Concept chapter 7

Ethical Decision-Making Model

ethical decision making and the nursing process, both of which are based on sound critical thinking. A variety of ethical decision-making models are available in published literature across many disciplines and share more similarities than differences. The following steps can be used in ethical decision making: 1. Clarify the ethical dilemma. 2. Gather additional data. 3. Identify options. 4. Make a decision. 5. Act. 6. Evaluate.

The ANA has developed a Social Networking Principles

help nurses understand their responsibilities when using social media (ANA, 2012). In August 2011 the NCSBN published a white paper, A Nurse's Guide to the Use of Social Media (www.ncsbn.org), a guideline that details the challenges related to ethical use of social media (NCSBN, 2012). The ANA and NCSBN have mutually endorsed their positions regarding nurses' professional use of social media (ANA, 2012) and their endorsement still stands. It is important to realize that the principles undergirding the protection of patients regarding social media do not change, even as digital media continue to grow and thrive.

The Florence Nigh-tingle high standards of professional ethical behaviour

high standard of professional ethical behavior. These principles are noted parenthetically in bold italics. I solemnly pledge myself before God and presence of this assembly; to pass my life in purity and to practice my profession faithfully (fidelity). I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug (nonmaleficence). I will do all in my power to maintain and elevate the standard of my profession (beneficence) and will hold in confidence all personal matters committed to my keeping and family affairs coming to my knowledge in the practice of my calling (confidentiality). With loyalty will I endeavor to aid the physician in his work (fidelity), and devote myself to the welfare of those committed to my care (justice).

applied ethics

which focus on specific difficult issues such as euthanasia, capital punishment, abortion, and health disparities

Normative Ethics

which focus on the moral standards that regulate behaviors

Metaethics

which focus on universal truths, and where and how ethical principles are developed

Numerous models have been developed for distributing health care resources. These models include the following (Jameton, 1984

• To each equally • To each according to merit (this may include past or future contributions to society) • To each according to what can be acquired in the marketplace • To each according to need

The following section will explore the major issues involved in these conflicts:

(1) personal value systems, (2) peers' and other professionals' behaviors , (3) patients' rights, (4) institutional and societal issues, and (5) patient data access issues.

Human dignity and respect for person are the foundation of the six ethical principles

1. Autonomy 2. Beneficence 3. Non maleficence 4. Justice 5. Fidelity 6.. veracity

three general type of ethics

1. Metaethics 2.normative ethics 3. Applied ethics

Gilligan levels of moral development

1. Orientation to individual survival 2. A focus on goodness with recognition of self sacrifice 3. The morality of caring and being responsible for others as well as self Focus of nursing on care as a moral attribute is congruent with Gilligan assertion that the dynamics of human relationships are central to moral understanding, joining the heart and the eye in an ethic that ties the activity of thought to the activity of care Critical thinking within a caring professional relationship is a sound basis for nursing practice Nurses at time combine the care/justice perspective when forced to make ethical decisions. Nurses shifted from the moral perspective of care to a justice orientation where universal rules and principles are used in moral decisions making

The rule of double effect justifies that an individual may rightfully perform an act that produces a good and bad effect provided the following four conditions are met at one and the same time (Buckley et Al 2012

1. The action must be good or at least morally indifferent (neutral). 2. The health care provider must intend only the good effect, and the bad effect is unintended. 3. The good effect is not achieved by means of the bad effect. 4. There is a favorable balance between the desirable and undesirable effects (the good outweighs the bad).

American Nurses Association's Code of Ethics for Nurses

1893 the Nightingale Pledge (Box 7.2) became the first public evidence of an ethical code in nursing. In 1896 the Nurses' Associated Alumnae of the United States and Canada, which later became the ANA, was organized with the purpose to establish and maintain a code of ethics. A suggested code was developed in 1926 and published in the American Journal of Nursing

Code of Ethics for Nurses

A code of ethics is a hallmark of mature professions and a social contract through which the profession informs society of the principles and rules by which it functions. Ethical codes shape professional self-regulation, serving as guidelines to the members of the profession, who then meet their responsibility as trustworthy, qualified, and accountable caregivers. Codes of ethics, however, are useful only to the extent that they are known and upheld by the members of the profession in practice.

