Ethical Considerations in Nursing - Week 10 Student PDF

Ethical Considerations in Nursing NURS 72050-Week 10  Agenda Ethics in Nursing Practice Theory Principles Issues Decision Making Class time to work on Case Analysis Next Week: Group Assignment: Case Analysis Due  Ethics in Nu...

Ethical Considerations in Nursing NURS 72050-Week 10  Agenda Ethics in Nursing Practice Theory Principles Issues Decision Making Class time to work on Case Analysis Next Week: Group Assignment: Case Analysis Due  Ethics in Nursing Practice Every day, nurses make complex ethical choices. How do they… Know if the actions they take are right? Know when they are facing an ethical issue? Identify the option that is best for everyone concerned? Acquire confidence in choosing a course of action from several alternatives? Demonstrate integrity in all circumstances and maintain a moral relationship of trust between themselves and those they serve? Access support in dealing with these challenges? Ethical Knowledge Assists Nurses with these Questions To meet moral standards, nurses benefit from an understanding of the  theories, concepts and principles that guide ethical behaviour and decision-making and their application to moral challenges in practice.  integration of professional and moral rights and obligations.  evolution from historical to contemporary theories from rationality alone to the value of caring and emotion.  Ethical Theory Key Terms Morality: culturally based beliefs and norms about what is right and wrong Ethics: the systematic exploration of what is morally right and wrong Ethical theory: the study of the nature and justification of general ethical principles that can be applied to moral problems Biomedical ethics: a field which explores ethical questions and moral issues associated with health care  Ethical Theory Key Terms continued Nursing ethics: addresses the moral questions within the sphere of nursing practice, including the  nurse–patient/client relationship  moral character of nurses  nurse as a moral agent Ethical dilemmas: arise when  the best course of action is unclear  strong moral reasons support each position  one must choose the least wrong option.  Moral Distress Nurses are at a high risk of moral distress  that can result when ethical issues are not identified or addressed effectively  when they are not able to act on what they believe is right  that can cause emotional and psychological pain, that may result in feelings of anger and powerlessness  when they do not receive the support to deal with these challenges issues and their consequences  Group Activity Review the list of possible sources of moral distress and in your small group discuss: o How do these situations impact nursing care and the way you feel about the nursing profession? o What steps can be taken to help reduce the moral distress?  Moral Distress Sources Inadequate communication about care between providers, patients, and families. Inappropriate use of healthcare resources. Inadequate staffing or staff inadequately trained to provide the required care. Inadequate pain relief provided to patients. Electronic health records – distracts from face-to-face care yet valuable for many purposes. Staying up-to-date on rapidly shifting protocols is unrealistic. Abandoning bedsides and proper protocols due to high patient volume and low resources.  Emergence of Ethical Theory  Thinking has advanced to acknowledge the influence of emotion, caring, relationships, and experience.  Nursing ethical theories emerged that integrate nursing concepts and values, such as caring, and compassion,  view nurses as moral agents, within the context of professional relationships.  Factors That Influence Morality Many factors influence thinking about what is right or wrong, good or bad, including:  the norms, beliefs and expectations of the society and culture  gender, age, and personal characteristics,  the context of the situation, previous experiences with similar situations  the potential outcomes or consequences of actions the relationship of the individuals involved, and professional and individual values and beliefs  Values A value is an ideal that has meaning or importance to an individual, a group, or society Canadian society values freedom, health, fairness, honesty, and integrity Evidence of these values can be found in  Canadian laws  Professional Codes of Ethics  the Charter of Rights and Freedoms  the structure of the Canadian health system  Influence of Values on Ethical Decision Making (1 of 2) Values influence  individual beliefs and opinions  behaviours, rituals, rules, and laws within a society  decisions and responses to moral challenges Values can shift over time. For example:  the shift from prolonging life at all costs, to the importance of the quality of life  the transition to informed consent, respect for individual rights over health care decisions  Influence of Values on Ethical Decision Making (2 of 2) Value Conflicts Arise when personal actions or the actions of others are at odds with individual beliefs Can arise when professionals disagree on how a situation should be managed May result in moral distress, so it is important to establish processes to  understand personal values and those of others  clarify and articulate values to others  Value Clarification A process through which individuals come to understand the values they and others hold and their relative importance The process requires  reflection  open discussion  active listening  mutual respect This process can be