keith. "Codes of Ethics." Ehtics Applied. Ed. Michael L. Richardson and Karen K. White. New York: McGraw- Hill. 1995. pg 686.
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