Ethics in Home Health

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Introduction   

Ethics originates from the Greek work ‘ethos’ which means character (17). Ethics is a division of philosophy and is used to study behavior. It is an approach to analyzing and understanding matters of right and wrong, and good and bad as they relate to the well-being and relationships of people (7). Nursing ethics infiltrates all roles of nursing. Ethics are beneficial for home health nurses, patients, family, and caregivers. Respect, equitable treatment, and quality care are benefits for patients. Healthcare providers benefit by having guidelines that support difficult decisions. Having an ethical framework allows for effective communication, fewer misunderstandings, and increased trust within colleagues and co-workers. Ethical guidelines assist in finding solutions to patient issues and reduce opportunities of unnecessary treatments or procedures (7).  

Home health nurses rely on the code of ethics for nurses, scope and standards for home health nursing, nursing principles, and values, for guidance and a framework to guide their practice in an ethical manner. The home health nurse needs to be knowledgeable on how to deal with the ethical dilemmas they will encounter in this role. Understanding ethics in home health is a crucial piece of being successful in this role. 

Role of the Home Health Nurse 

Home health care nursing is a complex area of nursing practice. Experienced nurses coming from intensive care, critical care and emergency rooms find home care to be complex and challenging. Despite the challenges many nurses find home health nursing to be very rewarding. They appreciate the independence, autonomy, flexibility, and challenges that are part of this type of nursing.  

Home health nurses provide care to all types of patients with the goal of promoting optimal health, wellbeing, and the quality of life to the patients, families, and caregivers within their homes.   

Home health nurses are unique in that they practice independently. While they do collaborate with other professionals, much of the time they are the only professional in the home providing care to the patient. This requires them to have exceptional skills in assessment, clinical decision-making, critical thinking, and clinical practice (13).  

Home health nurses possess specific characteristics making them unique from other nurses. They must have: 

• The ability to work independently 
• Very good skills in assessment and care coordination  
• Good organizational skills 
• Good time management skills 
• Compassion and empathy 
• Be able to provide patient and caregiver teaching 
• Be able to provide counselling and coaching to patients and caregivers 

Home health nurses provide a wide range of services including (13, 14): 

• Patient and caregiver education 
• Nutrition therapy 
• Intravenous therapy 
• Medication administration 
• Nursing assessments 
• Surgical wound care 
• Pressure injury care 
• Injections 
• Monitoring serious illness 
• Providing treatments 
• Collecting blood samples 
• Monitoring vital signs 
• Developing care plans 
• Monitoring health status 
• End of life care 
• Responding to emergencies 

Home Health Nursing: Scope and Standards of Practice 

The American Nurses Association (ANA) has defined home health nursing as a speciality area of nursing practice that promotes the well-being and optimal health of patients, families, and caregivers. Home health nurses deliver nursing services to patients in all stages of wellness and illness, including end of life. Their patients are all ages and cultures. Home health nurses practice in the patient’s residence. The goal of the home health nurse is to improve or maintain the quality of life for their patients, families, and caregivers, and to support their patients (13). 

The ANA developed the Home Health Nursing: Scope and Standards of Practice in 2007. In 2013 they updated and expanded this to the current second edition. This edition delineates the competence level of nursing practice and professional performance expected of home health nurses. The scope of practice defines the expectations of all home health nurses, and the 16 standards give home health nurses guidance and provides a framework for the evaluation of the practice outcomes and goals which they are held accountable for (15).  

The 16 standards of Home Health Nursing Practice are (13):   

Standards of Practice for Home Health Nursing (Standards 1 through 6) 

