Case Based Essay

The biopsychosocial model of health (Engel, 1977) claims that health and illness are: the product of a combination of factors including biological characteristics (e.g. genetic predisposition), behavioural factors (e.g. lifestyle, stress, health beliefs), and social conditions (e.g. cultural influences, family relationships, social support). (Marks et al,2005). The biopsychosocial model takes into account that each patient is completely different and as a result they are affected differently by each biological, psychological and social happening. (Atkinson et al, 2005). The biomedical model of health however sees the patient as a biological entity which has developed a fault; this model leads people to believe that all patients with the same injury/pathology will respond the same to treatment and in the same amount of time. (Atkinson et al, 2005). The main difference between these two models is the role of the patient and practitioner in each. The biomedical model see’s the patient as person who has to take orders from the practitioner. The biopsychosocial model sees the treatment as a negotiation between the practitioner and patient. (Annandale, 1998) The type of model a practitioner uses will greatly impact on the eventual outcome of the patient. In the case of Mrs. Chatsworth the biopsychosocial model of health would be the best approach to take when coming up with an effective treatment plan for her as there are many biological, psychological and social factors that a practitioner will have to contend with. This essay will explore these different biological, psychological and social factors that will face Mrs. Chatsworth throughout her treatment as well as the implications for her practitioner.

There are a number of biological factors affecting Mrs. Chatsworth, some resulting from the total joint replacement in her right hip six weeks ago and others stemming from osteoarthritic changes which have been occurring for a number of years. According to (Moskowitz et al, 2007) osteoarthritis diseases are a result of both mechanical and biological events that destabilize the normal coupling of degregation and synthesis of articular cartilage chondrocytes and extracellular matrix, and subchondral bone. Mrs. Chatsworth experiences osteoarthritis in her knees, hips and shoulders. It was these changes in her hip joint that led to her having a total hip athroplasty. Daily activities such as shopping would be difficult for Mrs. Chatsworth as the osteoarthritis in her shoulders will make it difficult for her to carry shopping bags. Another biological factor to be concerned with, when dealing with Mrs. Chatsworth is the residual knee and thigh swelling as a result of the hip replacement. “Wounds that failto heal in the expected time range are generally referred to as chronic.”(Shamely, 2005). Swelling present at this stage post-operatively would indicate chronic inflammation in the knee and thigh region. “Chronic inflammation must be replaced by acute inflammation for healing to occur” (Shamely, 2005 pg 4). This swelling has decreased the range of motion in her knee as it will be painful to move it. Mrs. Chatsworth is only partially weight bearing, with her knee slightly flexed and as a result requires elbow crutches to get around. This will affect Mrs. Chatsworth ability to climb stairs, which she has to do daily as her apartment is on the first floor of a building which has no lift. Her right hip is still very stiff after the operation; this again will affect her ability to get around. Also the therapist will have to be aware of the post operative guidelines when forming a plan, adduction and internal rotation of the hip are limited by these. Another issue facing Mrs. Chatsworth is weakened muscles in the thigh region; her right and left quadriceps have very little definition or bulk, also in her right leg there is a significant reduction in her gluteal muscle group, which are very important muscles involved with the movement of the hip and knee joint, her practitioner will have to prescribe strengthening exercises for these. According to (Schult et al, 2005 pg420) “the hip and gluteal muscles have evolved into massive and powerful movers and stabilizers of the femur counteracting the loads imposed by support of the whole body weight on two limbs and maintain balance and stability during bipedal locomotion.” This means that Mrs. Chatsworth’s balance is decreased as a result of this muscle atrophy and her practitioner will have to plan for this. Mrs. Chatsworth is also taking Atenalol for high blood pressure; this will affect her as over exertion may cause further injury. The practitioner will have to ensure that he/she makes a treatment plan that is effective but at the same time not too physically demanding on Mrs. Chatsworth.