Professional ethics codes ex

ANA provides substantial guidelines in determining how to respond and act in practice setting when faced with an ethical dilemma

To function effectively in complex health care arena nurse need to understand

Approach's to moral reasoning, theories of ethics, basic ethical principles, ethical decisions making models

Biothics

Are application of ethical theories and principles to moral issues or problem ms in health care Also referred to as biomedical ethics as an area of ethical inquiry came into existence around 1970 When health care providers began to embrace a holistic view of the patient and the rights of patients, treating and curing disease Bioethics are concerned with determining what should be done in a specific situation by applying ethical principles For instance, discussion about genetic testing often have a strong bioethical component surrounding use of knowledge from this type of testing

Values

Are attitudes, ideals or beliefs that an individual or a group holds and uses to guide behavior.

attitude is part of values

Are integrated with values and can shape nurses judgments and action May, how ever result in nurse bias if the nurse is not cognisant of how the belief may effect the nurse judgment

Unaddressed moral distress

Can lead to nurse behaviour that exacerbates an integrity compromising situation, including nurse apathy , indifference, avoidance, disengagement in patient care situation, feeling of powerlessness and loss of moral sensitivity

Beneficence

Commonly defined as the doing of good and is one of the critical ethical principles in health care Beneficence act may conflict with other ethical principles most often autonomy

Patient Self-Determination Act

Congress passed the Patient Self-Determination Act (PSDA) in 1990; it was enacted in December 1991. The PSDA is a safeguard for patients' rights, giving patients the legal right to determine how vigorously they wish to be treated in life-or-death situations, and calls for hospitals to abide by patients' advance directives. The PSDA specifies that any organization receiving Medicare or Medicaid funds must inform patients of state laws regarding directives, document the existence of directives in the patient's medical record, educate staff regarding directives, and educate the community about directives. This Act encourages individuals to think about the type of medical and nursing treatment they would want if they were to become critically injured or ill.

intentional deception

Consider morally wrong

The post conventional level

Consists of stage 5 and stage 6 and involves more independent mode of thinking than previous stages The individual has developed the ability to define his or her own moral values Individual who apply moral reasoning at the post conventional level may ignore both self interest and group norms in making moral choices ex : they may sacrifice themselves on behalf of the group Part of their moral reasoning and behaviour is based on a socially agreed on standard of human rights In this highest level of moral development, people create their own morality, which may differ from society norms. Kohlberg believed that only a minority of adults achieves this level

System Thinking

Continuing take experiences in and reflect on them from holistic , value based, knowledge driven stance

Nonmaleficence

Defined as the duty to do no harm. This principle is the foundation of the medical profession Hippocratic oath It is likewise critical to the nursing profession Inherent in code of ethics for nurses ANA Therapeutic interventions carry risk of harm for the patient Ex: chemotherapy and bone marrow or steam cell transplantation procedure The concept that justifies risking harm is referred to as the rule of "double effect." Double effect considers the intended foreseen effects of actions by the professional nurse.

moral development

Describe how a person learns to handle moral dilemmas from childhood through adulthood

Provision 2 of the code of Ethics

Describe the nurse primary commitment to the patient

provision 5 of the ANA Code of Ethics

Describe the responsibility of nurses to maintain their own integrity Provision 2,5 are not conflict but they do underscore the importance of understanding nursing primary ethical obligations to the care of patients

Dilemmas created by patient data access issues

Digital technologies and EHRs are powerful sources for the storage and transmission of information about patients across health care specialties and disciplines.

Fidelity

Fidelity suggests that one is faithful to the promises, agreements, and commitments made

Gilligan's stages of Moral Reasoning

Gilligan 1982 was concerned that Kohlberg did not adequately recognise women's experiences in the development of moral reasoning She noted that Kohlberg theories had largely been generated from research with men and boys, and when women were tested by using Kohlberg stages of moral reasoning, they scored lower than men. Gilligan believes that women and girls relational orientation to the word shaped their moral reasoning differently from that of men and boys.

Dilemmas Created by Institutional and Social Issues

Health care institutions must comply with many governmental regulations that affect both workers and patients. Nurse may experience moral dilemmas when they disagree with the policies of their institutions. If moral distress results for the nurse, it may negatively affect not only patients but the nurse as well Thoughtful and conscious action is required to address moral distress, which may lead to greater self-awareness and resilience (McCarthy and Gastmans, 2015). Ethics committees were created to assist with ethical dilemmas in institutional settings. These committees are multidisciplinary groups charged with the responsibility of providing consultation and emotional support in situations in which difficult ethical choices are necessary.

Dilemmas Regarding Patients' Rights

In 1971 the United Nations passed a resolution known as the Declaration of the Rights of Mentally Retarded Persons, an early model that recognized the interests of a particular group of persons with disabilities. In 1990 the Congress of the United States passed the Americans with Disabilities Act, which was amended in 2008. This extensive act has provided provided a significant improvement in the lives of persons with a variety of mental and physical disabilities, recognizing their rights to participate fully in all aspects of society . Other less formal interest groups have written guidelines such as the Dying Person's Bill of Rights, Pregnant Patient's Bill of Rights, and Rights of Senior Citizens.

