Ethics And Morals Evaluated And Scrutinized In Clinical Practice

Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay

While taking the survey I did get stuck on more than half of them and wasn’t able to make too many “strongly agree/disagree” choices and ended up doing more that were moderate answers. I did feel conflicted about several of the questions and the first one that made me stop and almost cringe was the question about the CRNA who had been suspected of abusing fentanyl. The reason for this is because at my job there was an LVN that was caught forging the doctor’s signature who did not end up being reprimanded. Thankfully it didn’t end up harming the patient in any way but I did feel like what that nurse did was unethical and unfair that she wasn’t reprimanded in any way by management. It led to me feeling like that job had rules in place but it seemed like they were only in effect when it was convenient for everyone. I still wonder to this day if I should’ve notified the nursing board because I never did anything about it.Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay


The question regarding the embezzlement led to me having to do critical thinking and I had to place myself in the hypothetical shoes of my co-workers to determine my answer. In the end this was one of the few where I chose “strongly agree”. I did rely on legal parameters for a couple of the questions, especially the ones regarding the pediatric patient that required the life-saving blood transfusion. While I believe my choices may conflict with few, I still would not feel comfortable having my choices made public and I would choose to remain anonymous. I can’t really say I know how a moral inventory like this one would impact my current clinical site because I haven’t been there very long, but I do believe that the job I discussed earlier regarding the nurse that forged the signature would actually benefit from having their ethics and morals evaluated and scrutinized.Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay

reply 2

During this survey, I found it difficult to choose strongly agree or strongly disagree for that reason of it not being black and white. I mostly chose moderate responses.
The subject area talking about the nurse practitioner and the opioid addicted patient having a miscarriage after abruptly stopping her pain medications triggers some personal emotions. It triggered some emotions, because as a nurse practitioner student, I placed myself in that situation. One can give advice to the patient, but it is truly what the patient does outside of the clinic that impacts that person’s health in the long run. Whether it has dire consequences or not. I was able to remain objective in a way, because I also thought of physicians and other healthcare workers that might be in a similar situation.
Many of the decisions were difficult to make. Especially the Jehovah’s witness child that needed a lifesaving blood transfusion.
I did employ critical thinking or resolution strategies to determine a response. When it came to physician assisted suicide. I offered a resolution of trying out a few treatments to see if it works or not, because sometimes not all physicians are correct. And patients do live longer than the allotted time given to them. Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay
I did rely on policy and legal parameters to make decisions, because it is very important to stick to the policy. For example, during that scenario with the transgender child taking hormones. Though there might be conflicting views, it is very important to stick to the policy and aid in this child’s care. And treat the child like everyone else.
I do not think I would feel comfortable making my answers public. I would rather remain anonymous.
Working in the ER, I have dealt with similar situations. Such as knowing when to keep going during a code or stop due to the patient’s quality of life after the fact. Or the durable power of attorney/ family member would like the patient to be full code and other family members know that the patient would like to be a no code.
I think a moral inventory would impact my clinical practice by making me more aware of ethical issues at hand. And being prepared to deal with them should they arise. Sometimes it is so easy to get caught up with day to day work that we forget that there might be ethical issues that need to be discussed.

