Discussion: Ethical Challenges in Health Care for Practicing NPs Consider the following case study:

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Discussion: Ethical Challenges in Health Care for Practicing NPs

Consider the following case study:

Mrs. ABC is a 35 year old woman who has a scheduled business trip today. It is currently 8 am, and her plan is to leave at 6 pm. Mrs. ABC has a sore throat and she thinks it is strep because her 5 year old daughter was recently treated for strep. Mrs. ABC calls her physician for an appointment, but there are no appointments available until next week. She has a mother who is a nurse practitioner and her office is 5 minutes away from where she lives. She calls and schedules an appointment with her mother. Her mother was surprised to see her daughter at the office. Mrs. ABC is frantic and begs her mother for an antibiotic. Her mother tests her and the rapid strep test is negative in office. Her mother (NP) sends out a strep DNA probe. Her mother prescribes an antibiotic and the patient (her daughter) is very satisfied. The results returned for the DNA probe 48 hours later and it confirmed negative for strep.

By Day 3


an explanation of whether NPs should treat family members. What are the ethical dilemmas in this situation? What are the laws in your state for NPs treating themselves, family, or friends?

****I live in Texas**** but you can choose any state in the US




Discussion: Ethical Challenges in Health Care for Practicing NPs Consider the following case study:
CHAPTER CONTENTS Characteristics of Ethical Dilemmas in Nursing, 328 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 C hanges 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 health care 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 rec­ ognizing 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 strate­ gies 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 prac­ tice that APNs can expect to confront. 328 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 lnterprofessional Barriers, 351 Patient-Provider Barriers, 351 Organizational and Environmental Barriers, 352 Conclusion, 354 Characteristics of Ethical Dilemmas lll~l12:’:1’Si~ ~~·-· ~ -······· …. ···~ ·-· 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 obliga­ tions 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), hon­ oring 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 appro­ priate 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 prac­ ticing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cul­ tural 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 dis­ tress 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 commu­ nication, 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 health care team, discussions are most effective when members are accountable for presenting informa­ tion in a precise and succinct manner. In patient encoun­ ters, disagreements between the patient and a family C HAP T E R 13 Ethical Decision Making member or within the family can be rooted in faulty com­ munication, which then leads to ethical conflict. The skill of listening is just as crucial in effective communication as having proficient verbal skills. Listening involves recog­ nizing 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 delibera­ tions (e.g., terms such as beneficence, autonomy, and utili­ tarian 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 com­ munication is the first key to negotiating and facilitating a resolution. Jameson (2003) has noted that the long history of conflict between certified registered nurse anes­ thetists (CRNAs) and anesthesiologists influences how these providers communicate in practice settings. In inter­ views 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. Interdisciplinary Conflict The second theme encountered is that most ethical dilem­ mas that occur in the health care setting are multidisci­ plinary in nature. Issues such as refusal of treatment, end-of-life decision making, cost containment, and confi­ dentiality all have interprofessional elements interwoven in the dilemmas, so an interprofessional approach is nec­ essary for successful resolution of the issue. Health care professionals bring varied viewpoints and perspectives into discussions of ethical issues (Hamric & Blackball, 2007; Piers, Azoulay, Ricou, et al., 2011; Shannon, Mitchell, & Cain, 2002). These differing positions can lead to creative and collaborative decision making or to a breakdown in communication and lack of problem solving. Thus, an interdisciplinary theme is prevalent in the presentation and resolution of ethical problems. For example, a clinical nurse specialist (CNS) is writing discharge orders for an older woman who is terminally ill with heart failure. The plan of care, agreed on by the inter­ professional team, patient, and family, is to continue oral medications but discontinue IV inotropic support and all other aggressive measures. Just prior to discharge, the social worker informs the CNS that medical coverage for 329 330 PART ll Competencies of Advanced Practice Nursing the patient’s care in the skilled nursing facility will only be covered by the insurer if the patient has an IV in place. The attending cardiologist determines that the patient can be discharged to her daughter’s home because she no longer requires skilled care and the social worker agrees to proceed with this plan. However, the CNS is concerned that the patient’s need for physical assistance will over­ whelm her daughter and believes that the patient is better off returning to the sldlled nursing facility. Although each team member shares responsibility to ensure that the plan of care is consistent with the patient’s wishes and mini­ mizes the cost burden to the patient, they differ in how to achieve these goals. Such legitimate but differing perspec­ tives from various team members can lead to ethical conflict. Multiple Commitments The third theme that frequently arises when ethical issues in nursing practice are examined is the issue of balancing commitments to multiple parties. Nurses have numerous and, at times, competing fidelity obligations to various stakeholders in the health care and legal systems (Chambliss, 1996; Hamric, 2001). Fidelity is an ethical concept that requires persons to be faithful to their com­ mitments and promises. For the APN, these obligations start with the patient and family but also include physi­ cians and other colleagues, the institution or employer, the larger profession, and oneself. Ethical deliberation involves analyzing and dealing with the differing and opposing demands that occur as a result of these commitments. An APN may face a dilemma if encouraged by a specialist consultant to pursue a costly intervention on behalf of a patient, whereas the APN’s hiring organization has estab­ lished cost containment as a key objective and does not support use of this intervention (Donagrandi & Eddy, 2000). In this and other situations, APNs are faced with an ethical dilemma created by multiple commitments and the need to balance obligations to all parties. The general themes of communication, interdisciplin­ ary conflict, and balancing multiple commitments are prevalent in most ethical dilemmas. Specific ethical issues may be Wlique to the specialty area and clinical setting in which the APN practices. Ethical Issues Affecting Advanced Practice Nurses Primary Care Issues Situations in which personal values contradict professional responsibilities often confront NPs in a primary care setting. Issues such as abortion, teen pregnancy, patient nonadherence to treatment, childhood immunizations, regulations and laws, and financial constraints that inter­ fere with care were cited in one older study as frequently encountered ethical issues (Turner, Marquis, & Burman, 1996). Ethical problems related to insurance reimburse­ ment, such as when implementation of a desired plan of care is delayed by the insurance authorization process or restrictive prescription plans, are an issue for APNs. The problem of inadequate reimbursement can also arise when there is a lack of transparency regarding the specifics of services covered by an insurance plan. For example, a patient who has undergone diagnostic testing during an inpatient stay may later be informed that the test is not covered by insurance because it was done on the day of discharge. Had the patient and nurse practitioner (NP) known of this policy, the testing could have been sched­ uled on an outpatient basis with prior authorization from the insurance company and thus be a covered expense. Viens {1994) found that primary care NPs interpret their moral responsibilities as balancing obligations to the patient, family, colleagues, employer, and society. More recently, Laabs (2005) has found that the issues most often noted by NP respondents as causing moral dilemmas are those of being required to follow policies and procedures that infringe on personal values, needing to bend the rules to ensure appropriate patient care, and dealing with patients who have refused appropriate care. Issues leading to moral distress included pressure to see an excessive number of patients, clinical decisions being made by others, and a lack of power to effect change (Laabs, 2005). Increasing expectations to care for more patients in less time are routine in all types of health care settings as pressures to contain costs escalate. APNs in rural settings may have fewer resources than their col­ leagues working in or near academic centers in which ethics committees, ethics consultants, and educational opportunities are more accessible. Issues of quality of life and symptom management tra­ verse primary and acute health care settings. Pain relief and symptom management can be problematic for nurses and physicians (Oberle & Hughes, 2001). APNs must con­ front the various and sometimes conflicting goals of the patient, family, and other health care providers regarding the plans for treatment, symptom management, and quality of life. The APN is often the individual who coor­ dinates the plan of care and thus is faced with clinical and ethical concerns when participants’ goals are not consis­ tent or appropriate. Acute and Chronic Care In the acute care setting, APNs struggle with dilemmas involving pain management, end-of-life decision making, advance directives, assisted suicide, and medical errors (Shannon, Foglia, Hardy, & Gallagher; 2009). Rajput and Bekes (2002) identified ethical issues faced by hospital­ based physicians, including obtaining informed consent, establishing a patient’s competence to make decisions, maintaining confidentiality, and transmitting health information electronically. APNs in acute care settings may experience similar ethical dilemmas. Recent studies of moral distress have revealed that feeling pressured to continue aggressive treatments that respondents thought were not in the patients’ best interest or in situations in which the patient was dying, working with physicians or nurses who were not fully competent, giving false hope to patients and families, poor team communication, and lack of provider continuity were all issues that engen­ dered moral distress (Hamric & Blackball, 2007; Hamric, Borchers, & Epstein, 2012). APNs bring a distinct perspective to collaborative decision making and often find themselves bridging com­ munication between the medical team and patient or family. For example, the neonatal nurse practitioner (NNP) is responsible for the day-to-day medical manage­ ment of the critically ill neonate and may be the first provider to respond in emergency situations (Juretschke, 2001). The NNP establishes a trusting relationship with the family and becomes aware of the values, beliefs, and attitudes that shape the family’s decisions. Thus, the NNP has insight into the perspectives of the health care team and family. This “in-the-middle” position, however, can be accompanied by moral distress (Hamric, 2001), particu­ larly when the team’s treatment decision carried out by the NNP is not congruent with the NNP’s professional judg­ ment or values. Botwinski (2010) conducted a needs assessment ofNNPs and found that most had not received formal ethics content in their education and desired more education on the management of end-of-life situations, such as delivery room resuscitation of a child on the edge of viability. Knowing the best interests of the infant and balancing those obligations to the infant with the emo­ tional, cognitive, financial, and moral concerns that face the family struggling with a critically ill neonate is a complex undertaking. Care must be guided by an NNP and health care team who understand the ethical princi­ ples and decision making related to issues confronted in neonatal intensive care unit (NICU) practice. Societal Issues Ongoing cost containment pressures in the health care sect01· have significantly changed the traditional practice of delivering health care. Goals of reduced expenditures and services and increased efficiency, although important, may compete with enhanced quality oflife for patients and cHAPTER 13 Ethical Decision Making improved treatment and care, creating tension between providers and administrators, particularly in managed care systems in which providers find that their clinical decisions are subject to outside review before they can be reimbursed. Ulrich and associates (2006) surveyed NPs and physician assistants to identify their ethical concerns in relation to cost containment efforts, including managed care. They found that 72% of respondents reported ethical concerns related to limited access to appropriate care and more than 50% reported concerns related to the quality of care. An earlier study of 254 NPs revealed that 80% of the sample perceived that to help patients, it was sometimes necessary to bend managed care guidelines to provide appropriate care (Ulrich, Soeken, & Miller, 2003). Most respondents in this study reported being moderately to extremely ethically concerned with managed care; more than 50% said that they were concerned that business decisions took priority over patient welfare and more than 75% stated that their primary obligation was shifting from the patient to the insurance plan. Although the passage of the Patient Protection and Affordable Care Act (PPACA; U.S. Department of Health & Human Services fHHSJ, 2011) may help with these concerns to some extent, the ethical tensions that underlie cost containment pressures and the business model orientation of health care delivery may continue. An example of how cost containment goals can create conflict is a situation in which a NP wishes to order a computed tomography (CT) scan to evaluate a patient complaining of abdominal pain. The NP knows that the patient has a history of diverticulosis resulting in abscess formation and the current pres·entation with fever and abdominal tenderness justifies this testing; however, the insurance approval process takes a minimum of 24 hours. By sending the patient to the emergency room, the test can be done more quickly, but the patient will also face a long wait and a high copay if she does not require subse­ quent hospital admission. Limiting access to CT scans is based on containing costs and avoiding unnecessary testing, which are two laudable goals. However, in this situation, the lengthy approval process means that the NP does not have needed information