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Nursing Ethics in Everyday Practice

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Written specifically for nurses who are at the front lines of health care in hospitals, outpatient clinics, surgery centers, home health care settings, etc, this author emphasizes real world ethical challenges for nurses. The book provides guidelines on current and future ethical challenges, how to have moral courage and project the readers own voice, and an overall guide to communication and ethics consultation. Author Connie Ulrich, a clinical ethics expert, describes types of everyday ethical challenges with which nurses are most likely to be confronted, the practical considerations, the questions to ask, and the specific steps to take to come to a satisfactory resolution for patient and family.

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13 Chapters

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1 What Does the Future Hold for Nursing Care?


–Connie M. Ulrich, PhD, RN, FAAN

Associate Professor of Bioethics and Nursing, University of Pennsylvania School of Nursing Secondary Appointment, Department of Medical Ethics and Health Policy Senior Fellow, Leonard Davis Institute for Health Economics, NewCourtland Center for Transitions and Health

–Kim Mooney-Doyle, MSN, RN

Doctoral candidate, University of Pennsylvania School of Nursing

• By 2030, those 65 and older will represent nearly 20% of the total U.S. population, requiring new models of health care delivery and a skilled workforce to meet these demands.

• Providing ethical care at the end of life will require shared decision-making between the patient and the provider and an honest dialogue about the benefits and burdens of treatment. Nurses must be part of these discussions.

• The electronic health record (EHR), as one indicator of health care reform, is a means to deliver safe, efficient, and quality patient care but it is not without ethical concerns, such as privacy, confidentiality, and ownership of data.


2 Ethical Decision-Making: A Framework for Understanding and Resolving Mental Health Dilemmas


–Marna S. Barrett, PhD

Clinical Associate Professor of Psychology in Psychiatry University of Pennsylvania Perelman School of Medicine

• Ethical dilemmas are inherently troublesome, primarily because they involve at least two competing yet equally “right” choices rather than a right versus wrong choice.

• Distinct from other branches of medicine, psychiatry raises unique challenges for ethical decision-making. Only in mental health are we asked to determine a person’s competence, restrict a person’s right to self-determination, participate in legal decisions about a person’s culpability, and engage with society in a reciprocal relationship of influence.

• Ethical principles such as autonomy, beneficence, nonmaleficence, fidelity, justice, and empathy are ideals to which we strive. Although useful for understanding the complexities of a dilemma, they are not sufficient for problem resolution.

• A framework for ethical decision-making is imperative for developing a consistent and effective personal standard for resolving ethical dilemmas. Key elements of such a framework include identifying and clarifying the issue, determining whether the situation is a “right versus wrong” or a “right versus right” dilemma, evaluating the principles involved, creating a “trilemma,” weighing benefits and burdens, consulting, considering possible outcomes, making document decisions, and reviewing and reflecting on the process.


3 Finding a Voice in Ethics: Everyday Ethical Behavior in Nursing


–Lucia D. Wocial, PhD, RN

Nurse Ethicist, Indiana University Health Adjunct Assistant Professor, Indiana University School of Nursing

• Speaking up in ethically challenging situations is a skill that takes practice.

• Finding your voice to express your values is the right thing to do for your patients and for yourself.

• Ethically challenging situations can be found in the seemingly mundane activities of routine nursing care.

• Nurses must cultivate a sense of moral courage to uphold the trust the public has placed in them.

If doing the right thing were easy, no one would need to study ethics. In any given situation, nurses might find more than one right thing to do, and it might not be clear which right thing someone should do. Studying ethics in a formal way can assist nurses with developing knowledge of what the right thing to do is. Knowledge alone, however, does not help nurses develop the skills necessary to act in challenging situations. In addition, the focus in ethics on the big topics (for example, end-of-life care, transplants, and clinical research) fails to help nurses appreciate and practice the skills necessary to navigate the everyday circumstances that define ethical behavior.


