Textbook of Medical-Surgical Nursing 3e

Smeltzer & Bare’s

Textbook of Medical-Surgical Nursing

THIRD EDITION

Volume 1

Maureen Farrell and Jennifer Dempsey

Textbook of Medical-Surgical Nursing, 3e

Sample Contents

Chapter Two Thoughtful Practice

Chapter Ten Chronic illness, disability and rehabilitation

Chapter Eleven Oncology: Nursing management in cancer care

View further details of this title and more online at www.LWWBooks.com.au

Chapter 2

Thoughtful practice

K E Y T E R M S

L E A R N I N G O B J E C T I V E S

Model for thoughtful practice The conceptual model provides a representation of how the important concepts inherent in professional, person-centred practice interrelate. In the context of medical-surgical nursing, a thoughtful practitioner is a nurse who is considerate and com- passionate, keeping the person at the centre of deliberation in order to promote the humanity and dignity of the person being cared for. At the same time, the nurse acts as a moral agent, preserving respect for the person and providing the care while examining the situation in order to learn. Inherent in thoughtful practice is an acknowledgement of the influence of power within institutional systems. Thoughtful care seeks to empower individuals to choose their own health pathway. To achieve this, essential care is delivered through processes that are holistic and tailored to meet the individual needs of the person. Care-related decisions are based on ethical and On completion of this chapter, you should be able to: 1 Examine the components of thoughtful practice and define the links between thoughtful practice, motivation, moral agency and person-centred care. 2 Outline the key components of clinical reasoning and explain how different types of thinking inform clinical reasoning. 3 Explain how clinical judgement and decision making relate to clinical reasoning. 4 Discuss ethical principles and how these relate to nursing care. 5 Explain the importance of reflection and self-awareness for professional self-assessment and development. 6 Identify key components of cultural assessment and apply culturally safe nursing principles, concepts, and theories when providing nursing care to individuals, families, groups, and communities. 7 Identify the use of the nursing process for optimising patient outcomes during a period of nursing care. 8 Identify the use of the nursing process conceptually by describing the purposes and significance of health education and health promotion and the role of the nurse in patient education using the nursing process.

moral agency moral dilemma moral distress moral problem moral uncertainty morality nursing diagnoses nursing process planning personhood person-centredness person-centred care problem solving reflection responsibility self-awareness subculture teaching teleological theory or consequentialism therapeutic regimen transcultural nursing utilitarianism wellness

assessment clinical judgement clinical reasoning collaborative problems community creative thinking critical thinking cues cue acquisition culturally competent nursing care cultural nursing assessment culture decision making deontological or formalist theory ethics evaluation

health education health promotion implementation intuitive thinking

learning minority

systematic reasoning processes that are evaluated and reviewed through reflective practice so that there is continual learning in and from practice for the benefit of future care encounters. Definition and theoretical basis The Macquarie Dictionary (2009) defines being thoughtful as being given to or marked by thought, being careful or mindful, and being considerate. Therefore, being thoughtful is an amalgamation of the reasoning for practice, the consideration of all aspects of the situation including its practicalities, the learning from practice, and the affective process of considering the needs of others. Medical-surgical nursing is an example of how these processes are integrated into a form of practice that requires well-developed cognitive processes of clinical rea- soning that is founded on a solid knowledge base of anatomy, physiology, epidemiology, pharmacology and sociology. The application of this knowledge and learning through reflection

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Unit 1 Contemporary concepts in nursing

within the professional framework provided by the Nursing and Midwifery Board of Australia’s National Competency Standards for the Registered Nurse (NMBA, 2006a), which articulates the professional attributes of the clinician. Personhood The concept of personhood relates to our being human, to being the person we are as we interact with each other in a complex world. Although much has been written about person­hood, there is not one single definition. Essentially the concept of personhood is an expression of our humanity, our values and beliefs that find expression through our attitudes and behaviour. These colour the way we interact with, inter- pret and give meaning to our world, our experiences, and our relationships. Each person has a concept of self that responds to the surroundings and others around them. Personhood has been described as being in a relationship, being in a social world and being in a place (McCormack & McCance, 2010). This sense of being a person can be disrupted by illness or disability, and when this occurs care should be more than a focus on the disease process but should also be directed towards rebuilding this sense of personhood. Person-centredness and person-centred care At the same time as respecting the person’s ‘self’ within relationships, there are ‘others’ considered in the concept. All people have a social context, ‘others’ are the people who occupy the social world of the person. This includes family (with its many permutations) and community in the geo- graphical and social sense (where and with whom they live). This attention to the extended family is important for any culture but is especially vital because of the special place for family in Indigenous cultures in Australia and New Zealand ( wh a¯ nau means extended family in Ma¯ori). By knowing the person, we can understand his or her present world and lived experience. Person-centredness is the demonstration of a respect for personhood through the words and actions of the professional. The way a person is described may be determined