to direct the treatment plan and alleviate the patient’s suffering in a timely manner. The use of the emergency room to obtain essen­ tial clinical information is a greater burden on the patient and may ultimately prove more expensive to the system. Technologic advances, such as the rapidly expanding :field of genetics, are also challenging APNs (Caulfield, 2012; Harris, Winship, & Spriggs, 2005; Horner, 2004; Pullman & Hodgkinson, 2006). As Hopldnson and Mackay (2002) have noted, although the potential impact of mapping the human genome is immense, the challenge of how to translate genetic data rapidly into improvements 331 332 PART IT Competencies of Advanced Practice Nursing in the prevention, diagnosis, and treatment of disease remains. To counsel patients effectively on the risks and benefits of genetic testing, APNs need to stay current in this rapidly changing field (a helpful resource for this and other issues is the text by Steinbock, Arras, and London, 2012), As one example, genetic testing poses a unique challenge to the informed consent process. Patients may feel pressured by family members to undergo or refuse testing, and may require intensive counseling to under­ stand the complex implications of such testing; APNs are also involved in post-test counseling, which raises ethical concerns regarding the disclosure of test results to other family members (Eden, 2006). Because genetic information is crucially linked to the concepts of privacy and confidentiality, and the availability of this information is increasing, it is inevitable that APNs will encounter legal issues and ethical dilemmas related to the use of genetic data. APNs may engage in research as principal investiga­ tors, co- investigators, or data collectors for clinical studies and trials. In addition, leading quality improvement (QI) initiatives is a key expectation of the DNP-prepared APN (AACN, 2006). Ethical issues abound in clinical research, including recruiting and retaining patients in studies, pro­ tecting vulnerable populations from undue risk, and ensuring informed consent, fair access to research, and study subjects’ privacy. As APNs move into QI and research initiatives, they may experience the conflict between the clinician role, in which the focus is on the best interests of an individual patient, and that of the researcher, in which the focus is on ensuring the integrity of the study (Edwards & Chalmers, 2002). Access to Resources and Issues of Justice Issues of access to and distribution of resources create powerful dilemmas for APNs, many of whom care for underserved populations. Issues of social justice and equi­ table access to resources present formidable challenges in clinical practice. Trotochard (2006) noted that a growing number of uninsured individuals lack access to routine health care; they experience worse outcomes from acute and chronic diseases and face higher mortality rates than those with insurance. McWilliams and colleagues (2007) found that previously uninsured Medicare beneficiaries require significantly more hospitalizations and office visits when compared with those with similar health problems who, prior to Medicare eligibility, had private insurance. The PPACA, when fully enacted, will help improve access to quality care and decrease the incidence of these dilem­ mas. However, as noted, the escalating costs of health care represent ethical challenges to providers and systems alike, regardless of the population’s insurance status. The allocation of scarce health care resources also creates ethical conflicts for providers; regardless of pay­ ment mechanisms, there are insufficient resources to meet all societal needs (Bodenheimer & Grumbach, 2012; Trotochard, 2006). Scarcity of resources is more severe in developing areas of the world and justice issues of fair and equitable distribution of health care services present serious ethical dilemmas for nurses in these regions (Harrowing & Mill, 2010). A further international issue is the “brain drain” of nurses and other health professionals who leave underdeveloped countries to take jobs in developed countries (Chaguturu & Vallabhaneni, 2007; Dwyer, 2007). Allocation issues have been described in the area of organ transplantation but dilemmas related to scarce resources also arise in regard to daily decision maldng, for example, with a CNS guiding the assignment of patients in a staffing shortage, or an FNP finding that a specialty consultation for a patient is not available for several months. Whether in community or acute care settings, APNs must, on a daily basis, balance their obligation to provide holistic, evidence-based care with the necessity to contain costs and the reality that some patients will not receive needed health care. As Bodenheimer and Grumbach (2012) have noted, “Perhaps no tension within the U.S. health care system is as far from reaching a satis­ factory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services” (p. 215). One of the value-added components that APNs bring to any practice setting is creativity and a wide range of patient management strategies, which are crucial in caring for large numbers of uninsured and underinsured persons. It is not uncommon for an APN to encounter a patient who has been forced to stop taking certain medications for financial reasons. Although many practitioners pre­ scribe generic forms of medications, if available, some patients still have to pay an exorbitant price for their medi­ cations. For example, an acute care nurse practitioner (ACNP) managing an underinsured patient with chronic lung disease and heart failure discovers that the patient is unable to pay for all the medications prescribed and has elected to forego the diuretic and an angiotensin­ converting enzyme inhibitor (ACE-I). Because the ACNP knows that ACE-Is are associated with reduced morbidity and mortality rates, and that diuretics control symptoms and prevent rehospitalization, these changes are discour­ aged. Instead, the ACNP helps the patient make more suitable choices when altering medications, such as dosing some medications on an every-other-day basis. The ACNP has helped the patient cope with the situation but must face the morally unsettling fact that this plan of care is medically inferior. Finally, as APNs broaden their perspectives to encom­ pass population health and increased policy activities, both essential competencies of the DNP-prepared APN (AACN, 2006), they will experience the tension between caring for the individual patient and the larger population (Emanuel, 2002). Caregivers are increasingly being asked to incorporate population-based cost considerations into individualized clinical decision making (Bodenheimer & Grumbach, 2012). Population-based considerations pre­ sent a challenge to the moral agency of APNs, who have been educated to privilege the individual clinical decision. Legal Issues Over the last 30 years, the complexity of ethical issues in the health care environment and the inability to reach agreement among parties has resulted in participants turning to the legal system for resolution. A body of legal precedent has emerged, reflecting changes in society’s moral consensus. Ideally, moral rights are upheld or protected by the law. For example, the Culturally and Linguistically Appropriate Services (CLAS) Standards established by the HHS mandate that health care institu­ tions receiving federal funds provide services that are accessible to patients regardless of their cultural back­ ground (HHS, Office of Minority Health, 2001). These standards provide a legislative voice for the ethical obliga­ tion to respect all persons, regardless of their cultural background and primary language. In a different voice, the PPACA (HHS, 20ll) has mandated that persons who can afford health insurance purchase it or pay a penalty, starting in 2014. According to this law, societal benefi­ cence, in the form of limiting high expenditures on the care of uninsured persons, is preferred over individual autonomy (Trautman, 2011). APNs must use caution and not conflate legal perspec­ tives with ethical decision making. In many cases, there is no relevant law and thoughtful deliberation of the ethical issues offers the best hope of resolution. In addition, looking to the judicial system for guidance in ethical deci­ sion making is troubling because the judicial aim is to interpret the law, not to satisfy the ethical concerns of all parties involved. In addition, clinical understanding may be absent from the judicial perspective. Involvement of the media may further confuse the situation, as was evident in the Schiavo case (Gostin, 2005). The legal guidelines in that case were dear; the Florida court system repeatedly upheld the right of Ms. Schiavo’s spouse to refuse nutrition and hydration on her behalf However, advocacy groups, politicians, and Ms. Schiavo’s parents used the media to offer a variety of interpretations of the case and wielded political power to prevent removal of the feeding tube and to have it replaced twice after it was removed. Clearly, the CHAPTER 13 Ethical Decision Making legal perspective did not satisfy the moral concerns of all involved. Unfortunately, much of the publicity focused on the emotional experience of the parents fearing the loss ,of their daughter and not on careful consideration of the ethical elements. Sometimes, the law not only falls short of resolving ethical concerns, but contributes to the creation of new dilemmas. Changes in the Medicare hospice benefit under the PPACA (HHS, 2011) offer a dear example. Designed to prevent hospice agencies from enrolling and re-enrolling patients who do not meet criteria, the new regulations require a face-to-face assessment by a health care provider to recertify hospice eligibility at set intervals after the initial enrollment (Kennedy, 2012). Often, patients with dementia or another slowly progressive disease state who enroll in hospice experience an initial period of stability, likely because they have improved symptom management and access to comprehensive services. If this stability extends to the next certification period, the patient may face disenrollment. For the practitioner conducting the assessment, this creates the ethical dilemma of wanting to be truthful regarding the patient’s status and at the same time avoid removing a service that is benefiting the patient and family. Ethical Decision Making Competency of Advanced Practice Nurses There are a number of reasons why ethical decision maldng is a core competency of advanced practice nursing. As noted, clinical practice gives rise to numerous ethical concerns and APNs must be able to address these con­ cerns. Also, ethical involvement follows and evolves from clinical expertise (Benner, Tanner, & Chesla, 2009). Another reason why ethical decision malting is a core competency can be seen in the expanded collaborative skills that APNs develop (see Chapter 12). APNs practice in a variety of settings and positions but, in most cases, the APN is part of an interprofessional team of caregivers. The team may be loosely defined and structured, as in a rural setting, or more definitive, as in the acute care setting. The recent re-emergence of an interprofes­ sional care model is changing practice for all providers (Interprofessional Collaborative Initiative [IPECJ, 2011). Regardless of the structure, APNs need the knowledge and skills to avoid power struggles, broker and lead interdis­ ciplinary communication, and facilitate consensus among team members in ethically difficult situations. Phases of Core Competency Development The core competency of ethical decision making for APNs can be organized into four phases. Each phase depends on 333 334 PART Il Competencies of Advanced Practice Nursing Phases of 1. Knowledge Development-Moral Sensitivity 2. Knowledge Application-Moral Action 3. Creating an Ethical Environment 4. Promoting Social Justice Within the Health Care System of Core Ethical theories Ethical issues in specialty Professional code Professional standards Legal precedent Moral distress Ethical decision-making frameworks Mediation and facilitation strategies Preventive ethics Awareness of environmental barriers to ethical practice Concepts of justice Health policies affecting a specialty population the acquisition of the lmowledge and skills embedded in the previous level. Thus, the competency of ethical deci­ sion making is understood as an evolutionary process in an APN’s development. Phase 1 and beginning exposure to Phase 2 should be explicitly taught in the APN’s gradu­ ate education. Phases 3 and 4 evolve as APNs mature in their roles and become comfortable in the practice setting; these phases represent leadership behavior and the full enactment of the ethical decision maldng competency. Phase 4 relies on competencies required of DNP-prepared APNs; the knowledge and sldlls needed for Phases 3 and 4 should be incorporated into DNP programs. Although an expectation of the practice doctorate, all APNs should develop their ethical knowledge and sldlls to include ele­ ments of all four phases of this competency. The essential elements of each phase are described in Table 13-1. Phase 1: Knowledge Development The first phase in the ethical decision making competency is developing core lmowledge in ethical theories and prin­ ciples and the ethical issues common to specific patient for Ethical Decision Sensitivity to ethical dimensions of clinical practice — — — —- —– — – — Values clarification Sensitivity to fidelity conflicts Gather relevant literature related to problems identified Evaluate practice setting for congruence with literature Identify ethical issues in the practice setting and bring to the attention of other team members Apply ethical decision making models to clinical problems Use skilled communication regarding ethical issues Facilitate decision making by using select strategies Recognize and manage moral distress in self and others Role model collaborative problem solving Mentor others to develop ethical practice Address barriers to ethical practice through system changes Use preventive ethics to decrease unit-level mor~l distress Ability to analyze the policy process Advocacy, communication, and leadership skills Involvement in health policy initiatives supporting social justice populations or clinical settings. This dual knowledge enables the APN student to integrate philosophical con­ cepts with contemporary clinical issues. The emphasis in this initial stage is on learning the language of ethical discourse and achieving cognitive mastery. The APN learns the theories, principles, codes, paradigm cases, and relevant laws that influence ethical decision making. With this knowledge, the APN begins to compare current prac­ tices in the clinical setting with the ethical standards desctibed in the literature. Phase 1 is the beginning of the APN’s personal journey toward developing a distinct and individualized ethical framework. The work of this phase includes developing sensitivity to the moral dimensions of clinical practice (Weaver, 2007). A helpful initial step in building moral sensitivity is understanding one’s values, in which students clarify the personal and professional values that inform their care (Fry & Johnstone, 2008). Engaging in this work uncovers personal values that may have been internalized and not openly aclmowledged, and is particularly impor­ tant in our