Welcome to the Professional Ethics Nursing Education Module

 

Nursing students at every level of nursing education grapple with the concept of professional ethics because it can be difficult to translate to the real world of clinical practice. This module engages the student by applying professional ethical concepts to caring for the sexual and reproductive needs of patients, specifically regarding unintended pregnancy prevention and care.

This module provides a framework for discussing ethical clinical issues in nursing practice as they relate to unintended pregnancy prevention and care using the ANA Code of Ethics for Nurses with Interpretive Statements as the foundation. The biomedical principles and theoretical modules that form the basis of ethical statements are also discussed. This module supports students in developing their understanding of the right of the nurse to invoke a conscientious objection with the competing priority of the patient’s right to health care.

How to Use This Module 

Provide’s Nursing Education Curriculum is designed for a flipped classroom model to incorporate unintended pregnancy prevention and care into existing curricula.

Students are encouraged to complete the Pre-Assessment below and then work through the module. Definitions and Orienting Facts provide context for the Patient Situations, which are clinical scenarios designed to raise critical issues and questions to put unintended pregnancy prevention and care in the context of Professional Ethics. Students may complete the Recommended Reading at any time while going through the Patient Situations. Please complete the Post-Assessment after finishing the module.

Faculty are encouraged to open the Faculty Guide tab below to access teaching tips, exercises and handouts for incorporating module content into the classroom, and to learn more about obtaining a “Site Code” to download and access students’ Pre- and Post-Assessment data.

Pre- and Post-Assessments

Please complete the Pre- and Post-Assessments. A new window will open to a Survey Monkey Pre-Assessment and the window must remain open while you work with the module. Once you have completed the module you will return to the Survey Monkey window to complete the Post-Assessment. If your faculty requires completion of this module as a course requirement, please check with them about due dates and credit allocations.

Relevant UPPC Essential Competencies

Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education (Hewitt, C. and Cappiello, J., 2015) 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education which provide a framework for curricular development in an important area of nursing education. The following competencies are relevant to this nursing education module.

  1. Demonstrate knowledge of the nurse’s professional ethical responsibilities in providing health care to clients.
  2. Demonstrate the ability to provide unintended pregnancy prevention and care that is free of evidence of bias and judgment.
  3. Demonstrate ability to recognize unique reproductive health needs of women from vulnerable and special populations (e.g. adolescents, women with mental or physical disabilities, survivors of violence) affected by many factors (e.g. relationship status, sexual orientation).
  4. Demonstrate ability to identify personal beliefs that may interfere with provision of nursing care.
  5. Demonstrate ability to apply the ethical principles of respect for autonomy, beneficence, non‐malfeasance, and justice as they relate to the care provision.

Learning Objectives

  • Define the four bioethical, biomedical principles
  • Demonstrate an understanding of the professional nursing code of ethics
  • Apply the application of bioethics and nursing codes of ethics to UPPC
  • Compare and contrast four professional nursing organization’s ethical statements as relates to UPPC
  • Identify four health disciplines’ application of professional ethics to UPPC

Bioethical principles:  The four bioethical principles that provide the underpinnings for health care codes of ethics include respect for autonomy of patient decision-making, beneficence (positive steps taken to help others), non-malfeasance (the principle that refers to do no harm), and justice (also referred to as fairness) which describes equity in the distribution of health care resources (Beauchamp and Childress, 2001).

Conscience:  The concept of “conscience” has three characteristics: an inner sense that distinguishes right from wrong, the internalization of parental and social norms, and a reflection of the integrity and wholeness of the person (Benjamin, 2004).

Nursing Code of Ethics:  The American Nursing Association (ANA) Code of Ethics for Nurses with Interpretive Statements provides a framework for nurses to use in ethical analysis and decision-making.

Professional Codes of ethics:  Developed by professional organizations, codes of ethics makes explicit the goals, values, and obligations of the profession.