is integrated with practical clinical skills and affective qualities such as compassion and caring. Thoughtful practice is illus- trated in Figure 2-1. Although the components of thoughtful practice all inter- relate, they are different but they all operate together to create thoughtful person-centred care. Thoughtful practice recognises the complexity of con- temporary nursing and draws wisdom and explanation from a number of validated theories. Its theoretical base is a syn- thesis of the theories that have been recognised as influential on nursing thinking, beliefs, values and behaviours. From humanist theory and the principle of holistic care comes the concept of personhood and person-centred care. The cognitive processes involved in clinical reasoning draw from theories related to learning such as constructivism, whereas reflective practice also draws from critical social theory in addition to constructivist theory. The theories that explain organisational behaviour that is influenced by personality, values and atti- tudes underpin the dimension related to clinicians’ actions. All these theories are contextualised for nursing as thoughtful practice draws from Virginia Henderson’s concept of individ- ualised service for people across their lifespan, from Neuman’s systems model that describes the interaction between people and their environment and from Watson’s theory of caring with its emphasis on interpersonal relations (Marriner Tomey & Alligood, 2009). Personal and professional attributes Thoughtful practice is intensely dependent on the personal attributes of the professional. At the same time, the highly complex medical and surgical nursing environment also requires clinicians who can make sound clinical judgements and decisions that are grounded in good technical knowl- edge, practical clinical experience and that are well reasoned using critical, creative and intuitive thinking. In addition, for thoughtful practice to occur, the registered nurse must practise in accordance with the professional domains determined by the regulating authority. Thoughtful practice must be interpreted

THOUGHTFUL PRACTICE

Reflective practice leading to personal learning

Clinical reasoning, judgement and decision making

PERSON

Clinician’s action in response to individual clinical need

Person-centred process of care

Figure 2-1  The thoughtful practice diagram (Dempsey, J., Hillege, S. & Hill, R. (2013). Fundamentals of nursing and midwifery: A person- centred approach to care (2nd ed., p. 236). Sydney: Lippincott Williams & Wilkins.)

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Chapter 2   Thoughtful practice

by which nurses collect cues ( the pieces of data collected through observation, reading records, and talking to patients and others), process and interpret the information, make a judgement about a patient’s problem or situation, come to a decision, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process. Clinical reasoning depends upon the nurse’s ability to collect the right cues and to take the right action for the right patient at the right time and for the right reason (Levett-Jones et al., 2010). By applying clinical reasoning skills, the clinician can identify options for care and choose a course of action that provides a solution or temporary relief of a health problem. This is called clinical judgement , which involves decision making, and which can be influenced by the personal attributes and experiences of the clinician and how they respond within the specific health setting. Thoughtful practice describes the global process of clinical reasoning (Figure 2-2). Reasoning environment The complexity of the healthcare environment, the way work is organised and the number of interruptions experienced can affect the reasoning undertaken by clinicians. The quality of the reasoning undertaken may also be affected if greater value is placed on activities such as completion of tasks (Smith, Higgs & Ellis, 2008). The social context in which the reason- ing takes place that involves the culture of the unit, and even the power differentials between work groups, have also been found to have an effect on the decisions and actions taken. Clinical reasoning depends on the expertise and confidence of the decision maker (Jensen, Resnik & Haddad, 2008). In order to reason through a clinical situation, nurses draw upon a body of knowledge that emanates from research. The specific knowledge base required is determined by the actual clinical situation. If the situation calls for reasoning related to the manifestation of a physical problem, reasoning will require an understanding of the disease or condition; its epidemiol- ogy; the mechanisms of its pathophysiology; its physical and psycho­logical manifestations, signs and symptoms; and the probabilities of its progression or outcome. If the clinical situ- ation is related to a cultural or ethical problem, the knowledge base must have regard to the cultural context as well as an understanding of the ethical principles involved. Personal attributes Reasoning has a logical cognitive (thinking) component as well as an emotional or affective (feeling) component and is affected by the personal attributes of the thinker. Clinical reasoning is also affected by the beliefs and values the clinician brings to the practice (Hoffman, Donoghue & Duffield, 2004). The willingness of the nurse to put all the data together into a complete picture is also crucial to the reasoning process. Person- centredness and clinical reasoning occur in tandem because rea- soning is also affected by how well the nurse has come to know the patient as not just a source of data to be reasoned through, but as a person with their own unique needs, values and individ- ual responses to a situation (Tanner, 2006). Open-mindedness and the ability to see several viewpoints is also an important attribute for clinical reasoning (Banning, 2008). Clinical experience The experience of the clinician has a profound effect on his or her ability to reason and make decisions about what action to