multicultural world. Another key aspect of this phase is developing the ability to distinguish a true ethical dilemma from a situa­ tion of moral distress or other clinically problematic situ­ ation. This requires a general understanding of ethical theories, principles, and standards that help the APN define and discern the essential elements of an ethical dilemma. Novice APNs should be able to recognize a moral problem and seek clarification and illumination of the concern. The APN identifies ethical issues and formu­ lates the concerns about which others are uneasy. This step earns credibility and enables the APN to gain self­ confidence by bringing the issue to the awareness and attention of others. If the issue remains a moral concern after clarification, the APN should pursue resolution, seeking additional help if needed. Formal education in ethical theories and concepts should be included in graduate education programs for APNs. Although some beginning graduate students will have had significant exposure to ethical issues in their undergraduate programs, most have not. A 2008 U.S. survey of nurses and social workers found that only 51% of the nurse respondents had formal ethics education in their undergraduate or graduate education; 23% had no ethics training at all (Grady, Danis, Soeken, et al., 2008). APN students with no ethics education will be at a disad­ vantage in developing this competency because graduate education builds on the ethical foundation of professional practice. The current master’s essentials (AACN, 2011) do not address ethics education directly but include compe­ tencies in the use of ethical theories and principles. The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) contains explicit ethical content in five of the eight major categories (Box 13-1). Even catego­ ries that do not explicitly list necessary ethical content imply it in referring to issues such as improving access to health care, addressing gaps in care, and using conceptual and analytic skills to address links between practice and organizational and policy issues. Exposure to ethical theories, principles, and concepts allows the APN to develop the language necessary to articulate ethical concerns in an interprofessional envi­ ronment. It is important, however, that lmowledge devel­ opment extend beyond classroom discussions. Clinical practicum experiences also need to build in discussions of ethical dimensions of practice explicitly rather than assume that these discussions will naturally occur. In one study of the clinical experiences of graduate students from four graduate programs, only 4 of20 students were identi­ fied as having experience with an ethical dilemma and only 2 of 22 preceptors noted any exposure to ethical dilemmas for students (Howard & Steinberg, 2002). The authors concluded that this apparent void in clinical edu­ cation may have been a function oflimited recognition of CHAPTER 13 Ethical Decision Maldng 335 Ethical Competencies in the DNP Essentials* Integrate nursing scierice with· knowledge: froin ethiCs .and biophysiCal •. psychoS()Ci~l~ analytic, ahd organizational sciences as the basis for the highest level’ Of nurSing practice. (I) Develop and/or eValuate etfective.stfategies for· man·aging the ethical dilemmas inherent in patient care, the health.~are orgimizatiOn; and research. (II) Desigll, direct, .arid evaluate qualitY: ImProv:eme.~t methodologies to promote safe, timely, effective, efficient, equitable (emphasis added), and patierit-centered care.·(I!I) Piovide’leadership i.n the ev~luation.and reSolution of ethical and legal issue’s within health care systems relating to ‘the use of inform·ation, inforrilatio·n technology, conirhunication netWorks; ‘arid ·patient care technology. (IV) Advocate for social justice, equity; .a~d ethi~al within. all health care arenas. (V) ‘Essential number in parentheses. From American Association of Colleges of Nursing. (2006). Tile essentials of doctoral education for advanced nursing practice. Washington, DC: Author. ethical decision making processes by APN students and preceptors. In another study, Laabs (2005) noted that 67% of NP respondents claimed that they never or rarely encountered ethical issues. Some respondents showed confusion regarding the language of ethics and related principles. In a later study, Laabs (2012) found that APN graduates, most of whom had had an ethics course in their graduate curriculum, indicated a fairly high level of con­ fidence in their ability to manage ethical problems, but their overall ethics knowledge was low. These three studies provide compelling commentary on the need for Phase 1 activity in graduate curricula. The core knowledge of ethical theories should be sup­ plemented with an understanding of issues central to the patient populations with whom the APN works. As APNs assume positions in specific clinical areas or with particu­ lar patient populations, it is incumbent upon them to gain an understanding of the applicable laws, standards, and regulations in their specialty, as well as relevant paradigm cases. This information may be garnered from current literature in the field, continuing education programs, or discussions with colleagues. Information on legal and policy guidelines should be offered during graduate pract­ icum experiences in the area of clinical concentration. 336 PART II Competencies of Advanced Practice Nursing Although Phase 1 is the building block for the other phases of this competency, it is also an ongoing process. APNs will gain core knowledge in graduate education but, as societal issues change and new technologies emerge, new dilemmas and ethical problems arise. The ability to be a leader in creating ethical environments involves a commitment to lifelong learning about ethical issues, of which professional education is just the beginning. Developing an Educational Foundation As noted, education in ethical theories, principles, rules, and moral concepts provides the foundation for develop­ ing skills in ethical reasoning. Because the APN will apply these theoretical p1inciples in actual encounters with patients, it is imperative that consideration of the context in specific situations be strengthened. A portion of gradu­ ate ethics education should involve discussion of typical issues encountered by APNs, rather than issues that receive extensive media attention but occur infrequently. Howard and Steinberg (2002) maintained that graduate curricula need to go beyond traditional ethical issues to encompass building trust in the APN -patient relationship, professionalism and patient advocacy, resource allocation decisions, individual versus population-based responsi­ bilities, and managing tensions between business ethics and professional ethics. The latter three areas are crucial for developing the Phase 4 level of the ethical decision malting competency. Continuing education programs are also effective and necessary forums in which current information can be provided in a rapidly changing health care environment. As technology changes and new dilemmas confront prac­ titioners, the APN must be prepared to anticipate condi­ tions that erode an ethical environment. Knowledge and skills in all phases of this competency depend on the appli­ cation of current ethical knowledge in the clinical setting; ethical reasoning and clinical judgment share a common process and each serves to teach and inform the other (Dreyfus, Dreyfus, & Benner, 2009). Therefore, the impor­ tance of clinical practice cannot be overemphasized. Overview ofEthkal11wories Prillciple-Based ll1odel. Although ethical decision making in health care is extensively discussed in the bio­ ethics literature, two dominant models are most often applied in the clinical setting. The first model of decision maldng is a principle-based model (Box 13-2), in which ethical decision maldng is guided by principles and rules (Beauchamp & Childress, 2009). In cases of conflict, the principles or rules in contention are balanced and inter­ preted with the contextual elements of the situation. However, the final decision and moral justification for actions are based on an appeal to principles. In this way, Principles and Rules Important to Professional Practice Principle’ofrespect,for autonomy: The duty to respect_othe1:s’ personal liberty and individual values, beliefs, and choices Principle-of ilorunaleficence: The duty not to inflict harm or evil Principle of beneficence: The duty to do good and pfevent or remove harm Principle of formal justice: The duty to treat equals equally and treat those who are_ t.lnequal according to their ne_eds Rule of veracity: The duty to tell the truth and not to deceive others Rukof fidelity: The duty to honor commitments Rule of confidentiality: The duty not to. disclose, information shared in ‘an intimate and tmSted manner Rule of privacy: The duty to respect limite<:l access to a_person Adapted from Beauct1amp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press. the principles are binding and tolerant of the particulari­ ties of specific cases (Beauchamp & Childress). The prin­ ciples of respect for persons, autonomy, beneficence, nonmaleficence, and justice are commonly applied in the analysis of ethical issues in nursing. The American Nurses Association (ANA) Code of Ethics for Nurses (2001) has endorsed the principle of respect for persons and under­ scores the profession’s commitment to serving individuals, families, and groups or communities. The emphasis on respect for persons throughout the code implies that it is not only a philosophical value of nursing, but also a binding principle within the profession. Although ethical principles and rules are the corner­ stone of most ethical decisions, the principle-based approach has been criticized as being too formalistic for many clinicians and lacldng in moral substance ( Gert, Culver, & Clouser, 2006). Other critics have argued that a principle-based approach conceals the particular person and relationships and reduces the resolution of a clinical case simply to balancing principles (Rushton & Penticuff, 2007). Because all the principles are considered of equal moral weight, this approach has been seen as inadequate to provide guidance for moral action ( Gett et al., 2006; Strong, 2007). In spite of these critiques, bioethical prin­ ciples remain the most common ethical language used in clinical practice settings. Casuistry. The second common approach to ethical decision maldng is the casuistic model (Box 13-3), in Alternative Ethical Casuistry Direct analysis of particular cases Uses previous paradigm cases to infer ethical action in a current case Analogues in common law and case law Values practical knowledge’ rather than theory (pretheoretical) Privileges experience Narrative Ethics Supplements principles by emphasizing importance of full context Gathers views of all parties to provide more complete baSis for moral justification Story and narrator substitute for ethical justification, which emerges naturally Privileges stories Virtue-Based Ethics Emphasizes the moral agent, not the situation or the action Right motives and character reveal more about moral worth than right actions Character more important than conformity to rules which current cases are compared with paradigm cases (Beauchamp & Childress, 2009; Jonsen & Toulmin, 1988; Toulmin, 1994). The strength of this approach is that a dilemma is examined in a context -specific manner and then compared with an analogous earlier case. The funda­ mental philosophical assumption of this model is that ethics emerges from human moral experiences. Casuists approach dilemmas from an inductive position and work from the specific case to generalizations, rather than from generalizations to specific cases (Beauchamp & Childress, 2009). Concerns have also been raised regarding the use of a casuistic model for ethical decision making. As a moral dilemma arises, the selection of the paradigm case may differ among the decision makers and thus the interpreta­ tion of the appropriate course of action will vary. In nursing, there are few paradigm cases of ethical issues on which to construct a decision making process. Further­ more, other than the reliance on previous cases, casuists have no mechanisms to justify their actions. The possibil­ ity that previous cases were reasoned in a faulty or inac­ curate manner may not be fully considered or evaluated (Beauchamp & Childress, 2009). In spite of these con­ cerns, the case-based moral reasoning used in casuistry appeals to clinicians because it mimics clinical reasoning, in which providers often appeal to earlier similar cases to CHAPTER 13 Ethical Decision Making “‘ Righ~ motives make for right actions Privileges actor’s values and motives Feminist Ethics Views women as embodied, fully rational, and having experiences relevant to moralt’easoning Emphasizes view of the disadvantaged-women and other underrepresented groups Emphasizes importance and value of openness to different perspectives Concerned with power differentials that create oppression Emphasizes importance of attention to the vulnerable and to resulting inequalities Privileges power imbalances Care-Based Ethics Emphasizes creating and sust Although this is no longer a dominant theme in nursing literature, it can still be seen. For example, Gallagher and Tschudin (2010) based their understanding of ethical leadership in professional values and virtues. The ethics of care has emerged as relevant to nursing (Cooper, 1991; Edwards, 2009; Lachman, 2012). The care perspective constructs the central moral problem as Clinical Situation To illustrate the different ethical approaches, consider the case of a 64-year-old man, GB, who is unable to speak for himself because of an aggressive brain tumor. He had seen a neurosurgeon 1 month prior to the current hospital adillission and was told that the tumor was inoperable. He has been undergoing outpatient radiation treatment and is now taken to his local hospital because of altered mental status. In the emergency room, his condition worsens; he is unable to communicate or breathe so he is started on mechanical ventilation and transferred to the ICU. Imaging shows that the tumor has continued to progress, despite radiation. The patient’s daughter requests that the patient be transferred to another facility for a second opinion from a different neurosurgeon. The social worker has a copy of the patient’s advance directive, completed prior to starting radiation, which states that he does not desire aggressive medical treatment if there is little hope of recovery. The team caring for the patient, including a staff nurse, resi­ dent, attending physician, social worker, and CNS apply different ethical theories when they approach this case. The nurse adopts a principle-based approach, favor­ ing patient autonomy and respect for persons, as empha­ sized in the Code of Ethics for Nurses (ANA, 2001). He sustaining responsive connections and relationships with important others, and consequently focuses on issues sur­ rounding the intrinsic needs and corresponding responsi­ bilities that occur in relationships (Gilligan, 1982; Little, 1998). In this approach, moral reasoning requires empathy and emphasizes responsibilities rather than rights. The response of an individual to a moral dilemma emerges from important relationship considerations and the norms of friendship, care, and love. Viens (1995) reported