NRS 104_ Notes 41
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UNIT 5 Chapter 41: Ethics & Values
~ ETHICS AND MORALS
A.
Generally, Morals refers to private, personal, or group standards of what is good or bad, right or wrong (“It’s wrong to steal”). Ethics answers the question, “What should I do in a given situation?” (“Is it wrong to steal if you have to do it to feed your children?”)
B.
Morals - “Our OWN Principles”
a.
learned from external influences and communicated through various systems (religious, political, educational, societal).
b.
Moral behavior
is that which is consistent with customs or traditions based on the external influence (such as religious beliefs). Behavior that’s inconsistent with traditional notions of right/wrong is labeled as immoral
C.
Ethics - “SOCIETY’s/EXTERNAL Rules”
a.
the study of a system of moral principles and standards, or the process of using them to decide your conduct and actions
D.
What is Nursing Ethics? p. 3,978
a.
Bioethics
refers to the application of ethical principles to every aspect of healthcare
b.
Nursing ethics
is a subset of bioethics. It refers to ethical questions that arise out of nursing practice
i.
Involve questions that have to do with the nurse’s actions, not the actions of others - “What should I
do?”
E.
Why Should Nurses Study Ethics? p. 3,977-3,978
a.
You will encounter ethical problems frequently in your work
i.
The most difficult questions you will face as a nurse will not be “How do I do this?” but “Should I do this?” b.
Ethics is central to nursing
c.
Interprofessional input is important
d.
Ethical knowledge is necessary for professional competence
e.
Ethical reasoning is necessary for nursing credibility among other disciplines
f.
Ethical proficiency is essential for providing holistic care
i.
Nurses care for the whole person—that includes providing support for spiritual and moral concerns
g.
Nurses have a responsibility to be advocates for patients
i.
Advocacy is the communication and defense of the rights and interests of another. It includes protecting patients’ legal or moral rights
h.
Studying ethics will help you to make better decisions
i.
Prepares you to analyze ethical dilemmas from multiple perspectives rather than relying entirely on your personal values, intuition, and emotions
F.
What Is Ethical Agency? p. 3,979-3,980
a.
Moral agency
or ethical agency
for nurses is the ability to base their practice on professional standards of ethical conduct and to participate in ethical decision making
i.
Nurses have choices and are responsible for their actions
1.
The 5 components of ethical agency p. 3,979
ii.
External constraints
: 1.
Providers, laws/lawsuits, nursing administration, other nurses, and clients and families -> Fear of being fired, losing license, punished… etc.
iii.
Internal constraints
:
1.
Lack of courage, concern for reputation, hope for a miracle
2.
Nursing students are socialized to follow orders, not to question; Some fail to act
ethically because they doubt their knowledge or motivation… etc.
b.
Moral distress can occur when nurses are unable to act as moral agents or carry out chosen ethical/moral decision/action p. 3,980 & 3,983
c.
Providers experience Moral outrage when they perceive that others are behaving immorally. The anger/outrage is directed toward individuals perceived as responsible for the wrongdoings, acts, or policies created p. 3,981 & 3,984
G.
Impaired Nursing Practice
a.
Occurs when the nurse’s ability to perform the essential nursing functions is diminished by chemical dependence on drugs or alcohol or by mental illness. MUST REPORT
b.
The Code of Ethics for Nurses
- guides that advocacy includes supporting nurses who return to practice after receiving the appropriate assistance and treatment for substance abuse
H.
What Are Some Sources of Ethical Problems for Nurses? p. 3,985-3,987
a.
Societal Factors
i.
Increased Consumer Awareness, Technological Advances, Multicultural Population, and Cost Containment
:
1.
Clients are being sent home from the hospital while they still require considerable nursing care, and to contain costs, healthcare agencies have increased the number of clients each nurse is assigned p. 3,987
b.
The Nature of Nursing Work p.3987-3989
i.
Nurses’ Ethical Problems, Nurses’ Unique Position in Healthcare Organizations, and The Nature of the Nursing Profession
:
1.
Caring versus time spent with patients, Autonomy versus escaping hard choices, Higher pay versus cost-effectiveness, and Professionalism versus caring p.3,989
~ WHAT FACTORS AFFECT MORAL DECISIONS?
I.
Developmental Stage
a.
A person’s stage of moral development affects the way they reason about moral issues
b.
Kohlberg
- conclude that children go through a sequence of moral reasoning ability, proceeding through several stages
i.
Stage 1 —> Moral reasoning is based on personal interest and avoiding punishment.
ii.
Stage 2 —> Principles focus on pleasing others and following rules.
iii.
Stage 3 —> Moral principles are based on universal and impartial principles of justice. This
is the final level; it occurs in adulthood.
c.
