Transcript Insert title here - University of Huddersfield

Nurses’ contributions to the
resolution of ethical dilemmas
Nichola Barlow Senior Lecture
Professor Janet Hargreaves
Dr Warren Gillibrand
Aim and Objectives
• Aim: To identify how nurses contribute to the resolution
of ethical dilemmas in practice.
• Objective: To identify and discuss:
– The beliefs that impact nurses’ decision ethical
making moral action.
– The values that influence nurses’ ethical decision
making and moral action.
– The contextual influences on nurses’ ethical decision
making and moral action.
Literature Review :
Themes
• Code of ethics
– Codes of ethics provide principles rather than clear
guidance.
• (Lere and Gaumnitz, 2003)
– Globally nurses have a varying degree of knowledge
of their professional codes.
• (Verpeet et al., 2005; Heikkinen et al., 2006)
– Conflict within nurses ethical decision making and
organisation.
• (Oberel and Hughes, 2001; Redman and Fry, 2000)
–(
Literature Review :
Themes
• Conflict
– Doctors, and healthcare professionals.
• (Heikkinen et al., 2006; Oberel and Hughes, 2001; Ulrich et al., 2010)
– Nurses values and those of patients, their families
and the organisation.
•
(Varcoe et al., 2004)
– Conflict within ethical decision making and the
organisation and it representatives.
• (Oberel and Hughes, 2001; Redman and Fry, 2000)
Literature Review :
Themes
• Moral distress:
– Occurs when conflict is experienced during ethical
decision making.
•(Kain, 2007)
– From nurses’ lack of involvement in decision making.
•(Dierchx de Casterle,et al., 2010; Long-Sutehall et al., 2011; Wolf and
Zuxelo, 2007)
–The consequences of moral distress are burnout, desensitisation and loss of nurses from the profession.
• (Corely, 2002: Ulrich et al., 2010)
Conceptualised
Theoretical
Ethical dilemmas
Two or more equally unacceptable courses of action
Beliefs
Moral reasoning
Values
Expectations
Ethical Decision making
Deontology
Utility
Virtue Ethics
Moral Action
Ethic of care
Exploratory interpretive
qualitative study design
•
•
•
•
Ethical approval.
Single NHS Trust multiple site.
Semi-structured interview.
Registered Nurses, variety of experience and
current practice within secondary care.
• Thematic, and contextual analysis using
Nvivo.
Data Collection
• Eleven interviews in total.
• Experience varied from 18months to 30years.
• Practice experience: surgery, vascular surgery,
intensive care, medicine for the older person,
stroke, Children's nursing.
• Audio recorded and transcribed semi-structured
interview.
• Field notes.
Results: Themes
• Best for the patient:
– ‘I have had a few ethical dilemma at the end of the day I always
considered the patients was uppermost and that justified my
position’
Ross
• Advocacy:
– ‘I felt like no-one was listening. Like I come on duty and try and
you know you're patients advocate.’
Nicky
• Standards of care:
– ‘...developing this area for the benefit of the patients and staff
until I retire, so you know it isn't one thing’.
Sam
Results: Themes
• Accountability
– ‘So then it was left for myself and some other members of staff to
then explain the procedure to the patient. So then it is not
necessarily my accountability, I suppose its more her
accountability but I had to intervene because to me she just did
not recognise that area of her accountability. She [the nurse who
made the error] felt it was important to follow certain procedures
in terms of the medical side of things but as to informing the
patient and maybe the relatives it wasn’t considered important’.
Drew
Results: Context
• Conflict
– ‘they could have sent the chief executive on the ward
I would have stuck to my guns and did what I thought
was best for these patients. And I know that there
were two other patients that were in need of a bed but
I actually had to look after the patients that were there
then. So, you know, it did make me question, even
now, I feel I made the right decision’.
Ross
Results: Context
• Collaboration
– ‘I think we all sing from the same hymn sheet, and I think
there are areas where what we do everybody does and
yes I think it works. I think we know exactly where we're
going. Once we've got that we know we're not giving nonessential medications, we're giving medications to be
comfortable with, we're not filling them full of fluids which
just you know hang around, we are just making them
comfortable, and I think that's really important’.