that NPs she interviewed used a moral reasoning process that mirrored Gilligan’s model in the major themes of caring and responsibility. Although every ethical theory has some limitations and problems, an understanding of contemporary approaches to bioethics enables the APN to appeal to a variety of perspectives in achieving a moral resolution. In the clinical setting, ethical decision making most often reflects a blend of the various approaches rather than the application of a single approach. Although there is some danger in oversimplifying these rich and complex approaches, Exemplar 13-1 shows how they can be reflected in ethical decision making. A more thorough discussion of ethical theory is beyond the scope of this chapter, but the reader is referred to the references cited for more detail. Ethical recognizes the daughter’s distress but believes that her desire to seek a second opinion comes from her own fear of losing her father and is not based on her knowledge of the patient’s wishes. Because the patient should be respected as a person, keeping him on life support or transferring him to another institution as a means to alleviate his daughter’s fears is unethical. The nurse believes that the daughter’s inability to support her father’s advanced directive renders her an inappropriate decision maker. The advance directive, as an indication of the patient’s autonomous wishes, should guide care. Because it clearly states the patient that does not wish to be kept alive with little hope of recovery, he favors with­ drawal of ventilator support and institution of comfort measures only. The resident had a case a year ago, when she was still a medical student, in which a patient’s cancer was thought to be inoperable but a second opinion was sought and the patient went on to survive surgical inter­ vention. This case, occurring early in her career in health care, profoundly influences her to support second opin­ ions on complicated surgical cases. Applying a casuistry­ based approach, the resident supports the daughter’s request and agrees to help her explore avenues for CHAPTER 13 Ethical Decision Maldng Clinical Situation Demonstrating Differing Ethical transferring the patient for consultation with a different neurosurgeon on the slim chance that he may be eligible for additional treatment to prolong his life. She consults the social worker to assist in investigating the feasibility of transferring the patient. The attending physician adopts a care-based approach, privileging the relationships within the patient’s family. He himself has a long-standing relation­ ship with the neurosurgeon who was previously con­ sulted, and he trusts that a second opinion at an outside facility will not yield a different prognosis. He favors keeping the patient in his current setting, because trans­ ferring him to a distant facility will take him far from his family, and their time with him is essentiaL He does not see any reason to withdraw mechanical ventilation but he also believes that initiating cardiopulmonary resusci­ tation (CPR) would be futile and would disrupt the peaceful atmosphere his family deserves as they struggle with the loss of their father and grandfather. He there­ fore convinces the patient’s daughter to agree to a do not resuscitate (DNR) order, and closes the discussion by encouraging her and the rest of the family to stay with the patient and to “be together at this crucial time:’ He also asks the ICU staff to relax the regulations regarding family visitation so that the daughter and her children can spend more time at GB’s bedside. The social worker completes a lengthy assessment of the patient and family in response to the consult requested by the resident. In the process, she learns that the family has limited financial resources and that the patient’s daughter has a lOth-grade education. Prior to GB’s diagnosis, her only interactions with the health care system were the births of her three children. Her mother died when she was teenager and, for the past few years, her father has assisted her in the care of her children. The social worker views the attending physi­ cian as condescending, and she hears one of the ICU nurses describe the daughter as “totally clueless:’ Inter­ preting the case from a feminist viewpoint, she worries that the family’s socioeconomic status and the daughter’s educational background are creating a bias against hon­ oring the request for transfer. She is determined to advocate for the patient’s daughter to correct this power imbalance. The CNS’s involvement in the case begins when the nurse consults her because his appeals to the resident and attending physician have failed to result in what he believes is the right course of action-namely with­ drawal of the ventilator. The CNS listens to the nurse’s story and attends carefully to the details he gives. She then seeks out the resident) attending physician, and social worker to hear their perspectives. She adopts a narrative-based approach and wants to hear all the con­ textual features of the case before coming to a conclusion about the best course of action. When she speaks to GB’s daughter, she learns about the conversation that she had with her father shortly before he became unresponsive, in which he expressed a desire to attend her oldest child’s high school graduation. It is this conversation that led the patient’s daughter tO request a transfer for a second opinion: “I know he wants to Jive;’ she explains, “no matter what it says on that paper:’ Resolution of the Case The CNS calls a team meeting. She asks the members to work toward a consistent message that can be given to GB’s family because the contrasting views are dearly creating confusion. This request results in careful review of the clinical aspects of the case, including the most recent magnetic resonance imaging (MRI) scan, and brings the team to an agreement that the patient’s prog­ nosis is poor and a second opinion from an outside neurosurgeon is not necessary to confirm this. The social worker has an opportunity to ask questions and is thus assured that the team was unaware of the daughter’s educational background and economic status and are not basing their care on these factors. The CNS then moves forward to establish a mutually acceptable plan of care. In a subsequent family meeting, the team explains the patient’s prognosis to the patient’s daughter using layman’s terms and simple pictures to clarify the growth of the tumor and its position. After addressing the family’s questions, the CNS presents two options­ withdt•awing intensive care interventions or continuing to provide this care with the DNR order in place. She explains that the team has met separately to consider carefully the daughter’s request for transfer GB and determined that the risks of such a plan outweigh poten­ tial benefits. The CNS ends the meeting with the family by offering them additional time to discuss their options and ask any further questions. After several days, the family elects to withdraw the ventilator and initiate comfort measures. 339 34D PART II Competencies of Advanced Practice Nursing Professional Codes and Guidelines The ANA’s Code of Ethics for Nurses (2001) describes the profession’s philosophy and general ethical obligations of the professional nurse. It describes broad guidelines that more reflect the profession’s conscience than provide specific directions for pa1ticular clinical situations. It provides a framework that delineates the nurse’s overrid­ ing moral obligations to the patient, family, community, and profession. Professional organizations delineate standards of per­ formance that reflect the responsibilities, obligations, duties, and rights of the members. These standards also can serve as guidelines for professional behavior and define desired conduct. Although the general principles are relatively stable, professional organizations often reflect on specific or contemporary issues and take a proactive position on pivotal concerns. For example, the American Association of Critical-Care Nurses (2008) has issued a position paper on moral distress, acknowledging that it negatively affects quality of care and influences nurses who are considering leaving the profession. The paper then lists the responsibilities of nurses to address moral distress, some resources that can be helpful to them, and the obligations of nurses’ employers to offer support, such as employee assistance programs and ethics committees, to assist with managing moral distress. An additional example is the International Association of Forensic Nurses’ position paper (2009) supporting the use of emergency contraception for victims of sexual assault. This document provides ethical and clinical rationales for policies that permit dispensing of these medications. Personal a11d Professional Values Individuals’ interpretations and positions on issues are a reflection of their underlying value system. Value systems are enduring beliefs that guide life choices and decisions in conflict resolution (Ludwick & Silva, 2000). Viens (1995) found that values were an essential feature of the everyday practice of the 10 primary care NPs she inter­ viewed. Values of caring, responsibility, trust, justice, honesty, sanctity and quality of life, empathy, and religious beliefs were articulated by the study participants, often as ideals that motivated their actions. An awareness of per­ sonal values generates more consistent choices and behav­ iors; it can also assist APNs to be aware of the boundaries of their personal and professional values so that they can recognize when their own positions may be unduly influ­ encing patient and family decision making. Values awareness should include an understanding of the complex interplay between cultural values and ethical decision making (Buryska, 2001; Ludwig & Silva, 2000). When patient and family decisions contradict traditional Western medical practice, health care providers may resort to coercive or paternalistic measures to influence patient’s choices to be more consistent with the provider’s values. APNs and other health care providers must under­ stand that the assumptions they make may be based on their own cultural values and biases and understand how these assumptions may influence their recommendations of particular treatments. As health care professionals gain an understanding of factors that guide a person’s deci­ sions, treatment plans that reflect the patient’s value pref­ erences are more easily developed. for example, a patient from a Southeast Asian culture may show respect to authority figures by obeying the APN’s treatment sug­ gestions, even if he or she disagrees with the plan. In this situation, the APN could assure the patient that ques­ tions about the plan of care are welcomed and are not disrespectful. By the same token, claims made in the name of reli­ gious and cultural beliefs are not absolute. Buryska (2001) offered helpful guidelines for clinicians to assess the defensibility of patient and family claims made in the name of cultural or religious considerations. For example, he maintained that spiritual or cultural claims grounded in an identifiable and established community are more defensible than those that are idiosyncratic to the person malting the claim. Although it is critical for caregivers to respond with respectful dialogue, support, and compas­ sionate care, patient and family demands for treatment must be considered in relation to other claims that also have ethical weight-the professional integrity of provid­ ers, legal considerations, economic realities, and issues of distributive justice. Professional Bou1utaries In their professional capacity, APNs have access to per­ sonal and private patient information and may develop long-term therapeutic relationships with many of their patients. The atmosphere of intimacy in the nurse-patient relationship, coupled with the need to touch the patient during a physical examination, sets up a power differential that accentuates the patient’s vulnerability (Holder & Schenthal, 2007). Boundaries must be established that acknowledge the appropriate and necessary use of this patient information and intimacy to meet the patient’s needs and provide care. The obligation to maintain profes­ sional boundaries within a therapeutic relationship is shared with all nurses (ANA, 2001), but APNs are also in a position to observe for boundary violations by others and to intervene when they occur. Boundary violations, in which the APN or another health care professional inadvertently or purposely breaches the limits and expectations of the relationship, may profoundly alter the foundation of a therapeutic relationship. Such transgressions may be subtle, such as the APN sharing excessive personal information, or blatant, as in sexually seductive behavior. Regardless of the magnitude of the violation, the behavior must be con­ fronted immediately and the culpable individual must be removed from interaction with the patient. Other members of the health care team should strive to restore the patient’s integrity and trust, involving the help of others as necessary (National Council of State Boards of Nursing, 2009). Phase 2: Knowledge Application The second phase of the core competency is applying the knowledge developed in the first level to the clinical practice arena. Phase 2 continues the APN’s journey in assessing ethical problems and being actively involved in the process of resolving ethical dilemmas. As APNs acquire core ethical decision making knowledge, the responsibility to take moral action becomes more compel­ ling. Rather than retrospectively analyzing ethical dilem­ mas, the APN takes moral action, which implies that the APN recognizes, pursues, and responds to ethical issues. Often, the inequities toward or infringements on other persons are enough to motivate moral action and a timely response can change the course in present and future situations. 1herefore, moral action should not be under­ estimated as a core APN skill and should be recognized, fostered, and valued by others. Once an advanced nursing role is assumed, the APN accepts the responsibility to be a fUll participant in the resolution of moral dilemmas rather than simply an interested observer or one of many parties in conflict. Although the core knowledge of ethical concepts pro­ vides the foundation for moral reasoning, the application of these concepts enables the APN to develop the practical wisdom of moral reasoning. It is the experience in the practice setting and the courage of the APN to discuss sensitive issues openly that enable the APN to assume an active role in dispute resolution. The success and speed with which the APN gains these behavioral skills is related to the presence of mentors in the clinical setting and the willingness of the APN to become immersed in ethical discussions. Institutional resources, such as ethics committees and institutional review boards, provide valuable opportuni­ ties for APNs to participate in the discussion of ethical issues. Typically, hospital ethics committees serve three functions-policy formation, case review, and education. As a member of the ethics committee, the APN exchanges ideas with colleagues and gains an understanding of ethical dilemmas from a variety of perspectives. In addi­ tion, the APN is informed of current legislation, regula­ tions, and hospital policies that have ethical implications. CHAP T E R 13 Ethical Decision Making This is an extremely valuable experience that can acceler­ ate the development of ethical decision making skills. Unfortunately, most APNs do not have the opportu­ nity to serve on interdisciplinary ethics committees and, in some cases, may have few professional colleagues avail­ able to mentor and develop the skills of ethical decision making. 