Post-test

1. Give the fundamental human events (3 points)2. these are two most important role of a nurse when

faced with patient that has moral dilemma in decision making? (2 points)

3. Give steps on how will a nurse become an advocate and support for client during a moral dilemma? (3 points)

4. Give 2 ways to acquire Value? (2 points)5. Give at least 2 reasons why there’s such a growth

in awareness of ethical problem ?6. Give at least 3 moral principles?

Legal Issues in Nursing practice

PHYSICIAN’S ORDER Nurses are

responsible for their actions regardless of

who told them to perform those

actions.

FLOATING Nurses should be given orientation to the

unit. The supervisor should be informed about a float nurse’s lack of experience on

the new unit.

INADEQUATE STAFFING

• A nurse who leaves an inadequately staffed unit could be charged with client abandonment.

CRITICAL CARE Constant

observation and assessment of

clients are required, especially in ICUs

that have monitors.

PEDIATRIC CARE Suspected child

abuse or neglect be reported.

FUNDAMENTAL HUMAN EVENTS

Birth

Death

Suffering

SENSISTIVE AREAS

SUPPORTADVOCATE

SOUND MORAL DECISIONS

NURSES NEEDS TO:

1. Examine their own values and their cl ient’s values? Understand how their values inf luence their decisions?

2. Develop sensit ivi ty to the ethical dimensions of nursing practice?

3. Think ahead what are the possible moral problems they are l ikely to face?

HOW?

VALUES

Freely chosen

Values underlie all moral dilemmas. though, not all

values are moral values (people values about work,

family, religion, politics, money and relationships.

IMPORTANT: Values influence decisions and actions,

such as nurses’ ethical decision making.

Beliefs or attitudes about the worth of a person,

object, idea, or action.

VALUES

Values

ATTITUDES

BELIEFS

BELIEFS Opinion, interpretation, or

conclusions that people accept as true (may it not be true)

“I believe if I study hard I will get a good grade”

“Good grades are really important to me. I believe I must study hard to obtain good grades”

ATTITUDES Mental position or feelings

toward a person, object, or idea (compassion, acceptance)

Some clients may feel strongly about their need for privacy, whereas others may dismiss it as unimportant.

VALUES

BELIEFS ATTITUDES

FAITH than FACT.

Last only briefly.

Judged as correct or

incorrect.

THINKING and

BEHAVIORAL aspects.

Continuous overtime.

Judged as bad or

good, positive or

negative.

ACTIVITY 1

Beliefs? Attitudes?

LIFE?

DEATH/DYING?

HEALTH?

ILLNESS?

VALUES TRANSMISSION

VALUES CLARIFICATION

Acquired through Observation and Experience.

Affected by Socio-Cultural environment (societal conditions, family and peers)

PERSONAL VALUES

Nurses should keep in mind the influences of Values on health.

PROFESSIONAL VALUES

A process by which people identify,

examine, and develop their own

individual values.

It promotes personal growth (promotes

awareness, empathy, and insight)

It is an important step for nurses to

take in dealing with ethical problems.

No One set of values is right for everyone.

People can retain or change the freely

chosen values

CLARIFYING THE NURSES’ VALUES

CLARIFYING CLIENT VALUES

FROM?

Professional ValuesClarifying Nurse’s Values

Acquired during experience from code of ethics, nursing, teachers, and peers.

5 VALUES ESSENTIAL FOR PROFESSIONAL NURSE: ALTRUISM AUTONOMY HUMAN DIGNITY INTEGRITY SOCIAL JUSTICE

Nurses and nursing students need to examine the values they hold about life, death, health and illness.

FROM?

Essential Nursing Values and Behaviors

VALUES Professional Behaviors

AltruismNurse’s concern for the welfare of patients, other nurses, and other health care providers.

•Understands cultures, beliefs, and perspectives of others.•Advocates for patients.•Take risks on behalf of patients and colleagues.

AutonomyNurses respects patient’s right to make decisions about their health care.