  • Professional organizations articulate broad ethical principles to govern the practice of their discipline. The profession of nursing has embraced ethical principles to guide the provision of care since the time of Florence Nightingale.
  • Guide to the Code of Ethics for Nurses: Developed in 1950, the Code of Ethics for Nurses (ANA, revised 2015), Provision One states that the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Provision Three states the nurse promotes, advocates for and protects the rights, health, and safety of the patient.
  • The right of conscience or more commonly referred to as conscientious refusal is the right of the health care professional to refuse to provide care or dispense medication. After the 1973 Supreme Court decision Roe v. Wade, the federal government enacted refusal clauses in health legislation to extend protection to physicians, nurses, and other health care workers who chose not to perform procedures such as abortions and sterilizations.
  • After 1973, most states enacted conscientious refusal legislation similar to the federal government. More recently, many states have extended conscientious refusal to include pharmacists and, in some cases, unlicensed professionals. A few states have expanded contentious refusal language to include the right to refuse to provide or dispense contraception, including emergency contraception. This expansion of conscientious refusal is the source of considerable public debate.
  • At the institutional level, particularly within faith based hospital systems, health care workers are prohibited from discussing contraceptive options, including emergency contraception and pregnancy options.
  • It is likely that many nurses will care for a woman with an unintended pregnancy. According to Finer and Zolna (2014) half of pregnancies among American women are unintended, and four in 10 of these are terminated by abortion. Nurses working in reproductive health settings may encounter this more than nurses working in other settings. However, nurses in other settings will encounter women with unintended pregnancy as well. For example, when providing education regarding medication, it is important to assess the risk of pregnancy in any woman of reproductive age when discussing medication side effects and interactions.
  • Gallup’s annual Values and Beliefs survey (May 2014) reports that U.S. adult population position of abortion is split when asked if they self -identified as “pro-choice” or “pro-life”: 47% “pro-choice”, 46% “pro-life.”

Each scenario described in this module is broken into sections to enable self-guided learning. Detailed information is provided on the patient and the setting in addition to the patient scenario that deals with the complex and often controversial nature of unintended pregnancy prevention and care.

Caring for Sara (Patient Situation #1)

The Patient

Sara is a 22 year-old woman with a complex medical history. She is 10 weeks pregnant. Sara is obese (BMI of 35) with a previously diagnosed bicornuate uterus and a history of severe anemia.

The Setting

Dr. Houston is a physician in a small rural community who runs an office-based practice with admitting privileges to the local community, nonprofit hospital. This is not a religious based institution. There are no family planning or abortion clinics in the community, so several private doctors offer abortions at their offices to their own patients to ensure access to these services in the area. These services are not advertised so the doctors and their patients do not have to deal with harassment from members of the anti-choice community.

What Happened

Sara comes to Dr. Houston requesting an abortion. After performing an ultrasound, Dr. Houston decides to perform a first trimester aspiration procedure for Sara in the hospital setting. While this is not always necessary, Dr. Houston thought the procedure would be easier if she were able to use anesthesia to relax the musculature, which would make the procedure easier for her and more comfortable for the patient.

Having just been scheduled that morning, the nurses are surprised by the presence of an abortion case on the operating room list. Dr. Houston had not thought to discuss the case in advance with the nursing staff, assuming that there would not be any issues. However, this is a case the nursing staff have not encountered previously and they are uneasy about how to care for a woman seeking abortion care. One nurse states that she does not believe in abortion and thus should not have to care for this woman. A nurse states that she does not believe in abortion and thus should not have to care for this woman. She tells Dr. Houston that she cannot participate in Sara’s care. The other nurse on duty decides to act similarly.

Can the nurses refuse to care for Sara?

Dr. Houston cancels the procedure because she had not foreseen problems with treating Sara’s case in the hospital. Over the next several days, the Clinical Nurse Specialist assigned to the unit initiates individual discussions with nurses about invoking conscience clauses with the goal of understanding this particular incident and to better understand each nurse’s ethical stance for future situations that may arise.