1hus, the APN must advance this phase by actively seeking opportunities to engage in ethical dia­ logue with professional colleagues. Professional organiza­ tions offer materials such as The 4 AS to Rise Above Moral Distress (American Association of Critical Care Nurses, 2004) and workshops in which case studies are discussed and analyzed. This format is helpful to the inexperienced APN who needs guidance in applying knowledge to clini­ cal cases. Ethical Decision Making Frameworks Several authors have proposed a stepwise approach to ethical decision making (McCormick-Gendzel & Jurchek, 2006; Purtilo & Doherty, 2011; Rushton & Penticuff, 2007; Spencer, 2005; Weuste, 2005). In Box 13-4, the steps sug­ gested by Purtilo and Doherty (2011) are listed as an example. The reader will note that this framework uses many elements of the various ethical approaches dis­ cussed earlier in considering contextual factors, seeking full information on a case, and specifying a step that explicitly appeals to ethical theory. This framework for ethical decision making is intended for all health profes­ sionals and therefore is applicable to a wide variety of situations. Most frameworks for ethical decision malting include information gathering as a key step. Generally, informa­ tion about the clinical situation, the parties involved, their obligations and values, and legal, cultural, and religious factors are needed. However, this factual information is not sufficient unless tempered with the contextual features of each case. Identifying the cause of the problem and determining why, where, and when it occurred, and who or what was affected, will help clarify the nature of the problem. Problem identification is also a common step in most frameworks. Strong emotional responses to a situation can be the first signal that ethical conflict exists. However, many conflicts that arise in the clinical setting generate powerful emotional responses but may not be ethical issues. Ethical issues are those that involve some form of controversy about conflicting moral values and/or funda­ mental duties or obligations. The APN must distinguish and separate moral dilemmas from other issues, such as administrative concerns, communication problems, and lack of clinical knowledge. For example, a communication problem between a stafi· nurse and physician may be resolved if an APN acts as a facilitator, ensuring that each 341 342 PART II Competencies of Advanced Practice Nursing Ethical Decision Framework , ,, C_autio~ ;·,’ .. lu _ _ ‘ :,tfse -~fltlca~ theories,:ot ,approaches _to analyze _ tllepr~blero: . . ·• · · . ·. . . .· .. . · · ••· · A:_.utilhariap_ approa_(;;h_wo~dfoc~s On_ the consequen9es:q(Potelltial a_Ctions. A Collaboration, however, is not always possible in resolving ethical disputes. Other approaches include the following: Compromise is an appropriate approach to ethical decision making when the parties involved are committed to preserving their relationship and each possesses a high moral certainty about their position. Alternatively, accommodation occurs when one party is more committed than the other to preserving the relationship; the committed party defers to the other, with the result that only one perspective directs the outcome. Accommodation is unlikely to promote the integrity of all involved parties and should be used only when time is limited or the issue is trivial. Coercion is also a strategy unlikely to result in an integrity-preserving outcome. In this approach, the more powerful party, who has a strong commitment C HAP T E R 13 Ethical Decision Making to a particular position, determines the outcome of the conflict through an aggressive stance. Avoidance is the most dangerous of the strategies considered by Spielman (1993), because the less powerful party does not articulate their ethical concerns. Exemplar 13-2 provides examples of each of these strategies in a situation that evoked considerable ethical conflict. Strategies Used in Resolving Ethical Conflict An ACNP in a hospital-based clinic provides compre­ hensive care to patients with HIV/AIDS. TD, a 44-year­ old female patient, also has a history of diabetes mellitus, hypertension, cigarette smoking, and depression. She arrives at the clinic after missing multiple appoint­ ments. In the interval since her last visit, she has been placed on house arrest because of pleading guilty to fraud. TD accepted government aid without reporting a change in income that rendered her ineligible for this support. At this visit, the patient reports that she has not taken medications for diabetes or hypertension because she ran out of pills and had no mechanism for refilling them. She is depressed, hyperglycemic, and dehydrated, and is given 2liters of IV fluids in the clinic because she refuses hospital admission. She is fearful of violating the condi­ tions of her house arrest; she is only permitted to leave her home for prescheduled medical appointments. She is scheduled to return in 1 week’s time and given pre­ scriptions for an antidepressant, oral hypoglycemic, and glucose monitoring supplies. The following day, a pharmacist calls the clinic to report that the prescriptions given to him by TD have been altered. The frequency of the antidepressant has been changed from once to twice a day, and the number of refills for the hypoglycemic agent has been changed from three to 18. Furthermore, the pharmacist is annoyed with the patient because her behavior in the pharmacy was disruptive. He states that he plans to refuse to dispense medications for her if this continues. On hearing about this incident, the clinic nurse, who has worked with the patient over a long period of time, becomes angry and states her view that this is consistent with the patient’s past behavior in clinic. She suggests that the ACNP tell the patient that her alteration of the prescriptions can be reported to the Department of Cor­ rections and that further incidents like this will result in termination from care at this clinic. The social worker, whose ongoing contact with the patient was instrumen­ tal in getting her to return to clinic after a long absence, advises the ACNP that no report to the correction officer is required. She states her belief that even to mention this to the patient would result in the patient ceasing to come to clinic. The ACNP notes the emotional responses of the interprofessional team members, which signal an ethical conflict. Her initial thought is to wait until TD’s sched­ uled return visit to identify a course of action. This strategy is an example of avoidance. Another avoidance option would be to send the patient to another provider for her medications. For example, an endocrinologist could be consulted for the diabetes medication. The ACNP considers, but does not select, these courses of action. In communications with the pharmacist, the ACNP uses accommodation as a strategy for managing ethical conflict. She validates his concern about the negative impact of the patient’s behavior on the other costumers and agrees that he can refer her’ to another pharmacy if her behavior continues to be inappropriate. The pharmacist agrees to accept corrected prescriptions faxed direCtly from the ACNP, and to dispense these to the patient, if she is not disruptive when she returns the next day. He also agrees to notify the ACNP if she is disruptive and therefore does not get her medications. The strategy favored by the social worker is also an example of accommodation. She believes that the obliga­ tion of the clinic staff is the delivery of patient care, i1ot upholding the legal regulations around the handling of prescriptions. She suggests not providing prescriptions to TD again, but adopting a policy of calling or faxing all prescriptions for her directly to a pharmacy. In this way, TD’s unethical behavior is accommodated by a change in clinic practice. The clinic nurse’s strategy is an example of coercion. In coercive strategies, the ethical decision maker resolves the conflict by exerting a controlling influence on another party whose actions or values are fueling the conflict. Suggesting to the patient that her actions will 343 344 PART ll Competencies of Advanced Practice Nursing Used in be reported and that these actions may affect her access to the care she needs can be expected to influence her behavior. The disadvantage of this type of strategy is the powerlessness it imposes. When the patient arrives for her follow-up appoint­ ment the next week, the ACNP uses collaboration to manage the ethical conflict. She informs the patient that the pharmacist called about the prescriptions and that this created concern among the providers at the clinic. She tells the patient, “I do not want you to be in trouble, and changed prescriptions can get you in trouble. I want to work with you to help you stay well:’ She asks the patient for her story. The patient then explains her fear of again running out of the hypoglycemic agent she knows she needs, and of being unable tp afford medication refills. TD mistakenly thought that by altering the prescriptions, she would get a larger supply of the medicines. The ACNP agrees to help TD identify strategies to obtain her medica­ tions through prescription assistance programs and There is an additional dynamic that may be operating in environments in which avoidance is the norm in dealing with ethical conflict. In a series of observational qualitative studies of hospital-based nurses, Chambliss (1996) documented a phenomenon he called “routiniza­ tion” of the moral world (p. 38). In routinization, nurses became enmeshed in the tasks and routines of care deliv­ ery and, over time, became accustomed and desensitized to the ethical conflicts around them. The routine blunted the nurses’ moral sensitivity and moral agency so that moral difficulties were not recognized; nurses commented, “You just get used to it:’ Chambliss (1996) also noted that nurses were aware of problems but often did not see them as “ethics problems”, and neither did those in authority. The great ethical danger in such environments is not that nurses would make the wrong choice when faced with an important decision, but that they would never realize that they are facing a decision at all. APNs must be alert for signs of routinization of the moral dimension of practice in the environments in which they practice. Identifying and addressing features of the system that blunt or dismiss the moral sensitivity of any care provider is a critical part of APNleadership and moves the APN into Phase 3 of the ethical decision making competency. Phase 3: Creating an Ethical Environment As the APN becomes more skilled in the application of ethical knowledge, the third phase of competence begins Ethical Conflict-contll the patient agrees not to alter prescriptions she is given. Another conflict evident in this case is between the nurse and social worker. Compromise is needed to maintain an effective working relationship because the two provide care to the same patient population. Com­ promise can be achieved if the two parties focus on a common goal and relinquish control of some elements of the final decision In this case, the ACNP meets with both parties and they identify that their common goal is efficient delivery of quality health care. Through compromise, the nurse recognized the value that the social worker placed on keeping the patient in care and relinquished her desire to report the patient to the Department of Corrections. Similarly, the social worker recognized that the nurse wanted to avoid dis­ ruptive behavior that upsets other clinic patients. She agreed to relinquish her accommodating approach to the patient’s behavior if it negatively affected the clinic’s operation in the future. —— to develop. The quality of the ethical environment is a critical factor in whether ethical problems are produc­ tively addressed. In one study of NPs, the participants’ perception of the ethical environment was the strongest predictor of ethical conflict in practice; the more ethical the environment, the lower was the ethical conflict (Ulrich, Soeken, & Miller, 2003). The APN’s level of influence needs to extend beyond the individual patient encounter to create a climate in which ethical concerns are routinely addressed. Role modeling, mentoring others regarding ethical decision malting, and creating an ethical environment are leadership behaviors seen in the practice of the mature APN. Once the APN transforms ethical knowl­ edge into moral action, the role of mentoring others emerges. Too often, other nurses and members of the health care team remain silent about ethical issues (Gordon & Hamric, 2006). In a mentoring capacity, the APN helps colleagues deal with moral uncertainty and develop the ability to voice ethical concerns. In this way, the APN supports and empowers other team members to develop confidence and fosters an environment in which diverse views are expressed and problems are moved toward resolution. The experienced APN also initiates informal learning opportunities for nurses and other professional colleagues. Ethics rounds and case review are two ways to engage colleagues in the discus­ sion of moral issues. In a classic article, Shannon noted that the roots of interdisciplinary conflict in the clinical setting are often based on preconceived stereotypes of the moral view­ points of other disciplines and perceptions of the moral superiority of one’s own discipline (Shannon, 1997). The APN can help professionals from other disciplines under­ stand the perspectives and socialization ofnurses.ln addi­ tion, the APN models successful negotiation with other disciplines. Teaching and mentoring activities of the mature APN often focus on other professional colleagues to prepare them proactively to communicate openly with patients about ethical concerns. One way for APNs to maintain the trust and respect of professional colleagues is to acquire ethical knowledge and expertise in their spe­ cialty area. This phase also encompasses aspects of coaching and teaching patients and families in ethical decision making. It is not sufficient for the APN simply to provide informa­ tion to patients and families facing difficult moral choices and expect them to arrive at a comfortable decision. The ethical competency is linked closely with the ability to mobilize patients and the APN’s colleagues so that those who need help move through the necessary steps to reach resolution. APNs should strive to develop environments that encourage patients and caregivers to express diverse views and raise questions. Thoughtful ethical decision making arises from an environment that supports and values the critical exchange of ideas and promotes collaboration among members of the health care team, patients, and families. A collaborative practice environment, in turn, supports shared decision making, shared accountability. and group participation, fostering relationships based on equality and mutuality. The APN is integral to the devel­ opment and preservation of