by the context in which the relationship takes place. In a hospital, the person may be referred to as a ‘patient’, whereas in the community the person may be called a ‘client’. The terminology becomes irrelevant because when care is delivered in a manner that reflects the principle of personhood, person- centred care is enacted. Indeed, the concept of personhood can only be maintained when processes of care are underpinned by these principles. In any healthcare setting, each individual interaction or intervention should be undertaken in the spirit of partnership and social justice. This partnership approach necessitates empower­ment, a sharing of power, by accepting the rights of people, acknowledging autonomy, and engaging in informed decision making with the person and others that are part of the relationship (National Ageing Research Institute, 2006). This is achieved by the person being empowered to make decisions about his or her healthcare and taking responsibility for those decisions. The person-centred care approach is sometimes criticised for being too individualistic and care can be time consum- ing and difficult to achieve within the demands of the acute care setting. However, when care focuses on tasks or a case it values the system rather than the person. As a result, it can lead to ritual behaviour and care where clinicians become disconnected and disengaged. However skilled and committed clinicians, whose focus on knowing the person carries over into the care processes, can assist in overcoming these barriers. In addition, the physical surrounding can be made to preserve people’s privacy and dignity so that their sense of self is not threatened. The culture of the healthcare environment can be directed to working in this person-centred way and services made supportive and easy for users to navigate a path through. Unfortunately, in many healthcare environments, schedules, routines and timetables take precedence over people. This does not mean that person-centred care is impossible in large organisations but it does mean that it can be more difficult to achieve. It requires commitment to the moral principles of personhood and an ethical approach to care delivery. In today’s healthcare arena, nurses are faced with increas- ingly complex issues and situations resulting from advanced technology, greater acuity of patients in hospital and com- munity settings, an ageing population, and complex disease processes, as well as ethical and cultural factors. Traditionally, nurses have used a problem-solving approach in planning and providing nursing care. Today the decision-making dimension of problem solving has become increasingly complex and requires clinical reasoning. The terms of clinical reasoning, critical thinking , clinical judgement, problem solving, and decision making do not have settled definitions. Although many of the explanations overlap, there are common features in the definitions such as their grounding in knowledge, a will- ingness to pursue answers, and an ability to develop new solu- tions that are often innovative and outside current knowledge. Clinical reasoning Clinical reasoning is the process for analysing a situation, making a judgement, determining possible alternative actions, and choosing an action to be taken. It includes the cognitive processes of critical thinking that occurs in response to a clinical situation within a specific context. It is the process

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Unit 1 Contemporary concepts in nursing

Clinical reasoning

Personal attributes

Clinician’s actions

Clinical judgement Decision making

Problem solving Critical thinking Creative thinking Intuitive thinking

Context of thoughtful nursing and midwifery practice

Knowledge base

Process of care

Clinical experience

Evaluation and reflection

Figure 2-2  Clinical reasoning and the process of care trajectory (Dempsey, J., Hillege, S. & Hill, R. (2013). Fundamentals of nursing and midwifery: A person-centred approach to care (2nd ed., Figure 14-1). Sydney: Lippincott Williams & Wilkins.)

fundamental to the processes of care. Unfortunately, problem solving does not always involve clinical reasoning, so the solution to a problem may be limited to traditional solutions with other potential solutions being ignored. Therefore the reasoning process must be expansive and unlimited exploring all possibilities in order to solve a problem. Problem solving Problem solving is a basic life skill which involves identifying a problem and then taking steps to resolve it. However, different approaches to problem solving yield different results. Problem solving that takes into account critical thinking, creative, non-traditional and reflective approaches enables additional solutions to be formulated (Chabelli, 2007). Trial-and-error problem solving involves testing a number of solutions until one is found that works for that particular problem. This type of problem solving in healthcare is limited to those situations where the wrong option that may harm the patient can be eliminated. Scientific problem solving is closely related to this more general problem-solving process; however, it involves identifying a problem, collecting some data, interpreting the results to form a hypothesis that is based on previously acquired scientific knowledge that in turn drives the action. This is often the point at which research commences. It can be informed by intuitive problem solving in which experienced clinicians act upon a ‘gut feeling’ or an ‘inner prompting.’ The type of knowledge that underpins this form of problem solving is referred to as tacit knowledge, and is built up over years

take (Chang et al., 2011). Cue acquisition is when the impor- tance of these pieces of data are recognised and collected. Experience influences the type and number of cues that are collected as experienced clinicians appear to be able to focus on the most important cues and anticipate others, whereas less experienced clinicians collect cues according to rules that are learnt. These cues can be clustered into patterns that can be compared with those previously encountered. Through clinical experience, the clinician retains memories of previous patients and clinical situations. Similarities and differences between the situations is called pattern recognition, and as the clini- cian gains more experience, more patterns are retained in the memory bank (Buckingham & Adams, 2000b). For example, experienced nurses who have performed many respiratory assessments have memory banks that enable comparing the current breath sounds with others they have heard in the past consolidated by what they have learnt from the evidence-based literature. New practitioners may have to rely initially on assis- tance with assimilation of ideas from other more experienced nurses, as this memory bank has not yet developed. Reasoning process The terms clinical reasoning, problem solving, clinical judge- ment and decision making are often used interchangeably (Simmons, 2010); however, most acknowledge this cyclical process of cue collection, interpretation, pattern matching and decision making. Indeed, it could be said that the need to reason is driven by a problem; therefore, problem solving is

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Chapter 2   Thoughtful practice