enhanced if consistent language and terminology are used  Categories of Ethical Study Nonnormative approaches to ethics involve analyzing morality without taking a moral position Descriptive Ethics Metaethics Normative ethics attempts to answer questions of what is right or what is wrong. Normative theories include: Virtue Ethics Teleological and Deontological Theories Principlism Narrative Ethics  Normative Ethical Theories (1 of 2) Provide frameworks and guidelines to help determine what is right and wrong Describe a system of principles or rules by which to determine what ought and ought not to be done They include historical and more recent contemporary/modern theories Are embedded in the moral tradition of Indigenous peoples in Canada  Virtue Ethics The focus is on the character, the virtues, of the person making moral decisions. A virtue is a characteristic, a distinguishing trait, considered to have moral value.  Includes courage, temperance, compassion, generosity, honesty  Considered indicator of a person with high moral standards Asserts that a virtuous person, is more likely to make the right decision and take the morally correct action Traditionally, nurses have been expected to possess strong moral virtues  Teleological Theories Considers outcomes and consequences (immediate and long term) of decisions and actions Outcomes are judged based on a theory of value, such as utility The best-known theory is utilitarianism  an action is right if it leads to the greatest good and the least harm for the greatest number of people Act Utilitarianism focuses on the particular act  there are no absolute rules to judge right and wrong Rule Utilitarianism considers the utility of general patterns of behaviour  Modern/Contemporary Theories Principilism: Ethical Principles as a guide for decision-making Theories of Social Justice Feminist and Feminine perspectives Nursing focused:  An Ethic of Care,  Caring and Relational Ethics  Narrative Ethics  Principle Based Ethics Introduced to health care in 1983 by Beauchamp and Childress These principles are expressed in many professional codes of ethics, and  serve as rules to guide moral conduct  assist individuals in taking consistent positions  provide a framework for decision making  Autonomy The principle of autonomy  asserts that a capable and competent individual is free to determine a self-chosen plan, including choices and actions as long as these do not harm or interfere with the rights of others  is the foundation the legal doctrine of informed consent May conflict with non-maleficence and beneficence  Fidelity The principle of fidelity  is the foundation of the nurse–patient relationship  obliges nurses to be loyal, keep their promises, and tell the truth (veracity)  upholds nurses’ commitments to provide quality care, for example: adequate pain control comfort and support Person centred care  Nonmaleficence The principle of nonmaleficence  is associated with the Latin maxim primum non nocere: “first, do no harm”  is expressed in many professional codes of ethics and the Hippocratic Oath  obliges individuals to act in a way that will prevent or remove harm  Beneficence The principle of beneficence  obliges individuals to make positive moves that produce good or benefit for others Critical to the role of health professionals  asserts that individuals should help others in need and help others further legitimate interests  may be in conflict with the principle of autonomy  Justice Based on the notion of fairness and equity focuses on how individuals treat each other Two forms of justice are relevant to health care:  Distributive justice requires the equitable distribution of benefits (e.g., health care) and burdens (e.g., taxes) distribution may be based on: an equal share, need, rights, effort, societal contribution, merit.  Compensatory justice ensures compensation or payment for harm done to an individual or group  negligence or malpractice  Social Justice Focus is on equity, opportunity and privilege within a society Grounds advocacy that influences the well-being of persons within a society Ensures responsibility for the disadvantaged  Guides policy and action John Rawls:  Equal Liberty Principle  Principle of Equal Opportunity  Social Justice: Policy and Legislation  Attempts to address challenging issues related to equity diversity and inclusion,  Influences government approaches and polices including those related to o welfare, o support for the homeless, o persons with disabilities, and so on.  Foundation of Jordan’s Principle, a child first principle, that ensures Indigenous children in Canada receive timely health care and services as needed.  An Ethic of Care The “ethic of care” evolved from feminine ethics Values feelings, emotions, empathy and care Ensures all dimensions of a situation are addressed  Starting point is the person’s circumstance or personal story  Aims to understand the context and complexity of relationships  Recognizes the unique needs of each person Critics suggest that this approach  Is a “compassion trap” that keeps women in traditional roles  May not recognize men as caring and nurturing.  Caring and Relational Ethics in Nursing Focus on understanding the concept of care  Organizes social and moral theory around care, connections and trusting relationships Aims to avoid objectification of the person Both the process and goal of nursing:  Preservation of human dignity, trusting relationships, equality within the context of illness and suffering Strong links to virtue ethics and the character traits of a nurse as a moral agent:  being a good person, presenting as a good person, being interested in the other person, and caring for the other person. (Izumi et al., 2006).  