a collaborative culture that inspires and empowers individuals to respond to moral dilemmas. The current nature of health care delivery in inpatient and outpatient settings creates a climate in which many workers feel overwhelmed, stressed, and discouraged by the lack of time to care for patients and their increased acuity levels. Combined with a sense of powerlessness and routinization (Chambliss, 1996), these factors can result in nurses retreating from a stance of moral agency. An ethically sensitive environment is one in which providers are encouraged to acknowledge when they feel over­ whelmed and seek help when they need it (Hamric, Epstein & White, in press). The Code of Ethics for Nurses (ANA, 2001} has affirmed the importance of nurses con­ tributing to an ethically sensitive health care environment, as well as preserving personal integrity. One provision states that “1he nurse owes the same duties to self as to others, including the responsibility to preserve integrity C HAP T E R 13 Ethical Decision Maldng and safety” (p. 4). Only when care providers recognize and attend to their personal needs will they be better able to detect and nurture the needs of others. As APNs become more competent and capable in ethical reasoning, they are able to anticipate situations in which moral conflicts will occur and recognize the more subtle presentations of moral dilemmas. The ability to look beyond the immediate situation and foresee potential issues directs the APN down a path of preventive ethics. Preventive Ethics Phase 2 concentrates on the resolution of current and ongoing issues rather than on preventing the recurrence of moral dilemmas. An additional important role of the APN in Phase 3 is to extend the concept of ethical decision making beyond problem solving in individual cases and to move toward a paradigm of preventive ethics. The term preventive ethics is derived from the model of preventive medicine; the term was coined by Farrow and associates (1993). It emphasizes developing effective organizational policies and practices that prevent ethical problems from developing (McCullough, 2005). The ability to predict areas of conflict and develop plans in a proactive rather than reactive manner will avert some potentially difficult dilemmas and can lead to more ethically responsive envi­ ronments (Farrow, Arnold, & Parker, 1993; Fox et al., 2007; McCullough, 2005; Nelson, Gardent, Shulman, et al., 2010). When value conflicts arise, resolution becomes more difficult because one value must be chosen over another. Preventive ethics emphasizes that all important values should be reviewed and examined prior to the conflict so that situations in which values may differ can be antici­ pated. In other words, the goals of the health care team should be articulated as clearly as possible to avoid poten­ tial misinterpretations. For example, a CRNA should have an understanding of a terminally ill patient’s values regard­ ing aggressive treatment in case a cardiopulmonary arrest occurs during surgery. However, the CRNA’s moral and legal obligations should be openly discussed so that the patient and professional appreciate and recognize each other’s values and moral and legal positions. Modeling this preventive approach in ethical deliberations encourages the early identification of values and beliefs that may influence treatment decisions and allows time to resolve impending issues before problems arise. In much the same way, early anticipation of potential complications in patient trajectories can lead to proactive discussions of ethical issues and restructuring of the care environment to anticipate and avoid ethical conflict. In addition to the early examination and ongoing dia­ logue regarding values, a conscientious inspection of other factors that influence the evolution of moral 345 346 PART II Competencies of Advanced Practice Nursing dilemmas is required. A number of environmental factors can become barriers to ethical practice; Chambliss (1996) made the important point that features of the work setting and their role as employees often create moral problems for nurses. The roles and responsibilities of all parties must be clearly defined to expose any existing power imbalance. During this process, issues of powerlessness surface as an area in which the APN can influence change. By providing lmowledge, promoting a positive self-image, and prepar­ ing others for participation in decision maldng, the APN empowers individuals. The skill of the APN is used not to resolve moral dilemmas single-handedly, but to mentor others to assume a position of moral accountability and engage in shared decision maldng. This process of enhanc­ ing others’ autonomy and providing opportunities for involvement in reaching resolution is a key concept in preventive ethics (Farrow et al., 1993). Ethically responsive environments are enhanced by a process of ongoing, rather than episodic, ethical inquiry. Throughout this process, the APN incorporates his or her skills, ethical expertise, and clinical background on issues necessary to facilitate dialogue, mediate disputes, analyze options, and design optimal solutions. In this phase, the ethical decision making skills of the APN move the resolu­ tion of moral dilemmas beyond individual cases toward the cultivation of an environment in which the moral integrity of individuals is respected. Development and preservation of this ethical environment is the key contri­ bution of the APN. Although ethical issues may develop with little warning, the practice of preventive ethics greatly improves a team’s ability to handle these issues in a morally responsible and innovative manner. Exemplar 13-3 pro­ vides an example of preventive ethics in addressing staff moral distress. Staff Moral Distress Preventive Ethics* Dea, a CNS in a neuroscience ICU, seeks to change the management of patients with traumatic brain injury (TBI). She and other members of the staff have noted that the care of this population is inconsistent, and many staff have a fatalistic attitude about these patients’ hope of recovery. She is also aware of recent research on the use of a new technology, brain tissue oxygen monitoring, that has shown promise in improving out­ comes for these patients. As an initial step, she invites a CNS from another state, an expert in the manage­ ment of TBI whom she knows to be an inspiring speaker, to give a presentation on brain tissue oxygen monitoring. Dea arranges for staff coverage so that all neuroscience ICU registered nurses (RNs) can attend the presentation, in which the speaker describes how the technology is used to prevent progressive injury in patients with TBI. Members of the respiratory therapy team, staff in the emergency room, and nurses from the trauma ICU are also invited to the presenta­ tion, Which is highly successful. Dea then collaborates with the nurse manager and administration to imple­ ment brain tissue oxygen monitoring in the neurosci~ ence ICU, She obtains key physician support, provides training sessioi1s, supports the staff when the technol­ ogy is introduced into patient care, and develops algo­ rithms for acting on the information this technology provides. Dea also creates a Wall of Fame, highlighting all unit patients who have recovered, to help staff cel­ eb~ate successes in caring for this challenging patient population, As staff develop skills and knowledge related to the management of TBI patients, they notice the improved outcomes in monitored patients as the technology detects changes in cerebral oxygen level; these data promote early aggressive intervention. However, Dea begins to realize that this success itself is creating a new source of moral distress. Although patients with TBI are often managed in the neuroscience ICU, they are also admitted to other reus where this technology is not available, In addition, the application of the tech­ nology varies depending on the preferences of the attending physician and residents assigned to manage TBI patients. Although some of the medical staff are open to the use of the brain tissue oxygen monitor, others do not agree that it is a valid tool. Because the nurses see the better than expected outcomes of moni­ tored patients as compared with those who do not receive monitoring, they believe that all patients should receive this technology. The staff’s moral distress height­ ens after a particularly troubling case of a young TBI patient who was never monitored with the new technology and subsequently died. Recognizing an ethical conflict with the potential to recur with increasing frequency, Dea takes action using a preventive ethics approach. She consults a nurse with expertise in ethics to meet with the staff. During that meeting, their moral distress is articulated. The nurses value their growing expertise in brain tissue oxygen monitoring and note that this new technology has served as the impetus for improving the care of TBI patients. However, the nurses are not empowered to maximize its application because decisions a bout the admission of patients with TBI to an ICU are made without nursing input, and because the medical staff, not CHAPTER 13 Ethical Decision Making Staff Moral Distress Preventive Ethics*-cont’d the nursing staff, makes the final decision to make use of the brain tissue oxygen monitor. During the meeting, the staff identify a number of strategies for decreasing their moral distress. One is directing admission of TBI patients to the neurosci­ ence ICU, recognizing at the same time that patients with thoracic and abdominal trauma, as well as TBI, would still be admitted to the trauma ICU; in addi­ tion, many TBI patients are first admitted to the trauma ICU while these other problems are ruled out. Better communication between ICU charge nurses was con­ sidered as a means to improve nursing input into bed assignment. Another strategy discussed in the meeting was advocacy for patients’ needs on the part of the neuroscience nurses with the medical staff. The staff is encouraged to use Dea as a resource when they encounter resistance from their medical colleagues. A final strategy identified at this meeting was to track the outcomes of patients who have received brain tissue oxygen monitoring and thus develop a database to support the value of this tool. Dea agrees to collect the data, review each case, and follow up on quality of care issues. Dea then works with a colleague in the trauma ICU to improve communication among the neuroscience ICU, trauma ICU, and neurosurgical team. They arrange a meeting with nurses from both ICUs and surgeons from the neurosurgery and trauma teams. At that meeting, the use of aggressive measures in TBI patients, including brain tissue oxygen monitoring, are discussed. In follow-up, Dea and her physician colleagues in neu­ rosurgery and neurocritical care develop algorithms for the management of TBI, identifying patients who may benefit from brain tissue oxygen monitoring and facili­ tating their admission to the neuroscience ICU. These algorithms are reviewed by the trauma service for incor­ poration into the trauma manual, a document used by all trauma residents. Dea also continues to encourage and support her staff to be proactive advocates. She coaches the nurses toward effective advocacy and role-models collaboration and information sharing in her own communications with residents and attending physicians. Over time, Dea begins to see an increased acceptance of the new tech­ nology and of an aggressive approach to managing TBI among the neurosurgery teams. Two members of the nursing staff, with Dea’s encour~ agement and guidance, developed a poster about their moral distress and steps to address it. The poster was accepted and presented at a national conference (Pracher, Moss, & Mahanes, 2006). The nurses attending the con­ ference to present the poster learned that their situation is not unique; other conference attendees noted similar conflicts in their own units and validated the distress experienced as a result. Although a closer connection between the neurosci­ ence and trauma ICUs is a secondary benefit, concerns about inconsistencies in care continue. Patients with TBI continue to be admitted to the neuroscience and trauma ICUs, and are not always transferred quickly if they need monitoring. Through a collaborative prOcess with the CNS in the trauma ICU, a new approach to standard­ izing the care ofTBI patients is identified and plans are made to incorporate brain tissue oxygen monitoring in the trauma I CU. The database that Dea has maintained demonstrates positive patient outcomes that support this change. Dea lends support to the CNS in that unit as she begins to train the staff in the use of the technol­ ogy and the algorithms for responding to the informa­ tion it provides. Two years after the initial educational session on this technology, Dea notes that “there is still work to do to optimize the care of these patients.” However, because of her proactive response to the staff’s distress, champions for this technology now exist on both units, and an environment for effecting positive change has been created. ·we gratefully acknowledge Dee Mahanes, MSN, RN, Charlottesville, VA, for sharing lhls exem~ar, This case highlights how the ethical decision making competency of APNs can lessen the reoccurrence of moral problems. In this situation, Dea’s actions went beyond resolving a single case of moral distress and focused on the features of the system that were contributing to the distress of the staff. As this exemplar shows, recurring ethical problems, particularly moral distress, are some­ times a result of the structure of care delivery systems in an institution. Dea’s case demonstrates that applying a preventive ethics approach to the system requires perse~ verance and ongoing identification of new strategies to change complex and interrelated system features. Phase 4: Promoting Social Justice Within the Health Care System The final phase in the ethical decision making competency is seen in mature APNs who have expanded their focus of concern to incorporate the needs of their larger specialty 347 348 PART II Competencies of Advanced Practice Nursing population. This phase again builds on the previous ones as APNs move their sphere of involvement beyond their institution into the societal sector. Moving into the arena of social justice is an historic legacy and a current impera­ tive. Falk-Raphael (2005) has noted that Nightingale’s work bequeathed to professional nursing “a legacy of justice-making as an expression of caring and compas­ sion” (p. 212). Increasing attention to social justice has been seen in nursing literature in the United States and internationally (Bell & Hulbert, 2008; Buettner-Schmidt & Lobo, 2011; Grace & Willis, 2012; Tarlier & Browne, 2011}. Although APNs prepared at the master’s level may develop Phase 4 practices over time, the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice (2006) strongly supports APNs moving into a larger arena of ethical decision making, with explicit preparation in DNP programs. The need for nursing to speak to mount­ ing concerns regarding the quality of patient care delivery and outcomes in policy and public forums is one justifica­ tion for doctoral-level education for APNs. Most of the DNP Essentials address the need for systems leadership in these larger forums; one in particular, “Health Care Policy for Advocacy in