It is necessary for nurses to have opportunities to engage in self-reflection and values clarification regarding the intersection of personal beliefs and professional responsibilities. Staffing dilemmas such as this one are more likely to occur in a unit that does not frequently care for such patients.

Invoking conscience clauses and the history of conscientious objection

Nurses engage in values clarification to sort their personal ethical stance on a variety of issues. Each nurse invokes his/her right to refuse an assignment based on their ethical beliefs, their understanding of nursing professional code of ethics and their understanding of their right to invoke conscientious objection. What if the nurse is unsure or confused about his/her convictions?

In terms of the patient, her procedure is delayed. Sara had arranged for her sister to spend the day with her and drive her home from the hospital. Her sister, Marie, took the day off of work with short notice and is uneasy about asking for another day off so soon with little notice. It was difficult to find a colleague to change shifts with her. She is not sure that she can be available to accompany Sara when/if the procedure is re-scheduled. Sara’s partner has recently started a new job and he is unable to take time off during the day. Sara is upset with the cancellation of her procedure; she has significant nausea and vomiting. She had been NPO (which was difficult for her), had arrived at the hospital by 7:00am and was sent home. Dr. Houston told her there was a nursing staffing problem but Sara heard some of the staff discussing the issue with the nurses. Sara felt ashamed of her situation and very angry that she does not know what will happen.

One nurse decides to provide nursing care for the patient. After reflection, the nurse determines that she can ethically provide care and respect the woman’s decision to terminate her pregnancy.

How did this nurse decide she does not have a conscientious objection to caring for Sara?

The nurse who decides to proceed with caring for Sara shares that she remains uncomfortable caring for Sara as she does not know the post-procedure care involved. This nurse administrator contacts the nursing education department to assist the nurse with understanding the appropriate care for Sara. The other nurses decline to be involved in Sara’s care. However, with one nurse to provide care, Sara is able to have her abortion procedure scheduled four days later.

What happens when one nurse decides to provide (or not provide) an abortion procedure when other nurses are making a different choice?
The culture of a work environment can have an impact on a nurse’s decisions to participate or not participate in the care of a patient. In some settings, the nurse who agrees to provide abortion care may experience negative comments from her/his colleagues. A 2008 review of the literature by Lipp on nurses who participate in abortion care reports that nurses who participate in abortion care, as well as those whose refused, had been criticized by their co-workers. A small qualitative study by Kade et al. (2004) showed that more than one third of physician respondents reported that they had to postpone abortion services due to a lack of nurses willing to assist. Gallagher et al. (2010) suggests that the support of the team is essential in providing abortion care, and that is just what happened in this scenario.

In Sara’s case, she was able to have the procedure she needed, however, postponements due to staff unwillingness to participate in care, or lack of knowledge, can be extremely detrimental to patient health.

Nurses who choose to not participate in abortion care can support the beliefs of nurses who choose to exercise their right of conscience to provide abortion care.

Nurses continue to face ethical dilemmas in reproductive health care that challenge their personal beliefs, their role as patient advocate and their belief in and respect for patient autonomy in decision-making and right to care. Professional nursing organizations can provide guidance and opportunities for nurses to discuss the application of ethical frameworks to complex ethical cases.

What If…

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

The nurses began Sara’s care and then decided to invoke a conscience clause?
American Nurses Association articulates the nurses’ duty to patients. Nurses must not abandon their patients: “Once a nurse begins treating a patient, she or he is legally bound to care for that patient until another nurse is available to assume responsibility for the patient” (Lachman, 2014).

In the case scenario, the nurse had not yet begun to care for Sara, however, the hospital had begun to care for Sara. This complicates the situation for the patient. In an ideal world, any nurse with a conscientious objection to caring for a woman with an abortion would have communicated this to her nursing colleagues at the time of her employment. In addition, in an ideal world the physician would have communicated with nursing staff prior to scheduling Sara’s case, since this was an unusual situation in that the physician has not previously scheduled abortion cases in the hospital.