•Plans care in partnership with patients

Human DignityNurses values and respects the inherent worth and uniqueness of all patients and colleagues.

•Provides culturally competent and sensitive care.•Protects patient’s privacy.•Designs care with s sensitivity to individual patient needs.

IntegrityNurses acts honestly and provides care based on an ethical framework.

•Provides honest information to patients and the public.•Document care honestly and accurately.•Seeks to remedy errors made by self or others.•Demonstrates accountability of own actions

Social JusticeNurse upholds moral, legal, and humanistic principles by ensuring equal treatment under the law and equal access to quality health care.

•Supports fairness and nondiscrimination in the delivery of care.

VALUES TRANSMISSION

VALUES CLARIFICATION

Acquired through Observation and Experience.

Affected by Socio-Cultural environment (societal conditions, family and peers)

PERSONAL VALUES

Nurses should keep in mind the influences of Values on health.

PROFESSIONAL VALUES

A process by which people identify,

examine, and develop their own

individual values.

It promotes personal growth (promotes

awareness, empathy, and insight)

It is an important step for nurses to

take in dealing with ethical problems.

No One set of values is right for everyone.

People can retain or change the freely

chosen values

CLARIFYING THE NURSES’ VALUES

CLARIFYING CLIENT VALUES

FROM?

Professional ValuesClarifying Nurse’s Values

Acquired during experience from code of ethics, nursing, teachers, and peers.

5 VALUES ESSENTIAL FOR PROFESSIONAL NURSE: ALTRUISM AUTONOMY HUMAN DIGNITY INTEGRITY SOCIAL JUSTICE

Nurses and nursing students need to examine the values they hold about life, death, health and illness.

FROM?

Theory of Values Clarification (Raths, Harmin, and Simon, 1978)

Valuing Process

Choosing Cognitive

•Beliefs are freely chosen.

•Without outside pressure

•After reflecting and considering

consequences or alternatives

Prizing Affective•Chosen beliefs are cherished or prized

Acting Behavior

•Chosen beliefs are affirmed to others, incorporated into one’s behavior and repeated consistently in one’s life.

Clarifying Client Values

Is an intervention used by the nurse s when clients experiences unclear values that are harmful to their health.

Behavior Example

Ignoring a health professional’s advice

A child client’s parent who values the

Inconsistent communication behavior

A n elderly who says she don’t want anymore to use cane when walking, but won’t cooperate during her therapy.

Numerous admissions to a health agency for the same problem

A hypertensive client repeatedly seeks help for headache but does not take the prescribed maintenance medicine.

Confusion about which course of action to take

A pregnant woman who values her job to meet financial obligations, but also needs to have complete bed rest for a safe labor and delivery.

Clarifying Client Values

Process How?

List Alternatives Ask: “Are you considering other alternative courses of actions?” “Tell me about them”

Examine possible consequences of choices

Ask: “What do you think you will gain from doing that?”

Choose freely Ask: “Did you have any say in that decision?”

Feel good about the choice

Ask: “How do you feel about that decision?” “Some people feel good after a decision is made; others feel bad. How do you feel?”

Affirm the choice Ask: “What will you say to family or friends about this?”

Act on the choice Ask: “Will it be difficult to tell your wife about this?” (it determines the client’s preparedness to act in his decision)

Act with a pattern Ask: “How many times have you done that before?” or “Would you act that way again?”

ACTIVITY 2

Observations and experience?

Examine the values you have about…?

LIFE?

DEATH/DYING?

HEALTH?

ILLNESS?

NURSES NEEDS TO:

1. Examine their own values and their cl ient’s values? Understand how their values inf luence their decisions?

2. Develop sensit ivi ty to the ethical dimensions of nursing practice?

3. Think ahead what are the possible moral problems they are l ikely to face?

HOW?

Standards of Professional Performance (ANA,1998)

Standard V: EthicsThe nurse’s decisions and actions on behalf of patients are determined in an ethical manner.

