NURS 6565 Week 4 Assignment 1: Practicum Journal Entry: Analyzing an Ethical Decision in Nursing

Analyzing an Ethical Decision in Nursing – In your role, as an advanced practice nurse, you will encounter several situations that will require your ability to make sound judgments and practice decisions for the safety and well-being of individuals, families, and communities. There may not be a clear cut answer of how to address the issue, but your ethical decision making must be based on evidenced based practice, and what is good, right, and beneficial for patients. You will encounter patients who do not hold your values, but you must remain professional and unbiased in the care you provide to all patients regardless of their sociodemographic and ethnic/racial background. You must be prepared to critically analyze ethical situations, and develop an appropriate plan of action. For this Assignment, you will review the literature and discover the various ethical dilemmas advanced practice nurses encounter and how these issues are typically addressed in Texas.

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To prepare for NURS 6565 Week 4 Assignment 1: Analyzing an Ethical Decision in Nursing:

Review literature for moral/ethical issues encountered by advanced practice nurses in clinical practice.
Select an article that was published within the last five years.

Write a two page paper that answers the following questions:

Summarize the moral/ethical issue in the article (no more than 1 paragraph)
Describe the moral and ethical dilemmas surrounding the issue
Analyze the ethical issue and compare them to the State Health Laws and Regulations in your state
Outline the process of ethical decision making you would use to address this ethical dilemma
APA format; include references

NURS 6565 Week 4 Assignment 1: Practicum Journal Entry: Analyzing an Ethical Decision in Nursing

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NURS 6565 Week 4 Assignment 1: Analyzing an Ethical Decision in Nursing References

REQUIRED READINGS

Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Sudbury, MA: Bartlett & Jones Learning.

Chapter 16, “Resolving Ethical Dilemmas” (pp. 471-479)

Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2014). Ethical decision making. In Advanced Practice Nursing: An Integrative Approach (5th ed.) (328 – 354). St. Louis, MO: Elsevier Saunders.

NURS 6565 Week 4 Assignment 1: Analyzing an Ethical Decision in Nursing: CHAPTER CONTENTS Characteristics of Ethical Dilemmas in Nursing, 328

Communication Problems, 329 Interdisciplinary Conflict, 329 Multiple Commitments, 330

Ethical Issues Affecting Advanced Practice Nurses, 330

Primary Care Issues, 330 Acute and Chronic Care, 330 Societal Issues, 331 Access to Resources and Issues of Justice, 332 Legal Issues, 333

Changes in interprofessional roles, advances in medical technology, privacy issues, revisions in patient care delivery systems, and heightened economic constraints have increased the complexity of ethical issues in the health care setting. Nurses in all areas of health care routinely encounter disturbing moral issues, yet the success with which these dilemmas are resolved varies significantly. Because nurses have a unique relationship with the patient and family, the moral position of nursing in the health care arena is distinct. As the complexity of issues intensifies, the role of the advanced practice nurse (APN) becomes particularly important in the identification, deliberation, and resolution of complicated and difficult moral problems. Although all nurses are moral agents, APNs are expected to be leaders in rec- ognizing and resolving moral problems, creating ethical practice environments, and promoting social justice in the larger health care system. It is a basic tenet of the central definition of advanced practice nursing (see Chapter 3) that skill in ethical decision making is one of the core competencies of all APNs. In addition, the Doctor of Nursing Practice {DNP) essential competencies emphasize leadership in developing and evaluating strate- gies to manage ethical dilemmas in patient care and organizational arenas (American Association of Colleges of Nursing [AACN], 2006). This chapter explores the distinctive ethical decision-making competency of advanced practice nursing, the process of developing and evaluating this competency, and barriers to ethical prac- tice that APNs can expect to confront.

NURS 6565 Week 4 Assignment 1: Practicum Journal Entry: Analyzing an Ethical Decision in Nursing

328

Ethical Decision Making

Ann B. Hamric • Sarah A. Delgado

Ethical Decision Making Competency of Advanced Practice Nurses, 333

Phases of Core Competency Development, 333 Evaluation of the Ethical Decision Making Competency, 349 Barriers to Ethical Practice and Potential Solutions, 350

Barriers Internal to the Advanced Practice Nurse, 350 lnterprofessional Barriers, 351 Patient-Provider Barriers, 351 Organizational and Environmental Barriers, 352