Charlie
‘I even used to think about Doctors doing it I mean Doctors feel or appear to be quite blasé about it they were quite happy to do i
Results: Context
• Concern for others
–
‘I even used to think about Doctors doing it I mean
Doctors feel or appear to be quite blasé about it they
were quite happy to do it. I used to think how do they
feel prescribing a drug for a patient they have never
clapped eyes on, how do they know – they are very
trusting themselves.’
Lee
Results: Relationships
– Nurses demonstrated through their accounts that the
relationships they maintain are the key to achieving
moral action.
– The context did present barriers as identified in both
the research data and literature review
– The most important is that with the patient, the
patients family
– Doctors
– Other health professionals
Reconceptualised
Theoretical Framework
Ethical dilemmas
Two or more equally unacceptable courses of action
Nurse patient
relationship
Beliefs
Moral reasoning
Values
Ethical Decision making
Virtue ethics
Ethic of care
Utility
Expectations
With other patients,
families, health and
social care team
members
Deontology
In partnership
Moral Action
R
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S
H
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Limitations
• This is relatively small sized study
exploratory.
• Nurse participants worked in the same
organisation
• The study is limited to secondary care
context.
Conclusion and
Recommendations
• Nurses’ professional relationships are central to nurses’
contributions to the resolution of ethical dilemmas.
• Support is required for nurses to acquire the skills to
develop and maintain professional relationships for
addressing ethical dilemmas in practice.
• Nurses need to be involved in the development of
organisational policy and individual patient decisions,
which place obligation on them.
• Research is required to explore this phenomenon in
other geographical areas and professional settings.
References
• Corley M.C. (2002) Nursing Moral Distress: A proposed Theory and
Agenda Nursing Ethics 9 (6) pp 636-650.
• Dierckx de Casterlé B. Denier Y. De Bal N. and Gastmans C. (2010)
Nursing care for patients requesting euthanasia in general hospitals
in Flanders, Belgium Journal of Advanced Nursing 66 (11) pp 2410
– 2420.
• Heikkinen, A. Lemonidou, C. Petsios, K., Sala, R. Barazzetti, G.
Radaelli, S. and Leino-Kilpi, H. (2006) Ethical codes in nursing
practice: the viewpoint of Finnish, Greek and Italian Nurses. Journal
of Advanced Nursing 55(30 pp 310 -319.
References
• Kain, V. (2007). Moral distress and providing care to dying babies in
neonatal nursing. International Journal of Palliative Nursing 13(5) pp
243-248.
• Lere J.C. and Gaummitz , B.R. (2003) The impact of codes of ethics
on decision-making Some insights from information Economics.
Journal of Business Ethics 48 pp365-379.
• Long-Sutehall, T. Willis, H. Palmer, R. Ugboma, D. Addingham-Hall,
J. and Coombs, M. (2011) Negotiated dying: A grounded theory of
how nurses shape withdrawal of treatment in hospital critical care
units. International Journal of Nursing Studies 48(12):1466-74.
References
• Oberle, K. and Hughes, D. (2001) Doctors’ and nurses’ Perceptions
of ethical problems in end of life decisions. Journal of Advanced
Nursing 33(6) pp707 - 715.
• Redman, B.K and Fry, S.T (2000) ‘Nurses Ethical Conflict: what is
really known about them?’ Nursing Ethics, 7(4), pp. 360-366.
• Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P.,Farrar, A., Danis,
M. & Grady,C. (2010), Everyday ethics: ethical issues and stress in
nursing practice. Journal of Advanced Nursing, 66: 2510–2519.
References
• Varcoe,. C. Doan, G. Pauly, B. Rodney, P. Storch, J. Mahoney, K.
McPherson, G. Brown, H. and Starzonomski, R.( 2004).Ethical
practice in nursing: working the in-betweens. Journal of Advanced
Nursing 45(3)pp 316-325
• Verpeet, E. Dierckx de Casterlé B. Van der Arend, A. and
Gastmans, C.A.E.
(2004). Nurses views on ethical codes: a
focus group study. Journal of Advanced Nursing 51 (2) 188-195
• Wolf , Z. R. and Zuzelo, P. R. (2007) ‘Never Again’ Stories of
Nurses: Dilemmas in Nursing Practice. Qualitive Research 16(9) pp
1191-1206