Measurement Criteria

1. The nurse’s practice is guided by the Code for Nurses.2. The nurse maintains patient confidentiality within legal and

regulatory parameters.3. The nurse acts as a patient advocate and assists patients in

developing skills so that they can advocate for themselves.4. The nurse delivers care in a non-judgmental and non-

discriminating manner that is sensitive to patient diversity.5. The nurse delivers care in a manner that preserves patient

autonomy, dignity, and rights.6. The nurse seek, available resources in formulating ethical

decisions.

NURSING ETHICS

No One profession is responsible for ethical decisions, nor does expertise in one discipline necessarily make a person an expert in ethics

(ethics committee)

Nursing Codes of Ethics

Purposes:

Inform the public about the minimum standards of the

profession and help them understand professional nursing

conduct.

Provide a sign of the profession’s commitment to the public

it serves.

Outline the major ethical considerations of the profession.

Provide standards for professional behaviors.

Remind nurses of special responsibility they assume when

caring for the sick.

CODE OF ETHICS

ETHICAL CODES are:

Systematic guides for developing ethical behavior.

Answers normative questions of what beliefs and

values should be morally accepted.

NO CODE could possibly provide absolute or

complete rules without conflict and ambiguity.

Four-fold responsibilities of nurses (PD 223)

Responsibility Ethical PrinciplesGuidelines to be

observed

NURSES AND PEOPLE

• Values, spiritual beliefs, and customs held by individual•Respect patient’s autonomy.•Personal information confidentiality.

•Consider individuality when giving care.•Take into consideration the spiritual beliefs (diet and treatment), the rights and the culture of patients.•However, welfare and safety must take precedence.

NURSES AND PRACTICE

•Human Life in inviolable.•Quality in care for patients•Accuracy in documentation of actions and outcomes of care.•Advocate to patient.•Awareness to ethic-moral and legal dimensions of practice.

•Know the scope of her practice•Acquire and develop necessary competence in knowledge, skills, and attitudes.•Ensure patient's records.•Respect “Patient’s Bill of rights”

Four-fold responsibilities of nurses

Responsibility Ethical PrinciplesGuidelines to be

observed

NURSES AND CO-WORKERS

•Maintain a collaborative working relationship

•Maintain their professional role/identity while working with other members.•Honor and safeguard the dignity and reputation of members of nursing.•Contribute to professional growth and development of other members.

NURSES AND SOCIETY/ENVIRONMENT

•Preservation of life, respect for human rights and promotion of a healthy environment•Establishment of linkages with the public in promoting local an national, and international efforts to meet health and social needs of people.

•Be conscious of their obligations as citizens.•Be equipped with knowledge of health resources within the community•Project an image.

ETHICAL PROBLEMS IN NURSING

Growing awareness of ethical problems has occurred because of:

SOCIAL AND TECHNOLOGICAL CHANGES

CONFLICTING LOYALTIES AND OBLIGATIONS

SOCIAL AND TECHNOLOGICAL CHANGES

CONFLICTING LOYALTIES AND OBLIGATIONS

Large number of people without health insurance.

High cost of health care Workplace redesign under managed

care

ISSUES OF FAIRNESS AND RESOURCE ALLOCATION

Before technology, there was no questions about whether to “allow”….who should be treated?...

According to nursing code of ethics, the nurse’s first loyalty is to the client.

However, it is not easy to determine which action best serves the client’s needs.

Client needs may conflict with the institutional policies, physician preferences, needs of their family, or even laws of the state.

ETHICAL PROBLEMS IN NURSING

SPECIFIC ETHICAL ISSUES• Sanctity of life vs. principle of Autonomy and the

woman’s right to control her own body.

• No public consensus has yet been reached.• Nurses have no right to impose their personal

values, instead, nurses have the right to inform and counsel the client in making decisions.

Abortion

• Nurses should help develop and follow security measures and policies to ensure appropriate use of client’s data.

Management of

Computerized Information.