Health Care:’ advocates for DNP gradu­ ates to “design, implement and advocate for health care policy which addresses issues of social justice and equity in health care. The powerful practice experiences of the DNP graduate can become potent influencers in policy formation” (p. 13). In a number of hallmark reports, the Institute of Medicine (!OM, 1999, 2001, 2003) has highlighted the fragmentation and systems failures in health care and called for restructuring efforts to achieve safe, effective, and equitable care. Equity is primarily an issue of justice; as noted, concerns about access to and distribution of Some have asserted that all nurses should include socio­ political ad,vocacy in their practice if the profession is to fulfill its social mandate (Falk-Raphael, 2005). TI1is is a tall order; most undergraduate nursing programs do not include the requisite skills needed for this level of advo­ cacy. Even APN curricula may not include such content, so the APN must commit to continued skill development and involvement in national organizations to reach this phase. One distinguishing feature of the APN’s activities in this arena as compared with other nurses is the clinical expertise of the APN. The central competency of direct clinical practice and the APN’s cutting edge understand­ ing of the clinical needs of her or his patient population provide the platform from which the APN speaks to social justice issues. Nurses in policy, research, or othernon-APN roles often call on APNs to provide expert information on the policy and larger system issues that confront their specialty populations. _ health care resources are key justice concerns of APNs. To enact this level of the ethical decision making competency requires sophisticated use of all of the core competencies of advanced practice nursing. In particular, advocacy, communication, collaboration (see Chapter 12), and leadership (see Chapter 11) are required. APNs active in this phase are often consultants to policy makers or serve on expert panels crafting policies for specialty groups. Essential knowledge needed for this phase includes an understanding of the concepts of justice, particularly distributive justice (the equitable allocation of scarce resources) and restorative justice (the duty owed to those who have been systematically dis­ advantaged through no fault of their own). In addition, knowledge of the health policy process in general (see Chapter 22) and specific health policies affecting their specialty population are needed by APNs to move into this level of activity. In this phase, APNs work as agents of change for justice in the health care system on behalf of their specialty populations. Nurses in many roles have been increasingly con­ cerned by the current health care system and the gaps in care provision to many of the neediest members of society. Exemplar 13-4 describes one APN’s development through the phases of the EDM competency, including beginning activity in Phase 4. Chapter 22 also provides examples of Phase 4 actions by nurses who have expanded their concerns about individual patients into working for social justice in the policy arena. Putting It All Together: Development Through the Four Phases of the Ethical Decision RT is a FNP who is completing a DNP program. Her experience with providing health care to Hispanic migrant farmworkers in rural Virginia has given her many opportunities to use her ethical decision making skills. This exemplar portrays her journey through the phases of ethical decision maldng as she has developed her APN practice. One fall evening, RT accompanies a team of outreach workers into a migrant farm camp to screen workers for diabetes and heart disease. Three older men approach her with concerns regarding Antonio, one of the new younger workers. They report that he has been losing weight, sweating all the time, shaking, and appears ill. They are scared for him and a little frightened that he J I I j! l ~ II ,, I !I II I ‘ I cHAPTER 13 Ethical Decision Making Putting It All Together: Development Through the Four Phases of the Ethical Decision Making Competency* -contli could be contagious. RT encourages the men to have him schedule an appointment with her the following night, because she would be staffing a mobile clinic in the community. The men are concerned that Antonio would be unwilling to give his information to anyone because he lacks legal documentation to be in the United States. The men promise that they vv:ill encourage Antonio to make an appointment and reassure him that RT will not report him to the authorities. The next night, RT waits for someone to come to her with these concerns. When this doesn’t happen, she walks outside the mobile clinic and luckily sees Antonio. He is easy to identify because he is sweating profusely and his hands are trembling. RT asks her community health worker to ask him to join her in the mobile clinic and, to her surprise, he agrees. Antonio looks much older than his reported age of 19. He is frail, anxious­ appearing, and sweaty. After taking a history and doing an examination, RT suspects that he might have hyper­ thyroidism. She convinces Antonio to allow her to check some laboratory values. The laboratory results confirm RT’s suspicions. Nor­ mally, she could refer a patient with hyperthyroidism to endocrinology for urgent treatment because she is con­ cerned that Antonio could go into a coma or die. Instead, she is faced with many barriers to accessing care for him. He is in this country illegally and uninsured. Although he lives well below the poverty line, he does not qualify for Medicaid. He might qualify for financial assistance but he would be leery of providing any identification or pay stubs. Furthermore, Antonio does not want to see any doctors in the United States, preferring to wait until he returns to Mexico in 6 months to have the issue addressed. He does not want to miss time from work because he thinks he might get fired. In addition, he has transportation and language barriers, which would make it difficult to see a specialist. RT struggles to determine whether the principle of beneficence or the principle of respect for autonomy should carry the most weight in her decision making. Stories such as this are common when working with migrant Hispanic farm workers. In Phases 1 and 2 of RT’s development in-ethical decision making, she would have thought only about the individual situation. The first two phases solidified knowledge regarding professional obligations and ethical theories that could help her deal with this situation. As she expanded into the third stage, she began to look at the bigger problem, the system. The existing referral system placed most of the burden on patients to obtain appointments with specialists. The referral staff was not allotted the needed time to assist non-English speaking or illiterate patients, such as Antonio, with obtaining financial assistance at the local academic hospital. RT realized that ethical dia­ logue would need to occur among staff and administra­ tion for the health care center’s culture to change. Antonio’s case helped shape a new system. The outreach coordinator now assists migrant farmworkers with the financial screening process, interpretation, and trans­ portation. Antonio’s case was the first success. Although it took three times as long to get him the care he needed, he finally underwent thyroid- ablation and is now a healthy 20-year-old. As RT is developing her pra’ctice as a DNP-prepared NP, she is looking for ways to promote social justice within the health care system. She knows that making changes in the ethical practice ·of one health care center is not enough to mal Evaluation of the Ethical Decision _M:aki’.’lL~r.e.t~——- The evaluation of ethical decision making should focus on two areas-the process and the outcome. Process 349 350 PART II Competencies of Advanced Practice Nursing evaluation is important because it provides an overview of the moral disagreement, interpersonal sldlls used, interac­ tions between both parties in conflict, and problems encountered during the phases of resolution. Whether the APN is the facilitator or a party in conflict, a deliberate and reflective evaluation of the process of resolution should occur. It is useful for the APN to assess the type of issue, interrelational and situational variables, ethical shifts that occurred during the process, and strategies used by all parties during the negotiation phase. Mediation can be a very useful process (Dubler & Liebman, 2011). As the APN reflects on the process, attention should be given to how similar situations could be anticipated and resolved in the future. Debriefing situations with the affected parties is also an impmtantprocess evaluation strategy. To avoid the debriefing session becoming simply a venting of emotions, the APN must keep the focus on preventive ethics and what needs to change in the environment to avoid or minimize future problems. Deliberate and consistent review of the process will help the APN assess various approaches to the resolution of ethical dilemmas and identify the onset of moral con­ flict earlier. This ongoing evaluation of process is particu­ larly important in Phase 4 because it takes years for changes in system-wide health policies that support social justice to be implemented. Evaluating grassroots and leg­ islative efforts as they occur will help identify strategies likely to be successful versus those that ought to be abandoned. Evaluation of the outcome is also critical because it acknowledges creative solutions and celebrates moral action. Components of the outcome evaluation include the short- and long-term consequences of the action taken and the satisfaction of all parties with the chosen solution. Unfortunately, a successful process does not always result in a satisfactory outcome. Occasionally, the outcome reveals the need for changes in the institution or health care system. The APN may need to become involved in advancing these desired changes or identifying appropri­ ate resources to pursue them. The goal of outcome evalu­ ation is to minimize the risks of a similar event by identifying predictable patterns and thereby averting recurrent and future dilemmas. The questions “What do we want to happen differently if we are confronted with a similar situation?” and “What first steps can we take to achieve this change?” can be helpful in framing the discussion. Although evaluation of the ethical problem is an important step for preventing future dilemmas and build­ ing ethically sensitive environments, tension and uneasi­ ness will remain in some situations. In true ethical dilemmas, even the best process may still result in a course of action that is not seen positively by all participants. It is important for the APN to acknowledge that many issues leave a “moral residue” that continues to trouble participants involved in the conflict (Epstein & Hamric, 2009). Part of the outcome evaluation must address the reality of these lingering feelings and the related tensions that they create. Barriers to Ethical Practice and Potential Solutions A number of factors influence how moral issues are addressed and resolved in the clinical setting. Some bar­ riers are easily corrected, but others may require attention at institutional, state, or even national levels. Regardless of type, the APN must identify and respond to the barriers that inhibit the development of morally responsive prac­ tice environments. Barriers Internal to the Advanced Practice Nurse Lack of knowledge about ethics, lack of confidence in one’s own ability to resolve ethical conflicts, and a sense of powerlessness are potent barriers to the application of the ethical decision making competency. Such moral uncer­ tainty and perceived powerlessness can lead to ethical issues being swept under the rug and unaddressed in clini­ cal settings. To address these barriers, APNs need to seek out opportunities for ethics education through schools of nursing and professional organizations. Values clarifica­ tion exercises can be helpful for APNs and all members of the health care team who experience conflict. For example, an emergency room NP may be faced with providing care for a climinal injured in a gunfight that killed innocent bystanders. Although it is disturbing and difficult to provide care for an individual who has caused harm to others, the NP’s personal views should not interfere with the quality of the care provided. The process of values clarification is helpful when preparing for this situation. Once personal values are realized, the NP can more easily anticipate situations in which these conflicts will arise and develop strategies for managing them. APNs can empower themselves by role-modeling ethical decision making within their team. For example, in the primary care setting, a clinic nurse mentions to the APN a concern about how a patient situation was handled. In addition to reflective listening and emotional support, the APN questions the nurse, encouraging her to gather all the necessary information, and together they begin to analyze the ethical elements and consider practical solu­ tions. This process demonstrates the process of ethical decision making for the clinic nurse and empowers the APN in the development of this core competency. Includ­ ing ethical aspects of a patient’s case in interdisciplinary rounds, scheduling debriefing sessions after a particularly difficult case, reading and discussing ethics articles specific to the specialty patient group in a journal club, and/or using simulation activities in which caregivers role-play different scenarios are additiollal strategies that APNs can use to empower themselves and other nurses to examine ethical issues. Lack of time is often a barrier faced by APNs seeking to enact this competency. In some cases, the APN may need to resolve a presenting dilemma in stages, with the most central issue addressed first. The APN also needs to enlist the aid of administrative and physician colleagues in recognizing the ongoing consequences of lack of time for team deliberations. For example, if a patient is not receiving adequate pain management because the bedside nurse is concerned about hastening death and is unaware of the full treatment plan, the CNS should first focus on relieving the patient’s pain. Once the immediate need is addressed, the CNS can help the nurse identify nonphar­ macologic interventions to promote comfort and educate the nurse about the dosage and timing of medications to prevent wide fluctuations in pain management. At this point, the administrative leadership may need to be approached about supporting ongoing staff education. An additional strategy, such as arranging for the nurse to rotate to a hospice unit, represents a preventive approach to help avert similar dilemmas in the future. lnterprofessional Barriers Different approaches among health care team members can pose a barrier to ethical practice. For example, nurses and physicians often define, perceive, analyze, and reason through ethical problems from distinct and sometimes opposing perspectives (Curtis & Shannon, 2006; Hamric & Blackhall, 2007; Shannon, 1997). Although the roles are complementary; these differing approaches may create conflict between a nurse and physician, further separating and isolating their perspectives. A physician may be unaware of the nurse’s differing opinion or may not