Alexandria University Faculty of nursing Doctorate course Nursing Ethics 2012-2013

Supervised by: - Prof\Dr: Nabila Bedier

Prepared by:- Saada Alsayed Rady Basem

Outline

Introduction Definition of - Problem - Ethical problem - Ethical decision making

How to identify an ethical issue Common ethical issues confronting nurses Foundation of ethical decision making Factors that influence ethical decision making Qualities of good decision Framework for ethical decision making Models of ethical decision making -DECIDE model -MORAL model -RESPRCT model -PRACTICE model -SPIRAL model -Ethical assessment framework model (EAF) -Nursing process model

Role of Nurse in ethical decision making References

General objective
By the end of this seminar the doctorate students will be able to solve any ethical problem facing them not only in their own work but in their daily life experiences.

Intended learning outcomes of course (ILOS):

a. Knowledge and understanding: Define basic terms (Problem , Ethical problem and Ethical decision making) Identify an ethical issue.

List quality of a good decision State Common ethical issues confronting nurses Explain Factors that influence ethical decision making. List ethical decision making modeles

b. Intellectual skills:

Compare between different models of decision making. Discuss the Framework for ethical decision making Discuss role of nurse in ethical decision making

c. Practical and professional skills Apply models of decision making in different situations in nursing practice.

d. General and transferable skills

Relate models of decision making to a variety of daily life experiences

Introduction
Advances in medicine, science, and technology have combined to make moral reasoning and ethical decision-making more necessary in today's healthcare setting. Ethical decision-making in healthcare is necessary when moral issues arise during the delivery of nursing care. Nurses must make decisions regarding what is the right thing to do. These decisions are aided by the use of critical thinking skills. Many decisions will involve a dilemma, which is: "problem that arises in clinical situations because people, attempting to make decisions guided by their value set, weigh differently the competing moral principles under consideration".

Problem
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It is a condition in which there is a discrepancy between the current situation and a desired outcome, requiring consideration of alternative course of action. Ethical problem It is a difficult moral problem that involves two or more mutually exclusive or morally options. For example: - tests on people who are dying, confidentiality versus prevention of harm, sedating patient for staff convenience autonomy versus safety. Ethical Decision-Making: It is a rational, analytical process of determining the best course of action regarding an ethical conflicting situation.
Making

ethical decisions is about choosing among options according to ethical

principles. How to identify an ethical issue There are two clues to identify an ethical issue:

First action or situation that involves actual or potential harm to someone

or something.

Secondthere is a possibility of a violation of what generally considered

right or good. Several suggestions about how to foster the recognition of ethical situation:1. Ethical discussion and ethical decision shouldn't occur in isolation.

Decision makers need to have access to peers, significant others and leaders for assistance in clarifying their perception and their labeling issues.

2.

Decision makers need to have adequate time to make good decision. They

should consider their opinion and reminded that the sense of urgency is unfounded.
3.

Personalizing the situation: consider the individual feature of the situation

the decision maker shouldn't follow "one size fits all' technique. For example: - consider what you would want done if this was your father? 4. Nurses need to continue to develop their theoretical knowledge bases

regarding ethics and current ethical issues. This is necessary because nurses may become "immune" to the emotional dynamics associated with recurring ethical situation.
5.

Nurses need to continue to develop strong communication skills as well

as the moral courage, to ask pointed questions, to seek clarification and to define their personal and professional values.

Common ethical issues confronting nurses

Registered professional nurses are in the best position to advocate for the rights of their patients and are frequently involved in ethical issues and ethical decision-making processes. Some of the more frequently occurring ethical issues confronting nurses today, including:

The protection of patients rights and human dignity The right to refuse treatment The prolongation of the living and dying process and the need to consider Informed consent Whether or not to use physical or chemical restraints Providing care that may be a risk to the nurses health
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the impact on the patients quality of life

Potential differences between nurse and patient belief systems regarding Bioethical issues raised by medical technologies and treatment such as the

issues such as abortion, , organ and tissue donation

use of stem cells from human embryos.

Foundations of ethical decision making

Code of ethics for nurses. The patient's bill of rights. Ethical principles

Factors that influence ethical decision making:

1Social and cultural factors: - The value system in the society e.g, preserving one's life as in heart transplantation; some societies accept it while others reject. - A culture's religious values and beliefs may play role in the health beliefs of individuals. 2Science and technology:
-

Scientific advancement and technology continue to offer some of

the greatest challenges and concerns e.g. organs transplantations, life support machines, terminal diseases patients as AIDS, participation in experiments and researches for the benefits of others. Legislation: legislation may follow changes in society attitudes,

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converting new ideas into law. E.g. birth certificate of infants born to single mothers.