When dealing with Mrs. Chatsworth case the practitioner will have to look closely at the psychological and social factors which will have a bearing on her treatment e.g. treatment time and the eventual outcome of this treatment. Mrs. Chatsworth may be depressed or stressed over the death of her husband six months ago; this may have an adverse effect on her rehabilitation. The practitioner will have to realise that because Mrs. Chatsworth is lonely her motivation to follow a recovery plan may be somewhat limited. On the other hand Mrs. Chatsworth is worried about being a burden on her daughter who will have less time on her hands soon as her children will be on holidays from school, so this may give her added drive to recover quicker; this may lead to Mrs. Chatsworth causing further injury to herself by over working to recover. This issue will may lead to Mrs. Chatsworth trying to perform daily tasks which she was not able to do post-operatively. Another obstacle for the practitioner to overcome is Mrs. Chatsworth’s fear of weight bearing on her right leg. Her therapist will have to encourage and reassure her, walking behind a while there taking their first fully weight bearing steps can be a great form of reassurance to a patient. (Stein-Parbury, pg209) highlights this- “the presence of another human being is reassuring in itself, especially during times of disquiet.” Mrs. Chatsworth also has two cats which she may be overly attached to; a problem may arise as looking after them may put extra pressure on her during her recovery. As well as these psychological factors there are also a number of social factors that the therapist will have to incorporate into his/her plan for Mrs. Chatsworth. The fact that Mrs. Chatsworth is recently retired will give her more time to focus on her recovery plan; also there will be no pressure on her to be fit to go back to work. As her daughter lives close by, only five miles away, this will alleviate some of the pressures on Mrs. Chatsworth such as shopping, cleaning and other common daily activities. Also her living conditions as mentioned earlier, living on the first floor and having to use stairs to go to and from her apartment will affect her recovery as it may be an incentive to follow her recovery plan.

To conclude, this essay identified the different biological factors that affected Mrs. Chatsworth such as loss of range of movement, swelling and osteoarthritis. Also this essay highlighted the different psychological factors affecting her such as stress, the fear of being a burden to her family and the fear of weight bearing on her right leg. This essay also highlighted the different social issues that will affect her recovery. All these factors were related to the therapist will manage Mrs. Chatsworth’s case and what the eventual outcome will be.

A literature for review is a carefully designed, logically developed discussion that provides the rationale for the problem statement, significance of the problem, theoretical perspective, research design and methodology reviewing the literature provides a better understanding and insight which is necessary to develop a broad conceptual framework in which the problem can be examined the researcher attempts to find out how the proposed study fits into a large universe of the related knowledge. Keeping this aspect in the mind the researcher probed into the available resources.

This chapter deals with the review of literature, the studies reviewed have been arranged under the following sections

Review related to menopause

Review related to studies on quality of life of postmenopausal women

REVIEW RELATED TO MENOPAUSE

Most women can expect to live into their ninth decade with changes that accompany aging. Especially those associated with the menopause can be a source of anxiety. Menopause is a natural event in the course of every woman’s life it is a time of last period but symptoms can begin several years before that these symptoms can last for months or years. Sometimes around 40 years, the women notice that her menstruation is different in its duration, frequency and amount of bleeding. Changing levels of estrogen and progesterone which are the two female hormone produced in the ovaries, might lead to these symptoms (National Institute of Aging, 2006).

According to North American Menopause Society (2000), the average age for the onset of perimenopause is 47.5 years and natural menopause occurs at the age of 51.4 years in western women. In rural North India, Singh and Arora (2005) found that the average age at menopause is 44.1 years. There were many studies reported the mean age of menopause between 45 to 55 years. Quazi (2006) reported it as 50 years. Dhillon Singh, Hamid and Mahmood (2001) document it as 49.4 + 3.4 years. Chim, Tan, Ang, Chew, Chowg and saw (2002), in their study mentioned as average range of 40 to 59 years with the mean of 49 years.