• Standard 1. Assessment 
  • The home health nurse is responsible for collecting data that is comprehensive and pertinent to the patient’s health and conditions.   
• Standard 2. Diagnosis 
  • The home health nurse is responsible for accurately analyzing the assessment data to determine the concerns, issues, and diagnosis.   
• Standard 3. Outcomes Identification 
  • The home health nurse is responsible to identify the expected outcomes for the plan, which pertains to the patient, family, caregivers, and caregiving situations. 
• Standard 4. Planning 
  • The home health nurse is responsible to develop a plan that includes strategies to achieve expected outcome. 
• Standard 5. Implementation 
  • The home health nurse is responsible for implementing individualized plans of care for their patients.  
• Standard 5A. Coordination of Care 
  • The home health nurse is responsible for coordinating care delivery. 
• Standard 5B. Health Teaching and Health Promotion 
  • The home health nurse provides and implements strategies to promote health and a safe environment.  
• Standard 5C. Consultation 
  • The home health nurse is responsible to provide consultation which influences the plan and effect change.  
• Standard 5D. Prescriptive Authority and Treatment 
  • The home health nurse is responsible for prescriptive authority, procedures, referrals, treatments, and therapies according to state and federal regulations and laws.  
• Standard 6. Evaluation 
  • The home health nurse is responsible in the evaluation of progress towards achieving outcomes.  ‘

Standards of Professional Performance for Home Health Nursing (Standards 7 through 16) 

• Standard 7. Ethics 
  • The home health nurse is responsible to practice ethically. 
• Standard 8. Education 
  • The home health nurse is responsible to acquire knowledge and competence in current nursing practice.  
• Standard 9. Evidence-Based Practice and Research 
  • The home health nurse is responsible to integrate evidence and research into their practice. 
• Standard 10. Quality of Practice 
  • The home health nurse is responsible to contribute to quality nursing practice. 
• Standard 11. Communication 
  • The home health nurse is responsible to communicate effectively in all areas of practice using an assortment of formats.  
• Standard 12. Leadership 
  • The home health nurse is responsible to demonstrate leadership in the profession and professional settings.  
• Standard 13. Collaboration 
  • The home health nurse is responsible for collaboration with other healthcare providers, patients, families, caregivers, and others in nursing practice. 
• Standard 14. Professional Practice Evaluation 
  • The home health nurse is responsible to evaluate their own nursing practice relative to the professional standards, guidelines, statutes, rules, and regulations. 
• Standard 15. Resource Utilization 
  • The home health nurse is responsible to use appropriate resources that promote nursing service that are financially responsible, safe, and effective 
• Standard 16. Environmental Health 
  • The home health nurse is responsible to practice in a safe environment in a healthy manner.  

Code of Ethics for Nurses with Interpretive Statements 

For 22 consecutive years nursing has ranked number one as the most honest and ethical of professions. According to the Gallop poll, 78% of Americans rank the honesty and ethical standards of nursing at the level of high or very high (1).  What contributes to this ranking, and why is nursing considered to be the most trusted profession in America?  Along with being trustworthy, empathetic, compassionate, and having integrity; nurses have a dedicated commitment to ethics and ethical behavior. At the heart of this dedication is the Nursing Code of Ethics, which has provided moral guidance since the 1950s.  

The nursing code of ethics was developed by the American Nurses Association (ANA) to provide guidance in “carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession” (2).  

The ANA nursing code of ethics was last revised in 2015. It consists of nine provisions based on the core values of nursing which are (3): 

• Respect for human dignity 
  • In nursing practice, human dignity is demonstrated when the nurse respects and values patients, co-workers, and colleagues. The nurse also respects the uniqueness of all individuals and populations (3).  
• Integrity 
  • The nurse demonstrates integrity when they are honest and deliver care based on an ethical framework that is professionally accepted (3).  
• Autonomy 
  • Autonomy is the right to self-determination. The nurse should respect the patient’s rights to make decisions about their health care (3).  
• Altruism 
  • Altruism is the concern for the well-being and welfare of others. In the practice of nursing, it is demonstrated by the nurse’s caring for the welfare of patients, other nurses, and other healthcare providers (3). 
• Social Justice 
  • The nurse demonstrates social justice by acting in accordance with fair treatment regardless of age, race, ethnicity, economic status, disability, citizenship or sexual orientation (3).  

The purpose of the nine provisions is to outline the ethical responsibilities of nursing and to provide a framework for ethical practice in nursing (3). The provisions are based on ethical nursing practice and each address one of the following qualities (3).  