Gilligan
- girls develop morally by paying attention to community and to relationships, whereas boys tend to process dilemmas through more abstract ideals or principles
i.
Stage 1 -> Caring for oneself
ii.
Stage 2 -> Caring for others
iii.
Stage 3 -> Caring for oneself and others
J.
Values, Attitudes, and Beliefs p. 3,991-3,993
a.
What are Values?
i.
Values are ideals, beliefs, customs, modes of conduct, qualities, or goals that are highly prized or preferred by individuals, groups, or society
b.
What Are Attitudes?
i.
Attitudes are mental dispositions or feelings toward a person, object, or idea. ii.
They can be cognitive (thinking), affective (feeling), and behavioral (doing)
c.
What are Beliefs?
i.
A belief is something that one accepts as true
ii.
Beliefs are sometimes based on faith and sometimes on facts and may be true or false
d.
Professional Versus Personal Values i.
Personal value system
: a set of values that you have reflected on and chosen that will help you to lead a good life (Table 41-1 p. 3,994-3,996)
1.
Personal and professional values are not always congruent
e.
How Are Values Transmitted? (p. 3,996 & Table 41-2 p. 3,998)
f.
What Is Value Neutrality? i.
Value neutrality
: we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgmental when providing care to clients
K.
Ethical Frameworks
a.
Ethical (or moral) frameworks are systems of thought (theories) that can explain the differing perspectives people have in ethical situations
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b.
What Is Consequentialism?
i.
In consequentialist theories, the rightness or wrongness of an action depends on the consequences of the act rather than on the act itself p. 4,000
1.
Utilitarianism
- the value of an action determines its usefulness. The principle of
utility states
that an act must result in the greatest good (positive benefit) for the greatest number of people
2.
Deontology
- uses rules, principles, and standards to determine whether an action
is right or wrong p.4,001
a.
Rights and Duties, Treat People as Ends and Never as Means, Ethical Rules and Principles, The Categorical Imperative
c.
What Is Feminist Ethics
i.
The belief that traditional ethical models provide a mostly masculine perspective that devalues the moral experience of women, The point is to address issues of gender inequality within each situation. P.4,002
d.
What is Ethics of Care?
iCare p.4,003
L.
Ethical Concepts and Principles
a.
Autonomy
- a person’s right to choose and ability to act on that choice p. 4,004-4,005
i.
You honor autonomy when you respect the client’s or surrogate decision maker’s right to decide, without judgment, even when you believe those choices are not in the client’s best interest ii.
Privacy and Confidentiality
: an autonomous person has control over the collection of, use of, and access to their personal information
b.
Nonmaleficence
- the twofold duty to (1) do no harm and (2) prevent harm p. 4,006
i.
It encompasses actual harm, risk of harm, and intentional and unintentional harm
ii.
Ex: Prevent medication errors or use an ambulation belt for assisting patients to walk
iii.
Respect for Dignity
: the nurse’s respect for the intrinsic worth of each person, without regard to age, race, religion, medical condition...etc
c.
Beneficence
- the duty to do or promote good p. 4,007
i.
Do no harm, prevent harm when you can, remove harm, and bring about positive good
ii.
Paternalism
: (treating others like children) can have negative consequences
1.
you’ll lose the client’s trust if you coerce the client to act based on what you think is best, rather than what the client wishes.
d.
Fidelity
- (faithfulness) is the duty to keep promises p. 4,008
i.
Instead of “I’ll be right back with your medication,” you might say, “I must go help another client, but I’ll get here with your medication as quickly as I can.
e.
Veracity
- the duty to tell the truth p. 4,009
i.
Most nurses would agree that it is not hard to tell the truth, but at times it may be very hard to determine how much of the truth to tell
ii.
Instead of saying, “Your father has a fatal illness and is unlikely to live for more than a month,” they may say, “Your father is very ill, but we will do everything we possibly can for him.” f.
Justice
- the obligation to be fair, it implies equal treatment of all patients p. 4,010
i.
Distributive Justice
: requires fair distribution of both benefits and burdens
1.
Allocating resources and fair access to care
ii.
Compensatory Justice
: making amends for wrongs that have been done to individuals or groups.
1.
Malpractice is an example because it focuses on making amends for wrongs that have been done to individuals or groups
iii.
Procedural Justice
: important in processes that require ranking or ordering
1.
Written institutional policies are to ensure that the same procedures apply to all clients or employees in the same way (e.g., visiting hours, working on holidays, sick leave)
M.
Professional Guidelines
a.
Nursing Codes of Ethics
- i.
Professional codes of ethics are formal statements of a group’s expectations and standards for professional behavior generally accepted by members of the profession
ii.
International Council of Nurses (ICN)
: 1.
“A guide for action based on social values and needs” and stresses respect for human rights like cultural rights, the right to life and choice…etc p. 4,011
iii.