Young kin & Davis, 2004, in normal menstrual cycle, rising levels of follicular stimulating hormone stimulates the developing dominant follicle to secrete increased amount of estradiol. The increased level of estradiol as well as inhibition from the granulose cells exerts a negative feedback on hypothalamus and the result is decreased in follicular stimulating hormone. After menopause, there is an increased FSH because of reduction in pituitary gonadotropin inhibition of estrogen and progesterone. This change in ovarian steroid production is often gradual, resulting in anovulatory bleeding patterns. Eventually, the ovaries are unable to respond to FSH and LH and the level of gonadotropin hyperactivity stabilizes, gonadotropin levels never return to pre menopausal levels.

Immediate changes of menopause are hot flushes, causing flushes in the chest, face, neck and back, insomnia, mild to moderate depression, bone, joint, muscle aches, swelling, heart beat fluctuations, headache, vagina dryness and increased swelling (Smith, 2002).

Avoidance of caffeine, smoking, wearing cotton clothes is the measures for hot flushes. Exercising regularly in the morning or early evening, doing quiet activity just before the bedtime, sleeping in a comfortable environment, avoidance of sleeping medications, limited food intake prior to sleep are the measures for sleep problems and night sweats. Consuming calcium contained food items to minimize the joint and back discomforts. Stress reduction techniques are helpful for the psychological problems. Seeking medical help are for the sexual and urinary problems. These are all some of the non-pharmacological measures for the menopausal symptoms (Young kin & Davis, 2004).

REVIEW RELATED TO STUDIES ON QUALITY OF LIFE OF POSTMENOPAUSAL WOMEN

Rita Luoto (2009) menopausal health is important since this stage of life is not to be avoided. A recent article in BMC Women’s Health from the Estonian Postmenopausal Hormone Therapy trial has concluded that quality of life is not related to hormonal therapy use. The commentary article discusses this finding and considers other factors related to symptoms and quality of life during menopause. Important factors known to affect hot flushes and quality of life are smoking and high body weight. Since both these factors are modifiable, menopause is a suitable area for health promotion. However, evidence concerning lifestyle changes in symptom relief or increase of quality of life is weak. More trials in this area are needed before women may consider non-pharmacological treatment of symptoms as a reliable option for menopausal symptom cure

Jones G L, Sutton A (2009) had done a study to assess the quality of life in obese postmenopausal women. The aim of this review was to identify the ways in which obesity affects the health-related quality of life of postmenopausal women. This was considered important because a growing body of literature has identified obesity as a significant predictor for a poor psychological wellbeing and negative HRQoL, particularly in women, and because during the transition through the menopause women tend to accumulate more body weight. After searching eight electronic databases, only nine papers appeared meaningful. Although a meta-analysis was not possible, we found that a body mass index >30 kg/m2 was associated with a poor HRQoL in postmenopausal women; particularly in the areas associated with physical functioning, energy and vitality, and health perceptions. Thus, clinical management of obese postmenopausal women should focus on weight reduction and exercise in an attempt to improve wellbeing in these areas.

Kevan Richard (2009) conducted a study to assess the quality of sexual life and menopause. The importance of female sexual fulfillment is increasingly recognized in today’s society. Women’s sexual lives continue well into the menopausal years and beyond; however, the impact of menopause on the quality of that sexual life has not been comprehensively studied in the medical literature. This review attempts to clarify the impact of the physiological, psychological and psychosocial changes occurring at midlife that may affect women’s quality of sexual life. Pharmaceutical and psychological interventions that may assist in improving the quality of sexual life of menopausal women are discussed. Contrary to popular expectation, there is a substantial prevalence of sexual activity among middle-aged women, and the majority of middle-aged women express satisfaction with the quality of their sexual lives.

Avis N E, Colvin (2009) did a study to assess the changes in health related quality of life during the time of menopausal transition. The study was done with the sample of 3302 who were between the age group of 42 to 52 years. The findings of the study revealed the little impact of menopausal transition on health related quality of life.

