NURS 6565 Week 2 Discussion Characteristics of Ethical Dilemmas in Nursing

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 healthcare 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 recognizing 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 strategies 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 practice that APNs can expect to confront.


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 interprofessional Barriers, 351 Patient-Provider Barriers, 351 Organizational and Environmental Barriers, 352 Conclusion, 354

Characteristics of Ethical Dilemmas

 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

obligations 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), honoring 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 appropriate 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

practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural 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 distress 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 communication, 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 healthcare team, discussions are most effective when members are accountable for presenting information in a precise and succinct manner.

In patient encounters, disagreements between the patient and a family member or within the family can be rooted in faulty communication, which then leads to ethical conflict. The skill of listening is just as crucial in effective communication as having proficient verbal skills. Listening involves recognizing 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 deliberations (e.g., terms such as beneficence, autonomy, and utilitarian 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 communication is the first key to negotiating and facilitating a resolution. Jameson(2003) has noted that the long history of conflict between certified registered nurse anesthetists (CRNAs) and anesthesiologists influences how these providers communicate in practice settings.

In interviews 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.