Providers who decide not to perform abortions primarily because they find the procedure unpleasant or because they fear criticism from those in society who advocate against it do not have a genuine claim of conscience. Nor do providers who refuse to provide care for individuals because of fear of disease transmission to themselves or other patients. Positions that are merely self-protective do not constitute the basis for a genuine claim of conscience.

The nurse should communicate a conscientious objection in advance in order for patient care to occur uninterrupted. The nurse may not abandon the patient, meaning in an emergency, care must be provided regardless of the ethical perspective of the nurse. In addition, if the nurse engages in care with the patient, the nurse may not withdraw providing care until alternative nursing staffing is available. The patient must not suffer.

Values clarification work

Exercise in Professionalism
These exercises from the Medical University of South Carolina are designed to help learners tease out their values related to abortion care and how their values may impact the care nurses can provide to patients experiencing unintended pregnancy.

The Abortion Option: A Values Clarification Guide for Health Care Professionals
These exercises from the National Abortion Federation are designed to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are used to identify and examine potential biases.

Caring for Elena (Patient Situation #2)

The Patient

Elena is a 38 year-old woman who is 22 weeks pregnant. Although she and her husband did not plan the pregnancy they decided to continue the pregnancy early on. Their other children are ages 10 and 15.

The Setting

A large religious based institution hospital downtown that serves hundreds of patients every day.

What Happened

Elena began experiencing heavy cramping, bright red bleeding and thinks her membranes ruptured. She and her husband went to the ER immediately, where she was put on bed rest and prepared for an examination and ultrasound. Her obstetrician reviewed the risks and a consultation with a neonatologist was ordered.

What is the evidence-based standard of care in this situation?
Survival rates for 22 week fetuses are low, averaging 0% – 10% (Brumbaugh et al., 2014), and survival without significant disabilities is rare. ACOG practice guidelines require that the pregnant woman should be counseled about all the risks and benefits of continuing her pregnancy without intervention (ACOG, 2007).

The National Organization of Nurse Practitioner Faculties (NONPF) articulates NP core competencies in the 2012 publication of Population-Focused Nurse Practitioner Competencies:

  • Works to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration.
  • Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect.
  • Incorporates the patient’s cultural and spiritual preferences, values, and beliefs into health care.
  • Preserves the patient’s control over decision making by negotiating a mutually acceptable plan of care.

In The Denial of Abortion Care information, Referrals, and Services Undermines Quality Care for U.S. Women Weitz and Fogel carefully craft an argument about how conscience clauses affect adherence to evidence-based benchmarks of quality and safety in abortion care.

The team suggests a non-interventionist plan of watchful waiting rather than intensive management with prenatal steroids and aggressive pulmonary treatment. What clinicians do not explain to Elena and her husband that, given her symptoms, there is a  low risk of survival of the fetus (Brumbaugh et al., 2014) and the rare, but real, risk of sepsis to the mother. Furthermore, they do not tell Elena and her husband that they have the option to terminate the pregnancy at this point, given the risks.

Why would a nurse choose to ignore evidence-based standards of care?
Standards For Professional Nursing Practice in the Care of Women and Newborns Standard X: Nurses have the right, under responsible procedures, to refuse to assist in [. . .] abortion or sterilization procedures, in keeping with their personal moral, ethical, or religious beliefs. Nurses have the professional responsibility to provide high quality, impartial nursing care to all patients in emergency situation, regardless of the nurses’ personal beliefs [. . .] and to provide nonjudgmental nursing care to all patients, either directly or through appropriate and timely referral.

While nurses have the ethical responsibility to implement and adhere to nursing practice standards, there is increasing evidence that political and institutional restrictions are jeopardizing patient health as well as nurses’ ability to adhere to an ethical standard of care. Institutions that impose ideological restrictions on health care delivery have assumed increasing control of hospitals, clinics and managed care systems in the United States. The standard of care is most often restricted based on ideology and personal belief are those related to reproductive health care. (See: Ethical and Religious Directives for Catholic Health Care Services).

