Chapter 4: ethics

12 The new nurse-manager has committed to modeling the leadership roles associated with applying ethics in the workplace. What is the manager's best action? Answers: A. Demonstrate self-awareness about his or her own beliefs, morals, and values B. Ensure that individual rights are always prioritized over collective rights C. Delegate ethical decision making to staff nurses whenever possible D. Ensure nurses are responsible for scrutinizing each other's behavior to monitor for ethical violations

A A core competency for ethical leadership is evaluating one's own values and beliefs. This form of self-reflection is foundational for providing ethical care and promoting in others. The balance between individual and collective rights is situation-specific; individual rights are not always priorities over group interests. The manager must show leadership in ethical decision making and cannot always delegate this important function to staff. Ethical nurses are observant for violations, but this should not result in an environment where each nurse is "scrutinizing" colleagues' practice. •

5 A nurse is integrating the code of ethics when making a decision about the best response to a challenging situation. What information will the nurse be able to obtain from this document? Answers: A. The principles that are most valued in nursing practice B. Legal guidelines to help the nurse make an ethical decision C. Guidelines that will help the nurse clarify his or her own values D. A model that will guide the nurse to make an ethical decision

A A professional code of ethics is a set of principles, established by a profession, to guide the individual practitioner. It is not, however, a decision-making model or a tool for clarifying one's own values. Codes of ethics are not legally binding documents.

4 Which activity best demonstrates a nursing unit manager's attention to ANA standards for ethics required of that position? A. Refers complex dilemmas to the institution's ethics board B. Terminates a staff member for absenteeism C. Assures staff and patients that unit decisions are ethically sound D. Maintains current licensure

A ANA standards for ethics related to nurse administrators identifies participants on multidisciplinary and interdisciplinary teams that address ethical risks, benefits, and outcomes as a criteria measurement. The remaining options, although addressing ethical behaviors on the administrator's part, are not as directly identified by the ANA. •

3 The principle of autonomy would have the greatest bearing on what clinical situation? A client is discussing a do-not-resuscitate order with the care team. B. The nurse is caring for two clients in pain and must choose which to treat first. C. A client is unable to afford the treatment that carries the best chance for a cure. D. A nurse is considering whether to report a colleague's rough treatment of a client.

A Autonomy, or self-determination, is also referred to as freedom of choice and accepting the responsibility for one's choice. Deciding on resuscitation options involves this principle because the client's preference is the final determinant on the matter. Situations involving scarce resources or time are more closely aligned with issues of justice. The nurse's ethical decision making around reporting bad practice align most closely with duty-based reasoning and beneficence for clients.

26 In which situation would the nurse be justified in overriding a client's right to confidentiality? Answers: A. An older adult client discloses to the nurse that her son occasionally hits her. B. A teenage client asks the nurse not to tell her parents that she is pregnant. C. A client does not want her husband to know that she is a client on the unit. D. A client states that he does not want to know the results of his recent diagnostic test.

A Health-care managers are required by law to report certain cases, such as drug abuse in employees, elder abuse, and child abuse. This is considered a justifiable violation of confidentiality. The manager is obliged to respect client confidentiality around disclosing pregnancy, acknowledging a hospital admission, or not wanting to know diagnostic results. •

14 The interdisciplinary team is considering whether to apply the principle of paternalism in the care of a client. What question should guide the team's decision? Answers: A. Is the client competent to make decisions? B. What is the client's most likely prognosis? C. Does the client have strong social or family support? D. What interventions are in the client's best interest?

A Paternalism can be invoked when a client is unable to make sound decisions for himself or herself. Consequently, the client's ability to make decisions underlies the question of whether acting paternalistic is justified or not? The presence or absence of social and family support does not justify or rule out paternalism. Likewise, the particulars of the client's prognosis do not determine whether it is appropriate to be paternalistic. The client's competence decides whether the care team is justified in stepping in to act in the client's "best interest."