Moral integrity

Is a goal in which one's professional beliefs and actions are assessed and analysed reflected on so that professional ethics continue to mature and respond to changes in practice

moral distress

Is a phenomenon of spiritual, emotional, and behavioural anguish Moral distress may arise when one knows the morally correct action to take but is unable to act as a result of internal constraints, such as lack of moral courage or external constraints including power differential Moral distress may also occur when a nurse moral action is ineffective in ensuring the moral outcome, often because of constraints beyond the nurse control Repercussions of moral distress affect not only the nurse but also the broader health care context including risk to health care quality and patient outcomes , job satisfaction, and retention as well as the physical, spiritual, and emotional wellness of the nurse

moral reasoning

Is a process in which maturation occurs over time as persons become more abstract in their thinking and understanding of the world

Ethics

Is a term used to reflect what actions an individual should take and maybe codified as in the ethical code of a profession Is derived from the Greek work ethos which means habits or customs Ethics are process oriented and involve a critical analysis of actions If ethicists person who study ethics reflected on the moral statement one should not lie , they would clarify definitions of lying and explore wether there are circumstances under which lying might me acceptance

The conventional

Is characterised by moral decisions that conform to the expectations of one's family, group, or society The person making moral choices based on what is pleasing to others characterises stage 3 this level An individual in stage 4 of the conventional level makes moral choices based on a larger notion of what is desired by society When confronted with a moral Choice, people functioning at the conventional level follow family or cultural group norms. According to Kohlberg, most adolescent and adult generally function at this level. Because it's the law is a common explanation of persons operating at a conventional level of moral reasoning

moral development

Is stimulated by the creation of conflict in setting in which the individual recognises the limitations of present modes of thinking. Ex: students have been stimulated to higher levels of moral reasoning through participating in courses on moral discussion and ethics

More typical example

Is that of a toddler for whom the word no has yet to have meaning as he or she persists in reaching for a breakable object on a table

Kohlberg's stages of moral development

Kohlberg 1972,1986 proposed three levels of moral reasoning as a function of cognitive development 1. Pre-conventional 2. Conventional 3. Post conventional

Exploring Ethical Dilemmas in nursing

Many ethical dilemmas arise in nursing because of conflicts among patients,

The Practice of Moral Courage

Moral courage is an individual's capacity to overcome fear and stand up for his or her core values with awareness, despite the potential risk (Lachman, 2010). In other words, moral courage is necessary when moral integrity is in jeopardy, and action to maintain integrity entails risk. Lachman (2010) coined a moral courage model using the acronym CODE to signify the necessity to respond to an integrity-compromising situation: Courage, Obligation to honor, Danger management, and Expression and action. Lachman's (2010) model illustrates the essential elements of being a moral agent. • Courage: The nurse in this step recognizes courage may be necessary to maintain integrity. The nurse analyzes the situation to determine whether an action is required to address the situation. • Obligations to honor: The nurse considers his or her values and beliefs, the ethical principles at stake with the situation, and the ANA (2015a) Code of Ethics for Nurses provisions to determine what obligations require honoring. • Danger management: The nurse identifies strategies to manage the fear of repercussions when maintaining integrity. Managing danger may include sharing the situation with a trusted nurse or mentor and seeking feedback on how to address the situation. Nurses may also rehearse and practice how they will address the situation and speak up to manage fear. Communicating concerns in an organized manner in an SBAR format guides communication also addressing fear. See Table 7.5, The Situational Briefing Model (SBAR), for additional detail. Another useful tool for managing danger is the CUS Method, coined by the Agency for Healthcare Quality and Research (2014) with Teamstepps. The CUS Method includes first stating the concern ("I am concerned about..."), next sharing why the situation is uncomfortable ("I am uncomfortable with..."), and last if the conflict is unresolved and is a potential safety issue, stating the specific concerns ("this is a safety issue..."). Expression and Action: In the final step, the nurse determines what action is required to maintain integrity considering personal values and beliefs and the obligations to honor. The action may direct (addressing the concern directly with the source) or indirect (addressing the concern with a secondary source such as a manager or supervisor You as students of nursing are encouraged to be aware of your own values, morals, and ethics and to become sensitive to the values, morals, and ethics at work in every nursing situation.