These organizations often impose limitations on the health care the clinicians in their systems can offer, essentially preventing health care professionals from delivering the care they were trained to provide. The International Federation of Gynecology and Obstetrics states that reproductive and sexual health of women is often compromised, not necessarily because of lack of medical knowledge, but rather as a result of basic infringements of women’s human rights that also violate the basic and universally agreed upon ethical and professional responsibilities of professionals caring for women. (See the ACLU’s 2013 report Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care).

In addition, providers working religious-based institutions, or highly religious communities, may face not only criticism, but there may be risks to employment as was the case for a nun who supported the decision to provide abortion care that saved a woman’s life in Arizona.

The couple receives extensive and focused care from the nursing staff but, since this is a religious-based institution, they cannot discuss all options with the couple. After considerable discussions with the health care team, as well as with family and friends, the couple decide (on their own) to leave the hospital. They want to have a discussion about terminating the pregnancy and feel they cannot receive the information they need to help them make a decision while at the hospital. They leave the hospital and contact an obstetrician gynecologist at another facility three hours drive away. They arrange to be seen and discuss all options for their extremely premature baby. An abortion procedure is scheduled at their request.

What If...

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Elena were 26 weeks pregnant?
The odds of fetal viability increase so Elena would likely be admitted to a tertiary care maternity setting for intensive management. It is unlikely that she would have been given information on all of her risks and options at this particular religious-based hospital.
The religious-based hospital had been able to provide all options for a very early premature rupture of pregnancy?
The discussion and resultant search for care would have been less traumatic for the couple. Nursing staff would have conducted a thorough discussion of options at the initial time of admission to the hospital so that the couple would be fully informed as they made this important decision. Once the couple made a decision based on the most current evidence, if they chose to terminate the pregnancy, the hospital could have made a referral for services they do not provide.

Code of Ethics

Code of Ethics for Nurses with Interpretive Statements (ANA, 2015)
Established the ethical standard for the profession and provides a guide for nurses to use in ethical analysis and decision-making.

The International Council of Nurses Code of Ethics (2012)
The ICN Code of Ethics for Nurses, fist adopted in 1953, is a guide for action based on social values and needs. The Code state that inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect and supports nurses’ refusal to participate in activities that conflict with their caring and healing.

American College of Nurse Midwives Code of Ethics (2005)
Certified nurse-midwives and certified midwives have three ethical mandates: the first mandate is directed toward the individual women and their families; the second mandate is to a broader “public good” for the benefit of all women and their families; and the third mandate is to the profession of midwifery to assure its integrity.

FIGO Code of Ethics
The International Federation of Gynecology and Obstetrics and states that reproductive and sexual health of women is often compromised, not necessarily because of lack of medical knowledge, but rather as a result of basic infringements of women’s human rights that also violate the basic and universally agreed upon ethical and professional responsibilities of professionals caring for women.

A Short History of Medical Ethics (Jonsen, A., 2000)
This book provides an overview of the evolution of medical ethics in both Western and Eastern culture and applies medical ethical theory to modern medical science and technology challenge the settled ethics of the long tradition.

Bioethics Beyond the Headlines: Who Lives? Who Dies? Who Decides? (Jonsen, A., 2005)
Jonsen applies key questions in bioethics to complex, modern health care issues, including euthanasia, assisted reproduction, cloning and stem cells, neuroscience, and access to healthcare.

Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (Jonsen et al., 2006)
The authors teach a clear Four-Topics method of questions about medical indications, patient preferences, quality of life, and contextual features to aid in thinking about clinical ethical issues.

American Pharmacists Association Code of Ethics
The Code defines the principles that form the fundamental basis of the roles and responsibilities of pharmacists. These principles, based on moral obligations and virtues, are established to guide pharmacists in relationships with patients, health professionals, and society. The most pertinent principles to the provision of reproductive health care state:

  • III.  A pharmacist respects the autonomy and dignity of each patient: A pharmacist promotes the right of self-determination and recognizes individual self-worth by encouraging patients to participate in decisions about their health (…) respecting personal and cultural differences among patients.