23 The nurse has applied the MORAL decision-making model to a situation that involved an ethical dilemma. The nurse should complete the process by: Answers: A. evaluating the effectiveness of the decision-making process. B. leading the implementation plan. C. reaffirming the nurse's relationships with stakeholders. D. disseminating the results of the process to other nurses.

A The final phase of the MORAL decision-making model involves "looking back." That is, evaluating the decision-making process. This model does not explicitly involve reaffirming relationships or disseminating the results, even though the model does not preclude these actions. Implementing the decision precedes the evaluation phase. •

29 A nurse is applying the MORAL decision-making model to a dilemma involving a colleague's possible dishonesty in documentation. What is the nurse's initial action? Answers: A. Gather as much information about the situation as possible B. Think of as many alternatives as possible C. Engage the colleague in the decision-making process D. Perform a critical self-reflection of the nurse's own morals and values

A The first step of the MORAL decision-making model is to "massage the dilemma." This involves collecting data about the ethical problem and who should be involved in the decision-making process. However, this does not necessarily mean that the nurse must engage the colleague who is the object of the decision. Outlining options (alternatives) is the second step in the model. It is presumed that a nurse will engage in self-reflection when addressing dilemmas, but this is not an explicit component of the MORAL model. •

11 The nurse-manager is applying the MORAL decision-making model to a decision around a client's plan of care. The manager has engaged all the necessary stakeholders and collected as much data about the situation as possible. What should the manager do next? Answers: A. Identify as many alternatives as possible B. Assess the client's values and beliefs C. Choose the option that best aligns with ethical principles D. Arrange to meet with the institution's ethics board

A The initial step in the MORAL decision-making model involves collecting data and determining who should be involved in the decision-making process. After this, the nurse identifies alternatives and then chooses the best option. Engaging with an ethics committee should take place in the first step when the manager decides who to involve. Assessing the client's values should take place early in the decision-making process. •

15 The A nurse is applying the ethical principle of justice when providing care for clients. What action best exemplifies this principle? Answers: A. Ensuring that time and resources are distributed equitably to clients B. Meeting continuing education requirements for license renewal C. Respecting clients' rights to make decisions about their care D. Prioritizing actions that will benefit the largest number of clients

A The principle of justice states that equals should be treated equally and that unequals should be treated according to their differences; this is the principle of equity. Justice is frequently applied when there are scarcities or competition for resources or benefits. Meeting requirements for licensure is a legal issue, not a principle of ethics. The principle of utility involves prioritizing actions that will benefit the largest number of clients. Respecting clients' rights to make decisions demonstrates autonomy. •

9 The care team is working with a client who has mental illness and who has been deemed a threat to self and others. It may be justified to take away the client's right to: Answers: A. self-determination. B. justice. C. beneficence. D. confidentiality.

A When an individual's impaired decision making poses a threat to self or others, it may be in the interests of the client and other people to temporarily remove the client's right to self-determination. That is, to remove the client's right to reject treatment. This is ultimately an act of beneficence, even though the client may perceive otherwise. Justice is more closely aligned with the distribution of benefits between people. Confidentiality is maintained whether or not the client's right to self-determination remains in place.

2 Which statement is correct regarding the distinction between legal and ethical obligations in decision making? Answers: A. Legal controls are clearer and philosophically impartial. B. Ethical controls are clearer and philosophically impartial. C. Legal controls are much less clear and individualized. D. Ethical controls are much clearer and individualized.

A In general, legal controls are clearer and philosophically impartial; ethical controls are much less clear and individualized.

7 Which statements concerning autonomy are true? Select all that apply. Answers: A. It supports the process of progressive employee discipline. B. It is a form of personal liberty. C. It overrides paternalism but not beneficence. D. Its legal equivalent is self-determination. E. It is based on a person's right to make a choice.

