Ethics: Ethical Grounding for Entry into Practice: Respect, Collaboration, and Accountability

"Moral questions are raised that must be answered . . . because the status quo in nursing practice, licensure, and education is morally unacceptable" (Hess, 1996, p. 289).

What was your entry into practice? Did you enter nursing through a diploma, associate degree, baccalaureate, or perhaps the more rare doctoral program? Nurses tend to have affinities and "pick sides" of this issue based on what they know and with what they are comfortable. Yet the issue of practice entry goes beyond individuals; the decisions impact the structure and quality of health care and its ultimate delivery.

The articles about entry into practice presented in the Online Journal of Issues in Nursing, (OJIN) Vol. 7 No. 2 are presented from the nursing perspective and mostly from a perspective that reflects practice in the USA. However, the issue of entry into practice is a broad one that nurses across the world and many other professions within and outside of health care face. While there is much to learn from others, the focus of this column will be in keeping with the articles presented in this issue of OJIN.

While Gosnell (2002)states that the pattern of entry into practice has changed, nurses' points of view about entry issues have not changed. Often heard phrases are: "We can run circles around those BSN graduates;" "In six months we can do as well as any nurse and we can think critically;" "But we all take the same test, so what does it matter?"

As with many issues in nursing and in health care, the answers are not black and white nor should they come from personal bias. Thus, we can seek guidance about entry into practice issues from an ethical perspective. The question becomes, "What ethical perspective should guide us in decision making about entry into practice?" The guide we have chosen is the 2001 Code of Ethics for Nurses with Interpretive Statements, hereafter referred to as the Code.

Recognizing that the ANA Code (2001) is the "profession's nonnegotiable ethical standard" (p. 5) regardless of entry into practice or educational level, we have identified three themes that are recurrent in the Code to guide this column: respect for persons, collaboration, and accountability. We have chosen these themes because they are timeless and transcend a single profession or an individual country and, thus, provide universal dimensions to examine the dilemma of entry into practice from an ethical perspective.

Respect for Persons

"A fundamental principle that underlies all nursing practice is respect for the inherent worth, dignity, and human rights of every individual" (ANA, 2001, p. 7). Respect for persons is violated when nurses and student nurses denigrate each other over credentials and over who are the competent nurses. Nurse educators and administrators violate respect for persons when they bicker and dispute each other over educational preparation and hiring practices. The ethical solution is not to participate in verbal sparring but to speak against it when it is heard and to engage in conversation about entry into practice with each other based on mutual respect and concern for what is best for the profession.

Collaboration

"Collaboration is not just cooperation, but it is the concentrated effort of individuals and groups to attain a shared goal" (ANA, 2001, p. 10). The issue is why collaboration and concerted effort seemingly have failed regarding entry into practice. Each entry level has its proponents, and each group of proponents has tended to put forth an agenda without consideration of other groups. Each entry-level group seems to lack the "trust, recognition and respect" (ANA, 2001, p. 11) that are vital to collaboration. The ethical solutions at the individual level are to become involved and/or stay involved with your professional association, namely, the American Nurses' Association and to push for collaboration on ending the stalemate on entry into practice. At the organizational level, all major nursing organizations must come together not only to promote nursing in the current shortage as Mahaffey (2002) describes in the OJIN issue on "Entry into Practice", but also to lead our profession in settling entry into practice issues.

Accountability

"Accountability means to be answerable to oneself and others . . ." (ANA, 2001, p. 16). Have nurses been accountable about entry into practice as a profession? As individuals? What does it mean to be accountable about practice entry? Usually nurses speak of accountability in the context of practice; they make decisions and are answerable for those decisions in service, administration, or education. Less obvious is how nurses can be ethically accountable about entry into practice. We offer the following suggestions: First, at the individual level, nurses can increase their accountability by becoming informed about entry into practice issues and also by becoming involved in a united nursing movement with the purpose of deciding entry into practice issues by the year 2010. Second, at the organizational level, nurses can increase their accountability by putting aside power agendas and examining what education plan for entry into practice will best serve future nurses as well as the public good. Organizations also must help create an infrastructure that will facilitate decision making and enable change once decisions are made. Finally, educators and administrators can increase their accountability by addressing the current ethical inequalities that exist regarding entry into practice. Hess (1996) asks:

"Is the ADN graduate receiving just reward for nursing educational program requirements?" (p. 295).

"Is BSN education just, fair, and caring to the student when the cost of that education is weighed against its value?" (p. 295).

We ask:

Should the shortage be used as rationale to jump start diploma programs that have in the last 20 years taken a back seat to ADN and BSN programs?

Can we ethically justify to society and to ourselves three educational routes with differing costs and time frames for completion and then "use" those nurses interchangeably and expect the same level of service provision?

To be accountable as individuals and as a profession, do we not need to resolve this issue in a more timely fashion than the past 35 years?