Conclusion, 354

Characteristics of Ethical Dilemmas

lll~l12:’:1’Si~ ~~·-· ~ -······· …. ···~ ·-· In this chapter, the terms ethics and morality or morals are used interchangeably (see Beauchamp & Childress, 2009, for a discussion of the distinctions between these terms). A problem becomes an ethical or moral problem when issues of core values or fundamental obligations are present. An ethical or moral dilemma occurs when obliga- tions require or appear to require that a person adopt two (or more) alternative actions, but the person cannot carry out all the required alternatives. The agent experiences tension because the moral obligations resulting from the dilemma create differing and opposing demands (Beauchamp & Childress, 2009; Purtilo & Doherty, 2011). In some moral dilemmas, the agent must choose between equally unacceptable alternatives; that is, both may have elements that are morally unsatisfactory. For example, based on her evaluation, a family nurse practitioner (FNP) may suspect that a patient is a victim of domestic violence, although the patient denies it. The FNP is faced with two options that are both ethically troubling-connect the patient with existing social services, possibly straining the family and jeopardizing the FNP-patient relationship, or avoid intervention and potentially allow the violence to continue. As described by Silva and Ludwick (2002), hon- oring the FNP’s desire to prevent harm (the principle of beneficence) justifies reporting the suspicion, whereas respect for the patient’s autonomy justifies the opposite course of action.

Jameton (1984, 1993) has distinguished two additional types of moral problems from the classic moral dilemma, which he termed moral uncertainty and moral distress. In situations of moral uncertainty, the nurse experiences unease and questions the right course of action. In moral distress, nurses believe that they know the ethically appro- priate action but feel constrained from carrying out that action because of institutional obstacles (e.g., lack of time or supervisory support, physician power, institutional policies, legal constraints). Noting that nurses and others often take varied actions in response to moral distress, Varcoe and colleagues (2012) have proposed a revision to Jameton’s definition: “moral distress is the experience of being seriously compromised as a moral agent in prac- ticing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cul- tural context of the workplace environment” (p. 60). The phenomenon of moral distress has received increasing national and international attention in nursing and medical literature. Studies have reported that moral dis- tress is significantly related to unit-level ethical climate and to health care professionals’ decisions to leave clinical practice (Corley, Minick, Elswick, et al., 2005; Epstein & Hamric, 2009; Hamric, Borchers, & Epstein, 2012; Hamric, Davis, & Childress, 2006; Pauly, Varcoe, Storch, et al., 2009; Schluter, Winch, Hozhauser, et al., 2008; Varcoe, Pauly, Webster, & Storch, 2012). APNs work to decrease the incidence of moral uncertainty and moral distress for themselves and their colleagues through edu- cation, empowerment, and problem solving.

Although the scope and nature of moral problems experienced by nurses and, more specifically APNs, reflect the varied clinical settings in which they practice, three general themes emerge when ethical issues in nursing practice are examined. These are problems with commu- nication, the presence of interdisciplinary conflict, and nurses’ difficulties with managing multiple commitments and obligations.

Communication Problems

The first theme encountered in many ethical dilemmas is the erosion of open and honest communication. Clear communication is an essential prerequisite for informed and responsible decision making. Some ethical disputes reflect inadequate communication rather than a difference in values (Hamric & Blackball, 2007; Ulrich, 2012). The APN’s communication skills are applied in several arenas. Within the health care team, discussions are most effective when members are accountable for presenting informa- tion in a precise and succinct manner. In patient encoun- ters, disagreements between the patient and a family

C HAP T E R 13 Ethical Decision Making

member or within the family can be rooted in faulty com- munication, which then leads to ethical conflict. The skill of listening is just as crucial in effective communication as having proficient verbal skills. Listening involves recog- nizing and appreciating various perspectives and showing respect to individuals with differing ideas. To listen well is to allow others the necessary time to form and present their thoughts and ideas.

Understanding the language used in ethical delibera- tions (e.g., terms such as beneficence, autonomy, and utili- tarian justice) helps the APN frame the concern. This can help those involved to see the components of the ethical problem rather than be mired in their own emotional responses. When ethical dilemmas arise, effective com- munication is the first key to negotiating and facilitating a resolution. Jameson (2003) has noted that the long history of conflict between certified registered nurse anes- thetists (CRNAs) and anesthesiologists influences how these providers communicate in practice settings. In inter- views with members of both groups, she found that some transcended role-based conflict whereas others became mired in it, particularly in the emotions around perceived threats to role fulfillment. She recommended enhancing communication through focus on the common goal of patient care, rather than on the conflicting opinions about supervision and autonomous practice. In other words, focusing on shared values rather than the values in conflict can promote effective communication.

Interdisciplinary Conflict

The second theme encountered is that most ethical dilem- mas that occur in the health care setting are multidisci- plinary in nature. Issues such as refusal of treatment, end-of-life decision making, cost containment, and confi- dentiality all have interprofessional elements interwoven in the dilemmas, so an interprofessional approach is nec- essary for successful resolution of the issue. Health care professionals bring varied viewpoints and perspectives into discussions of ethical issues (Hamric & Blackball, 2007; Piers, Azoulay, Ricou, et al., 2011; Shannon, Mitchell, & Cain, 2002). These differing positions can lead to creative and collaborative decision making or to a breakdown in communication and lack of problem solving. Thus, an interdisciplinary theme is prevalent in the presentation and resolution of ethical problems.