Uncovering the Story - a Narrative Approach to Ethics Narrative ethics encourages the sharing of real stories in order to  gain a clearer understanding of the ethical issues and challenges embedded in them  reveal ethical themes, respective values and perspectives  reflect, question, challenge and seek information so that the moral dimensions of the experience are better understood  encourage discourse that will ultimately enhance learning in a way that theory cannot achieve Sharing an experience through the story deepens the relationship, furthering one’s understanding of the person and the issues.  Ethical Concerns Review the following scenario and respond to the questions on the next slide: “Nancy is working in a community hospital’s emergency department when a local correctional facility patient arrives for treatment of a large leg wound. The patient has a history of acute mental illness, is handcuffed and accompanied by two correctional officers. The nurse asks the officers to remove the handcuffs and respect the patient’s privacy while in the emergency department. Although able to assess and treat his leg wound with the handcuffs in place, Nancy is uncomfortable with the patient’s movements being restricted by the handcuffs.” (CNO, 2024)  Case Scenario Questions Does least restraint policy apply in this situation? What ethical principles might apply to this case? How do the CNO standards and Code of Conduct apply to this circumstance? Is there provincial legislation that needs to be considered? Should restraints interfere with the patient receiving medical treatment, the nurse, health care team? Who should be deciding a plan of care that considers best use of restraints in this situation?  Escape Room Click on the link provided and complete the Escape Room as a small group. https://forms.gle/ttyPngh7PCaKXVBv5  Break Ethical Decision Making  Ethical Issues Patient care issues  Futile care  Advance care planning  Medical assistance in dying (MAID) Issues of safety and ethics in the work environment  Social Media and safety  Working with a health care team to promote safe care Moral distress Moral integrity Moral residue (Bouchal & Ecker, 2019)  Codes of Ethics A code of ethics, grounded on ethical theory and principles, is a  key characteristic of a professional body  public declaration of a profession’s commitments and obligations to society  formal expression of a profession’s values and responsibilities  means to ensure the integrity of the profession and to position its members as moral agents.  standard of moral conduct and behaviour  The Canadian Nurses Association Code of Ethics (1 of 2) The CNA Code of Ethics for Registered Nurses  First published in 1980 and has been periodically revised, most recently in 2008  Offers nurses a framework for ethical practice  Consists of two parts I: Nursing Values and Ethical Responsibilities II: Ethical Endeavours  The Canadian Nurses Association Code of Ethics (2 of 2) Part I: Nursing Values and Ethical Responsibilities The Code is organized around seven values For each value responsibilities are clarified Part II: Ethical Endeavours Makes explicit the role nurses and the profession play in advocating for social justice and its influence on the health of the population  Part I: Nursing Values and Ethical Responsibilities The seven values include I. Providing safe, compassionate, competent, and ethical care II. Promoting health and well-being III. Promoting and respecting informed decision making IV. Preserving dignity V. Maintaining privacy and confidentiality VI. Promoting justice VII. Being accountable  1. Providing Safe, Compassionate, Competent, and Ethical Care Ethical responsibilities include  using speech and body language to demonstrate compassion  questioning unsafe care  collaborating with others to provide safe care  providing care during a natural or human-made disaster  preventing and minimizing all forms of violence  2. Promoting Health and Well-Being Ethical responsibilities include  providing care directed first and foremost to the person, family, or community in their care  advocating for the least restrictive measures possible for those in their care  collaborating with others to maximize health benefits  3. Promoting and Respecting Informed Decision Making When caring for a capable person, ethical responsibilities include  providing information needed for informed decisions  recognizing that individuals may choose to defer to family or community values in decision making  supporting the right to refuse or withdraw consent for treatment  respecting the choice to engage in unhealthy lifestyles or treatments  4. Preserving Dignity Ethical responsibilities include  relating to all persons with respect  intervening when others fail to do so  taking into account a person’s unique values, customs, and beliefs, as well as their social circumstances  providing care in a discreet manner  maintaining professional boundaries  advocating for a dignified and peaceful death  5. Maintaining Privacy and Confidentiality Ethical responsibilities related to the collection, use, access to, and disclosure of personal and health information, and include  respecting information and adhering to privacy laws  taking reasonable measures to avoid being overheard when conversing with patients  taking care not to access