Nurses’ contributions to the resolution of ethical dilemmas

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Nurses’ contributions to the

resolution of ethical dilemmas

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Aim and Objectives

•

Aim:

To identify how nurses contribute to the resolution

of ethical dilemmas in practice.

•

Objective

: To identify and discuss:

–

The beliefs that impact nurses’ decision ethical

making moral action.

–

The values that influence nurses’ ethical decision

making and moral action.

–

The contextual influences on nurses’ ethical decision

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Literature Review :

Themes

•

Code of ethics

–

Codes of ethics provide principles rather than clear

guidance.

•_{(Lere and Gaumnitz, 2003)}

–

Globally nurses have a varying degree of knowledge

of their professional codes.

• _{(Verpeet et al., 2005; Heikkinen et al., 2006)}

–

Conflict within nurses ethical decision making and

organisation.

• _{(Oberel and Hughes, 2001; Redman and Fry, 2000)}

–

(

(4)

Literature Review :

Themes

•

Conflict

–

Doctors, and healthcare professionals.

• _{(Heikkinen et al., 2006; Oberel and Hughes, 2001; Ulrich et al., 2010)}

–

Nurses values and those of patients, their families

and the organisation.

• _{(Varcoe et al., 2004)}

–

Conflict within ethical decision making and the

organisation and it representatives.

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Literature Review :

Themes

•

Moral distress

:

–

Occurs when conflict is experienced during ethical

decision making.

•_{(Kain, 2007)}

–

From nurses’ lack of involvement in decision making.

•_{(Dierchx de Casterle,et al., 2010; Long-Sutehall et al., 2011; Wolf and}

Zuxelo, 2007)

–

The consequences of moral distress are burnout,

de-sensitisation and loss of nurses from the profession

.

(6)

Conceptualised

Theoretical

Moral Action

Ethical Decision making

Deontology Utility Virtue Ethics Ethic of care

Moral reasoning

Beliefs Values Expectations

Ethical dilemmas

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Exploratory interpretive

qualitative study design

•

Ethical approval.

•

Single NHS Trust multiple site.

•

Semi-structured interview.

•

Registered Nurses, variety of experience and

current practice within secondary care.

•

Thematic, and contextual analysis using

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Data Collection

•

Eleven interviews in total.

•

Experience varied from 18months to 30years.

•

Practice experience: surgery, vascular surgery,

intensive care, medicine for the older person,

stroke, Children's nursing.

•

Audio recorded and transcribed semi-structured

interview.

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Results: Themes

•

Best for the patient:

– _{‘I have had a few ethical dilemma at the end of the day I always}

considered the patients was uppermost and that justified my

position’ Ross

•

Advocacy:

– _{‘I felt like no-one was listening. Like I come on duty and try and}

you know you're patients advocate.’ Nicky

•

Standards of care:

– _{‘...developing this area for the benefit of the patients and staff}

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Results: Themes

•

Accountability

– _‘_{So then it was left for myself and some other members of staff}

to then explain the procedure to the patient. So then it is not necessarily my accountability, I suppose its more her accountability but I had to intervene because to me she just did not recognise that area of her accountability. She [the nurse who made the error] felt it was important to follow certain procedures in terms of the medical side of things but as to informing the patient and maybe the relatives it wasn’t considered important’.

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Results: Context

•

Conflict

–

‘they could have sent the chief executive on the ward

I would have stuck to my guns and did what I thought

was best for these patients. And I know that there

were two other patients that were in need of a bed but

I actually had to look after the patients that were there

then. So, you know, it did make me question, even

now, I feel I made the right decision’.

(12)

Results: Context

•

Collaboration

–

‘I think we all sing from the same hymn sheet, and I think

there are areas where what we do everybody does and

yes I think it works. I think we know exactly where we're

going. Once we've got that we know we're not giving

non-essential medications, we're giving medications to be

comfortable with, we're not filling them full of fluids which

just you know hang around, we are just making them

comfortable, and I think that's really important’.

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Results: Context

•

Concern for others

– _‘

I even used to think about Doctors doing it I mean

Doctors feel or appear to be quite blasé about it they

were quite happy to do it. I used to think how do they

feel prescribing a drug for a patient they have never

clapped eyes on, how do they know – they are very

trusting themselves.’