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Judicial decisions: judicial decisions are taken to determine the

appropriate action. E.g the issue of abortion and the defending behavior of physicians.
5-

Funding: the financing of health care represents a major area of conflict Personal religious and philosophic viewpoints; achieving self work environment
o Status as employee: decisions may affect the employer adversely. o Collegial relationships. o Authoritarian and paternalistic backgrounds: in some settings ethical

that has ethical dimensions.

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understanding in values is a lifelong learning task 7-

decisions are made without the participation of nurses.

o Ethics committees in health care

Qualities of good decision

A Good decision is
1-

both effective and ethical

Effective.. If it is efficiently accomplishes intended and desirable objectives without causing unintended and undesirable results. Ethical. If it demonstrates an understanding of and commitment to core ethical values 2Rational not rationalization

Rational .. Decision result from a careful reasoning process evaluating the effectiveness and ethics of the options Rationalization. Are stated reasons developed to justify decisions that decision maker wants to make or has already made. 3Reflect both discernment and discipline
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Discernment.the ability to evaluate facts and potential consequences from a practical and moral perspective

Discipline the strength of character to do what should be done

even when it is costly or don't go with your interest.

Framework for Ethical Decision Making

Recognize an Ethical Issue 1. Could this decision or situation be damaging to someone or to some

group? Does this decision involve a choice between a good and bad alternative, or perhaps between two "goods" or between two "bads"? 2. how? Get the Facts 3. 4. 5. What are the relevant facts of the case? What facts are not known? Can I What individuals and groups have an important stake in the outcome? Are What are the options for acting? Have all the relevant persons and groups Is this issue about more than what is legal or what is most efficient? If so,

learn more about the situation? Do I know enough to make a decision? some concerns more important? Why? been consulted? Have I identified creative options? Evaluate Alternative Actions 6.

Evaluate the options by asking the following questions: Which option will produce the most good and do the least harm? Which option best respects the rights of all who have a stake? Which option treats people equally or proportionately?

Which option best serves the community as whole, not just some Which option leads me to act as the sort of person I want to be?

members?

Make a Decision and Test It

7.

Considering all these approaches, which option best address the situation? If I told someone I respect-or told a television audience-which option I

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have chosen, what would they say? Act and Reflect on the Outcome 9. 10. How can my decision be implemented with the greatest care and attention How did my decision turn out and what have I learned from this specific

to the concerns of all stakeholders? situation?

Models for Ethical Decision-Making:

Different models for ethical decision making represent the various systemic processes or approaches that a nurse might take in making an ethical decision related to the health and nursing care of an individual or a population group. No single decision making model is appropriate or useful for every one. It is likely that differences in patient care situation will require different approaches to ethical problems depending on the values of the decision maker, the nurse, and other parties involved.

DECIDE model
Ian Thompson and colleagues (2000) have outlined a model based on the acronym DECIDE:
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Define the problem(s) What are the key facts of the case? Who involved? What are their rights and your duties? What is the main ethical problem to be addressed?

Ethical review What ethical principles have a bearing on the case and which give priority in making decision?

Consider the options What options do you have in the situation? What alternative courses of action? What help, mean and methods do you need to use?

Investigate outcomes Given each available option, what consequences are likely to follow from each course of action open to you/ which is the ethical thing to do?

Decide on action Chose the best available option, determine a specific plan, set clear objectives and then act decisively an effectively.

Evaluate the results Initiate a course of action, monitor how things progress, and when concluded, assess carefully whether or not you achieved goals.

MORAL model
Crisham (1985) developed a model incorporating the nursing process and principles of biomedical ethics. This model is especially useful in clarifying ethical problems that occur as a result of conflicting obligations. Nurses frequently have conflicting duties as a result of their differing responsibilities to patient, staff, self and to the organization .this model is representing by MORAL M .. Message the dilemma; collect data about the ethical problem and who should be involved in decision making process.
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OOutline the options: identify options and analyze the causes and consequences.
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R Review criteria and resolve: weight the option against the values of those involved in the decision. It is sometimes easier to list these options in a graph format indicating a positive option with a+ and negative options with a-.
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A Affirm position and act: develop the plan of action or strategy for implementation.
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Look back and evaluate the entire process.