Suzanne (2009) published a study on postmenopausal women’s loss of sexual desire effects health, quality of life. The study was done through telephone interview with 1189 postmenopausal women by using quality of life surveys. The study result shown between 9% and 26% of women suffer with the loss of sexual desire and it is mainly depends on the age and the menopausal stage.

Amanda J Welton (2008) conducted a study among postmenopausal women aged 50 to 69 to assess the effect of combined hormone replacement therapy (HRT) on health related quality of life. Health related quality of life and psychological wellbeing as measured by the women’s health questionnaire. After one year small but significant improvements were observed in three of nine components of the women’s health questionnaire for those taking combined HRT compared with those taking placebo. Hot flushes were experienced in the combined HRT and placebo groups by 30% and 29% at trial entry and 9% and 25% at one year, respectively. No significant differences in other menopausal symptoms, depression, or overall quality of life were observed at one year. Combined HRT started many years after the menopause can improve health related quality of life.

Mary C, Mark D (2008) has conducted a cross sectional study to assess the quality of life and related factors to impairment of quality of life among postmenopausal women. Cluster sampling technique was used and the data was collected from 480 postmenopausal women by using MENQOL scale. The study revealed that the menopause causes poor quality of life which is dependent to the work of the women and socio demographic variables.

Mahadeen A.I. (2008) did a study to describe the perceptions of Jordanian midlife women about making the menopausal transition. Audio taped interviews were conducted with 25 peri-menopausal Jordanian women. Interviews were analyzed as appropriate for descriptive qualitative inquiry. The major theme generated was ‘A Life Transition’, which included: a time of no more reproductive obligations, changing from the burdens and obligations of reproductive roles and responsibilities to freedom, relief and rest; a time for managing peri-menopausal symptoms; and a time for growing into a wise woman and accepting aging as a part of life.

Syamala & sivakami (2007) told about the study carried out in 1998 and 1999 with the sample of more than 90,000 married women with the age between 15 and 49, where the average age of menopause is 44.3 years.

Young, Rabago, (2007) objectively measured the sleep quality among 589 premenopausal, perimenopausal, postmenopausal women. Sleep quality was measured by polysomnography and self reported sleep problems. Results revealed that the quality of sleep was not worse in perimenopausal compared with premenopausal women.

Jeremy (2007) done a study to determine the age of attaining menopause among Indian women and they found that 3.1 percent about 17 million of Indian women are attaining menopause between the ages of 30 and 34, 8 percent are in the age of 39 and 19 percent have attained in the age of 41 years. Medical experts say that natural menopause occurs in between the ages of 45 and 55 and the mean age is 51.

Peter Chedrauiab (2006) to evaluate quality of life and determine factors related to its impairment among postmenopausal Ecuadorian women. Postmenopausal women that participated in a metabolic syndrome screening and educational program at the Institute of Biomedicine of the Universidad Católica of Guayaquil, Ecuador were interviewed using the Menopause-Specific Quality of Life Questionnaire. Mean domain scores as well as factors associated to higher scores within each of the domains of the questionnaire (vasomotor, psycho-social, physical and sexual) were determined. Three hundred twenty-five postmenopausal women were surveyed. More than 50% of women had scores above the median for each domain of the questionnaire. In this postmenopausal Ecuadorian population, impairment of quality of life was found to be associated to age and related conditions such as abdominal obesity, hypertension and hyperglycemia.

Gupta, Sturdee and Hunter (2006) examined the experience of menopause and quality of life in a migrated Asian population from the Indian sub continent living in Birmingham, United Kingdom (UK) and to compare their experience with a matched sample of Caucasian women living in the same geographical area and also with a sample of Asian women with similar socioeconomic background living in Delhi, India. In this cross sectional study of 153 peri and postmenopausal women aged 45 to 55 years, 52 Asian women originating from the Indian subcontinent living Birmingham, 51 Caucasian women and 50 Asian women living in India were interviewed to collect the information about their life style, general health, menopause experiences and health seeking behavior.