Lee

‘I even used to think about Doctors doing it I mean Doctors feel or appear to be quite blasé about it they were quite happy to do it. I used to think how do they feel prescribing a drug for a patient they have never clapped eyes on, how do they know – they are very trusting themselves. Trusting is the word for it these weren’t doctors that regularly worked on my ward so they did not know my capabilities and could not trust my capabilities they did not know me. I might have been a really poor nurse for all they knew, who did

not recognise these things.’ Lee

‘I even used to think about Doctors doing it I mean Doctors feel or appear to be quite blasé about it they were quite happy to do it. I used to think how do they feel prescribing a drug for a patient they have never clapped eyes on, how do they know – they are very trusting themselves. Trusting is the word for it these weren’t doctors that regularly worked on my ward so they did not know my capabilities and could not trust my capabilities they did not know me. I might have been a really poor nurse for all they knew, who did

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Results: Relationships

–

Nurses demonstrated through their accounts that the

relationships they maintain are the key to achieving

moral action.

–

The context did present barriers as identified in both

the research data and literature review

–

The most important is that with the patient, the

patients family

–

Doctors

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Reconceptualised

Theoretical Framework

R E L A T I O N S H I P S

Nurse patient relationship

Nurse patient relationship

With other patients, families, health and social care team members

In partnership

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Limitations

•

This is relatively small sized study

exploratory.

•

Nurse participants worked in the same

organisation

•

The study is limited to secondary care

(17)

Conclusion and

Recommendations

•

Nurses’ professional relationships are central to nurses’

contributions to the resolution of ethical dilemmas.

•

Support is required for nurses to acquire the skills to

develop and maintain professional relationships for

addressing ethical dilemmas in practice.

•

Nurses need to be involved in the development of

organisational policy and individual patient decisions,

which place obligation on them.

•

Research is required to explore this phenomenon in

(18)

References

• _{Corley M.C. (2002) Nursing Moral Distress: A proposed Theory and}

Agenda Nursing Ethics 9 (6) pp 636-650.

• _{Dierckx de}_Casterlé_{B. Denier Y. De Bal N. and Gastmans C. (2010)}

Nursing care for patients requesting euthanasia in general hospitals

in Flanders, Belgium Journal of Advanced Nursing 66 (11) pp 2410

– 2420.

• _{Heikkinen, A. Lemonidou, C. Petsios, K., Sala, R. Barazzetti, G.}

(19)

References

• _{Kain, V. (2007). Moral distress and providing care to dying babies in}

neonatal nursing. International Journal of Palliative Nursing 13(5) pp 243-248.

• _{Lere J.C. and Gaummitz , B.R. (2003) The impact of codes of}

ethics on decision-making Some insights from information Economics. Journal of Business Ethics 48 pp365-379.

• _{Long-Sutehall, T. Willis, H. Palmer, R. Ugboma, D. Addingham-Hall,}

(20)

References

• _{Oberle, K. and Hughes, D. (2001) Doctors’ and nurses’ Perceptions}

of ethical problems in end of life decisions. Journal of Advanced Nursing 33(6) pp707 - 715.

• _{Redman, B.K and Fry, S.T (2000) ‘Nurses Ethical Conflict: what is}

really known about them?’ Nursing Ethics, 7(4), pp. 360-366.

• _{Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P.,Farrar, A., Danis,}

(21)

References

• _{Varcoe,. C. Doan, G. Pauly, B. Rodney, P. Storch, J. Mahoney, K.}

McPherson, G. Brown, H. and Starzonomski, R.( 2004).Ethical practice in nursing: working the in-betweens. Journal of Advanced Nursing 45(3)pp 316-325

• _{Verpeet, E. Dierckx de}_Casterlé_{B. Van der Arend, A. and}

Gastmans, C.A.E. (2004). Nurses views on ethical codes: a focus group study. Journal of Advanced Nursing 51 (2) 188-195

• _{Wolf , Z. R. and Zuzelo, P. R. (2007) ‘Never Again’ Stories of}