• The nurse’s responsibility to uphold patient confidentiality 
• Advocating for patient rights 
• Maintaining competence 
• Ongoing professional development 

The code of ethics expands on these provisions by providing very detailed interpretive statements for each one. The purpose of the interpretive statement is to clarify each provision and to provide guidance in professional conduct and decision-making (3). 

The Nine Provisions with Interpretive Statements  

• Provision 1: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (4).  
  • Interpretive Statements 
  • 1.1 – Respect for Human Dignity 
  • 1.2 – Relationships with Patients 
  • 1.3 – The Nature of Health 
  • 1.4 – The Right to Self Determination 
  • 1.5 – Relationships with Colleagues and Others 
• Provision 2: “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population” (4). 
  • Interpretive Statements 
  • 2.1 – Primacy of the Patients Interests 
  • 2.2 – Conflict of Interest of Nurses 
  • 2.3 -Collaboration 
  • 2.4 – Professional Boundaries  
• Provision 3: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (4).  
  • Interpretive Statements 
  • 3.1 – Protection of the Rights of Privacy and Confidentiality 
  • 3.2 – Protection of Human Participants in Research 
  • 3.3 – Performance Standards and Review Mechanisms 
  • 3.4 – Professional Responsibility in Promoting a Culture of Safety 
  • 3.5 – Protection of Patient Health and Safety by Acting on      Questionable Practice 
• Provision 4: “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and acts consistent with the obligation to promote health and to provide optimal care” (4). 
  • Interpretive Statements 
  • 4.1 – Authority, Accountability, and Responsibility 
  • 4.2 – Accountability for Nursing Judgements, Decisions, and Actions 
  • 4.3 – Responsibility for Nursing Judgements, Decisions, and Actions 
  • 4.4 – Assignment and Delegation. Of Nursing Activities or Tasks  
• Provision 5: “The nurse owes the same duties to self as others; including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth” (4).  
  • Interpretive Statements 
  • 5.1 – Duties to Self and Others 
  • 5.2 – Promotion of Personal Health, Safety, and Well-Being 
  • 5.3 – Preservation of Wholeness of Character 
  • 5.4 – Preservation of Integrity 
• Provision 6: “The nurse through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care” (4).  
  • Interpretive Statements 
  • 6.1 – The Environment and Moral Virtue 
  • 6.2 – The Environment and Ethical Obligation 
  • 6.3 – Responsibility for the Healthcare Environment 
• Provision 7: “The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy” (4). 
  • Interpretive Statements 
  • 7.1 – Contributions through Research and Scholarly Inquiry 
  • 7.2 – Contributions through Developing, Maintaining, and Implementing Professional Practice Standards 
  • 7.3 – Contributions through Nursing and Health Policy Development 
• Provision 8: “The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” (4).  
  • Interpretive Statements 
  • 8.1 – Health is a Universal Right 
  • 8.2 – Collaboration for Health, Human Rights, and Health Diplomacy 
  • 8.3 – Obligation to Advance Health and Human Rights and Reduce Disparities 
  • 8.4 – Collaboration for Human Rights in Complex, Extreme, or Extraordinary Practice Settings 
• Provision 9: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy” (4).  
  • Interpretive Statements 
  • 9.1 – Articulation and Assertion of Values 
  • 9.2 – Integrity of the Profession 
  • 9.3 – Integrating Social Justice 
  • 9.4 – Social Justice in Nursing and Health Policy 

Nursing Principles 

The nursing code of ethics and nursing principles are equally important as they each play a part in guiding nurses’ decision-making and professional conduct. The nursing code of ethics promotes quality of care and safety for patients by providing a framework for ethical decision-making. Nursing principles provide guidance for nursing practice and originate from nursing research and theories. The nursing principles include the following (5).  

• Accountability 
• Nonmaleficence 
• Fidelity 
• Beneficence 
• Autonomy 
• Justice 
• Veracity 

Accountability 

Accountability is a critical ethical principle. This principle demands nurses to adhere to the professional and ethical standards required in the practice of nursing. Nurses demonstrate accountability by taking ownership of their actions, work, and interactions with patients and colleagues. Nurses also need to honest in communication and documentation. The purpose of accountability is to guarantee the actions of nurses correlate with the highest standards of care and conduct (5).  