4 Nursing Ethics in Everyday Practice: Using Communication Skills Effectively


–Fiona Timmins, PhD, MSc, BNS RNT, FFNRCSI, BSc Health & Soc (Open)

Associate Professor School of Nursing and Midwifery Trinity College Dublin

• Changing disease patterns and treatments; social trends; and increased population mobility, together with increasingly older population—all present ethical issues for nurses.

• Nurses need a systematic approach to dealing with ethical issues, including:

• Identifying the situation that requires ethical consideration and decision-making

• Reviewing relevant formal ethical standards

• Developing alternative courses of action

• Evaluating the alternative courses of action

• Assuming personal responsibility for the consequences of your action

• Communication skills are essential to dealing with ethical issues effectively.

• The complexity of contemporary nursing environments, coupled with the rapid way those environments change, has made effective communication more vital for nurses than ever before.


5 Ethics Consultation


–Mary K. Walton, MSN, MBE, RN

Hospital of the University of Pennsylvania Center for Bioethics, University of Pennsylvania

• Raising and addressing ethical concerns are professional obligations.

• Nursing colleagues are a resource; articulating ethical concerns gives them visibility and is the first step in addressing them.

• Seek to elicit the preferences and values of others. Work to understand them, rather than defending your own values.

• Ethics consultation is a valuable resource for caregivers, patients, and families in the acute care setting when ethical concerns arise in the provision of care.

Given the vulnerability of patients and the complexity of health care, nursing practice demands ethical decision-making. Nurses make decisions when providing care so frequently and so comfortably they might not recognize that these decisions reflect their personal values and the values of their profession, specialty, or practice setting. Patients trust nurses to act in their best interest at all times, especially when they are vulnerable and might be unconscious, fearful, or in pain. This trust represents a unique bond that exists between the public and the nursing profession.


6 Genetics and Genomics in the 21st Century: Ethical Considerations


–Kathleen A. Calzone, PhD, RN, APNG, FAAN

Senior Nurse Specialist, Research National Institutes of Health, National Cancer Institute Center for Cancer Research, Genetics Branch

Genetic and genomic information and technology:

• Can be collected, analyzed, and stored prior to conception, at any point in a person’s life, and after death.

• Predict future health risks, but prediction is not absolute and results can also be unexpected or incidental findings (i.e., misattributed paternity).

• Create an opportunity for misinterpretation or misuse.

• Alter lifestyle, family relationships, reproductive decision-making, and health behaviors (i.e., increased screening or risk-reducing surgery).

• Nurses are optimally positioned to contribute to the ethical translation of genetic and genomic information and technology into health care.

Genetic/genomic information is already being used to identify people and families at risk for certain conditions, better inform screening and risk-reduction options, screen for certain conditions, inform prognostic and therapeutic decisions, develop targeted therapies, and personalize therapy by informing medication selection and dosing. These advancing technologies and this knowledge about genetics and genomics influence the entire wellness-to-illness health care continuum and, therefore, are fundamental to all nursing practice (Calzone, et al., 2010). Though initially many of the discoveries were not ready for clinical application, the rapidity in which these discoveries are transitioning to the clinical arena has accelerated (Feero, Guttmacher, & Collins, 2010). And though advances in genetics/genomics also have significant potential to improve health outcomes, they also present a myriad of ethical challenges.


7 Research Advocacy in Clinical Nursing


–Kim Mooney-Doyle, MSN, RN

Doctoral candidate, University of Pennsylvania School of Nursing

–Gwenyth R. Wallen, PhD, RN

Chief of Nursing Research and Translational Science, National Institutes of Health Clinical Center

–Connie M. Ulrich, PhD, RN, FAAN

Associate Professor of Bioethics and Nursing University of Pennsylvania School of Nursing Secondary Appointment, Department of Medical Ethics and Health Policy Senior Fellow, Leonard Davis Institute for Health Economics New Courtland Center for Health and Transitions

• Clinical practice and clinical research are distinctly different aspects of patient care.