A B D E A form of personal liberty, autonomy is also called freedom of choice or accepting the responsibility for one's choice. The legal right of self-determination supports this moral principle. The use of progressive discipline recognizes the autonomy of the employee. The employee, in essence, has the choice to meet organizational expectations or to be disciplined further. If the employee's continued behavior warrants termination, the principle of autonomy says that the employee has made the choice to be terminated by virtue of his or her actions, not by that of the manager. Ethical situations always differ, so it is impossible to state that one particular principle always overrides another. •

24 Which statement best describes ethics? Answers: A. How people make decisions they see as legally and morally appropriate B. What our conduct and actions should be regarding what is right and good C. The conflict, power, and interdependency associated with the way we live D. How our lives and relationships are led in day-to-day circumstances

B Ethics is the systematic study of what a person's conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and the study of what a person's life and relationships should be, not necessarily what they are. It is not the study of what people actually do in their daily lives or how they live but rather what they should do. Ethics is related to legality and morality, but it is not synonymous with these concepts. •

27 The managers of a hospital unit have been approached by a nurse educator who wants to conduct research into a particular nursing intervention. In order to ensure that the rights of clients who may participate are protected, the managers should: Answers: A. ask the hospital ethics committee to approve or deny the application. B. refer the educator to the institutional review board. C. discuss the educator's values, beliefs, and ethics. D. compare the study methodology to the code of ethics.

B Institutional review boards are primarily formed to protect the rights and welfare of research subjects. They are the main gatekeepers for research that takes place in the institution. Ethics committees more often deal with specific situations involved in client care. Discussing the educator's values and beliefs is insufficient to protect the rights of participants. There may be some benefit in comparing the research proposal to the code of ethics, but ultimately, this is within the jurisdiction of the IRB. •

17 A nurse has applied for a management position in a new organization. How can the manager best prevent intrapersonal conflict related to ethical issues in this role? Answers: A. Become familiar with the nurse practice act in the jurisdiction where the organization is located B. Clarify his or her own values and beliefs and compare to those of the organization C. Identify a mentor in the organization who maintains high ethical standards D. Determine whether nurses in the organization are required to follow a code of ethics

B The likelihood of intrapersonal conflict resulting from disagreement between a manager's values and those of the organization is reduced if the manager clarifies his or her own values and those of the organization. A mentor cannot necessarily help a manager do this because values are personal. All nurses must follow a code of ethics, so this is not a variable. Becoming familiar with the nurse practice act is beneficial, but this legislation does not address ethical issues and values. •

21 The policies in a long-term care facility specify that immobile residents should be repositioned at least every 2 hours. Despite this, it is well known that many residents endure long periods without being repositioned. How should the nurse best interpret this situation? Answers: A. The nurses at the facility should apply the MORAL decision-making model to address this. B. There is a need for actions to address this theory-practice-ethics gap. C. It is necessary for the nurses at the facility to review the code of ethics. D. The nurses at the facility are experiencing intrapersonal conflict that affects their practice.

B Theory-practice-ethics gaps exist when there is incongruence between what nurses know they should or must do and what they actually do. Intrapersonal conflict is internal discontent resulting from inconsistency between what should be done and what a nurse can realistically do. However, there is no evidence that this is the case. Reviewing a code of ethics is unlikely to bring about meaningful change without the addition of other incentives. The MORAL decision-making model guides ethical decision making but does not address these gaps between what should be done and what is actually done. •

28 The nurse-manager has learned there is conflict between a nonresponsive client's family members about the best plan of care. The manager recognizes the complex ethics of this situation. What is the manager's best action? Answers: A. Base a decision on the most recent precedent in the organization B. Make contact with the hospital's ethics committee C. Ask an impartial staff member to mediate D. Refer the family to the hospital's spiritual care service

B An ethics committee can bring needed experience, perspective, and insight to challenging ethical situations. Precedent cannot always be used as a guide because each situation is unique even if they appear superficially similar. Clients and families often benefit from spiritual care, but this does not help the manager make a good decision. Mediation can sometimes be beneficial, but this does not release the nurse-manager from addressing the situation as best as he or she can. •

25 The nurse has navigating a difficult situation that involved an ethical dilemma. Which factors should be considered when assessing the quality of the nurse's ethical problem-solving process? Select all that apply. Answers: A. The process the nurse used for data gathering B. The outcomes of the process C. The process that was used to arrive at a decision D. Precedents in the organization involving similar situations E. The number of alternatives that the nurse initially generated