Maria L Bianchi (2005) has done a study to assess the impact of osteoporosis on quality of life. Totally 100 postmenopausal women were selected as samples and the data collected from them by interview technique. Overall 41% of the women showed a reduced quality of life.

Addis, et al (2005) examined the prevalence and correlation of sexual activity and function among 2,763 postmenopausal women with heart disease. They found that 39% of them were sexually active and 65% of them reported at least 1 or 5 sexual problems such as lack of interest, inability to relax, difficulty in arousal in orgasm and discomfort with sex.

Singh and Arora (2005) conducted a study to ascertain the profile of menopausal women in rural North India results revealed that out of 558 enlisted women aged 35 to 55 years the majority (85%) of the women admitted that menopause adversely affected their physical health. Many postmenopausal women continue to engage in sexual activity and 2/3rd of these report discomfort and other sexual function problems.

Martee L Hensley (2002) did a study to investigate the postmenopausal risk women undergoing screening for ovarian cancer, anxiety risk perception and quality of life. Totally 147 high risk women were selected as samples and among them 69 postmenopausal and 78 premenopausal women had transvaginal ultrasound screening, in which 37 % of premenopausal women and 26 % of post menopausal women had risk perception of ovarian cancer. Regarding the quality of life 38 % of premenopausal women and 27 % of postmenopausal women showed general quality of lfie.

Jennifer R. Clarkson (2002) did a study to investigate the health-related quality of life in African-American and white obese women. Participants were 145 obese women 87 premenopausal and 58 postmenopausal, who completed the Medical Outcomes Study short form, the Brief Symptom Inventory, the Life Distress Inventory, the Satisfaction with Life Scale, and the Rosenberg Self-Esteem Scale before entering a weight-loss study. The mean age of the subjects was 46.3. Menopausal status had a significant effect on HR-QOL; with premenopausal women being more distressed having more limitations in social activity and having less vitality than the postmenopausal women. This was especially true in the AA women. These data show no difference in HR-QOL between AA and W obese women and suggest that menopausal status may have an impact on HR-QOL, especially in AA women.

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Abstract

This paper aims to evaluate both the necessity for and benefit of the American Nurses Association (ANA) Code of

Ethics for Nurses

, specifically in relation to provision 5.2.  The focus of this provision is promotion of the nurse’s health and well-being via application of the nurse’s own skills to heal and care (ANA, 2015).  The nature of nursing inevitably involves experiencing the full parameter of life and death, and because of the interpersonal intimacy this often cultivates, the nurse is at risk for the development of negative states, such as depression, acute stress, and anxiety (Boyle, 2011; Chipas & Boyle, 2011; Laschinger & Fida, 2014; Lombardo & Eyre, 2011; Perry, Gallagher, Duffeld, Sibbritt, Bichel-Findlay, & Nicholls, 2016; Perry, Lamont, Brurero, Gallagher, & Duffeld, 2015).  Additionally, nursing shortages are a common occurrence within American society, and this can result in exhaustion, job dissatisfaction, and feelings of inadequacy (Kravits, McAllister-Black, Grant, & Kirk, 2010).  Despite the aim of the nursing profession to promote health and well-being, nurses are more likely to experience certain health disparities, as well as report increased levels of stress and burnout (Chipas & McKenna, 2011; Henry 2014; Kravits et. al., 2010; Laschinger & Fida, 2014).  In addition to these insights, suggestions for revisions of the code with supportive evidence will be provided.

Code of Nursing Ethics: Provision 5.2

5.2 Promotion of Personal Health, Safety, and Well-Being

As professionals who assess, intervene, evaluate, protect, promote, advocate, educate, and conduct research for the health and safety of others and society, nurses have a duty to take the same care for their own health and safety. Nurses should model the same health maintenance and health promotion measures that they teach and research, obtain health care when needed, and avoid taking unnecessary risks to health or safety in the course of their professional and personal activities. Fatigue and compassion fatigue affect a nurse’s professional performance and personal life. To mitigate these effects, nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs. These activities and satisfying work must be held in balance to promote and maintain their own health and well-being. Nurses in all roles should seek this balance, and it is the responsibility of nurse leaders to foster this balance within their organizations (ANA, 2015).