rec­ ognize this difference as a conflict (Hamric & BJackhall; Shannon, Mitchell, & Cain, 2002). One study has indi­ cated that physicians and nurses deal with the same ethical problems and use similar moral reasoning but that differ­ ences are related to professional roles, the types of respon­ sibilities each group had in the situation, and the resulting different questions each group raised (Oberle & Hughes, 2001). Similar to a ground figure optical illusion, the nurse and physician may look at the same ethically troubling clinical situation but, because of differences in their per­ spectives, they focus on opposing features and arrive at different conclusions about the appropriate course of action. In such situations, the APN first seeks to under­ stand alternative interpretations of the situation and estab­ lish respectful and open communication before seeking resolution of ethical problems. cHAPTER 13 Ethical Decision Making 351 Open communication, cooperation, demonstrated competence, accountability for both role and actions, and developing trust by the physician and APN will facilitate a successful collaborative relationship. Physi­ cians, nurses, and APNs need to engage in moral dis­ course to understand and support the ethical burden that each professional carries (Curtis & Shannon, 2006; Hamric & Blackhall, 2007; Oberle & Hughes, 2001). Encouraging examples of interprofessional collaboration include the European MURINET (Multidisciplinary Research Network on Health and Disability) project, which launched a training course for researchers on ethics, human rights, and classification of functionality (Ajovalasit et al., 2012), and the National Consensus Project, comprised of nursing and medical professional organizations that appointed a team of doctors and nurses to revise the Clinical Practice Guidelines for Quality Palliative Care (National Consensus Project for Quality Palliative Care, 2009). A third robust initiative, initiative including multiple professions has been the establishment of the Interprofes­ sional Education Collaborative (IPEC), whose mission is to advance interprofessional education so that students entering the health care professions not only seek collab­ orative relationships with other providers but view col­ laboration as the norm and not the exception (IPEC, 2011). An expert panel developed core competencies for interprofessional education; one of the four domains focuses on values and ethics.The emphasis of this domain is developing climates of mutual respect and shared values. Box 13-Slists the 10 competencies identified. These statements focus on values shared by all health care disciplines and can serve as a basis for building col­ laborative interprofessional teams that emphasize preven­ tive ethics. As noted, collaboration is the key strategy for eliminating interprofessional barriers. Patient-Provider Barriers Additional barriers to ethical practice arise from issues in the patient-provider relationship. Health care providers, employees of the health care institution, and patients and families all contribute to the settings in which most APNs practice, offering opportunities for both personal enrich­ ment and cultural conflict (Linnard-Palmer & Kools, 2004). For example, parents may inform an NP in a pedi~ atric outpatient setting that for cultural and religious reasons, they do not want their child immunized. In this case, the NP is faced with a belief that places the child and community at risk. The NP wants to preserve the parent’s rights and preferences but is concerned about the child’s best interests and the potential harm to other children if they are exposed to an illness from a nonimmunized child (Fernbach, 2011). Issues that result from culh1ral diversity 352 PART Il Competencies of Advanced Practice Nursing Values and Ethics -Plate the interests of patients and populations at , the_ cent’erof hlt’e_rprofessional health cm;e deUyery. . RespeCt _the dignity and privacy’ of patie’ntS l~hile mah1taining cOnfideritiality in the delivery of team~based care. 3. Em.brace the cultural diversity and , individual differences that characterize patie_nts,:popu!a:tions, and the health care , , team. ,-4, Respect t,he m1ique cultUres, Values, roles and r.espollsibilities, and expertise ofothe.r·health professf~ns, . · 5. Work ill cooperationwith those. who .r.e.ceive qwe, those who provide care, and others Who cOp.trihute ~o or support’ the delivery of Prevention. and health services, 6 .. pevelop a trustirig rdationship.with patients, familieS(an,d other team memb~rs. · P~m M_ana,ge_ ethical dilemmas specific to :int~rprOfessional_patient!pop~lation-c_entered :care situations. 9. Act with honesty and integrity in relationships wij:h -p~tients, f Ensuring appropriate care for patients at the end of life is an additional challenge to ethical practice. Although some patients use advance directives to convey their wishes, these forms are not always applicable to specific clinical situations and the appointed decision maker may never have discussed end-of-life care with the patient. APNs in primary care settings should encourage such conversations or guide patients, particularly those with life-limiting conditions, through the process of making their wishes known if they become incapacitated. The “Physician Orders for Life-Sustaining Treatment” (POLST) framework (Center for Ethics in Health Care, 2012) pro­ vides an effective approach to discuss and document patient wishes. In acute care settings, particularly ICUs, APNs can broker conversations with families who are facing difficult decisions and ensure that the choices in care are based on what the patient would want and not on anticipatory grief. In a study of families of ICU patients, Ahrens and coworkers (2003) found that 42 of 43 families receiving support and enhanced communica­ tion from a CNS-physician team were able to make deci­ sions to withhold or withdraw care at the end of life. The authors noted that “This finding underscores the impor­ tance of intentional and well-designed communication and support systems for families making medical and moral decisions” (p. 322). More recently, Curtis and col­ leagues (2012) reported an evidence-based intervention involving “communication facilitators” to improve inter­ professional team and family communications in the ICU (Curtis, Ciechanowski, Downey, et al., 2012). Another barrier to ethical practice that challenges many APNs is the issue of patient non-adherence. Patients and families may choose not to be actively involved in their care or resist an APN’s attempts to improve their well-being, which raises clinical and ethical questions. Managing non -adherent patients is ethically troubling because they consume a disproportionate amount of health care resources, including the APN’s time, redirect­ ing these resources from patients who are more amenable to the established plan of care. There are no easy solutions to managing the non-adherent patient (Resnick, 2005); however, full consideration of this issue is beyond the scope of this chapter. In many case.<>, other factors, such as impaired thinking and concentration, knowledge deficits, financial issues, and emotional disorders, can conflict with the patient’s ability to follow the prescribed treatment plan (Bishop & Brodkey, 2006). APNs should seek additional support from resources such as social workers or horne health nurses to discover the underlying causes and find solutions. Organizational and Environmental Barriers Lack of support for nurses who speak up regarding ethical problems in work settings is a potent barrier to ethical practice. Unfortunately, early research and recent litera­ ture have revealed disturbing examples of environments I r- i II I i I fi II I ! ji ~ .. II j in which nurses’ concerns were minimized or ignored by physicians, administrators, and even by other nurses (Ceci, 2004; Gordon & Hamric, 2006; Klaidrnan, 2007; Ulrich, 2012); such environments can lead to moral dis­ tress. Recent studies have revealed significant correlations between the level of moral distress and turnover of nurses and physicians (Hamric, Borchers, & Epstein, 2012; see Schluter et al. [2008] for a review of other studies). These findings lend urgency to the need for APNs to provide leadership in building ethical practice environments. APNs need to assess the level of support that nurses receive from others and work to create environments that are “morally habitable places” (Austin, 2007, p. 86). Con­ sideration should be given to organizational ethics pro­ grams, which focus on building structures and processes to deal with conflicts of roles and expectations (Rorty, Werhane, & Mills, 2004; Hamric, White, & .Epstein, in press). APNs need to develop skills in collaborative con­ flict resolution and preventive ethics to build ethical prac­ tice environments in which moral distress is minimized and the moral integrity of all caregivers is respected and protected. APNs should identify resources within and outside the institution to assist with the resolution of ethical problems. Internal resources may include chaplain staff, liaison psychiatrists, patient representatives, social work staff, ethics committees and their members, and ethics consultation services. Resources outside the institution include the ANA’s Center on Ethics and Human Rights (www.nursingworld.org/ethics), Veterans Administra­ tion’s National Center for Ethics in Health Care (www. ethics.va.gov), ethics groups in national specialty organi­ zations, and ethics centers in universities or large health care institutions. The recognition of a moral dilemma does not commit the APN to conducting and managing the process of resolution individually. APNs should engage appropriate resources to address the identified needs and work toward agreement. As noted, nursing’s ethical obligations to patients and their families can also be challenged when organizations implement cost containment practices. Continuity of care and knowing the patient and family are significant issues for APNs in in acute and primary care settings. In outpa­ tient settings, pressures to see more patients in less time can decrease the APN’s opportunity for individualized problem solving for patients and families. Thomas and colleagues (2005) noted that NPs’ interpersonal skills can enhance the patient’s “personhood:’ an essential part of the caring relationship and the provision of holistic care. Whittemore (2000) has argued that resolving ethical dilemmas requires knowing the patient as a person to be able to recognize the salient aspects of a situation that are important for resolution. However, in time-pressured CHAPTER 13 EthicalDecisionMaking 353 settings, the emphasis is on efficiency and not on the patient-provider relationship or the provision of holistic care. APNs struggle in these types of environments to balance the needs of individuals with generalized treat­ ment approaches and productivity targets. However, it is also the case that the costs of the U.S. health care system are unsustainably high and growing (Emanuel et al., 2012). Improving the efficiency and effec­ tiveness of care delivery at a reduced cost can itself be seen as a moral good, one that requires clinicians to work together with administrators to achieve cost-effective goals. Also, there are times when cost -conscious care can enhance accessibility and quality. APNs can bridge clinical and administrative perspectives and collaborate with administrators to help achieve quality patient outcomes at reduced cost to the system. One proposal for decreasing costs involves removing scope of practice barriers to increase the use of APNs in the United States (Emanuel et al., 2012; IOM, 2011). APNs can be instrumental in decreasing the adversarial view between clinicians and administrators that hampers decision making in many settings. Many institutions are willing to make concessions in the delivery of patient care if there are clear outcome data that support a change in practice. APNs can suc­ cessfully navigate the cost -conscious health care environ­ ment if they effectively demonstrate how their unique contributions to patient care; although more time­ intensive, ultimately reduce health care expenditures (see Chapter 23). Because patients have shorter hospital stays, open communication and collaboration \lith the health care team, patients, and families are essential behaviors for optimal planning. Also, as described in Phase 4, APNs should maintain and affirm patient’s rights and articulate strong ethical reasons for the interventions; questioning and challenging features in the health care system that negatively affect the quality of care delivered may be necessary. Finally, there is a need to review patient out­ comes consistently and the quality of nursing care pro­ vided {see Chapters 23 and 24) because these data can be powerful in building the case for quality changes to promote ethically responsive environments. With its emphasis on cost-effectiveness research and incentives for achieving positive patient outcomes, together with sanctions for underachievement (e.g., charging hospitals for high levels of readmissions), the PPACA is expected to accelerate the reliance on outcome data as a guide to practice. Box 13-6 lists websites that contain valuable ethics resources for clinicians. Many specialty organizations issue policy statements related to ethical issues or publish guidelines for their members’ use in responding to ethical problems. Box 13-6 also contains sites useful 354· PART II Competencies of Advanced Practice Nursing Websites for Ethics Resources P<;>licy Stat!’lrnent~ or Guidelines .A,)l~Jri~1i!l.Acaderny ,of N~qrology,. Practic~ Statement.s: http://~.aan.~om{resqurces.html Apleric~ ,:·.Acade.fi?y .·,of· .Pe~atrics,. Policy .Statements: httjJ:/IjVWW.aap,org/policy •.. A¢ericaU .. ,Association ofNurse~,Anesthe{ists:(AA.NA): >ftp://)VWW.aan~ .. com American· ·College of Nurse-Midwives: IJ.ttp://www. ·Www.aslrne.org ,A,meric’l11 SoCietY for Reproductive Medicine: http:// www~asnp.org Aille.ikarl :society: of :An:est,h¢#ologis.ts •. PollCy,.State:. .l1lents: http:l/www.asahq.org/standards • . . American Society. £or ·Transplantation, P9licy State~ l1len(s: http://www.a+t,org/index.html I 1JU<:ric:an.s for Better. Care of the Dying: http://W”W. Canadian Resourcefor Nursing Ethics: http://www. Nur~in~Efhi~s~ca ,. . . . . . Institute . of Me4ici?.e;: N~t;ii:mal Academy. of Science.s:: . ·.http:/ /jVWW4.nas,edunON!/IOMJ{orne.nsf for Nursing Ethics:. http:/lwww. for gathering current literature on legal and ethical issues. Conclusion The changing health care environment has placed extra­ ordinary demands on nurses in all care settings. Many forces conflict with nursing’s moral imperatives of involve­ ment, connection, and commitment. The ethical decision making competency involves four phases of progressively complex knowledge and skill development necessary to move patient care, caregiving environments, and the larger system toward ethical practices. As a core competency for Iriternatio.P.al.COuJ!cil of Nurses: http://www,icn.ch Mi_dwest Bioethics Center: .http://www.midbiO,org ·}J ·NatiOilal. Inst!tutes of Health. Resources on Bioethics: http://www.nih.gov/sigs/bioetbics/ . . NaHon Preparation for this competency begins in graduate educa­ tion, but continues throughout the APN’s career.

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