The American Nurses Association (ANA)
: 1.
“Establishes the ethical standard for the profession” and serves as a “guide for nurses to use in ethical analysis and decision making”
iv.
The Patient Care Partnership
1.
Encourages healthcare providers to be more aware of the need to treat patients in an ethical manner and to protect their rights 2.
Patients are entitled to specific rights in terms of their treatment—the right to: Make their own decisions, Be active partners in the treatment process, and Be treated with dignity and respect (Box 41-1 p. 4,013)
v.
The Joint Commission Accreditation Standards
1.
Contain sections on organizational ethics and individual rights p. 4,015
~ ETHICAL ISSUES IN HEALTHCARE
N.
You’re likely to encounter several ethical issues that occur in healthcare: Abortion; Advance directives; Allocation of healthcare goods and services; Compelling unwanted treatment; Confidentiality and privacy;
DNAR/Allow Natural Death (AND) prescriptions; Medical aid in dying/continuous palliative sedation; Organ transplantation; & Withdrawing or withholding life-sustaining treatments
~ VALUES CLARIFICATION
O.
Values clarification refers to the process of becoming conscious of and naming one’s values
a.
A values clarification process doesn’t tell you what your values ought to be; it merely helps you discover what they are. STEPS
: Choosing -> Prizing -> Acting (Table 41-3 p. 4,017-4,018)
~ ETHICAL DECISION MAKING
P.
Problem or Dilemma? a.
An ethical dilemma is a situation in which a choice is required between two equally undesirable actions. There is no clearly right or wrong option
Q.
How Do I Work Through an Ethical Problem? p. 4,021-
a.
Using the MORAL Model for Ethical Decision Making
b.
First, Use Problem Solving
i.
Assessment—What are the relevant facts?
ii.
Analysis/Diagnosis—Identify the problem; state the conflict
c.
Next, Use the MORAL Model i.
M-massage the dilemma
1.
First identify and define the issues in the dilemma, and consider the values and options of all the major players
2.
Then identify the information gaps
ii.
O—Outline the Options 1.
You or others (e.g., charge nurse, ethics committee member) should outline the options to all parties, including those that are less realistic and conflicting.
iii.
R—Resolve the Dilemma
1.
Autonomy (respect for their values and their freedom to choose)
2.
Beneficence and nonmaleficence
a.
How are we defining “good” (beneficence) and “harm” (nonmaleficence) in this situation
3.
Fidelity (being loyal)
4.
Veracity
iv.
A—Act by Applying the Chosen Option
1.
The hospital is bound to follow the parents’ decision because Alan is a minor.
2.
If there is time, administrators might refer this situation to the hospital ethics committee.
v.
L—Look Back and Evaluate
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1.
This phase calls for evaluation of the entire process, not just the consequence of the decided action.
2.
How well did the process work?; Were all parties’ expectations realistic?; How well did you do in the situation?; Were policies and procedures in place to guide you; Has anything changed since the dilemma emerged?
R.
Look for a Good Compromise p. 4025-4026
a.
The discussions are carried out in a spirit of mutual respect, The compromise solution itself is ethically sound, First, it is never good to settle things by force, Keeping peace on a nursing unit is good for both the nurses and patients, There is intrinsic good in taking part in a process in which we
try to see things from others’ points of view, Keep in mind that most issues do contain room for reasonable differences of opinion, A compromise may achieve mutual respect
S.
What Are My Obligations in Ethical Situations? p. 4,026-4,027
a.
Be aware of and sensitive to issues; Assume responsibility for your own ethical actions; Function as a team member; Support the patient and family members; Support clients who cannot decide for themselves; Use and participate in institutional ethics committees; Most important, advocate for your client; Continually strive to improve your ethical decision making
T.
Use and Participate in Institutional Ethics Committees
a.
Autonomy Model
- is useful when the patient is competent to decide and emphasizes patient autonomy and choice
b.
Patient Benefit Model
- assists in decision making for the incompetent patient by using substituted judgment (what the patient would want for themself if they were capable of making their wishes known)
c.
Social Justice Model
- focuses more on broad social issues involving the entire institution, rather than on a single client issue. Might consider whether, in general, an institution ought ever to seek a legal order to act against the wishes of the parents
U.
Be a Patient Advocate p. 4,029-4,030
a.
You Have Special Knowledge That the Patient Does Not Have
b.
Your Professional Role Includes Defending Patients’ Autonomous Decisions
c.
You Have a Special Relationship With Patients
d.
Your Role as an Advocate Is to Inform, Support, and Communicate
V.
Improve Your Ethical Decision Making p. 4,030-4,031
a.
Use theoretical knowledge
b.
Use self-knowledge
c.
Use practical knowledge
d.
Consult reliable sources
e.
Share
f.
Evaluate