Creative thinking Critical thinking is not simply a cognitive process, based on logical thinking alone but also involves reflection and creative thinking , which belongs to the affective domain. Creative thinking involves imagination, intuition and spontaneity, and complements scientific thinking for innovative problem solving in clinical practice (Karadag˘, Saritas & Erginer, 2009). Creative thinking is most beneficial when conventional solu- tions have not resolved a situation, or when a desired change Critical thinking leading to decision making differs between various levels of clinicians according to their experience. Intuitive thinking , subconsciously drawing on knowledge gained through experience, is also sometimes described as a ‘hunch’ or a ‘gut feeling,’ but actually this kind of knowledge is based on a memory of the cue patterns of the patients that have previously been cared for (Buckingham & Adams, 2000b). This takes time and explains how expertise is slow to develop. Critical thinking in nursing practice Critical thinking in nursing practice results in a comprehen- sive patient plan of care with maximised potential for success. Using critical thinking to develop a plan of nursing care requires considering the human factors that might influence the plan. The nurse interacts with the patient, family, and other healthcare providers in the process of providing appro- priate, person-centred nursing care. The culture, attitude and thought processes of the nurse, the patient and others will affect the critical thinking process from the data-gathering stage through the decision-making stage; therefore, aspects of the nurse–patient interaction must be considered (Wilkinson, 2007). Nurses must use critical thinking skills in all practice settings—acute care, ambulatory care, extended care, and in the home and community. In decision making related to the nursing process, nurses use intellectual skills in critical thinking. These skills include systematic and comprehensive assessment , recognition of assumptions and inconsistencies, verification of reliability and accuracy, identification of missing information, distinguishing relevant from irrelevant information, support of the evidence with facts and conclusions, priority setting with timely decision making, determination of patient specific outcomes, and reas- sessment of responses and outcomes (Alfaro-LeFevre, 2011). For example, nurses use critical thinking and decision-making skills in providing genetics-related nursing care when they, through reflection on practice: • Assess and analyse family history data for genetic risk factors. • Identify those individuals and families in need of referral for genetic testing or counselling. • Ensure the privacy and confidentiality of genetic information. Throughout this text, there are icons that direct the reader to the ancillaries where there are Genetics in Nursing Practice charts that will assist this process. To depict the process of ‘thinking like a nurse,’ Tanner (2006) developed a model known as the clinical judgement model. This model supports the idea that nurses engage in a complex process of clinical reasoning when caring for patients. has not occurred. Intuitive thinking

of experience. Beginning clinicians must use their scientific problem-solving skills as the basis of the care they give because intuitive problem solving ability comes only through years of practice and observation. The use of intuition can often move problem solving forward quickly, however, it can also result in a trial-and-error approach and it does not necessarily foster creative ways of solving problems. For this reason, care should be taken when choosing the most appropriate problem-solving approach to be used in any given situation. Of course problem solving in practice does not always occur in a linear fashion, as practice is complex and messy. Problem solving is often cyclical in nature: once you have completed the process, you often go back to the beginning and repeat the process until the problem has been resolved. In addition, problems often overlap in any given situation, so problem solving may occur in concurrent cycles. The constituent parts of clinical reasoning are discussed in the following section. Critical thinking The cognitive component for clinical reasoning is critical thinking, which is a mental process or set of procedures that is purposeful and systematic, rational and outcome-directed. Like problem solving, it is based on a body of knowledge, as well as an analysis of all available information and ideas. Critical thinking leads to the formulation of conclusions and the most appropriate alternatives for patient care. High-levels of critical thinking within the nursing process are necessity for contem- porary healthcare environments. Critical thinking and critical thinkers have distinctive characteristics. As indicated in the above definition, critical thinking is a conscious, outcome-oriented activity; it is pur- poseful and intentional. The critical thinker is an inquisitive, fair-minded truth-seeker with an open mind to the alternative solutions that might surface (Alfaro-LeFevre, 2011). Components of critical thinking Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation (Levett-Jones et al., 2010). The critical thinker uses real- ity-based deliberation based on knowledge to validate the accuracy of data and the reliability of sources, being mindful of and questioning inconsistencies. Interpretation is used to determine the significance of data that are gathered, and analysis is used to identify patient problems indicated by the data and inference to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move towards desired outcomes. Evaluation is the process of determining whether outcomes have been or are being met, and self-regulation is the process of examining the care provided and adjusting the interventions as needed (Banning, 2008). Critical thinking also includes metacognition, the exami­ nation of one’s own reasoning or thought processes while thinking (through reflection), to help strengthen and refine thinking skills (Wilkinson, 2007). The critical thinker consid- ers the possibility of personal bias when interpreting data and determining appropriate actions. The critical reflective thinker must be insightful and have a sense of fairness and integrity, the courage to question personal ethics, and the perseverance to strive continuously to minimise the effects of egocentricity, ethnocentricity, and other biases on the decision-making process (Alfaro-LeFevre, 2011).