The goal of nursing is to work for the good of the patient. Nursing can
therefore be regarded as an ethical practice (Gastmans, Dierckx de Casterle &
Schotsmans, 1998). This means that the ethical dimension of nursing care is
not restricted to specific situations but is rather an integral part of all nursing
care (Bishop & Scudder, 1990). Ever since the beginning of modern nursing,
starting with the Nightingale era, ethics has been regarded as a vital part of
nursing. In her Notes on Nursing, Nightingale points to the importance of
listening to patients, putting their needs first and upholding confidentiality
(Nightingale, 2010). Today we would describe these as ethical actions. They
were in some sense formalized in 1953, when the International Council of
Nurses (ICN) launched its first code of ethics (ICN, 1953). But laws and other
regulations on a national level, such as the Swedish Health and Medical Service
Act (Ministry of Health and Social Affairs, 1982:763), also regulate how nurses
and other healthcare staff should act. This means that nurses have to navigate
among the ethical values of different stakeholders: patient, organization,
profession and society. When these values are threatened or clash, nurses have
to take a stand on how to deal with this. The aim of this thesis is to explore and
describe what nurses find ethically problematic and morally distressing in their
work, the factors contributing to the arising of ethically problematic situations
and the actions reported taken in order to handle them, thus creating an ethical
climate.Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay
Ethical problems
This thesis takes its starting point in nurses’ experiences of situations they
consider ethically problematic and morally distressing. A number of different
concepts are used in the literature to describe situations that are in one way or
another ethically problematic. Some of these concepts are ethical problems,
ethical dilemmas, ethical conflicts, ethical concerns and ethical issues. However,
although these situations are labeled differently their core seems to entail a
person encountering situations in which values, norms or principles are
threatened or in conflict and a decision has to be made on how to act. In the
literature, such as in Thompson, Melia, Boyd and Hornsburgh (2006),
differences between concepts are described. However, in research studies
motivation is seldom given for the use of a specific concept, and they seem to be
used quite interchangeably. Due to an apparent lack of consensus on what
concept to use when for ethical problems, and as a consequence of taking as a
starting point the nurses’ experiences and thereby relying on an inductive
perspective, the nurses were given the preferential right to define what
situations they considered ethically problematic.
In this thesis no distinction is made between the two terms “ethics” and
“morals”. They can be regarded as overlapping, and distinctions are mostly
made when they are used in a more formal way (Thompson et al., 2006). With
regard to the aim of this thesis, a distinction was not considered necessary.
Ethical problems in nursing care
Ethical problems for nurses can arise in situations such as when decisions are to
be made on life-sustaining treatment, but also in other situations when there is
a question of what is in the patient’s best interest. Sometimes it is difficult to
decide how much information should be given to patients and next of kin,
leading to ethical problems concerning informed consent. Policies intended to
facilitate can sometimes give rise to ethical problems if different policies apply,
supporting different actions. Factors that can contribute to the arising of ethical
problems are, among others, hierarchical structures and a lack of different kinds
of resources.Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay

The area of decision making regarding life-sustaining treatment is one where
nurses experience ethical problems. This mainly concerns how long futile
treatment should be continued (Bunch, 2001; Çobanoglu & Algier, 2004) and
what ethical criteria can be used to terminate life-sustaining treatment
(Hermsen & van der Donk, 2009). In a setting like intensive care there can be
tension between nurses’ personal values regarding what constitutes a good death
and the purpose of intensive care, i.e. saving life (Cronqvist, Theorell, Burns &
Lützén, 2004). The decision on the course of treatment is experienced as being
further complicated when the patient whom the decision concerns is decisionincompetent (Enes & de Vries, 2004). Ethical problems involving the
withholding or withdrawal of treatment also can give rise to conflict between
nurses and physicians, according to nurses. Nurses have advocated withdrawal
of treatment sooner than physicians (Torjuul & Sörlie, 2006). This has been
explained by differences of perspective, whereby physicians are the ones who
make the decisions while nurses are the ones who carry out these decisions
(Oberle & Hughes, 2001). However, other studies (Eliasson, Howard,
Torrington, Dillard & Phillips, 1997; Svantesson, Sjökvist, Thorsén &
Ahlström, 2006) have shown contradictory results, with high agreement
between nurses and physicians regarding aggressiveness of treatment for the
patients they care for.
Ethical problems in the form of divergent opinions also arise in other situations,
for example when patients refuse the care offered (Karlsson, Roxberg, da Silva
& Berggren, 2010) or make, from a professional perspective, irrational decisions
(Hermsen & van der Donk, 2009; Sandman & Nordmark, 2006). It can also
happen that nurses and next of kin have different opinions on what is in the
best interest of the patient, or that different family members disagree on the
patient’s best interest (Sandman & Nordmark, 2006).
Nurses have also told about ethical problems related to giving information and
informed decision (Killen, 2002; Ulrich et al., 2010). This comprises
difficulties involving how much information a patient or next of kin should be
given (Torjuul & Sörlie, 2006) or having to get a patient sign agreement for
treatment although it is uncertain if the patient understands what this means
(Shapira-Lishchinsky, 2009). Information can also be withheld from a next of
kin at the request of the patient (Torjuul & Sörlie, 2006).
Although policies can be a guide in decision making when facing an ethical
problem, they can sometimes be perceived as constraining and as giving rise to
ethical problems (Oberle & Tenove, 2000). An ethical problem can consist of a
conflict between different policies or between a policy and a judgment about
what should be in the patient’s best interest (Sandman & Nordmark, 2006).
As there is a considerable amount of research on what situations nurses find
ethically problematic, what may contribute to the rise of an ethically
problematic situation is more sparsely discussed here. However, some of the
factors that have been pointed out are nurses’ position in the hierarchical
structure of professions (Oberle & Hughes, 2001) and physicians’ way of
handling situations involving decision making concerning life-sustaining
treatment (Cronqvist et al., 2004). Lack of resources, such as equipment,
finances (Gaudine, LeFort, Lamb & Thorne, 2011) time, staffing and private
rooms (Torjuul & Sörlie, 2006) might also contribute to there being ethical
problems regarding prioritization.Ethics And Morals Evaluated And Scrutinized In Clinical Practice Essay
Factors affecting the handling of ethical problems
When confronted with an ethical problem, nurses have to decide what actions
to take in order to handle it. In a review, Goethals, Gastmans and de Casterlé
(2010) have described this as two interrelated processes, beginning with
reasoning about how to deal with the ethical problem. In this process the nurses
observe, analyze and judge the problem, which results in a decision. Thereafter,
a process of implementing this decision in clinical practice follows. During both
these processes there are several factors that affect the nurses, some personal and
others contextual. Among the personal factors are nurses’ values, convictions,
experiences and skills. Examples of contextual factors include opinions and
expectations of others, rules, routines, procedures and guidelines (Goethals et
al., 2010).
The process of reasoning cannot be reduced to a cognitive activity as it is
contextually embedded, and it is the personal relationship between nurses and
patients that forms this context. Factors that facilitate this process include
education, guidelines and standards, supportive colleagues and experience at the
same workplace. However, if the nurses experience a stressful working
environment with complex patient situations, insufficient resources such as
time, and dominance within the medical profession, this hinders the process of
reasoning (Goethals et al., 2010). A personal factor that is believed to affect the
reasoning process is moral sensitivity (Lützén, Dahlqvist, Eriksson & Norberg,
2006). This has been described as a personal capacity that is the result of
personal experience. Moral sensitivity involves more than relying on one’s
emotions when identifying the moral values in a conflict situation. It means
having an attention to moral values and an awareness of one’s own role and
responsibility in the situation (Lützén, 1993).
In the process of implementing a decision into clinical practice, it has been
shown that this can prove to be difficult due to contextual factors that limit
nurses’ ability to act in the desired way. These include hierarchical relationships,
traditional structures of power, not being involved in decision making, poor
cooperation with physicians and feelings of not being respected as a
professional. However, if the nurses are involved in ethical decision making
with a mandate in ethics deliberations and have a positive collaboration with
physicians this facilitates the implementation process. Besides these contextual
factors, personal factors such as knowledge, experience, risk taking and boldness
facilitate this process (Goethals et al., 2010).
To summarize, research on nurses’ conceptions of ethical problems has shown
that these are experienced in a number of situations, those regarding lifesustaining treatment among the most prominent. However, it is less well
described what factors are perceived as contributing to the rise of an ethical
problem, which is important when it comes to how a certain ethical problem
should be dealt with, and what actions are taken in order to handle the
situation. All situations of ethical difficulty are not experienced as ethical
problems, however; at times it might be difficult to know how to act, but there
is at least acting space. If this acting space is lacking, a situation might be
experienced as morally distressing.
Moral distress
The term moral distress was coined in 1984 by Jameton, who viewed it as one
of three categories into which ethical problems arising in a hospital context
could be sorted. The first of these categories was moral uncertainty, which he
described as “when one is unsure what moral principles or values apply, or even
what the moral problem is” (1984, p.6). The next category of ethical problems
was, according to Jameton, moral dilemmas that “arise when two (or more)
clear moral principles apply, but they support mutually inconsistent courses of
action” (1984, p.6). Moral distress, finally, “arises when one knows the right
thing to do, but institutional constraints make it nearly impossible to pursue
the right course of action” (1984, p.6). Jameton later (1993) made a distinction
between two forms of distress, namely that of initial and reactive distress. Initial
distress is felt in the form of frustration, anger and anxiety when confronted
with institutional obstacles, while reactive distress is the result of not acting
upon the initial distress (Jameton, 1993).