Nonmaleficence 

Nonmaleficence is a crucial basis of nursing practice. This ensures that nurses prioritize patient safety and not cause patient harm. Nurses should examine the risks and benefits of treatments and attempt to decrease the possibility for harm. Nurses should always promote health (5).  

Fidelity 

Fidelity is a necessary principle in nursing ethics as it addresses providing the best care possible to patients. It promotes truth and reliability in interactions with patients and assists in establishing trust among patients and nurses. Fidelity stresses the components of quality of care including patient autonomy, respect, and dignity (5).  

Beneficence 

Beneficence addresses the promotion of the patients’ well-being and interests. Beneficence focuses on actions that improve health outcomes and the patients’ welfare. This principle makes sure that nurses provide the best quality of care, in addition to providing compassionate patient-centered care (5).    

Autonomy 

Autonomy recognizes the right to make informed decisions regarding care. This principle promotes respect and the empowerment of patients. Nurses empower the patients in making decisions by providing them with options, information, and support. Autonomy focuses on collaboration and communication between patients and nurses which also enriches quality of care (5).  

Justice 

Justice encourages and assists in ensuring equal and fair healthcare to all, regardless of race, gender, age, ethnicity, or social standing. Justice in nursing helps to ensure equal distribution of healthcare opportunities and resources. It is also important in addressing social justice concerns that may affect health. Nurses should also advocate for practice and policy that promotes equity in health (5). 

Veracity 

Veracity is critical in that it highlights integrity, honesty, and truth in the interactions with patients, families, and colleagues. Nurses need to be truthful and transparent when having interactions about a patient’s health status, treatments, and outcomes. Veracity assists in the development of trust between the patient and the nurse, which fosters healing and health (5). 

Morals 

The terminology ethics and morals are often used together, and the two concepts do have similarities. However, they are also different and have unique characteristics.  

Morality is based on ethical reasoning and is the idea of what is right or wrong. This can apply to a society or an individual person. Especially concerning an individual’s behavior (6). Morals have been defined as the goodness of how a person behaves (7). Moral principles dictate how an individual or group will act, behave, or conduct themselves. Everyone has their own set of morals that guide their decision making, actions, and even how they approach patient care (8). 

Moral Distress 

Moral distress in nursing is not uncommon. It is a very complicated and perplexing experience that can have very undesirable outcomes for those involved. The outcomes can be as serious as impacting patient care and advocacy or making the decision to leave the profession (18).  

Moral distress happens when you believe you know the ethically correct action to take, but constraints, conflict, uncertainty, or dilemmas make it impossible to take the right action. A key characteristic of moral distress is that it threatens core values and has ethical implications (18).  

Moral distress can result in physical, emotional, or psychological symptoms, and can be a result of common situations encountered in the profession of nursing. Some of these include (18): 

• Inadequate staffing 
• Lack of resources 
• Pressure to decrease cost 
• Ineffective communication 
• Working with incompetent coworkers 
• Bullying 
• Lack of a healthy work environment 
• End of Life choices 
• Value conflicts 
• Conflicting team dynamics 
• Implementing unnecessary treatments 
• Witnessing inadequate pain relief 
• Providing false hope to patients 

It is important for nurses to be aware of and knowledgeable about moral distress and what to do about it if it is encountered. If a nurse is in a situation involving moral distress, there are four key components to address (18).  

• Determine what you are experiencing 
  • It is important to distinguish between moral distress, compassion fatigue, or burnout. All of these can cause distress but involve different strategies. 
• Identify the causes 
  • It is important to identify and recognize what factors and situations have contributed to the moral distress. This knowledge will be important in determining what steps should be taken. 
• Determine the severity of the distress 
  • Rate your distress and become familiar with symptoms you are experiencing. This will assist in determining strategies to address the distress.  
• Take action that will help you to move forward  
  • Become familiar with and consider options addressing moral distress. Become familiar with available resources. Explore the resources offered by the organization. 