SPIRAL model
It is one of ethical decision making models; it used to analyze the ethical issues present in a hypothetical situation. It is simple in ordering thinking about the ethical problem.
S.Specify the key factors of the case and ethical problem, link these to ethical

principles as specified in the code of ethics.

P.Principles:

what are the key ethical principles, legal, policy and

administrative parameters that have a bearing on the decision required?

I..Identify what options or choices are actually to you. R..Review each option and consider likely ethical outcomes A..Action act effectively and with resolution based on a clear action plan

L...Learn what you can from the results by evaluating them against your plan.

Ethical Assessment Framework (EAF):

A framework nurses may choose to use for ethical decision-making developed by Casseus in 1998. Provides a systematic approach to processing an ethical issue in nursing practice: Assessment: 1. Identify the problem: issues, conflicts and/or uncertainties.
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2.

Gather relevant facts: medical (objective data); contextual (subjective Identify methods of ethical justification to help resolve the dilemma: Consciously clarify relevant values, rights, and duties of patient, self and Identify if there is an ethical dilemma(s) present. Identify guidelines from nursing and professional codes of ethics. Identify and use relevant interdisciplinary resources: ethics committee, Identify and prioritize alternative actions/options.

data); policies, state and federal laws etc.

3.

4. 5. 6. 7. 8.

significant persons associated with issue(s).

ethics consultants, literature, administrators, lawyers, colleagues, etc. Plan of action: Select a morally justified action/option from alternatives identified. Implementation: Act upon/support the action/option selected. Evaluation: Evaluate action/option(s) taken short and long term.

The nursing process as a model:

Another problem solving model not specifically designed or ethical analysis but appropriate for it is the nursing process. The cyclic nature of the process allows for feedback to occur at any step. It also allows the cycle to be repeated until adequate information is gathered to make decision.
1)

Assessment: Determine the problem and carefully assess the situation as

extensively as possible. Data-gathering in this initial step presupposes examining multiple perspectives of the problem.
2)

Analyze the data for common components and differences that will precede Select the optimal solution after examining the advantages and disadvantages of

examination of potential solutions (as many as can be generated).

3)

each option identified in step 2.

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4) 5)

Implement the selected option or decision. Evaluate the effect of the decision on the individuals involved to determine the

extent to which the decision worked. If a determination is made that the decision was ineffective in solving the problem, collect data to justify why the option failed to work. At this point, subject the new problem (the one unresponsive to the selected strategy) to the decision-making process and start the cycle again. Role of the registered professional nurse in Ethical Decision-Making: 1. 2. 3. 4. Evaluate their own personal and professional values and reassess them Utilize principles that guide ethical decision-making in practice: Participate in interdisciplinary ethics committees and ethics rounds. Recognize the values and standards that guide ethical practice in nursing The ANA Code of Ethics for Nursing. The ANA Scope and Standards of Practice. The International Nursing Council Code of Ethics.

periodically. (Autonomy, Beneficence, Caring, Justice, Non-malfeasance).

as represented in:
o o o

5. 6. 7. 8.

Describe laws that govern nursing practice and address the rights of Utilize a decision-making model or framework that will facilitate the Contact the authorized personnel for counsel and support in ethical the nurse raised questions and seeks clarification from the member of

patients. recognition and resolution of ethical dilemmas. decision-making processes. heath team

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References
1. Marquis B, Huston C. Leadership roles and management functions in

nursing : theory and application . Lippincott Williams& Wilkins.2008.

2.

Burkhardt MA. Nathaniel AK. Ethics & Issues in Contemporary Nursing.

3rd ed., Thomson Delmar Learning Company. United States; 2008

3.

Tschudin V. Ethics in Nursing: The caring Relationship. 3rd ed. London:

Butterworth Heinemann; 2003. 4. Robinson D, Kish Ch. Core Concepts in Advanced practice Nursing. St.

Louis: Mosby; 2001.

5.

Thompson I, Melia K, Boyd K. Nursing Ethics. 4th ed. Edinburgh:

Churchill Livingstone; 2000.

6.

Cherry B, Jacob S. Contemporary Nursing: Issues, Trends, and

Management. 3rd ed. St. Louis: ElsevierMosby; 2005.

7.

The New York State Nurses Association. Role of the Registered

Professional Nurse in Ethical Decision-Making. 2005. Available at: www.nysna.org. 8. Hammond, John S., et al. "The Hidden Traps in Decision Making."

Harvard Business Review, September-October 1998, 47.

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