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Unit 1 Contemporary concepts in nursing

CHART 2-1

The inquiring mind: Critical thinking in action

he or she is said to have poor clinical judgement. The decision must also be person-centred as these ‘higher order thinking skills have no value unless they are applied for the good of the patient’ (Tanner, 2006, p. 209). Leadership and management In the clinical situation, nurses are constantly required to assume a leadership and management role and this may affect how a problem is reasoned through. This has become particularly important as different classifications of nurses are introduced into the healthcare setting. Although often considered together, management and leadership are different things. Management concerns the organisation of resources to meet a specific objective. It is about structures, systems, policies, methods, results, finance and logistics. As contem- porary healthcare is characterised by financial constraints, effective management of resources is considered an essen- tial competency for all registered nurses (NMBA, 2006a). Leadership however is about influencing others to achieve a goal. It is enacted through articulating a vision, demonstrating sound values and purpose (Davidson, 2009). By these means, others are inspired and motivated to work with the leader to achieve a defined purpose. There are different styles of leader- ship (Frankel, 2008). Transactional leaders use conventional reward and punishment to achieve the goal. It can be the style of leadership used when the power to lead comes from the authority invested in the position itself. This is the traditional model for leadership in hierarchical traditional health systems. However, transformational leadership is a style of leader- ship where the leader gains followers by focusing on people, encouraging innovation and providing inspiration through empowering people to take ownership of the problem and the goal. The leadership style of the clinician can affect decisions when delegation is necessary. Clinical practice has become extremely complex. Clinicians may be caring for a number of significantly ill people at any given time as well as providing supervision for a number of • What possible complications must I anticipate? • What are the most important problems in this situation? Do the patient and the patient’s family recognise the same problems? • What are the desired outcomes for this patient? Which have the highest priority? Do the patient and I agree with these points? • What is going to be my first action in this situation? • How can I construct a plan of care to achieve the goals? • Are there any age-related factors involved, and will they require some special approach? Will I need to make some change in the plan of care to take these factors into account? • How do the family dynamics affect this situation, and will this have an effect on my actions or the plan of care? • Are there cultural factors that I must address and consider? • Am I dealing with an ethical problem here? If so, how am I going to resolve it? • Has any nursing research been conducted on this subject? What are the nursing implications of this research for care of this patient?

Nurses draw on personal knowledge and a variety of situations and consider the contextual background of the clinical culture. As nursing students develop their clinical reasoning skills and become professional nurses, their ability to reason clinically and to make sound clinical nursing judgements becomes more refined. Critical thinking exercises are offered throughout this book as a means of practising one’s ability to think critically because developing the skill of critical thinking takes time and practice. Additional exercises can be found in the study guide that accompanies the text. The questions listed in Chart 2-1 can serve as a guide in working through the exercises, although it is important to remember that each situation is unique and calls for an approach that fits the particular circumstances being described. Clinical judgement and decision making The culmination of clinical reasoning is clinical judgement and decision making , a term frequently linked to, and used interchangeably with, critical thinking, decision making, and problem solving. Clinical judgement has been described as ‘an interpretation or conclusion about a patient’s needs, concerns or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response’ (Tanner, 2006, p. 204). However, not all clinical situations are clear cut, and in many circumstances a range of possible solutions to an identified problem is available to the clinician. Clinical judge- ment is sometimes a process of elimination and the product of clinical judgement is a decision. There are degrees of clinical judgement as the correct clinical decision can be dependent on the accuracy of the data collected, the experience of the clinician, and the confidence of the decision maker. For instance, when a clinician decides to alert a doctor to a poten- tial problem that may be developing, he or she is described as having good clinical judgement. Similarly, when a clinician does not respond appropriately to an abnormal observation, • To what problems does this information point? Have I identified the most important ones? Does the information point to any other problems that I should consider? • Have I gathered all the information I need (signs/symptoms, laboratory results, medication history, emotional factors, mental status)? Is anything missing? • Is there anything that needs to be reported immediately? Do I need to seek additional assistance? • Does this patient have any special risk factors? Which ones are most significant? What must I do to minimise these risks? Throughout the critical thinking process, a continuous flow of questions evolves in the thinker’s mind. Although the questions will vary according to the particular clinical ­situation, certain general inquiries can serve as a basis for reaching conclusions and determining a course of action. When faced with a patient situation, it is often helpful to seek answers to some or all of the following questions in an attempt to determine those actions that are most ­appropriate: • What relevant assessment information do I need, and how do I interpret this information? What does this information tell me? What contextual factors must be considered when gathering this information?

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Chapter 2   Thoughtful practice

personal values. However, because the distinction between the two is slight, and ‘moral’ also has connotations and assumptions of personal-judging behaviour, they are often used

other nurses. Therefore, nurses will be confronted with a range of situations that require clinical reasoning, judgement and decision making. In a normal shift, any clinician may be required to make a decision every minute (Thompson et al., 2008). Thoughtful practice acknowledges the interconnected- ness of the process of clinical reasoning and reflection that is discussed in the following section. Reflective practice Reflection (Figure 2-3) can be seen as the final component of reasoning as it is the component that informs future deci- sions and actions. The learning that comes from experience that complements the knowledge acquired through inquiry is exponential when it is accompanied by reflection, the act of examining what we have experienced in order to learn from it and improve what we do. The process of reflection is based on ‘metacognition’ therefore, reflection should occur after actions are taken and evaluation completed. Reflection is only made possible through self-awareness (Jack & Smith, 2007). Self- awareness is the conscious process of understanding ourselves, our beliefs and values, and is developed and nurtured through reflection. As reflection will always be influenced by the personal and professional ethics of the person reflecting, the thoughtful practitioner must have a complete understanding of professional ethics. The next section considers ethics in more detail. Ethics and morality The terms ethics and morality are used to describe beliefs about right and wrong and to suggest appropriate guidelines for action. In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is adhering to informal