Values 

Professional values in nursing also provide guidelines for professional behavior and can be defined as standards of acceptable actions that can be used to evaluate the integrity of individuals or organizations. Professional values are based on personal values that have been influenced by culture, environment, family, ethnicity, and religion (9). Nursing values can be thought of as the moral knowledge which guides ethical behaviors and attitudes of nurses. It promotes quality patient care and assists in developing nurse-patient relationships and interprofessional relationships (10).  

Because nursing has been identified as a trusted profession, it is important to recognize its professional ethics and values. Nursing values consist of the following (9, 10).   

• Respect for human dignity 
• Integrity 
• Altruism 
• Social justice 
• Diversity 
• Ingenuity 
• Compassion 
• Trustworthiness 
• Ethical 
• Advocacy 
• Accountability 
• Curiosity 
• Autonomy 
• Precision 
• Empathy 
• Professionalism 
• Desire for excellence 
• Dedicated to learning 

Respect for Human Dignity 

A very important value in nursing is to respect the dignity of patients. A nurse should treat their patients with thoughtfulness, kindness, and caring. The nurse should be respectful of patient’s rights and privacy. The nurse should respect every person’s individuality and uniqueness. The value of dignity includes all components of patient care and rights including respect, autonomy, and privacy.  

Integrity 

The nurse should provide ethical quality care and make honest moral decisions. Qualities of integrity include being honest, fair, and adhering to a code of moral values and principles. Integrity in nursing results in positive patient outcomes, and strong work environments, and promotes integrity in others.   

Altruism 

The nurse should be considerate of the well-being of their patients and their co-workers. This includes advocating for the best treatment for patients. An important component of altruism is the nurse does not expect anything in return. The value of altruism promotes a positive and willing approach in caring for others.   

Social Justice 

The nurse should support all moral and legal standards for all patients. Care and treatment should be provided equally to all patients. Social justice can also be provided by listening to the needs of patients.  

Diversity 

The nurse should value diversity and recognize the differences among patients, peers, and colleagues. This includes recognition and acceptance of lifestyles, experiences, and interests. This promotes the development of culturally competent care.  

Ingenuity 

This value promotes and encourages critical thinking in providing and creating treatments which help patients. Ingenuity is defined as the quality of being inventive, original, and clever, and encourages evidence-based decision-making and critical thinking.  

Compassion 

This is considered a key component in giving quality care. It is another very important value as compassion assists patients in feeling respected. The nurse can demonstrate compassion by listening to patients, responding quickly to their concerns, and treating patients in a kind manner. Compassion is the ability to show sensitivity to others and to understand their feelings. Compassion in nursing results in patient satisfaction, safe environments, and increased confidence among nurses.   

Trustworthiness 

To demonstrate trustworthiness the nurse should show interest in the patient’s care, answer their questions honestly, and provide them with accurate education and information. Recovery is better and stress is less in patients who trust their healthcare providers. The characteristics of trustworthiness include honesty, reliability, and competence.  

Ethical 

This value relates to the morals and principles of morality. The nurse should understand the difference between right and wrong. Nurses should possess a moral compass which assists in guiding them in performing their job. Ethical behavior results in good quality of care and positive patient outcomes.  

Advocacy 

Advocacy in nursing is any act the nurse performs on behalf of the patient. Advocacy is an influential nursing value. Nurses should question and speak up for their patients.  

Accountability 

This is one of the most important values in nursing. This is being accountable for and acknowledging your actions. It also means learning from your experiences and mistakes as a nurse. Accountability is significant as it holds the nurse responsible and is a commendable professional value.  

Curiosity 

This value promotes learning and the improvement of skills. In addition to helping in identifying personal goals in nursing, curiosity encourages the nurse to ask questions. The nurse should maintain a desire to learn, this value stimulates a culture of continuous learning. This value is essential in the development of critical thinking and clinical reasoning skills.  

Autonomy 

Autonomy allows nurses to make decisions and act within their knowledge base and scope of practice. This results in innovation, promotes involvement, increases critical thinking, and increases patient satisfaction.  