Conscientious Refusal

Professional Right of Conscience (Beal, M., and Cappiello, J., 2008)
In this article, the literature on provider right of refusal is reviewed along with the approaches advised by professional nursing associations.

Conscientious Objection in Nursing: Definition and Criteria for Acceptance (Lachman, V. D., 2014)
Lachman provides of review of conscientious objection in nursing with reference to the ANA Code of Ethics and Magelsson’s criteria.

Dishonourable Disobedience – Why Refusal to Treat in Reproductive Healthcare is Not Conscientious Objection (Fialaa, C. and Arthur, J., 2014)
In medicine, the majority of conscientious objection is exercised within the reproductive health care.  According to the authors, current laws and practices suggest that conscientious objection impacts women’s healthcare and rights negatively. Healthcare professionals who exercise conscientious objection are using their position of trust and authority to impose their personal beliefs on patients, which is a failure to perform one’s professional duty.

The Limits of Conscientious Refusal in Reproductive Medicine (ACOG, 2007)
The ACOG Committee on Ethics developed a specific ethical statement on the provision of reproductive health care: Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled.

Health Care Refusals: Undermining Quality Care for Women (Weitz, T.A., and Fogel, S.B., 2009)
This report from the National Health Law Program provides background and analysis of the ethical and legal concepts of standards of care and informed consent, and then analyzes religious, ideological and political restrictions and denials of care that conflict with and undermine established clinical and professional standards. It also provides detailed descriptions and analysis of the standards of care that govern health professional practice for a range of common health conditions and illustrates how refusals and denials of care violate those standards and put population health at risk, particularly sexual and reproductive health. This analysis provides a new framework for evaluating refusal clauses and denials of care, hospital mergers, and other transactions when they conflict with accepted and expected medical and nursing practice.

Conscientious Objection in Medicine (Savulescu, J., 2006)
This British medical ethicist crafts a strong argument regarding conscientious objection in the daily practice of medicine. His points include that a doctor’s conscience should not be allowed to interfere with medical care, all doctors and medical students should be aware of their responsibility to provide all legal and beneficial care, conscientious objection may be permissible if sufficient doctors are willing to provide the service, conscientious objectors must ensure that their patients are aware of the care they are entitled to and refer them to another professional and that conscientious objectors who compromise the care of their patients must be disciplined.

Conscientious Refusal: A Workshop to Promote Reflective and Active Learning of Ethics, Communication Skills and Professionalism (Lupi, C., 2012)
This workshop from the Association of Professors of Gynecology and Obstetrics was originally designed for medical students to use independently or in small groups to improve their competency in non-directive options counseling. The workshop is comprised of three learning modules using case studies, videos, and discussion tools: the first module is an introduction into conscientious refusal; the second module consists of a values clarification exercise; and the third module involves role play technique to practice skills on how to handling an ethical conflict with patients seeking objectionable medical interventions.

Conscientious Objection in Health Care: An Ethical Analysis (Wicclair, M.R., 2011)
Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the ‘incompatibility thesis’, that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and ‘conscience absolutism’, that they should be exempted from performing any action contrary to their conscience.

When Should Conscientious Objection be Accepted? (Magelssen, M., 2012)
The main interests that are at stake in the dilemma of conscientious objection are the patient’s interests and the health professional’s moral integrity. Magelssen defines five criteria for evaluating the acceptability of claims to conscientious objection.

The Denial of Abortion Care Information, Referrals, and Services Undermines Quality Care for U.S. Women (Weitz, T.A., and Fogel, S.B., 2010)
In this commentary, Weitz and Fogel summarized their careful crafting of an argument as to how conscience clauses affect adherence to evidence-based benchmarks of quality and safety in abortion care. See their full report on the National Health Law Program website.

The Celestial Fire of Conscience-Refusing to Deliver Medical Care (Charo, R., 2005)
Charo muses on the “tricky business of conscience” and what it means to be a health care provider in the U.S, touching on the surge of conscience clause legislation, pharmacists refusing to dispense legal prescriptions and the influence of religion on our culture.