I deemed provision 5.2 from the ANA Code of Ethics for Nurses to be the most important provision to my practice because to have integrity of character and vocation, the nurse must first observe the same goals of healthfulness towards which he or she encourages the patient.  An article by Blake, Malik, Mo, & Pisano (2011), ironically titled ”Do as I say, but not as I do”, describes the findings of a cross-sectional survey of over 300 pre-registration nurses, and found that less than 50% met recommendations for exercise levels, less than a quarter consumed adequate fresh produce, almost 20% smoked, and only 60% regularly received adequate sleep.  Similarly, a 382-member survey by Perry et. al. (2015) also discovered links to health disparities: 21% of participants admitted to disordered relationships with food, almost three quarters reported sleep disturbances, 18% were smokers, and 92.5% consumed alcoholic beverages with almost 40% having moderate to high risk consumption habits.  Yet we cannot simply look at the unhealthy nurse, tell them he or she should be ashamed, and to try a salad and gym membership; the issue is much more multifaceted than the adjustment of hypocritic lifestyle habits.

Two common terms I encountered during my literature review were “compassion fatigue” and  “burnout”. First coined by C. Joinson in 1992, the term “compassion fatigue” is typified by discontent, aversion to one’s workplace, persistent exhaustion, depression, and increase in physical illness (Potter, Deshields, Divanbeigi, Berger, Cipriano, Norris, & Olsen, 2010).  Compassion fatigue occurs when a nurse continues to give energy and emotional output into his or her profession, yet does not have a nurturing environment to replenish his or her stores while away from the workplace.  On the other hand, Henry (2011) defines “burnout” in terms of the psychoemotional effects of chronic exposure to stressors, involving fatigue, hopelessness, lack of confidence, pessimism, and lack of empathy.  A study performed by Aiken, Clarke, and Sloane involving over 10,000 nurses revealed that approximately 54% of American nurses reported burnout during their career (Kravits et. al., 2010).  The effects of compassion fatigue and provider burnout not only have the propensity to negatively affect patient care, but wear on the nurse to the point of despair.  In a 2011 evaluation of 7,537 Certified Registered Nurse Anesthetists and Student Registered Nurse Anesthetists, Chipas and McKenna discovered that almost one third had made efforts to consult a counselor or other form of psychotherapist, and that almost one fifth were on prescription anxiolytics.  Laschinger and Fida (2014) reported that upwards of 60% of newly graduated nurses experienced burnout which was often correlated with feelings of depression and being overwhelmed at work.  It is from these negative psychoemotional experiences that the physical manifestations of unhealth stem.  In nursing, there is a fine line between serving our patients out of genuineness and serving our patients out of resentful obligation.  The nurse is not entirely to blame for a transition from the former to the latter; after all, we have been taught how to care for others, not ourselves.  When we forsake self-care, it becomes a challenge to extend the care we need to give ourselves to another, often without thanks.  Only when we care for ourselves with the same kindness are we able to continue to do so for others.  As Boyle so eloquently points out, “While many nurses perceive their work as a calling, few anticipate the emotional implications and sequelae that come from their close interpersonal relationships with patients and families” (2011).  Engaging empathy, selflessly caring for those who cannot reciprocate, showing kindness to those who have been forsaken by even their family: these actions do not come without emotional toll. Yet to continue to serve in genuineness, we cannot forsake these actions so fundamental to our vocation.

