2.2 Ethical and Professional Foundations of Safe Medication Administration by Nurses

ANA Code of Ethics for Nurses

The American Nurses Association (ANA) is a professional organization that represents the interests of the nation’s 4 million registered nurses and is at the forefront of improving the quality of health care for all.^[1] The ANA developed the Code of Ethics for Nurses as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.^[2]Several provisions from the Code of Ethics impact how nurses should administer medication in an ethical manner. A summary of each provision from the Code of Ethics and how it affects medication administration is outlined below.

• Provision 1 focuses on respect for human dignity and the right for self-determination: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”
• Provision 2 states, “The nurse’s primary commitment is to the patient…” ^[3] In health care settings, nurses often experience several competing loyalties, such as to their employer, to the doctor(s), to their supervisor, or to others on the health care team. However, the patient should always receive the primary commitment of the nurse. Additionally, the patient has the right to accept, refuse, or terminate any treatment, including medications.
• Provision 3 states, “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient…”^[4]This provision includes a nurse’s responsibility to promote a culture of safety for patients. If errors occur, they must be reported, and nurses should ensure responsible disclosure of errors to patients. This also includes proper disclosure of questionable practices, such as drug diversion or impaired practice by any professional.
• Provision 4 involves authority, accountability, and responsibility by a nurse to follow legal requirements, such state practice acts and professional standards of care.
• Provision 5 includes the responsibility of the nurse to promote health and safety.
• Provision 6 focuses on virtues that make a nurse a morally good person. For example, nurses are held accountable to use their clinical judgment to avoid causing harm to patients (maleficence) and to do good (beneficence). When administering medications, nurses should validate the medication is doing more “good” than “harm” (adverse or side effects).
• Provision 7 focuses on a nurse practicing within the professional standards set forth by their state nurse practice act, as well as standards established by professional nursing organizations.
• Provision 8 explains that a nurse must address the social determinants of health, such as poverty, education, safe medication, and healthcare disparities.^[5]

Whenever a nurse provides patient care, the ANA Code of Ethics should be kept in mind.

ANA Professional Standards and Scope of Practice

The American Nurses Association (ANA) publishes the Nursing: Scope and Standards of Practice. This resource is updated regularly and outlines professional nursing performance according to national standards.^[6] The ANA defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.” A registered nurse (RN) is defined as an individual who is educationally prepared and licensed by a state to practice as a registered nurse. Nursing practice is characterized by the following tenets:

• Caring and health are central to the practice of the registered nurse.
• Nursing practice is individualized to the unique needs of the healthcare consumer.
• Registered nurses use the nursing process to plan and provide individualized care for healthcare consumers.
• Nurses coordinate care by establishing partnerships to reach a shared goal of delivering safe, quality health care. ^[7]

State nurse practice acts further define the scope of practice of RNs and Licensed Practical Nurses (LPNs) within each state. The Wisconsin Nurse Practice Act is further discussed in the “Legal Foundations” section.

ANA Standards of Practice

ANA Standards of Practice are authoritative statements of duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Standards of Practice include assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ADOPIE) components of providing patient care. Implementation also includes the components of health promotion and health teaching. Medication administration should include all components of ADOPIE.

Health Promotion and Patient Teaching

The ANA standards for patient teaching state, “The registered nurse employs strategies to promote health and a safe environment.”^[8] Specific behaviors related to patient teaching about medication include:

• Use health promotion and health teaching methods in collaboration with the patient’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
• Provide patients with information about intended effects and potential adverse effects of the plan of care.
• Provide anticipatory guidance to patients to promote health and prevent or reduce the risk of negative health outcomes.^[9]

In the book Preventing Medication Errors by the Institute of Medicine (2007), additional key actions to include when teaching patients about safe use of their medications are:

• Patients should maintain an active list of all prescription drugs, over-the-counter (OTC) drugs, and dietary supplements they are taking, the reasons for taking them, and any known drug allergies. Every provider involved in the medication-use process for a patient should have access to this list.
• Patients should be provided information about side effects, contraindications, methods for handling adverse reactions, and sources for obtaining additional objective, high-quality information.^[10]

ANA Standards of Professional Performance

ANA Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice, and quality of practice.^[11]

Cultural Congruent Practice

The ANA defines culturally congruent practice as the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the healthcare consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses must assess the cultural beliefs and practices of their patients and implement culturally congruent interventions when administering medications and teaching about them. Additional information about cultural implications for medication administration is further discussed in the “Cultural and Social Determinants Related to Medication Administration” section later in this chapter.

Figure 2.1 is an image from Nursing: Scope and Standards of Practice by the ANA (2015). ^[12] It explains how professional scope of practice, standards, and code of ethics are the “base” of nursing practice. Nursing practice is further defined by the State’s Nurse Practice Act, rules and regulations, institutional policies and procedures, and self-determination by the individual nurse. All these components are required to provide quality, safe patient care that is evidence-based.