Religion, Conscience, and Controversial Clinical Practices (Curlin, F.A., et al., 2007)
In this study, the authors conducted a random sample of 2000 U.S. physicians about their beliefs about their ethical rights and obligations when patients request a legal procedure to which the physician objects for moral or religious reasons. The results found that most physicians indicated they would do so, some physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures.

Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care (ACLU, 2013)
Religious restrictions govern health care at Catholic-sponsored hospitals and networks. Within these systems, health professionals are prohibited from providing specific health services or honoring patients’ health care decision-making when it conflicts with religious doctrine. Often health professionals are prohibited from providing basic counseling and referrals for services prohibited on religious grounds, such as counseling and referrals for unplanned pregnancy.

Professionalism in Nursing

Providing Abortion Care: A Professional Toolkit for Nurse-Midwives, Nurse Practitioners, and Physician Assistants
This toolkit provides a thoroughly researched and referenced discussion of scope of practice and abortion care as pertains to APNs and physician assistants.

Population-Focused Nurse Practitioner Competencies (National Organization of Nurse Practitioner Faculties, 2012)
The National Organization of Nurse Practitioner Faculties promulgated competencies to align with the six population foci in the Advanced Practice Registered Nurse (APRN) Consensus Model. In the women’s health/gender related population foci, an entry level into practice competency states that nurse practitioner graduates must demonstrate skill to: Support a woman’s right to make her own decisions regarding her health and reproductive choices within the context of her belief system.

Applying Ethical Practice Competencies to the Prevention and Management of Unintended Pregnancy (Cappiello, J., et al., 2011)
The authors apply ethical principles to the clinical case of woman with an unintended pregnancy.  They note that nurses are not responsible for the decisions made by patients who are exercising their right to autonomy in decision-making.  Much of the public discussion of provider right of conscience has moved from a framework of protecting the patient to that of protecting the provider.

The Concept of ‘Nursing’ in the Abortion Services (Gallagher, K., et al., 2010)
This qualitative study investigates the perceptions of nurses who work in abortion services through in-depth interviews with nine nurses from three different abortion clinics in the United Kingdom.

Innovating Education in Reproductive Health
This website provides exercises and presentations from on providing quality options counseling to adolescents, and other related sexual and reproductive health issues such as “Caring for Challenging Patients” and  “A Counseling Model for Ambivalent Patients.”

Theory of Social Justice is Defined as Working to Address Disparities of Health and Care
This In Focus series in the Journal of Obstetrical, Gynecologic, Neonatal Nursing (JOGNN) discuss the application of the theory of social justice to address disparities in health care.  The authors suggest that if nurses adopt an ethical framework of social justice, nurses can better understand and thus influence outcomes and ameliorate health disparities and inequalities.  Readers can apply the social justice theory to the provision of reproductive health care along with other aspects of care.

Effect of Nurses’ Attitudes on Hospital-Based Abortion Procedures in Massachusetts (Kade, K., et al., 2004)
This study used qualitative data from physicians and nurse managers to explore how nurses’ attitudes affect hospital-based abortion services in Massachusetts. The study concludes that nurses’ attitudes toward abortion and their unwillingness to participate in procedures may hinder access to abortion services.

A Review of Termination of Pregnancy: Prevalent Health Care Professional Attitudes and Ways of Influencing Them (Lipp, A., 2008)
This paper explores research that has been conducted on health care professionals’ attitudes towards abortion, and gives consideration to various remedies that create optimal environments for women who undergo a termination of pregnancy.

Proof and Policy from Medical Research Evidence (Mulrow, C. D. and Lohr, K. N., 2001)
The authors review the importance of basing practice on evidence and research. They then go on to articulate the challenges of applying population-based research and guidelines to individual patient care.