The nurse should respect and should not try to influence patient’s healthcare choices. The nurse should also educate patients on their options without bias, and they should support their patient’s decisions.  

Precision 

This value addresses accuracy and exactness. The nurse should be willing to review their past work and explore ways to improve skills. Accurate nursing care promotes a safe practice environment and positive patient outcomes.  

Empathy 

Being empathetic allows the nurse to see a situation from the perspective of their patients. The ability to do this provides the nurse with a better understanding of their patient and the patient’s treatments. Empathy also helps the patient to be less stressed and more comfortable. As nurses practice empathy, they become more skilled at assessing their patients. The value of empathy encourages positive attitudes and respect, along with promoting ethical decision-making.  

Professionalism 

The value of professionalism is the standard in which performance and reputation is measured. This includes patient care, attitude toward patients and colleagues, and the ability to work in a team. Maintaining the standard of professionalism is very important as it demonstrates an understanding of the importance of nursing as a profession, and the dedication to perform it well. Professionalism in nursing includes the values of respect, integrity, and accountability.  

Desire for Excellence 

Nurses should value a commitment to providing excellent service and care. They should also work on improving their knowledge to provide quality support and care to patients.  

Dedicated to Learning 

Nurses should be willing to advance themselves to the next level and take opportunities to increase their knowledge and skills. The nurse should have a dedication to lifelong learning. This creates chances for expanded roles and increases their knowledge and skills which result in improved patient care. 

Ethical Dilemmas 

Nurses face ethical dilemmas on a regular basis. Frequently, they will encounter situations where they will have to make difficult decisions. The nurse may have to make a choice between two or more options, and sometimes the choices might not align with the nursing code of ethics. The choices may be conflicting between the nurses’ values, morals, or the code of ethics. This is an ethical dilemma (11).  

There are many situations that could be considered an ethical dilemma for a nurse. The following are some examples of ethical dilemmas nurses may encounter (12).  

Patient Autonomy versus Beneficence 

An example of this could be a patient with diabetes that refuses to take their insulin, even though it controls their blood sugar levels.  

This involves the patient’s right to make decisions regarding their care and the nurse’s role is to promote their overall well-being. This involves following the code of ethics. This includes respecting autonomy, providing information, assessing the patient’s understanding, collaborative decision-making, seeking additional perspectives and documenting the process.  

Confidentiality versus the Duty to Warn 

An example of this could be a violent patient who confides in the nurse their intent to seriously harm their partner. 

This addresses the dilemma of maintaining patient confidentiality considering the possibility of harm to someone if information is not shared. This involves the nurse evaluating the severity of the threat, engaging the patient in a therapeutic relationship, seeking supervision and consultation, following legal and ethical guidelines, and documenting the process.  

End of Life Care 

This is a very complex ethical dilemma as it is a conflict between the wishes of the patient and respecting the family’s feelings and concerns. Patient wishes, quality of life, and family dynamics must be considered.  

An example of this could be a patient with a terminal illness who expresses the wish to die without lifesaving interventions. The patient’s family does not agree with this and wants everything possible to be done for their dying family member.  

This involves the nurse engaging in open and honest communication and education, respect for autonomy, collaboration, mediation, use of ethical decision-making frameworks, and supportive care.   

Resource Allocation 

This addresses the fair distribution of limited resources among patients. 

An example of this could be the decisions the nurse must make when determining which patient receives resources when the resources are limited, and the facility is overwhelmed.  

This involves the nurse managing the dilemma with fairness and transparency and using the steps of prioritization and triage, open communication, ethical decision-making frameworks, and advocacy and support.     

Informed Consent 

Informed consent is confirming that patients have the correct understanding of the risks, benefits, and alternatives to treatments or procedures before they provide their consent to them.  

An example of this dilemma could be a patient who is anxious, in pain and is rushed to give consent to their surgery. The nurse should recognize the patient’s incomplete understanding of the surgery and identify the ethical dilemma regarding informed consent.  

