Nursing Code of Ethics and the Para-Professional
27th Annual Convention
October 16-18, 1984
Red Deer Lodge, Red Deer,
Alberta
Gayle
Gilchrist James, MSW,
Division
Head and Associate Professor
Characteristics
of AARNA (AARNA, 1984)
The Alberta Association of Registered Nursing Assistants (AARNA) is an organization with a twenty-seven year history in the Province of Alberta, albeit at times with a slightly different focus and with a different name than marked the organization in 1984.
Two types of membership are in evidence. At the corporate level, AARNA appears to be a federation of registered nursing assistants, nursing attendants (previously termed "ward aides"), operating room technicians, ambulance drivers, ambulance assistants, physiotherapy assistants, physiotherapy attendants, and occupational therapy attendants. Within each of these groups, individual membership in AARNA is available, and the total membership comprises some forty-five hundred members in all categories, approximately thirty-four hundred of whom are RNA's. Approximately ninety-five per cent of those eligible for membership in AARNA actually belong.
From a structural point of view, the organizational form is one of chapters (between 120 and 133 of them), organized in ten districts. The bargaining unit of which AARNA is a part is the Auxilliary Nursing Care Personnel who undertake negotiations with the corporate employer, i.e. the Alberta Hospital Association. The AARNA offices are located in the City of Edmonton and employ approximately twelve persons.
The mandate of AARNA is currently in change, in that AARNA will soon come under the governance of the Health Occupations Act.
The nature of AARNA is similar to that of the Alberta Teachers' Association (ATA) in that it combines the functions of a trade union and of a professional association. They, themselves, ask "How can we be both a union and a professional association?". Historically the trade union function has been dominant and necessary because of the "highly technical and legal procedures in obtaining and maintaining bargaining rights, master negotiations, handling grievances and complaints, employee-management liaison, labour education and a job steward network" (AARNA, 1984). More recently, AARNA has come to take on some of the characteristics of a professional association, in part through their venture into an Accreditation Program in 1983: "As a professional association we now offer official recognition for approved courses that will provide our members with documentation to show they are working hard at keeping their health care skills current" (AARNA. 1983). In fact, AARNA operated ten accredited continuing education programs in 1983-84, involving in excess of nine hundred students.
Thus, we have an organization on the one hand that has an emphasis on labour relations, although it appears to be labour relations with a difference ("...preventive labour relations....we want to be the most responsible union in the marketplace") and, on the other hand. to be taking on some aspects of a professional association through their beginning emphasis on professional development and continuing education.
AARNA As A Professional Association
The legislation that mandates AARNA's existence is administered by Alberta Social Services and Community Health. Registration is mandatory and the controlled title for practice is "R.N.A." (and prior to 1977 it was "C.N.A."). The legislation sets out educational criteria, provides a mechanism for disciplinary action, and establishes practice parameters. AARNA is, therefore, a membership body and not a registration/licensing body, i.e., they are not a profession with self-regulation as an inherent feature. While membership in AARNA is voluntary members "are required to pay dues under...contract" (AARNA 1982). In general, membership activities are focused around the issues of professional development, collective action, and education.
All professional and, increasingly, para-professional organizations demonstrate an interest in standards of care, whatever their field of endeavour. AARNA has issued documents in this area. The first is "Standards of Nursing Practices for Registered Assistants 1981"… which sets out the minimum level of competence in practice and describes how well skills are performed. The second document is "Nursing Assistant Competencies Brochure 1982", which actively promotes the competencies (skills) taught at Alberta Vocational Centres in Alberta where the formal training occurs. Neither of these can be considered to be job descriptions, per se.
Most on-the-job complaints are resolved informally through discussion between the AARNA member who may feel that he or she has been wronged, and the Labour Chairperson/Chief Steward. Grievances are a somewhat different matter and represent a violation of the "Collective Agreement, federal or provincial laws..." (AARNA, 1982). A grievance and the procedures thereto usually occur when a member feels that their rights as an employee have been violated. The procedures thus set out are in some ways similar to the beginning process in a disciplinary hearing within a profession, but there are some important differences. It would appear that the steps undertaken in a typical grievance procedure could ultimately result in arbitration as the final step; in professions, decisions made by disciplinary bodies within the profession, which take on a quasi-judicial aspect, can be appealed to properly constituted courts, provincially or federally. Further, professions tend to rely in individual disciplinary hearings on case law or on a standard of practice that has been established on national or international bases as acceptable or unacceptable within that profession; grievances within a particular labour union or para-professional group seem, often, to be confined to the terms of the Collective Agreement that applies to that particular workplace setting.