• Informed consent is an essential element of the ethical conduct of research and is an ongoing process.

• The ethical principles of respect for persons, beneficence, and justice can guide nurses in their daily care of patients enrolled in research.

Nurses often state that they go into nursing to make a significant difference in the lives of their patients and families. Actively diminishing the pain and suffering of those who are acutely, critically, or chronically ill is especially rewarding to them. Staff nurses on the front lines of health care delivery consistently assess and evaluate the physical and psychosocial needs of their patients. Research is not usually on the minds of practicing nurses, yet research is integral to improving patient-related outcomes. In fact, Willis and Grace (2011) argue that nurses are ethically responsible for understanding the science behind their patients’ conditions, including learning about topics that advance the theoretical and empirical knowledge base of nursing practice. Additionally, Grady and Edgerly (2009) note that “in many settings, nurses are ethically responsible for contributing to both the promotion of good science and to the protection of the rights and welfare of patient subjects, a balance which requires knowledge, competence, advocacy, creativity, and close working relationships within the research and clinical teams” (p. 3).


8 Ethical Issues in Critical Care


–Mindy B. Zeitzer, PhD, MBE, RN

Adjunct Professor Thomas Jefferson University, School of Nursing

• Recognizing the ethical issue you are experiencing is important. If you are feeling conflicted over a patient care issue that is related to a value, moral, or ethic, you are experiencing an ethical issue.

• Consider how to approach ethical issues and what avenues are available to you within your unit and within your hospital. Familiarizing yourself with these before experiencing ethical issues is beneficial.

• Decide how you are going to deal with the issue and act on it.

• Remember to assess and reflect on how the issue was dealt with and how you ultimately feel about the situation.

Critical-care nursing includes caring for critically and acutely ill patients who can range from neonates to geriatrics in a general or specific critical-care unit (CCU) or emergency department. Critical-care nurses care for a broad range of patients suffering from various diseases or injury-related illnesses. Needless to say, critical care is complex; it typically includes many types of technology, raising an increasing number of ethical questions. In addition, critical-care nurses care for the sickest patients, many of whom are at the end of their lives. This creates a stressful atmosphere for families, who must often watch their loved one undergo intense hospitalization while often needing to make immediate and difficult decisions related to the loved one’s care. Nurses working in critical-care units often deal with a multitude of ethical issues related to these factors. Being able to recognize ethical issues, formulate a plan, take action, and cope emotionally are important tasks for all critical-care nurses to absorb. This information is vital to their personal and professional well-being. This chapter discusses some typical ethical issues critical-care nurses encounter, their effects, and steps on how to tackle ethical problems.


9 Ethics in Long-Term Care


–Michele Mathes, JD

Education Director Center for Advocacy for the Rights and Interests of the Elderly

• The nature of long-term care presents nurses with unique ethical challenges.

• The particular nature and challenges of long-term care call for the application of a distinctive ethical framework.

• An ethical framework based upon commitment to the care recipient best captures the responsibilities of nurses working in long-term care settings.

• The responsibilities of long-term care providers are comprised within five overarching commitments to care recipients.

• The IDEAS decision-making process offers a pathway for resolving ethical dilemmas when they arise.

History reflects our evolving understanding about the proper goals of long-term care and the kind of care to which frail older adults are entitled. Today, possibly more than at any time in our past, the purposes of long-term care are being deeply examined, debated, and discussed. Resulting changes in policy and practice, though generally welcomed, pose new ethical challenges for practitioners in the field. This chapter presents an ethics of responsibility approach to addressing ethical issues that arise in the course of providing long-term care.


10 Ethical Challenges in Transitioning to End-of-Life Care: Exploring the Meaning of a “Good Death”


–Gwenyth R. Wallen, PhD, RN

Chief of Nursing Research and Translational Science, National Institutes of Health Clinical Center

–Karen Baker, MSN, CRNP

Pain and Palliative Care Service, National Institutes of Health Clinical Center

• When caring for a patient at the end of life, a nurse must examine her or his own ethical perspectives and the meaning of a “good death,” as well as those of the patient and her or his family.