• Advance Directives• Euthanasia• Termination of Life-sustaining treatment• Withdraw or withholding Food and

fluids

End-of-Life Issues

• Health resourcesAllocation of

scarce resources

MAKING ETHICAL DECISIONS

It should be based on ethical principles and codes rather than emotions, intuition, or precedent.

GOOD DECISION The one that is in the Client’s best interest and at the same

time preserve the integrity of all involved.

Establish support system; use of counseling

professionalsCollaboration, communication, and compromise

(important skills)Determine EXISTENCE OF MORAL SITUATION

(important first step)

EXISTENCE OF MORAL SITUATION?

1. A diff icult choice exists?

2. There are moral principles exist that can

be used to justify the action?

3. The decision must be freely and

consciously chosen?

4. The choice is aff ected by personal

feelings?

MORAL PRINCIPLES

AUTONOMYNONMALEFICENCEBENEFICENCEJUSTICEFIDELITYVERACITY

AUTONOMY - Autos ( self)- nomos (governance)- born from The New Testament (freedom to make decisions)- In Health care Setting: “ Principle of INFORMED CONSENT”- IMPORTANT : while you respect patient’s autonomy, it is also our

duty to explain clearly to them what are the consequences or effect of their decision, explain to them the purpose of informed consent the treatment and its alternatives which are all indicated or written in the informed consent.

OVERRIDING PATIENT’S AUTONOMY( Paternalism) > MEDICAL --acting without consent to benefit the patient and

prevent harm (ex. emergency cases, incompetency etc.) > STRONG – benefit is stronger than autonomy (ex. Refusal to

treatment) > WEAK – if our purpose is to help patient in restoring his/her

competence to decide.

MORAL PRINCIPLES

JUSTICE- the right to demand a just, fair and treatment- “we get what we merit from our conduct in life”- uses TRIAGE SCHEMES:

1. According to medical prognosis (who is most likely to survive)

2. Social value (must favor first the socially disadvantaged, ill,elderly,disabled,women and children (ART.III of PHILIPPINE CONSTITUTION))

3. First come first serve (for patients with same cases and treatment)

- this DOESN’T tell us what needs are most important.

Fidelity Being faithful to ones commitments (providing self

care and competence in nursing care) and promises.

Veracity Telling the truth (essential to nurse-client

relationship)

MORAL PRINCIPLES

BENEFICENCE NONMALEFICENCE

-“do good” (stated in positive form)

-Do good for patient’s interest

-However, this can pose patient at risk of harm (provided, that patient’s values and dignity are considered first)

-Good communication with patient of his/her desires and needs promotes acceptance.

-“do no harm” (stated in negative form

-Avoid harm which is against patient’s interest.

- harm may be INTENTIONAL (never accepted because it places patient to harm) or UNINTENTIONAL (risk was inevitable or not anticipated, example is catching a falling patient)

-Unintentionally created a needless harm, provided, that nurse should do what’s best for her patient.

-PATIENT: the one who determines or interpret what is harmful.

MORAL PRINCIPLES

AUTONOMY – self governance; Informed Consent

NONMALEFICENCE- do no harmBENEFICENCE- do goodJUSTICE- fair treatmentFIDELITYVERACITY

Criteria if Moral aspects exists

A difficult choice exists?

There are moral principles exist that can be

used to justify the action?

The decision must be freely and consciously

chosen?

The choice is affected by personal feelings?

SITUATION

Mrs . L , a 67 -year -o ld woman, i s hosp i ta l i zed w i th mu l t ip le f rac tu res and lacera t ions caused by an au tomob i le acc iden t . Her husband , who was k i l l ed in the acc iden t , was taken to the same hosp i ta l . Mrs . L , who had been d r i v ing the au tomob i le , cons tan t l y ques t ions her p r imary nurse abou t he r husband . The su rgeon has to ld the nurse no t to te l l Mrs . L ; however, he does no t g ive the nurse the reason fo r these ins t ruc t ions . The nurse expresses concern to the charge nurse , who says the su rgeon ’s o rder mus t be fo l lowed. However, the nurse i s no t comfor tab le w i th th is and wonders wha t shou ld be done .