Nursing Code of Ethics and the Para-Professional
It is not possible to discuss the nursing code of ethics and the para-professionals who. in some ways. are touched by that particular code. or who wish to develop their own, without examining the characteristics of professions themselves and without examining the terminology used by professions to describe themselves and their varying degrees of self-regulation and self-control.
Definition
Professions have typically used a variety of terms to describe the means by which their members are mandated to practice in their chosen field. These are:
1. Certification
A piece of paper certifying some standard of achievement or commitment guaranteed by the organization sponsoring the certificate. It is a trademark only and carries no legal significance.
2. Registration
Means that the title is protected by law and that there is a penalty for misuse.
3. Licensing
Controls not only title, but practice. A mechanism by which the state decrees that persons may not engage in particular economic activities and behaviour, except within the specific conditions set forth by the authority of the state and under its regulatory power.
Professions vs. Occupations
There are many elements that distinguish a profession from an occupation. Doctor Douglas Cameron (1980). the then-President of the Royal College of Physicians and Surgeons of Canada, included in his list these factors: a long and arduous formal education followed by stiff examinations for entry into a profession; community approval of members reflected in formal individual licensure and. where appropriate, certification of specialty competence; a Code of Ethics governing the conduct of members; a well-recognized body of systematic knowledge and technical skills; and self-regulation and a great deal of autonomy with the authority to discipline members who do not comply with the rules.
Ernest Greenwood (1976), writing in a major social work text, also lists the attributes that he feels all professions possess: theory; authority; community sanction; ethical codes; "a culture".
Rose (1974) would seem to be in agreement with Greenwood (1976). in that the attributes of professions that he designates essentially parallels Greenwood's list. Rose maintains that within professions practice is founded upon a base of theoretical, esoteric knowledge, and that this knowledge is acquired through a long period of education and socialization. Further, Rose (1974) notes that practitioners are "motivated by an ideal of altruistic service rather than the pursuit of material and economic gain". Rose also indicates that within professions the colleague group is well organized "and has disciplinary powers to enforce a code of ethical practice", and that "careful control is exercised over recruitment, training, certification and standards of practice."
Rose (1974), writing on the same subject in another publication notes that "the key factors in professionalization seem to be most closely related to questions of status; that is, how closely the profession is related to those things which society tends to regard as of great importance and ranks highly....". Rose (1974) feels that professions are, first of all, associated with high-status knowledge, and by that he means university-approved knowledge. This same association with universities, he feels, adds to the status of professions, by association, in that universities tend possess to high status. Further, he notes the social class variable and states that it "does not necessarily mean that all practitioners are of high social class, but that there is a substantial relationship for the leaders of the profession...". Professions are also affiliated with "people work" and these kinds of activities tend, Rose feels, to have higher status than does work with "things". The higher-status are ones in which members "do things which are fundamental to people's safety and comfort...". Further, the knowledge base of any profession is in many ways associated with beliefs and processes that have acquired some degree of mystique (Rose. 1974). Finally. Rose reiterates that professions usually have an affiliation or association with other major power bases and feels that the association that professions have with universities provides them with a ready-made power base, because the university is usually "respected and assigned high status by a major power base, usually the government...". (Rose, 1974).
Christopher Lasch (1979) talks, also, about the personal attributes of professionals, and it is this list by Lasch that captures the attitudes of professionals, perhaps better than any other. So often the word "professional" is used to describe an attitude rather than the specific sets of mandates, education, and control over practice that are referred to by authors such as Cameron, Greenwood, and Rose. Lasch (1979) describes the personal attributes of individual professionals as discipline; courage; persistence; self-possession; a pattern within the profession of repeated success over generations; an insistence on the authority of the individual professional and insistence on the authority of the profession over time; a sense of generational and inter-generational continuity, i.e. that individual professionals treasure the heritage of their predecessors within the profession, develop their own discipline, and partake in the training of a future generation of professionals; and, finally, a powerful sense of community pride.
It is against this backdrop, then, that one can "rate" an individual professional or, indeed, a profession. It is also against this backdrop that one can look at a code of ethics developed by a profession which manifests its particular set of beliefs about practice and standards of care, in codified form.
Code of Ethics: Definition of Terms
To set the stage, it is perhaps well to look at the definitions of key words such as "ethic", "ethical", "ethics", and "code" (Funk & Wagnalls, 1976).