For example, a clinical nurse specialist (CNS) is writing discharge orders for an older woman who is terminally ill with heart failure. The plan of care, agreed on by the inter- professional team, patient, and family, is to continue oral medications but discontinue IV inotropic support and all other aggressive measures. Just prior to discharge, the social worker informs the CNS that medical coverage for

329

NURS 6565 Week 4 Assignment 1: Practicum Journal Entry: Analyzing an Ethical Decision in Nursing

330 PART ll Competencies of Advanced Practice Nursing

the patient’s care in the skilled nursing facility will only be covered by the insurer if the patient has an IV in place. The attending cardiologist determines that the patient can be discharged to her daughter’s home because she no longer requires skilled care and the social worker agrees to proceed with this plan. However, the CNS is concerned that the patient’s need for physical assistance will over- whelm her daughter and believes that the patient is better off returning to the sldlled nursing facility. Although each team member shares responsibility to ensure that the plan of care is consistent with the patient’s wishes and mini- mizes the cost burden to the patient, they differ in how to achieve these goals. Such legitimate but differing perspec- tives from various team members can lead to ethical conflict.

Multiple Commitments

The third theme that frequently arises when ethical issues in nursing practice are examined is the issue of balancing commitments to multiple parties. Nurses have numerous and, at times, competing fidelity obligations to various stakeholders in the health care and legal systems (Chambliss, 1996; Hamric, 2001). Fidelity is an ethical concept that requires persons to be faithful to their com- mitments and promises. For the APN, these obligations start with the patient and family but also include physi- cians and other colleagues, the institution or employer, the larger profession, and oneself. Ethical deliberation involves analyzing and dealing with the differing and opposing demands that occur as a result of these commitments. An APN may face a dilemma if encouraged by a specialist consultant to pursue a costly intervention on behalf of a patient, whereas the APN’s hiring organization has estab- lished cost containment as a key objective and does not support use of this intervention (Donagrandi & Eddy, 2000). In this and other situations, APNs are faced with an ethical dilemma created by multiple commitments and the need to balance obligations to all parties.

The general themes of communication, interdisciplin- ary conflict, and balancing multiple commitments are prevalent in most ethical dilemmas. Specific ethical issues may be Wlique to the specialty area and clinical setting in which the APN practices.

Ethical Issues Affecting Advanced Practice Nurses

Primary Care Issues

Situations in which personal values contradict professional responsibilities often confront NPs in a primary care setting. Issues such as abortion, teen pregnancy, patient

nonadherence to treatment, childhood immunizations, regulations and laws, and financial constraints that inter- fere with care were cited in one older study as frequently encountered ethical issues (Turner, Marquis, & Burman, 1996). Ethical problems related to insurance reimburse- ment, such as when implementation of a desired plan of care is delayed by the insurance authorization process or restrictive prescription plans, are an issue for APNs. The problem of inadequate reimbursement can also arise when there is a lack of transparency regarding the specifics of services covered by an insurance plan. For example, a patient who has undergone diagnostic testing during an inpatient stay may later be informed that the test is not covered by insurance because it was done on the day of discharge. Had the patient and nurse practitioner (NP) known of this policy, the testing could have been sched- uled on an outpatient basis with prior authorization from the insurance company and thus be a covered expense.

Viens {1994) found that primary care NPs interpret their moral responsibilities as balancing obligations to the patient, family, colleagues, employer, and society. More recently, Laabs (2005) has found that the issues most often noted by NP respondents as causing moral dilemmas are those of being required to follow policies and procedures that infringe on personal values, needing to bend the rules to ensure appropriate patient care, and dealing with patients who have refused appropriate care. Issues leading to moral distress included pressure to see an excessive number of patients, clinical decisions being made by others, and a lack of power to effect change (Laabs, 2005). Increasing expectations to care for more patients in less time are routine in all types of health care settings as pressures to contain costs escalate. APNs in rural settings may have fewer resources than their col- leagues working in or near academic centers in which ethics committees, ethics consultants, and educational opportunities are more accessible.

Issues of quality of life and symptom management tra- verse primary and acute health care settings. Pain relief and symptom management can be problematic for nurses and physicians (Oberle & Hughes, 2001). APNs must con- front the various and sometimes conflicting goals of the patient, family, and other health care providers regarding the plans for treatment, symptom management, and quality of life. The APN is often the individual who coor- dinates the plan of care and thus is faced with clinical and ethical concerns when participants’ goals are not consis- tent or appropriate.