APPLICATION

MODELS of decision-making

CASSELLS and REDMAN (1989)SITUATIONMrs. L, a 67-year-old woman, is hospitalized with multiple fractures and lacerations caused by an automobile accident. Her husband, who was killed in the accident, was taken to the same hospital. Mrs. L, who had been driving the automobile, constantly questions her primary nurse about her husband. The surgeon has told the nurse not to tell Mrs. L; however, he does not give the nurse the reason for these instructions. The nurse expresses concern to the Charge nurse, who says the surgeon’s order must be followed. However, the nurse is not comfortable with this and wonders what should be done.

ACTION CONSIDERATIONS1. Identify the moral

aspects.

2. Gather relevant facts that relate to the issue

Whether to tell the truth or not?Honesty and loyalty (moral principles)

Client’s health problem information?Who is involved? Nature of involvement? Motives of actions (not known)

MODELS of decision-making

3. Determine for whom the decision being made? Who should decide and why?

4. Clarify and apply personal values

5. Identify ethical theories and principles

6. Identify applicable laws or agency policies

7. Use competent interdisciplinary resources

8. Propose alternative actions

Mrs. L values her husband’s welfare, the charge nurse values policy and procedure, the nurse value a client’s right to have information.

Autonomy? Beneficence?

Nurse might consult literature

Follow the charge nurse; possible outcome: Mrs. L might become anxious and angry, wait Mr.s L to recover

The agency may not allow the nurse to follow the doctor’s order (instructions rather than order)

MODELS of decision-making

9. Apply nursing code of ethics

10. For alternative action, identify the risk and seriousness of consequences

11. Evaluate the action taken

If the nurse follows the charge nurse and doctor?If the nurse tells Mrs. L?

If the client is not satisfied the nurse can review other alternatives and work through the process again.

STRATEGIES TO ENHANCE ETHICAL DECISIONS AND PRACTICE

√ BE AWARE OF YOUR OWN VALUE.

√ BE FAMILIAR WITH THE CODE OF ETHICS

RESPECT VALUES, OPINIONS, AND

RESPONSIBILITIES OF OTHER HEALTHCARE

PROFESSIONALS

SERVE ON INSTITUTIONAL ETHICS COMMITTEE

STRIVE FOR COLLABORATIVE PRACTICE

PATIENT’S BILL OF RIGHTS

• Right to considerate and respectful care.• Right to obtain from his doctor complete current information about his diagnosis.• Obtain from his doctor complete current information about his diagnosis, treatment

and prognosis in terms patients can be reasonably expected to understand.• Right for complete and accurate information necessary to give informed consent

prior to start of procedure or treatment.• Right to refuse treatment .• Right to privacy.• Right confidentiality.• Right to expect that a hospital must take reasonable response for the client’s

request for services, within the hospital’s capacity.• Right to obtain information: any relationship of the hospital to other healthcare and

educational institutions concerning his care; human experimentation• Right to expect reasonable continuity of care.• Right to examine and receive an explanation of his bill, regardless of source.• Right to know what hospital rules and regulations apply to his conduct as a patient.

Project

Using the following phases of the Nursing Care Process, create your own diagram or illustration on how the process works. (50 points)

•Assessing•Diagnosing•Planning•Implementing•Evaluating

Rubrics

Criteria 10 5 2Use of the following phases given

All of the items given were used in the diagram

Some of the items given were used in the diagram

All of the items given were not used in the diagram

Creativity The illustration is creative

The illustration in some way shows creativity

The illustration do not show creativity

Effectiveness of the illustration

The diagram shows exact process on how NCP works

The diagram somehow shows a process on how NCP works

The diagram doesn’t show any relevance on the NCP

KOZIER, ERB G. , BERMAN A. , SNYDER S. (2004) “FUNDAMENTALS OF NURSING” 7 T H EDITION

UDAN “FUNDAMENTALS OF NURSING”

Reference