To address this situation the nurse should ensure adequate information about the procedure, clarify patient understanding, advocate for time and support, and document the process.  

Cultural and Religious Beliefs 

Nurses may encounter ethical dilemmas when a patient’s cultural or religious preferences, values, or beliefs conflict with standard practices in healthcare.  

An example of this could be encountered when caring for a patient who believes in traditional health methods and does not accept Western medicine.   

In this situation the nurse should demonstrate respect for diversity and establish trust and rapport, complete a culturally competent assessment, use collaborative decision-making, use consultation and education, and advocate for the patient.  

Impaired Co-worker or Colleague 

This ethical dilemma occurs when the nurse struggles with the responsibility of reporting concerns about a co-worker or colleague’s impairment due to substance abuse or mental health concerns. 

An example of this could be noticing a co-worker that is impaired on duty. The nurse observes signs of impairment including bizarre behavior and the smell of alcohol. The nurse experiences the ethical dilemma of ensuring patient safety and being loyal to their colleague.  

The nurse should put patient safety first and act professionally. Steps taken to address this could include immediate concern for patient safety, reporting, confidentiality and professionalism, collaboration and support, and ethical obligation.    

Professional Boundaries 

Professional boundaries are a common ethical dilemma involving personal relationships with patients. It involves a balance between providing care and maintaining appropriate professional boundaries.  

An example of this ethical dilemma could occur when a nurse develops a personal and close relationship with patient. The nurse shares personal details that are unrelated to the patient’s care or needs.  

The nurse should always maintain professional boundaries and act in the best interest of the patient by using these guidelines. The nurse should recognize the boundary issue, re-establish boundaries, reflect on the nurse-patient relationship, seek guidance and supervision, and continuous professional development.  

Whistleblowing 

Reporting unethical practice or misconduct in the healthcare system can be an ethical dilemma. The nurse may fear professional or personal repercussions.  

An example of this ethical dilemma would be a nurse who discovers a co-worker has been stealing narcotics from the medication supply. The nurse recognizes this comprises patient safety and professional standards and reports this to the supervisor. However, the nurse is also concerned about the co-worker being disciplined.  

The nurse should include the following in their actions related to this dilemma. The nurse should gather evidence, consult with colleagues, follow the chain of command, be familiar with protection and confidentiality, and document everything that occurs. 

Case Studies 

Case Study One 

The home health nurse is assigned to make home visits and care for Mr. Jones. Mr. Jones is an 80-year-old male diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Diabetes. Mr. Jones lives alone in a rural area with no family nearby. The home health nurse visits three time weekly and assists with medication administration, monitoring vital signs, and overall activities of daily living and cares.  

During the last visit, the home health nurse notices Mr. Jones home is more cluttered, unclean, and unsanitary. The house has deteriorated to the point where the home health nurse becomes concerned for Mr. Jones safety.  

Mr. Jones is also refusing to take a new medication prescribed for his COPD. The home health nurse provides Mr. Jones with education regarding the medication and explains the risks versus benefits. Despite this effort, Mr. Jones continues to refuse the medication.  

When the home health nurse expresses their concern to Mr. Jones, he becomes slightly agitated and insists he can maintain his home and manage on his own. He refuses the offer of extra assistance, or the option of moving into an assisted living facility.    

1. What ethical dilemmas can be identified in this scenario? 
2. Identify the nursing principles that should be considered in this scenario? 
3. Compare and contrast the different options the home health nurse should consider in this scenario.  
4. What nursing values should the home health nurse use as guidance in this scenario? 

Case Study Two 

The home health nurse has been providing care for Ms. Smith, a 72-year-old woman, with advanced Alzheimer’s Disease. The home health nurse has been providing care in Ms. Smith’s home three times weekly for the past six months. The patient’s daughter Mary also lives in the home and has become the primary caregiver. During the visits the home health nurse assists with medication management, monitoring vital signs, assessing, and monitoring physical and mental status, and providing support and education to the patient and caregiver. During her visits in the past month the home health nurse has noticed that Mary seems to be overwhelmed, anxious, and is struggling to provide the basic care for her mother.  