B C E Outcomes should never be used as the sole criterion for assessing the quality of ethical problem solving because many variables affect outcomes that have no reflection on whether the problem solving was appropriate. Quality, instead, should be evaluated both by the outcome and the process used to make the decision. Rigorous data gathering enhances the decision-making process, but this is not the criteria by which the overall process is gauged. Similarly, precedents can be used to inform decision making but do not constitute the basis for evaluating the overall process. Generating multiple alternatives aids the problem-solving process by identifying as many options as possible. •

30 A nurse has been asked to stay after a shift and work overtime because three nurses have called in sick. The nurse is reluctant to work the overtime because of a social commitment. Duty-based reasoning would dictate that the nurse: Answers: A. base the decision on recent precedents in the health-care organization. B. contact the three nurses to remind them of their obligations. C. work overtime because of the responsibility owed to clients. D. carefully weigh the effect of the decision on workplace relationships.

C Duty-based reasoning is an ethical framework stating that some decisions must be made because there is a duty to do something or to refrain from doing something. In this case, it could be construed that the nurse has a duty to care for clients that supersedes social activities. Duty-based reasoning would not prioritize the effect on relationships over the nurse's moral duty. Precedents would not necessarily indicate what the nurse's duty is. Duty-based reasoning emphasizes the nurse's own duty, not that of colleagues.

20 Which statement by a nurse most clearly demonstrates an intuitionist framework for ethical decision making? Answers: A. "I'm trying to think of as many different options as I can rather than focusing on those that look most attractive." B. "I'll make the best decision if I choose the option that comes to mind first rather than overanalyzing the situation." C. "I've got to look at this situation on the basis of its unique characteristics, not by comparing it to other situations." D. "It's important that I consider the effect of my decision on the organization, not just the people who are directly involved."

C Intuitionist states that each case weighed on a case-by-case basis to determine relative goals, duties, and rights. Consequently, there is a focus on the specific characteristics of a situation, not its commonalities with other situations. Thinking of as many options as possible is a good practice for ethical decision making, but it is not specifically aligned with an intuitionist framework. Similarly, considering the effects on the organization is not a particular characteristic of this framework. Intuition does not entail choosing the option that first comes to mind, without any further analysis or consideration.

19 A nurse has repeatedly witnessed a physician being dismissive of clients' reports of pain and anxiety. The nurse recognizes that the best action would be to address this behavior with the physician, but the nurse strongly suspects that these concerns would be dismissed. What phenomenon is this nurse experiencing? Answers: A. Ethical universalism B. Ethical relativism C. Moral outrage D. Moral conflict

C Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it. Moral uncertainty or moral conflict occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is. Ethical relativism suggests that individuals make decisions based only on what seems right or reasonable according to their value system or culture. Ethical universalism holds that ethical principles are universal and constant and that ethical decision making should not vary as a result of individual circumstances or cultural differences. •

16 The nurse is practicing in a challenging environment where ethical and moral issues must often be dealt with. Which statement describes how moral uncertainty occurs? Answers: A. An individual witnesses the immoral act of another but feels powerless to stop it. B. An individual knows the right thing to do but organizational constraints make it difficult to take the right course of action. C.An individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is. D. An individual is forced to choose between two or more undesirable alternatives.

C Moral uncertainty occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is. Moral distress occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action. Moral outrage occurs when an individual witnesses the immoral act of another but feels powerless to stop it. Ethical dilemma is being forced to choose between two or more undesirable alternatives.

1 Which ethical principle is demonstrated when an adult child is legally given the right to make medical decisions for a cognitively impaired parent? A. Beneficence B. Justice C. Paternalism D. Fidelity

C Paternalism is when one individual assumes the right to make decisions for another. Justice requires that a person seek fairness, treat "equals" equally, and treat "unequals" according to their differences. Fidelity involves the need to keep promises. Beneficence involves actions that are taken in an effort to promote good.