Despite the overwhelming occurrence of compassion fatigue and burnout among American nurses, there is a notable amount of research providing suggestions to identify and prevent these phenomenon.  These include adequate support systems, appropriate work-life balance, mindfulness, working out, religious or spiritual activities, and time for oneself (Chipas & McKenna, 2011).  Additional steps the nurse can take are engaging in therapy, joining a support group, or seeking help from an employing assistance program (Henry, 2014).  Although it may seem petty and selfish to prioritize these activities, every life deserves health and happiness, especially one dedicated towards promoting the health and happiness of others.

The ANA Code of Ethics for Nurses is an essential document that provides a standard of character and practice among nurses, outlining the foundations of the nursing profession and validating the purpose of our vocation.  My experience within the world of nursing speaks to the Code not being utilized to its greatest potential for the augmentation and admonition of the nursing profession.  The Code of Ethics for Nursing creates an even playing ground for all those under the umbrella of nursing: it allows those without a voice to find leverage, both patients and nurses alike.  For example, lack of support from nursing management, as well as from fellow nurses, can create a caustic work environment that is an all-too-common occurrence in the nursing world.  The Code of Ethics calls these leading nurses to a standard of behavior that is supportive of their fellow nurses; specifically, provision 6.3 dictates the necessity of a “morally good environment” to promote the wellbeing of the nurse and prevent discontent and/or anxiety (ANA, 2015).  The Code goes on to say that nurse educators hold a responsibility to care for the learning and professional growth of those in their care, discussed in provision 7.3.  I have witnessed nurses being undermined by management simply because they are disliked by a senior nurse, young nurses criticized because they use newer terminology that the senior nurse is unfamiliar with, ambitious nurses with dreams of going back to school discouraged and actively hindered by management from obtaining additional credentials necessary to pursue their desired degree, and female nurses sexually harassed by male employees who confided in their nurse manager with the hopes of protection and advocacy, yet who went by the wayside because their perpetrator held power.  Personally, I have been the victim of more than one of the above examples.  Reading the Code gives me hope that if I am ever in a similar situation, I now am prepared to better advocate for myself; even more encouraging is the hope that I can provide this advocacy for one of my fellow nurses in the future should they incur such injustices.

The Code of Ethics for Nurses has origins dating back to 1893 (ANA, 2015).  There are very few discrepancies to address that another has not in the past 126 years.  Nearing the end of the Code of Ethics for Nurses in provision 8.4, the issue of human rights is addressed.  Certain groups are named, specifically those with limited resources, at age extremes, female, and lastly, “socially stigmatized groups” (ANA, 2015).  There is no mention of homosexual, transsexual, transgender, or otherwise queer people groups and the magnanimous need for recognition of the unique health disparities specific to these individuals, such as lack of healthcare, preconceptions among providers, and lack of knowledge regarding their lifestyle, beliefs, and identity (Sirota, 2013).  Additionally, other socioeconomic factors plague queer individuals, such as higher rates of homelessness among young adults, less effort towards tertiary health measures, and higher occurrence of suicide among queer teens at rates up to three times their hetero counterparts (Lim, Brown, & Jones, 2013).  Although it is possible that the ANA intended to cover these with the umbrella of “socially stigmatized groups”, to do so would both be minimizing to the diversity of such individuals, as well as unintentionally accepting of the inequalities and misunderstandings these members of our society experience.  The health needs of these different groups of people vary greatly: a homosexual male is probably at greater risk for certain sexually transmitted diseases, a transgender individual undergoing gender reassignment surgery may incur unique challenges related to their assumed identity postoperatively, and the patient using non-cisgender pronouns may feel misunderstood or even disrespected by staff, and their healing environment may suffer from it.  Although the issue of sexual identity and orientation may not be an easy topic for the ANA to incorporate into their Code of Ethics, if our job as nurses is to accept and care for each patient with attention to their unique differences and daily struggles, then we must do so in wholeness of person, incorporating aspects of their physical, mental, emotional, psychological, spiritual, and sexual health.

Provision 5.2 of the ANA Code of Ethics for Nurses focuses on

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