interchangeably. Moral agency

Being person-centred applies to the behaviour of the clinician as an agent, that is the clinician intentionally makes some- thing happen through a deliberate action (Kalaitzidis, 2009). Moral agency is the responsibility of the individual to translate their own and the profession’s moral principles into action (Edwards et al., 2011). In a therapeutic relationship, there is a moral agency that demands that the notion of personhood is preserved through the actions of the healthcare professional. In order for clinicians to be person-centred, moral agency means that they must be reflective. In this way, clinicians can know themselves, so that their own values, beliefs, biases and prejudices, and the impact these can have on the care they deliver is understood. Through examining their own values and beliefs, reviewing their knowledge base and rectifying any deficits or omissions, person-centred care can be optimised. Moral situations In the complex modern world, and in contemporary nursing, we are surrounded by ethical issues in all facets of our lives. Many situations exist in which ethical analysis is needed. Some are moral dilemmas , situations in which a clear conflict exists between two or more moral principles or competing moral claims. Other situations represent moral problems , in which there may be competing moral claims or principles, but one claim or principle is clearly dominant. Some situations result in moral uncertainty , when one cannot accurately define the moral situation, or the moral principles to apply, but has a strong feeling that something is not right. Still other

Self-awareness

Context of thoughtful nursing and midwifery practice

Reflective practice

Reflection

Critical thinking

Figure 2-3  The components of reflective practice (Dempsey, J., Hillege, S. & Hill, R. (2013). Fundamentals of nursing and midwifery: A person-centred approach to care (2nd ed., Figure 13-1). Sydney: Lippincott Williams & Wilkins.)

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Unit 1 Contemporary concepts in nursing

situations may result in moral distress , through experiencing an ethical dilemma in which the nurse is aware of the correct course of action but institutional constraints stand in the way of pursuing that action. The moral dilemmas a nurse may encounter in the medical- surgical arena are numerous and diverse. An awareness of underlying ethical concepts will help the nurse to reason through these dilemmas. Basic concepts related to moral philosophy, such as ethics terminology, theories, and approaches, are included in this chapter. The nurse should be an advocate for patient rights in each situation (Johnstone, 2009). Understanding the role of the professional nurse in ethical decision making will assist nurses in articulating their ethical positions and in developing the skills needed to make ethical decisions. Ethics theories One classic theory in ethics is teleological theory or conse- quentialism , which focuses on the ends or consequences of actions (Noureddine, 2001). The most well-known form of this theory, utilitarianism , is based on the concept of ‘the greatest good for the greatest number.’ The choice of action is clear under this theory because the action that maximises good over bad is the correct one. The theory poses difficulty when one must judge intrinsic values and determine whose good is the greatest. Additionally, the question must be asked whether good consequences can justify any amoral actions that might be used to achieve them. Another theory in ethics is the deontological or formal- ist theory , which argues that moral standards or principles exist independently of the ends or consequences. In a given situation, one or more moral principles may apply. The nurse has a duty to act based on the one relevant principle, or the most relevant of several moral principles. Problems arise when personal and cultural biases influence the choice of the most Two approaches to ethics are ‘metaethics’ and ‘applied ethics’. An example of metaethics (understanding the concepts and linguistic terminology used in ethics) in the healthcare environ­ment would be analysis of the concept of informed or valid consent (informed consent). Nurses are aware that patients must give consent before surgery, but sometimes a question arises as to whether the patient is truly informed. Delving more deeply into the concept of informed consent would be a metaethical inquiry. Applied ethics is the term used when questions are asked of a specific discipline to identify ethical problems within that discipline’s practice. Various disciplines use the frameworks of general ethical theories and moral principles and apply them to specific problems within their domain. Common ethical principles that apply in nursing include autonomy, beneficence, confidentiality, double effect, fidelity, justice, non-maleficence, paternalism, respect for people, sanctity of life, and veracity. Brief definitions of these important princi- ples can be found in Chart 2-2. Nursing ethics may be considered a form of applied ethics because it addresses moral situations that are specific to the nursing profession and patient care. Some ethical problems that affect nursing may also apply to the broader area of bio- ethics and healthcare ethics. However, the nursing profession primary moral principle. Approaches to ethics