Sociocultural Influences Posing Ethical Challenges: Social Media and Substance Abuse

Nurses face two serious ethical challenges in today's sociocultural context : (1) the use of social media and (2) substance use/abuse. The widespread use of social media, such as Facebook, Twitter, and blogs, has created two distinct problems : (1) the transmission of potentially identifiable patient information and (2) the blurring of professional and personal boundaries this blurring is a myth, and in fact distinct boundaries still exist).

Example of significant advances in the professionalisation of traditional occupation

Nursing is the adoption of a formal code of ethics

Theories of ethics

Phenomenon in ethnic the phenomenon describes are understanding of behaviors in terms of their moral implications 1. Meta ethics which focuses on universal truths and where and how ethical principles are developed 2. Normative ethics which focuses on the moral standards that regulate behaviors 3. Applied ethics which focuses on specific difficulties issues such as euthanasia, capital punishment, abortion, and health disparities

The American Nurse Association ANA

Published a position statement in 1983 that remains in effect today and that contains this statement " the ANA believes the Code of ethics for nurses is nonnegotiable and that each nurse has an obligation to uphold and adhere to the code of ethics ANA, 1994

Faced with ethical dilemma the professional nurse's cognitive process

Reflection, reasoning, and a review of competing values, ultimately leading to purposeful action on behalf of patients and families in the nurse care

Six ethical principles based on human dignity and respect

Respect for human as a function of human dignity is the primary ethical responsibility for nurses in practice The code of ethics for nurses states that the nurse practices with compassion and respect for inherent dignity, worth, and uniqueness of every individual, unrestricted by consideration of social or economic status personal attributes or the nature of health problems ANA 2015 Respect for persons requires that each person be valued as a unique individual equal to all others and that every aspect of a person life is valued

A model of nurses ethical reasoning developed by

Roseanne Fairchild phD RN is featured in professional profile

Economics and scarcity of resources

Shape the delivery of health care nurse may find themselves less able to use critical thinking , reflection , and higher stages of moral reasoning in their practice setting

Kohlberg 1976

Suggested that certain conditions might stimulate higher levels of moral development intellectual development is one necessary characteristic Individual at higher levels intellectually generally operate at a higher stage of moral reasoning than those with lower levels of intellect

The ANA Nursing

The ANA's Nursing: Scope and Standards of Practice (3rd edition) is another very important document for professional nurses. It defines standards of practice and standards of professional performance. The standards describe the minimal expectations and duties a registered nurse should perform competently regardless of role or population served. The current version of the Nursing: Scope and Standards of Practice was published in 2015. Standard 7: Ethics emphasizes that an ethical practice spans across all roles and settings and is integral to nursing professionalism Standard 7 also incorporates the ANA Code of Ethics for Nurses recognizing its moral foundation for nursing practice.

The Florence Nightingale Pledge

The Florence Nightingale Pledge was written in 1893 by Lystra Gretter at the Farrand Training School in Detroit, Michigan. It was modeled after the Hippocratic Oath taken by physicians as they begin their medical careers.

International Council of Nurses Code of Ethics for Nurses

The International Council of Nurses (ICN) also has published a code of ethics for the profession (ICN, 2012). This document discusses the rights and responsibilities of nurses related to people, practice, society, co-workers, and the profession. The ICN first adopted a code of ethics in 1953. Its last revision, adopted in 2012, represents an agreement by more than 80 national nursing associations that participate in the international association. The preamble of The ICN Code of Ethics for Nurses (Box 7.3) is unchanged from the previous version and details the four fundamental responsibilities for nurses and describes the ethical foundations of nursing practice.

Ethics

The examination of questions of right and wrong, how values are determined, and how ethics are applied in specific situations

Navigating The Gray Areas: Ethical Decision Making

The gray area of ethical decision making in nursing practice entails addressing ethical dilemmas. An ethical dilemma is a moral conflict in which the decision maker experiences indecision because the available choices or alternatives result in conflicting values or ethical principles. With an ethical dilemma, there is no one good decision; however, two or more decisions may be deemed as right (also known as a right versus right dilemma).