Sexual Health Competencies: an Integrated Career and Competence Framework for Sexual and Reproductive Health Nursing Across the UK (Royal College of Nursing, 2009)
This document outlines a framework of competences that sexual and reproductive health nurses from primary, secondary and community care settings across the UK need to develop in order to provide safe, effective and accountable care to clients.

Community Sexual and Reproductive Health Curriculum (Royal College of Obstetricians and Gynecologists, 2012)
This training plan from the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists outlines a multi-year raining program in sexual and reproductive Health care. The modules provide detailed objectives for learning knowledge, attitudes and skills in 15 sexual and reproductive health related topics.

Sexual and Reproductive Health Core Competencies in Primary Care (World Health Organization, 2011)
In this document the WHO presents core competences in sexual and reproductive health that should be addressed in primary care settings including essential services and principles of service provision.

Role of the Catholic Church in Health Care Refusals

Ethical and Religious Directives for Catholic Health Care Services (United States Conference of Catholic Bishops, 2009)
The United States Conference of Catholic Bishops outlines directives for Catholic hospitals and health care systems.

Nun at St. Joseph’s Hospital Rebuked Over Abortion to Save Woman
In 2010, a Catholic nun and administrator of St. Joseph’s Hospital and Medical Center in Phoenix was reassigned in the wake of a decision to allow treatment for an ectopic pregnancy. The ectopic pregnancy was terminated in order to save the life of a critically ill woman.

When There’s a Heartbeat: Miscarriage Management in Catholic-owned Hospitals (Freedman, L., et al., 2008)
This article presents five cases from a qualitative study of physician’s experiences with miscarriage management with in Catholic institutions.

Within the context of professional ethics, this module aims to examine the tension between nurses as individuals with deeply held beliefs or biases, and the imperative to care for patients with a variety of needs. It is essential for nursing students to identify and confront their own beliefs that might hinder their ability to provide the highest quality of care to women seeking unintended pregnancy prevention and care services.

These modules are designed to use with a flipped classroom model in which students are directed to complete the module as homework, including the Pre- and Post-Assessments. Once students have completed the module in its entirety, including the recommended reading, faculty can use the Teaching Tips document and materials from the Exercises and Handouts section below to integrate concepts from the module into the classroom or group setting.

Teaching Tips

Exercises and Handouts

These materials can be used to enhance classroom learning. The Teaching Tips document provides recommendations on how to incorporate these materials into a classroom or group setting.

The Abortion Option: A Values Clarification Guide for Health Care Professionals: These exercises from the National Abortion Federation include tools that can be used in class for clarifying values related to abortion and discussing the role of health care providers.

Exercise in Professionalism: This document describes how to facilitate five values clarification exercises in class where students respond to various scenarios with written responses and group discussion.

Exercise in Professionalism – Learner Handout: This document is designed to accompany the facilitators’ guide (above) to leading five exercises in values clarification. These exercises are also included as part of the values clarification section in the “Caring for Sara” scenario in the module.

Professional Ethics In-Class Presentation

For a more traditional approach to classroom learning, content from the Professional Ethics online module was used to develop this 15 – 20 minute presentation. Faculty can use this presentation in the classroom as a substitute for students completing the module independently. The Teaching Tips document and exercises and handouts that are provided as part of the module can be used to supplement this presentation and incorporate student participation in class.

Accessing Student Pre- and Post-Assessment Data

Pre- and Post-Assessments are designed to measure students’ satisfaction with the module as well as what they have learned. To be able to complete the Assessments students will need to enter a “Site Code” prior to working through the online module. Faculty will use this Site Code to download and review students’ Pre- and Post-Assessment data. To obtain a Site Code your institution must e-mail Provide. In the text of the email, please include your name (as instructor), the name of the institution, and the module(s) for which you would like to access data. Provide will send you 1) a Site Code for your students to enter at the beginning of the assessment, 2) a web link to access the results from each module, and 3) an “answer key” to help grade your students’ responses. You may also assign a unique Student Code to each student that you would like to assess on an individual basis. Students must enter the correct Site Code for faculty to be able to access their data.

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