is traditionally viewed as a ‘caring’ rather than a predominantly ‘curing’ profession; therefore, it is imperative that one not equate nursing ethics solely with medical ethics, because the medical profession has a ‘cure’ focus. Types of ethical problems in nursing As a profession, nursing is accountable to society. This accountability is spelled out by the Australian Council on Healthcare Standards (ACHS, 2012), which stipulates that patients receive and understand information on their rights and responsibilities for any healthcare services they may receive. Nursing has also defined its standards of account- ability in a formal code of ethics that explicitly states the profession’s values and goals (Chart 2-3). The code is a framework for nurses to use in ethical decision making, and the value statements provide guidance to address and resolve ethical dilemmas. New Zealand also has a code of conduct for nurses and midwives consisting of ethical principles, each with its explicit criteria. Efforts to enact this standard may cause conflict in healthcare settings in which the traditional roles of the nurse are delineated within a bureaucratic structure. If, however, nurses learn to present ethical conflicts within a logical, systematic framework, struggles over jurisdictional boundaries may decrease. Although technological advances and diminished resources have been instrumental in raising numerous ethical questions and controversies, including life-and-death issues, nurses should not ignore the many routine situations that involve ethical considerations. Some of the most common issues faced by nurses today include confidentiality, use of restraints, trust, end-of-life concerns, issues of pain control, resuscitation, life support and removal of sustenance. Confidentiality The principle of confidentiality pertains to all forms of commu- nication whether it be written, oral or electronic. Information, often of a personal nature, is constantly obtained in daily practice and if this information is not pertinent to a case, it should not be recorded in the patient’s healthcare record. When discussion of the patient with other members of the healthcare team is necessary, it should occur in a private area where it is unlikely that the conversation will be overheard. The wide- spread use of electronic information in clinical practice requires special emphasis. The disclosure of sensitive information such as genetic testing or pathology results may lead to loss of employ- ment or insurance if the information is misused. Adherence to the principle of confidentiality is essential because of these possibilities of maleficence (Chart 2-2) to the patient. Restraints The use of restraints (including physical and pharmacological measures) is another issue with ethical overtones. It is import- ant to weigh carefully the risks of limiting a person’s autonomy and increasing the risk of injury by using restraints against the risks of not using restraints. Other strategies, such as asking family members to sit with the patient, have been shown to be effective alternatives to restraints (Randle, 2013). Each state has specific policies and the inappropriate use of restraint can lead to an action of false imprisonment. Trust issues Two dilemmas in clinical practice that can directly conflict with ethical principles are the use of placebos (non-active

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Chapter 2   Thoughtful practice

CHART 2-2

Common ethical principles

is distributive justice, which refers to the distribution of social benefits and burdens based on various criteria that may include the following: Equality Individual need Individual effort Societal contribution Individual merit Legal entitlement. Retributive justice is concerned with the distribution of punishment. Non-maleficence Non-maleficence is the duty not to inflict harm as well as to prevent and remove harm. It may be included within the principle of beneficence, in which case non-maleficence would be more binding. Paternalism Paternalism is the intentional limitation of another’s autonomy, justified by an appeal to beneficence or the welfare or needs of another. Under this principle, the prevention of evils or harm takes precedence over any potential evils caused by interference with the individual’s autonomy or liberty. Respect for people Respect for people is frequently used synonymously with autonomy. However, it goes beyond accepting the notion or attitude that people have autonomous choice, to treating others in such a way that enables them to make choices. Sanctity of life The sanctity of life principle proposes that life is the highest good. Therefore, all forms of life, including mere biological existence, should take precedence over external criteria for judging quality of life. Veracity Veracity is the obligation to tell the truth and not to lie or deceive others.

The following common ethical principles may be used to validate moral claims. Autonomy This word is derived from the Greek words autos (‘self’) and nomos (‘rule’ or ‘law’), and therefore refers to self-rule. In contemporary discourse it has broad meanings, including individual rights, privacy and choice. Autonomy entails the ability to make a choice free from external constraints. Beneficence Beneficence is the duty to do good and the active promotion of benevolent acts (eg, goodness, kindness, charity). It may also include the injunction not to inflict harm (see Confidentiality relates to the concept of privacy. Information obtained from an individual will not be disclosed to another unless it will benefit the person or there is a direct threat to the social good. Double effect The double effect principle may morally justify some actions that produce both good and evil effects. All four of the following criteria must be fulfilled: 1. The action itself is good or morally neutral. 2. The agent sincerely intends the good and not the evil effect (the evil effect may be foreseen but is not intended). 3. The good effect is not achieved by means of the evil effect. 4. There is proportionate or favourable balance of good over evil. Fidelity Fidelity is promise keeping; the duty to be faithful to one’s commitments. It includes both explicit and implicit promises to another person. Justice From a broad perspective, justice states that like cases should be treated alike. A more restricted version of justice Non-maleficence). Confidentiality

Ethics and related matters Nursing codes in Australia and New Zealand

CHART 2-3

Code of Ethics for Nurses in Australia 1. Nurses value quality nursing care for all people. 2. Nurses value respect and kindness for self and others. 3. Nurses value the diversity of people. 4. Nurses value access to quality nursing and healthcare for all people. 5. Nurses value informed decision making. 6. Nurses value a culture of safety in nursing and healthcare. 7. Nurses value ethical management of information. 8. Nurses value a socially, economically and ecologically sustainable environment promoting health and well-being. Code of Conduct for Nurses in New Zealand PRINCIPLE 1 Respect the dignity and individuality of health consumers.