During a recent assessment of the patient the home health nurse notices bruising on Ms. Smith’s arms and hands. When queried about this, Mary becomes very evasive and defensive, stating that her mother “bumps into things.”  

During her last visit Ms. Smith was confused and stated she wanted to go home and get out of this place. She also repeatedly stated that Mary yells at her, scares her, and hurts her sometimes. Mary persists that her mother has accidents which result in her bruises.  

1. Identify the ethical dilemma the home health nurse is faced with in this scenario. 
2. Discuss the ethical principles involved in this scenario. 
3. Analyze steps that could be taken by the home health nurse that would address Mary’s caregiver burnout. 
4. Discuss the home health nurse’s responsibility in this scenario. 

Case Study Three 

A new home health nurse has been assigned to visit and provide care for Donna, a 57-year-old female with terminal cancer of the pancreas. Donna lives with her husband, who is her primary caregiver. The home health nurse visits three times weekly and provides medication administration, pain management, and education and support to the patient and caregiver.  

During her past few visits, the home health nurse has noticed the patient has had increasing pain despite the use of pain medication. During the last visit the pain appeared to be severe. The patient confirmed the severity and worsening of the pain. The patient verbalizes that she would like more pain medication, which includes opioids. The home health nurse has discussed the risks versus benefits and the patient has verbalized understanding. 

Donna’s husband is against the increase in pain medications and fears that this would lead to addiction to opioids, and possibly hasten Donna’s death.  

1. As a new home health nurse what additional steps and resources should guide the decision-making process in this scenario? 
2. Identify the ethical principles in this scenario. 
3. Discuss how the home health nurse should address the conflict between patient and spouse/caregiver. 
4. Compare different methods the home health nurse could use to provide emotional support to both the patient and spouse/caregiver. 

Case Study Four 

The home health nurse has been caring for Alfred for over a year in his home. Alfred is a 68-year-old male with chronic health conditions. The home health nurse visits weekly and provides medication management, assessment, and monitoring of physical and mental status, monitoring vital signs, and assisting with general care. The past several months Alfred has become more isolated and starts to share with the home health nurse that he is lonely. He has started to ask the home health nurse to stay longer than her scheduled visits. He also has attempted to give the home health nurses money and gifts. The home health nurse has attempted to explain to Alfred why it is inappropriate to accept these gifts. However, on one visit Alfred appeared so hurt by her refusal, she accepted the gift of $100 dollars. Alfred stated it was well worth her company.  

1. Identify the ethical dilemma the home health nurse faces in this scenario. 
2. List and explain the nursing principles related to this scenario. 
3. Explain how morals could have changed the home health care nurses’ actions in this scenario. 
4. Analyze what nursing principles could provide the home health care nurse with guidance in this scenario. 

Conclusion

Home health nurses rely heavily on the guidance of the code of ethics in nursing as they primarily work independently. Home health care ethics is a complex domain that involves critical thinking, sensitivity, and the desire to do what is right for the patients. Understanding the importance of the nursing code of ethics is imperative in this role (16).  

It is apparent that the home health nurse will encounter ethical dilemmas during their career. It is important that the home health nurse be aware of the frameworks and guidelines available to them to guide them through these situations.   

Home health nurses should be familiar with the scope and standards of practice for home health nursing (and the 16 standards it contains), the code of ethics for nurses with interpretive statements, nursing principles, morals, values, and possible ethical dilemmas. These all provide valuable guidance as the home health nurse navigates the arena of home health care nursing.  

Working in home health care can be very rewarding for the nurse that chooses this path. These nurses have the opportunity to work directly in their patients’ homes, getting to know their patients and having access to a more personal relationship. Other benefits of becoming a home health nurse include (19):  

• Having a flexible schedule 
• Having independence and autonomy 
• Opportunity to care for diverse patient populations 
• Develop rewarding patient relationships 
• Make an impact on patients and their families 

If the home health nurse uses the code of ethics for nursing as their moral compass to guide their practice, they should provide a high standard of care to their patients, along with enjoying all the rewards and benefits that accompany being a home health nurse.  

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