information inappropriately  intervening if others inappropriately access or disclose information  6. Promoting Justice Ethical responsibilities include  avoiding discrimination (on any grounds) when providing care  refraining from judging, stigmatizing, or demeaning behaviours  refusing to engage in any inhumane or degrading action, and intervening with others do so  making fair decisions and advocating for fair allocation of resources  7. Being Accountable Ethical responsibilities are met by  practising with honesty and integrity, in accordance with the Code  practising within the limits of competence  protecting the safety of others when a colleague is unable to perform his or her duties  clearly and accurately representing self by name, title, and role  identifying and addressing conflicts of interest  Part II: Ethical Endeavours (1 of 2) Nurses have a role in the provision of social justice, including advocating for policies to address the social determinants of health accessible, universal, comprehensive health care services environmental preservation positive, healthy work environments the resolution of global health issues  Part II: Ethical Endeavours (2 of 2) The nursing profession has a responsibility to work collectively with others to recognize the diversity of the Canadian population consider the challenges that influence the health and well- being of the world population strive to reduce health disparities due to  poverty  homelessness  vulnerability  Who Is Vulnerable? The Code draws attention to those who are vulnerable in our society, including  children  older persons  visible minorities  the homeless  Ethical Decision Making Working through ethical issues requires deliberate, critical, and systematic thinking Nurses need to be able to be able to make knowledgeable, fair and consistent decisions. Frameworks or guides provide a step by step process to work trough the ethical issue. (Bouchal & Ecker, 2019) An Ethical Decision-Making Process (1 of 2) 1. Identify problem or issue statement. 2. Decide who should be involved in the discussion. 3. Describe the issue in detail. 4. Share preliminary perspectives on the issue. 5. Share the person’s story and undertake a comprehensive assessment and analysis of the situation. 6. Explore relevant legal factors. 7. Evaluate the plan.  An Ethical Decision Making Process (2 of 2) 1. Share values. 2. Clarify ethical principles. 3. Select applicable ethical theories. 4. Identify alternatives or options available. 5. Deliberate and agree on the potential alternatives. 6. Choose a course of action. 7. Develop an action plan. Ethical Decision-Making Process  Critical Thinking Scenario Review the critical thinking scenario posted in e-Conestoga, or on the next slide and as a group, work through the three questions Be prepared to share your responses with the large group.  Scenario 1 J. C., an 89-year-old living in a long-term care facility, has advanced dementia but is generally in good spirits. Occasionally, J. C. exhibits behaviours that suggest some paranoia. J. C. has limited mobility, requires a wheelchair, and is frequently incontinent of urine and stool. One evening, the nurses find J. C. soiled to the extent of needing a shower to be cleaned adequately. They abandon their attempts when J. C. becomes resistant, lashes out, and yells profanities at the staff. When the other residents complain about the smell, the nurses believe they have no choice but to proceed with the shower. J. C. becomes extremely agitated, physically aggressive, and strikes one of the nurses in the face.  Scenario 2 K. M., only 1 month old, was born with a complex genetic syndrome and is not likely to live beyond the age of 3 years. The syndrome causes many cardiac and respiratory conditions and developmental delays that will likely result in suffering and pain. Recently, K. M. developed a respiratory viral infection, which, owing to difficulties expectorating secretions, progressed to pneumonia. Respiratory failure ensued, necessitating ventilation, and K. M. is now in the Critical Care Unit (CCU). The team considers K. M.’s condition grave, and the prognosis for a good quality of life poor. However, the team considers the decision regarding treatment is the family’s to make. The baby’s parents are distraught. The parents have bonded with K. M. over the weeks, their only child, and they want to do what is best for their baby. They have developed a strong professional relationship with a home care nurse who has been assisting them with K. M.’s care and they ask this nurse for advice.  Critical Thinking Questions 1. What are the key moral issues raised by the scenario? 2. Considering the CNO Code of Conduct or the CNA Code of Ethics, what advice would you offer the nurse to meet ethical, professional, and legal expectations? 3. What people, resources, departments, and organizations could the nurse consult with? 4. What are your options and what course of action do you feel would be the most ethical?  Clinical Ethics Committees May provide one or more of the following functions  consultation: advice and support in ethical decision making  education: through in-services, workshops, case presentations, and internal publications  policy making: by establishing policies or guidelines to assist staff in dealing with complex issues  Case Analysis Students may use remaining class time to work with their groups on the Ethics and Law: Case Analysis.  Plan for next week Professional Rights and Obligations Group Assignment due 1 hour before class.