Pre-conventional

The individual is inattentive to the norms of society when responding to moral problems Instead, the individual's perspectives is self cantered At this level what individuals wants or needs takes precedence over right or wrong A person in stage 1 of the pre conventional level responds to punishment Stage 2 the person responds to the prospect of personal reward Kohlberg observed the pre conventional level of moral development in children younger than 9 years of age, as well as in some adolescents and adults criminal offenders

autonomy

The principal of autonomy asserts that individuals have the right to determine their own actions and freedoms to make their own decisions Respect for the individual is the cornerstone of this principles Autonomous decisions are based on 1. Individuals values 2. Adequate information 3. Freedom from coercion 4. Reason and deliberation Autonomous decision lead to independence, autonomous actions. Autonomous actions by a patient include deciding to refuse treatment giving consent for treatment or procedures and obtaining information regarding results is diagnostic tests , diagnosis and treatment options Some patients prefer to have decision made for them , possibly because of a lack of information, fear of making a poor choice, or trusting that a care provider will make the right decision for them Other patients may be unable to participate in decisions making because of external constraints such as lack of necessary information or the norm of their culture. The principle of autonomy is an increasingly important principle in health care and nu In fact when two or more principles are conflict often autonomy is weighted higher in health care.

fidelity

The principle of fidelity refers to faithfulness or honoring one's commitments or promises. For nurses, this specifically refers to fidelity to patients. Through the process of licensure, nurses are granted the privilege to practice. The licensure process is intended to ensure that only a qualified nurse, appropriately trained and educated, can practice nursing. When nurses are licensed and become a part of the profession, they accept certain responsibilities as part of the contract with society. Nurses must be faithful in keeping their promises of respecting all individuals, upholding the Code of Ethics for Nurses (ANA,

Justice

The principle of justice is that equals should be treated the same and that unequals should be treated differently. In other words, patients with the same diagnosis and health care needs should receive the same care, and those with greater or lesser needs should receive care that is appropriate to their needs. Basic to the principle of justice are questions of who receives health care and whether health is a right or a privilege.

Ethical Issues Related to Immigration and Migration

Two distinct issues are addressed here that affect nursing and have ethical implications: (1) communication/language problems between patients and heath care providers and (2) the migration of nurses. Communication is fundamental to safe, effective health care, the moral commitment to patients. Patients who do not speak English, and who hold a variety of health care beliefs and practices to which American health care workers may not be accustomed, pose achallenge. Many health care institutions, especially larger medical centers, have addressed the issue of language by hiring professional medical interpreters. Interpretation involves the spoken word, and translation refers to the written word. Medical interpretation is a specialty that requires extensive knowledge of medical terminology, in addition to cultural humility and sensitivity to the needs of the patient.

approach to moral reasoning

Two important theorists in moral development and reasoning are Lawrence Kohlberg and Carol Gilligan

What can help you as a nurse face the complex ethical issues that confront nurses?

Understanding ethical principles Frameworks Nursing code of ethics My value My belief

Ethical Theories

Useful to nurses are introduced with emphasis on the normative ethical theories ( virtue ethics, deontological ethics, and utilitarian ethics) , and principalism ethics.

Values

Usually expressed in terms of right and wrong Hierarchies of importance or how one should behave Freely chosen and indicate what the individual consider important ex honesty and hard work Assimilated from and influenced by personal and professional experiences Deeply rooted in an individual culture

Dilemmas Resulting From Personal Value Systems

Values are important preferences that influence the behavior of individuals. Values are learned beliefs that help people choose among difficult alternatives, even when there may not be a good choice. Each person has a set of values that was shaped by the beliefs, purposes, attitudes, qualities, and objects of a child's early caregivers.

veracity

Veracity is defined as telling the truth, or not lying. Truth-telling is fundamental to the development and continuance of trust among human beings.

gray area

Where what are right or wrong act is not clear or sharply delineated

Dilemmas Involving Peers' and Other Professionals' Behavior

conflicts can evolve because of differing value systems, cultures, education levels, or a variety of other factors. Conflicts relevant to human rights often center around one of the ethical principles discussed earlier: autonomy, beneficence, nonmaleficence, veracity, or justice.

moral reflection

critical analysis of one's morals, beliefs, & actions; A process through which a person develops & maintains moral integrity

advance directives

designed to ensure individuals the rights of autonomy, refusal of medical intervention, and death with dignity. Advance directives are legal documents that indicate the wishes of individuals in regard to end-of-life issues. Critically ill individuals can remain in charge of their own end-of-life decisions if their advance directives are carried out. Each time they enter a health care institution, patients should have in their possession their advance directives. In addition, copies should be given to significant others, primary care providers, and any legal counsel that may be involved with the patient. The best directive is one that has been notarized or developed in conjunction with a legal expert, and the contents of which have been discussed with family or the person with designated health care power of attorney who will carry out one's directives in the event of a sudden catastrophic or terminal illness. Ideally, family members, caregivers, and courts (in very extreme cases) will not need to make decisions for the patient. Too often the first time a patient learns about advance directives is on admission to a health care facility.