Textbook of Medical-Surgical Nursing 3e

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Chapter 2   Thoughtful practice

Institutional ethics committees, which exist in many hos- pitals to assist practitioners with ethical dilemmas, also aid in preventive ethics. The approach to ethical decision making can follow the steps of the nursing process. Chart 2-4 outlines the steps of an ethical analysis. This analysis can be used in reflection on an ethical experience. Self-awareness not only requires a moral compass so we are in tune with our own moral values and ethical reasoning, it requires nurses to be intensely aware of their own biases and prejudices when dealing with people from diverse cultural backgrounds in order to provide culturally safe care. Cultural safety In the healthcare system, as in society, nurses interact with people of similar and different cultural backgrounds. People may have similar or different frames of reference and varied preferences regarding their health and healthcare needs. Acknowledging and adapting to the cultural needs of people are important components of nursing care in thoughtful practice. To plan and deliver culturally safe and competent care, the nurse must understand the definitions of culture, cultural competence, and cultural safety and the various aspects of culture that should be explored for each patient. Leininger (2001) developed a model of nursing known as transcultural nursing to guide nurses in providing culturally competent care. Definitions of culture The concept of culture and its relationship to the healthcare beliefs and practices of patients and their families and friends is central to the exploration of cross-cultural nursing. Awareness of culture in the delivery of nursing care has been described in different ways, including respect for cultural diversity (Kruske, Hikuroa & Bradford, 2008) and the need for the provision of e. Identify the ethical/moral issues and competing claims. Implementation 3. List the alternatives. Compare alternatives with applicable ethical principles and professional codes of ethics. Choose either of the frameworks below, or other frameworks, and compare outcomes. a. Utilitarian approach: Predict the consequences of the alternatives; assign a positive or negative value to each consequence; choose the consequence that predicts the highest positive value or ‘the greatest good for the greatest number.’ b. Deontological approach: Identify the relevant moral principles, compare alternatives with moral principles, appeal to the ‘higher-level’ moral principle if there is a conflict. c. Implement the plan of action. This stage could involve a range of actions, including reporting the matter to a supervisor or consulting the Ethics Committee. Evaluation 4. Decide and evaluate the decision. a. What is the best or morally correct action? b. Give the ethical reasons for your decision. c. What are the ethical reasons against your decision? d. How do you respond to the reasons against your decision?

decision making. The Commonwealth of Australia has no legislation regarding living wills, which can be regarded as a form of advance directive. Recognition of advance directives depends on individual State or Territory legislation. In most situations advance directives are limited to situations in which the patient’s medical condition is deemed terminal; they are frequently written while the person is in good health. They are not always honoured. It is not unusual for people to change their minds as their illness progresses. Therefore, the patient retains the option to nullify the document. Another type of advance directive is the enduring power of attorney for medical treatment, in which the patient identifies another individual to make healthcare decisions on his or her behalf. In this type of directive, the patient may have clarified his or her wishes concerning a variety of medical situations. As such, the power of attorney for medical treatment is a less- restrictive type of advance directive. Laws concerning advance directives vary among State jurisdictions. Even in States where these documents are not legally binding, however, they provide helpful information and assist healthcare providers to determine the patient’s prior expressed wishes in situations where this information can no longer be obtained directly. CLINICAL REASONING CHALLENGE You are at the bedside of a 93-year-old patient who has no advance directive. The patient has been comatose for 3 days and the doctor has not prescribed any feedings. When you ask the doctor about an enteral nutritional supplement (tube feeding), he responds: ‘No, I don’t think so.’ What actions should be taken in this situation? What ethical and legal dilemmas exist? What other health profes- sionals could be helpful in resolving any issues? The following guidelines will assist nurses in ethical decision making. These guidelines reflect an active process in decision making, similar to the nursing process detailed in this chapter. Assessment 1. Assess the ethical/moral dimensions of the problem. This step entails recognition of the ethical, legal and professional dimensions involved. a. Does the situation entail substantive moral problems (conflicts among ethical principles or professional ­obligations)? b. Are there procedural conflicts? (For example, who should make the decisions? Any conflicts among the patient, healthcare providers, family and guardians?) c. Identify the significant people involved and those affected by the decision. Planning 2. Collect information. a. Include the following data: medical facts, treatment options, nursing diagnoses, legal data, and the cultural (values, beliefs) and religious components. b. Make a distinction between the factual information and the values/beliefs. c. Validate the patient’s capacity, or lack of capacity, to make decisions. d. Identify other relevant information that should be elicited. CHART 2-4 Ethics and related matters Steps of an ethical analysis