• Advance directives must be verified to examine patient preferences. Printing a copy of the advance directive from the electronic medical record and having it available in the direct care setting are optimal.

• Ongoing assessment of symptom control is paramount and should include exploring unmet psychosocial and spiritual needs.

• When palliative sedation is being considered, assess whether all symptom relieving agents have been maximized.

• Patient care conferences that include the interdisciplinary team, patient, and family should occur early and often.


11 Ethical Issues in Neonatal Nursing


–Elizabeth Gingell Epstein, PhD, RN

Assistant Professor University of Virginia School of Nursing

• Neonatal nurses encounter ethical issues every day and play an important role in preventing and resolving ethical conflict.

• One of the most pressing ethical concerns today in neonatal ethics is how nurses and other health care providers communicate with each other and with parents.

• Strategies for identifying and acting on common triggers of ethical conflict are provided.

Ethics is an inescapable aspect of neonatal nursing. Consciously or not, neonatal nurses practice ethics in some way on every shift. Balancing benefits and burdens; advocating for infants and parents; maintaining confidentiality; promoting privacy; and speaking carefully and truthfully with colleagues and parents—all require ethical judgment. Most encounters with ethics do not involve conflict. Instead, making judgment calls independently and speaking up for those who cannot speak take center stage. Supporting parents when they need support is also a frequent factor. Simply put, encounters with neonatal ethics situations involve respecting the dignity of human beings.


12 Pediatric Ethics: What Makes Children Different?


–Lucia D. Wocial, PhD, RN

Nurse Ethicist, Indiana University Health Adjunct Assistant Professor Indiana University School of Nursing

• Children may not be adults, but nurses owe them the same obligation of respect.

• Children should be allowed the opportunity to participate in decisions about their own health care.

• Nursing caring behaviors can promote parents’ trust and confidence that they are doing the right thing for their children.

• The close relationships nurses form with children and their family are central to nurses’ role in addressing ethically challenging situations in pediatrics.

Children are not miniature adults. They face different types of illnesses, have an incredible capacity for recovery, and are not considered fully independent autonomous agents. First and foremost, it seems unnatural to consider that children get serious illnesses or die. We tend to view children as innocents and so feel that any illness or harm that comes to them is somehow unfair. (Jecker & Pagon, 1995). Life-threatening injury and illness in childhood create intense emotional burdens on those who are charged with making decisions for those children, compounding the ethical challenges in these circumstances. The relationships among children, their parents, and those who care for them add another layer of complexity to the ethical issues in pediatrics.


13 Revisiting Therapeutic Relationship in Psychiatric-Mental Health Nursing: Toward a Relational Ethic


–Margaret Cotroneo, PhD, PMHCNS-BC

Emeritus Associate Professor of Psychiatric-Mental Health Nursing University of Pennsylvania School of Nursing

–Freida Hopkins Outlaw, PhD, RN, FAAN

Director, Youth Health and Wellness Center Meharry Medical College

–June M. Roman, MSN, RN, PMHCNS-BC

Psychiatric Clinical Nurse Specialist University of Pennsylvania School of Nursing

• A healing relationship is essential to ethical nursing practice.

• Science and technology are changing the nature of psychiatric-mental health nursing practice

• The nature of practice is changing the way psychiatric-mental health nurses must think about ethics

• In a time of constant change, practice is the living laboratory that shapes and informs ethics.

• The therapeutic relationship is the ethical framework of psychiatric-mental health nursing practice.

The link between quality of health care and quality of life gives rise to some of the most challenging ethical claims of our time. As health care providers, improving the patient’s quality of life is our challenge, and providing therapeutic quality of care is our mandate. This mandate shapes professional ethics and comprises the profession’s response to social needs, the conduct expected of the professional, and the skills associated with the specific practice of the professional.



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