Ethic is a "philosophy or system of morals...", derived from the Greek word "ethos", meaning "character". "Ethics" is the "study and philosophy of human conduct, with emphasis on the determination of right and wrong... the principles of right conduct..." "Ethical" means "conforming to right principles of conduct as generally accepted by a specific profession..." and a code is "A systematized body of law" or " any system of principles or regulations".
Comparison of Codes of Ethics
The chart (Appendix A) compares the general aspects of specific codes of ethics of these organizations: The Canadian Association of Social Workers (CASW, 1983); The International Federation of Social Workers (IFSW, 1976); The National Association of Social Workers (NASW, 1979); The Canadian Bar Association (CBA, 1974); The Canadian Medical Association (CMA. 1982); The International Council of Nurses (ICN, 1973); and the Alberta Teachers' Association (ATA, 1975-under review).
If one reviews the characteristics of the traditional professions, then, one sees that the elements for all professional codes remain essentially the same. Most codes, at their outset, have a preamble in which is stated that profession's particular philosophy, purpose, group to whom they are accountable, their primary professional obligation, and they may or may not include a personal declaration or a declaration on the part of the profession that relates to the individual responsibilities of the individual professionals within the professional association.
Further, codes of ethics typically have statements about the integrity of individual professionals, about their standards of ethical conduct in relationship (usually) to the primary group that they serve, in relation to the work site; in relation to colleagues within the profession or to the profession as a whole; and the code usually closes with some statement that relates that profession or its individual professionals to their societal responsibilities. Although most codes make some reference to "conflict of interest", only two codes (social work and law) make specific references to the role that outside interests may play in the lives of professionals within those two groupings.
Comments on the ICN/AARNA Code
The first difficulty that one foresees in AARNA's adopting the code of ICN is the general applicability of a para-professional organization adopting the code of a professional organization. Most codes for professions are written for individuals in those professions who have. as a right, a great deal of autonomy, independence. and control over the practice situations in which they function. Using the criteria for the characteristics of professions, as opposed to occupations, I would judge AARNA to be (properly) a "para-professional" organization, rather than a profession. Whether AARNA is purposefully in the para-professional category or is. at this moment in time, on the way to becoming a professional organization is, I suppose, for the membership and administration of AARNA to determine. The characteristics that indicate that AARNA is much more than an occupational grouping are that practice is founded upon a base of theoretical and technical knowledge; that there is a definite educational plan to prepare practitioners; that through the adoption of a code of ethics that the membership of AARNA mean to establish publicly that their motivation is governed by the ideal of altruistic service and not solely material and economic gain; that AARNA is beginning to exercise some control over educational programming, certification, and standards of practice. On the other hand, although practice is founded on a knowledge base of theory and applied skills, that educational experience is offered through vocational colleges as opposed to community colleges and universities, which somewhat impedes the "educational ladder" concept that I sense AARNA is trying to establish. Further, the period of education is, when compared to the educational preparation in other professions, not as long. To move more clearly into the professional camp, AARNA would need to exercise greater control over recruitment, training, and certification of graduates from educational institutions. Also, and this will probably present the greatest problem. AARNA would have to take over the disciplinary powers to enforce a code of ethical practice, said powers now appearing to be resident in government officialdom. Again, AARNA is "on the way" to developing its own "culture", i.e., although the history of AARNA in the Province of Alberta is of considerable duration and indicates dynamic progress in its pattern of development, the history, and belief system, will not for some time reach the magnitude of the heritage that one sees in the older professions such as law and medicine.
I have implied, above, that there are considerable difficulties when the association controls the membership function of an organization while the disciplinary/registration/licensing function rests with a separate body. This means, in effect, that AARNA would not be able to conduct itself as a fully self-governing profession and this has grave implications for the role of a code of ethics. Disciplinary hearings conducted under the aegis of a code of ethics make provision for practitioners within a profession to be judged by their peers and when those disciplinary hearings are held outside of the profession, in the first instance, it is extremely difficult to ensure that the individual RNA will indeed have his or her first hearing by peers.
A third difficulty arises around the issue of how the proposed Code of Ethics by AARNA would be used. Would it, in fact, become part of a Collective Agreement? If it does not become part of the Collective Agreement, then how can it be enforced?