8 Which nurse is experiencing moral distress? Answers: A. The children of a terminally ill client do not want the client's prognosis communicated to the client. B. A nurse knows that a colleague called in sick to work because the colleague had a social engagement. C. A heavy workload prevents a nurse from providing the care that each client requires. D. A nurse witnesses a colleague using a racial slur in a conversation with another nurse.

C. Each of the listed situations has an ethical element. However, moral distress occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action. A nurse who lacks the time and energy to give clients what they need is likely to experience moral distress. Issues of respect, honesty, and confidentiality require ethical decision making, but they do not directly involve a disconnect between the desire and the ability to do the right thing.

10 The nurse is faced with a situation that requires ethical decision making. What statement should guide the nurse's action? Answers: A. Outcomes are the main criterion for evaluating ethical decision making. B. Critical ethical decisions should be made quickly so the situation does not worsen. C. Only desirable alternatives should be identified when solving ethical dilemmas. D. Accepting some ambiguity and uncertainty is a part of ethical decision making.

D Ethical decision makers choose between two or more undesirable alternatives, and because they can use only the information and resources available at the time, they must live with some ambiguity and uncertainty. Processes must be considered during ethical decision making, not only outcomes. The nurse should identify as many alternatives as possible during the early stages of decision making, not only desirable alternatives. Ethical decisions often require a careful and methodical approach rather than a quick decision.

18 A nurse is facing an ethical dilemma about whether to report a colleague's offensive comment, an action which is likely to jeopardize their relationship. What is a characteristic of this nurse's ethical dilemma? Answers: A. The dilemma has no realistic solution. B. The dilemma can be solved by applying empirical data. C. The situation involves a breach of the law. D. The situation involves two or more undesirable alternatives.

D Ethical dilemmas involve being forced to choose between two or more undesirable alternatives. Ethical dilemmas are often not amenable to being solved with empirical data; they involve values and beliefs, not only facts. Most ethical dilemmas do not involve a breach of the law; legal issues often have a more clear and unambiguous response. Even though ethical dilemmas are difficult to manage, this does not mean that there is no possibility of a realistic solution.

6 A nurse has recognized that many older adult clients on the unit do not receive enough nutrition because they are unable to feed themselves independently. What action by a manager would be most likely to resolve the nurse's moral distress? Answers: A. Acknowledging and validating the nurse's observation B. Providing a reference so the nurse can seek new employment C. Arranging to have the clients' diets changed so they are more nutrient-dense D. Hiring more nursing assistants to help feed these clients

D Moral distress occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action. In this case, the nurse knows what needs to be done (the clients need assistance with feeding) and arranging for more employees to do this function would remove the organizational constraint. Validation is of no value if it is not followed up by action. Changing the clients' diets is not helpful if they cannot be fed the new diet. Helping the nurse seek employment elsewhere does not benefit the clients and may not relieve the nurse's moral distress.

13 The only treatment alternative left for a client diagnosed with advanced cancer is a rare, highly experimental bone marrow transfusion with a 10% success rate. Some individuals are arguing that the high cost of the procedure could be better spent providing well-baby screening for 2,000 residents in the service area. What ethical principle is most directly involved in this situation? Answers: A. Maleficence B. Unethical conduct C. Paternalism D. Utility

D The principle of utility states that what is best for the common good outweighs what is best for the individual. There is no indication of unethical or maleficent (harmful) behavior. Paternalism would be characterized by decisions being made without the client having input.

22 A nurse-manager is discussing a proposed change in practice the interdisciplinary team. What question by the manager best reflects a utilitarian perspective? Answers: A. "Does our code of ethics address this?" B. "Are the benefits greater than the risks?" C. "Have we asked clients and families what they think?" D. "How many people will this benefit?"

D Utilitarianism prioritizes the greatest good for the largest number of people. For this reason, a question about how many individuals would benefit would be more indicative of utilitarianism than issues related to consulting clients, weighing risks and benefits, and consulting the code of ethics. •