PRINCIPLE 2 Respect the cultural needs and values of health consumers. PRINCIPLE 3 Work in partnership with health consumers to promote and protect their well-being. PRINCIPLE 4 Maintain health consumer trust by providing safe and competent care. PRINCIPLE 5 Respect health consumers’ privacy and confidentiality. PRINCIPLE 6 Work respectfully with colleagues to best meet health consumers’ needs. PRINCIPLE 7 Act with integrity to justify health consumers’ trust. PRINCIPLE 8 Maintain public trust and confidence in the nursing profession.

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Unit 1 Contemporary concepts in nursing

interpreted to mean that the patient requires less nursing care, when actually these patients may have significant medical and nursing needs, all of which demand attention. Ethically, all patients deserve and should receive appropriate nursing inter- ventions, regardless of their resuscitation status. Life support In contrast to the previous situations are those in which a DNR decision has not been made by or for a dying patient. The nurse may be put in the uncomfortable position of initiating life-support measures when, because of the patient’s physical condition, they appear futile. This situation frequently occurs when the patient is not competent to make the decision and the family (or surrogate decision maker) refuses to consider a DNR order as an option. The nurse may be told to perform a ‘slow code’ (i.e. not to rush to resuscitate the patient) or may be given a verbal order not to resuscitate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to be aware of hospital policy related to advance directives and reversal of treatment. The nurse should communicate with the doctor. Discussing the matter with the doctor may lead to further communication with the family and to a reconsideration of their decision, especially if they are afraid to let a loved one die with no further efforts to resuscitate. Food and fluid In addition to requesting that no heroic measures be taken to prolong life, a dying patient may request that no more food or fluid be administered. Many individuals think that food and hydration are basic human needs, not ‘invasive measures,’ and therefore should always be maintained. However, some consider food and hydration as means of prolonging suffering. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or withdrawing sustenance. Research has not supported the belief that withholding fluids results in a painful death due to thirst (Hunter, 2012). Evaluation of harm requires a careful review of the reasons the person has requested the withdrawal of food and hydra- tion. Although the principle of autonomy is supported by the NMBA (2008; Chart 2-3), there may be situations when the request for withdrawal of food and hydration cannot be upheld. For patients with decreased decision-making capacity, the issues are more complex. Preventive ethics and advance directives In order to prevent a dilemma, strategies to help nurses antici­ pate or avoid certain kinds of ethical dilemmas should be part of care planning. A patient may be able to make their wishes known but the legal situation is unclear. When uncer- tainty exists, this may be resolved through a legal petition. In Australia the possibility of a person refusing food and fluid varies between States. Most Australian States and Territories have legislation regarding end-of-life decisions. It is important to be aware of the legislation relevant to the State in which the nurse is practising. Frequently, dilemmas occur when the healthcare practi- tioners are unsure of the patient’s wishes before the person becomes unconscious or too cognitively impaired to com- municate directly. Advance directives are documents that specify a patient’s wishes before hospitalisation and provide valuable information that may assist healthcare providers in

substances used to treat symptoms) and withholding a diagno- sis to the patient. Both involve the issue of trust, which is an essential element in a person-centred relationship. Placebos may be used in experimental research in which the patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. However, the use of a placebo as a substitute for an active drug to show that the patient does not have real symptoms is deceptive. Informing patients of their diagnoses when the family and doctor have chosen to withhold information are ethical situations commonly encountered. Nurses often use evasive responses to the patient’s questions as a means of maintaining that request. This area challenges the nurse’s integrity as trust is an essential part of the therapeutic relationship. Strategies the nurse could consider in this situation include the following: • Being truthful to the patient. • Providing all information related to nursing procedures and diagnoses. • Communicating the patient’s requests for information to the family and doctor. Finally, although providing the information may be the morally appropriate choice, the manner in which the patient is told is important. Disclosure of information merely for the sake of patient autonomy does not convey respect for others. End-of-life issues Dilemmas that centre on death and dying are prevalent in medical-surgical nursing practice and frequently initiate moral discussion. The dilemmas are compounded by the fact that the idea of curing is paramount in healthcare. With advanced technology, it may be difficult to accept the fact that nothing more can be done, or that technology may prolong life but at the expense of comfort and quality of life. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations. End-of-life issues are dis- cussed in detail in Chapter 12. Pain control The use of opioids to alleviate a patient’s pain may present a dilemma for nurses. Patients with intractable pain may require large doses of analgesics. Fear of respiratory depression or unwarranted fear of addiction should not prevent nurses from attempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally ill patient, for example, the actions may be justified by the principle of double effect (Chart 2-2). The intent or goal of nursing interventions is to alleviate pain and suffering while promoting comfort. The risk of respiratory depression is not the intent of the actions and should not be used as an excuse for withholding analgesia. However, the patient’s respir­atory status should be carefully monitored and any signs of respiratory depression reported to the doctor. Do-not-resuscitate orders Although it is acknowledged that there are various levels of a ‘do not resuscitate’ (DNR) order (also known as ‘not for resuscitation’ (NFR)) that can range from total DNR to ‘CPR but no intubation’, all these orders present controversial issues for nurses. When a patient is competent to make decisions, his or her choice for a DNR order should be honoured, according to the principles of autonomy or respect for the individ- ual (Johnstone, 2009). However, a DNR order is at times