A fourth problem arises because of the inherent contradictions in attempting to operate a professional association that also has trade union purposes, when these two major and important functions are managed simultaneously by the same administrative structure. By this, I mean that it is extremely difficult to operate as both a trade union and as a profession because the two functions are derived from inherently different suppositions about the nature of practice. A collective agreement, it seems to me. sets the working relationships between management and labour for a specific period of time, and governs the relationship of those in the work place around such issues as hours of work entitlements. remuneration, and the like. In such a setting, what may be viewed as grievances become solely related to whether or not a particular agreement has or has not been infringed upon, by either employer or employee. In a profession, however, the rules tend not to be so explicit, particularly around hours of work. and sets of power relationships within the work place. At least in theory, all members of a profession are peers, and distinctions that obtain in the work place (supervisor, executive director, and the like) do not obtain within the professional association. Ethical behaviour is ethical behaviour whether it is practiced by those in direct service to a client or patient or consumer group, and one is not absolved (in a profession) by being in indirect service. Within a profession, then, management and workers are compelled to manifest the same kinds of ethical behaviour, and they are not, theoretically, in an adversarial or even bargaining relationship. Codes of ethics work best and seem to apply best in those situations where individual professionals are responsible for their individual practices of that profession; there are inherent conflicts, however, when individuals are also employees and, at the same time, professionals (as are many social workers).
Suggestions for Modifying the ICN/AARNA Code
Given the reservations described, above, one can still entertain the worthwhileness of a particular para-professional grouping espousing a code of ethics and developing a set of procedures for manifesting how the code would be operationalized in the work place. This is, I believe, an ideal worth pursuing although it is. in my judgment, difficult to operationalize unless the code of ethics that is finally developed is part of collective agreements.
Undoubtedly, when the administration of AARNA reviews the elements of the codes of various professional organizations, they may wish to include or exclude specific items that are included by the other professions are cited.
The first suggestions one might wish to make is that the words "registered nursing assistant" be substituted for the word "nurse", wherever it occurs in the proposed code.
Second, while the proposed code does include the goal of nursing, and makes some statements about its philosophy and focus, AARNA may wish to include a statement that speaks to the accountability of nursing assistants for their practice. These things properly belong in a preamble, or a general statement at the beginning of the (eventual) final form of the Code of Ethics.
Given development in human rights legislation provincially, nationally, and internationally the philosophical stance of AARNA might be explicated further, to include such items as national ancestry, religion, gender, political affiliation, socioeconomic status, ethnicity, language, marital status, abilities, and sexual orientation. No doubt the inclusion or exclusion of any of these items could be the subject for much debate!
Further, one might go through the entire proposed code and modify the language so that it is not gender-related, i.e. by pluralizing one can often avoid using "his" or "her", as it becomes most awkward to include these at every turn.
Although the core of the proposed AARNA code is solid in terms of the items that it enumerates, most of the items require a great deal of expansion (see specifically the CASW Code, 1983). For example, the phrase that "the nurse holds in confidence personal information and uses judgment in sharing this information" appears to be rather skimpy in view of the wealth of literature in case law currently available around the professional issue of confidentiality. If the nurse or RNA "uses judgment" in sharing confidential information, one must ask by what standard the practitioner is to measure their judgement? Is it enough that the individual practitioner says they use their own judgment and they believe themselves to be correct? It is, I believe, extremely useful for AARNA to study the section on confidential information in the CASW Code of Ethics (which is also the Code of Ethics of the Alberta Association of Social Workers), around confidential information. I would tend to believe that that section separates clearly the individual professional's responsibilities for the receiving, recording, disclosure, and retention of confidential information, quite apart from any institutional requirements for those same aspects of the use of confidential information. In short, I think that AARNA can make use of the approximately thirty sub-items that relate to the use of confidential information, as enunciated in the CASW Code, and thereby usefully expand the one sentence that they are proposing to adopt from the ICN Code.
The same sort of exercise may be undertaken with other aspects of the proposed code. The solidity of the proposed code is that it does incorporate those aspects of all professional codes (with. perhaps, the exception of the Code of the Alberta Teachers' Association) that professions have deemed to be important in their relationships among themselves, among other professions, within the work place, and in their connection to the broader society and the mandate that that society offers them to practice.
In summary, AARNA is to be commended for
proposing the development of a code of ethics but they must also be cognizant
that the development of such a code may well lead them to develop their
organization into two separate aspects, one that looks after their trade union
functions, and one that looks after their para-professional functions. Further,
the development of a code by the membership and one that the membership expects
to operationalize would seem to imply that the code thus developed must become
part of collective agreements or it will merely be a statement of lofty
principles with no hope of operationalizing it at the practice level. And
finally, the exercise of developing a code of ethics will in and of itself
offer this para-professional organization an unparalleled opportunity to
examine, itself, its belief systems, its current training, its continuing
educational development, and its role vis-à-vis other professional
organizations and para-professional organizations in the Province of Alberta.
For this difficult and enduring exercise the administration of AARNA is to be
commended.