NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses

NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses INSTRUCTION: This assignment reinforces the importance of ethical decision-making in nursing. You will apply an ethical decision making model from this week’s readings to an ethical issue. Review “An Integrated Ethical-Decision-Making Model for Nurses” from this week’s Electronic Reserve Readings . Apply the ethical decision-making model in the article to access to care or an ethical issue of your choice: SOCIAL MEDIAL USE IN HEALTHCARE INSTRUCTION: Follow the steps provided in the model, including the following: State the ethical issue and its relevance for nursing practice. Collect and analyze additional information: NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses What populations does this serve? Who are the key stakeholders? What information is needed to overcome the problem? After looking at additional information, decide whether the initial problem was correctly stated. Develop alternatives and compare them: What alternative programs address the issues? Justify the decision: Explain why this is important, needed, or beneficial for vulnerable populations. Find strategies to implement the plan: What ethical arguments could you use to dissuade someone who disagrees with the program? Format your assignment as one of the following: 18- to 20-slide presentation 15- to 20-minute oral presentation 875-word paper Another format approved by your instructor Cite at least 3 evidence-based, peer-reviewed sources published within the last 5 years to support your position(s). Include an APA-formatted reference list. an_integrated_ethical_decision.pdf Article An integrated ethical decision-making model for nurses Nursing Ethics 19(1) 139–159 ª The Author(s) 2012 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733011413491 nej.sagepub.com Eun-Jun Park Kyungwon University, Korea Abstract The study reviewed 20 currently-available structured ethical decision-making models and developed an integrated model consisting of six steps with useful questions and tools that help better performance each step: (1) the identification of an ethical problem; (2) the collection of additional information to identify the problem and develop solutions; (3) the development of alternatives for analysis and comparison; (4) the selection of the best alternatives and justification; (5) the development of diverse, practical ways to implement ethical decisions and actions; and (6) the evaluation of effects and development of strategies to prevent a similar occurrence. From a pilot-test of the model, nursing students reported positive experiences, including being satisfied with having access to a comprehensive review process of the ethical aspects of decision making and becoming more confident in their decisions. There is a need for the model to be further tested and refined in both the educational and practical environments. Keywords decision making, ethics, ethical issues, nursing ethics, problem solving Introduction Patients’ safety and well-being are dependent, to a large extent, on professionals’ ethical decisions.1 Regardless of his or her excellence in clinical knowledge and skills, a healthcare professional who has low or non-existent ethical standards should be considered unfit to practice. For responsible healthcare, professionals have to be competent in ethical decision making.2 An ethical problem is ‘as [an ethical] matter or issue that is difficult to deal with, solve, or overcome and which stands in need of a solution’ (p.94).3 Ethical problems in a clinical setting are those we rarely confront in our daily lives, and ethical norms learned from our parents or schools are not sufficient to resolve clinical ethical issues. There are concerns about professionals’ ethical competency. Health professionals often adopt an inconsistent decision-making process or reach inconsistent ethical conclusions in attempts to resolve identical ethical problems.1,4,5 Moreover, they tend to come to decisions of an ethical nature before reviewing all possible alternatives or going through a systematic and comprehensive decision process.2 It is challenging for clinicians to make ethical decisions. Health professionals attempt to achieve the best possible and morally-justifiable resolution while prioritizing a patient’s interest.6 Accordingly, the quality of ethical decision making should be evaluated in terms not only of its conclusion but also the process of decision making. For example, whether all individuals Corresponding author: Eun-Jun Park, Department of Nursing, Kyungwon University, San65, Bokjeong-Dong, Sujeong-Gu, Seongnam-Si, Gyeonggi-Do, 461-701, Korea Email: [email protected] 139 140 Nursing Ethics 19(1) affected by the decision have an opportunity to share their informed decisions or preferences.7 An explicit and systematic method for ethical decision making is highly likely to improve the quality of such decisions for several reasons.2,8-11 First, ‘a model functions as an intellectual device that simplifies and clarifies the sources of moral perplexity and enables one to arrive at a self-directed choice’ (p.1701). NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 2 Second, it eliminates a possibility of deviated assessment of an ethical problem, for example, not considering all relevant parties and their diverse preferences,12 or reaching conclusions based on his/her intuition rather than on intellectual rigor.13,14 Third, ‘communication and documentation of an explanation for a course of action’8 and collaboration among stakeholders become easier throughout an ethical decision-making process when a systematic decision-making model is shared.7 A systematic decisionmaking model helps identify where a gap in understanding an issue or a difference in value systems (disagreements) exist among stakeholders (interdisciplinary team) through transparent communication.1,15,16 Finally, the use of a systematic model of ethical decision making will allow for the accumulation of information concerning ethical decisions, thus revealing norms.7 Although nurses make ethical decisions every day, we know little about how similar are our ethical decisions to those of other nurses. If we collect information on our ethical decisions, codes of ethics can be developed being based on our normative ethics,7 which can be more acceptable and evidence based. Structured models for ethical decision making have been introduced by different authors. To name a few, Johnstone’s moral decision-making model3 includes stages to assess the situation, to identify moral problem(s), to set moral goals and plan moral action, to implement moral plans of action, and to evaluate moral outcomes. According to Davis, Fowler, and Aroskar,17 if a conflict of moral duties or values exists, we need to go through the following stages: 1) review of the overall situation to identify what is going on; 2) identification of the significant facts about the patient; 3) identification of the parties or stakeholders involved in the situation or affected by the decision(s) that is made; 4) identification of morally relevant legal data; 5) identification of specific conflicts of ethical principles or values; 6) identification of possible choices, their intent, and probable consequences for the welfare of the patient(s) as the primary concern; 7) identification of practical constraints and facilitators; 8) make recommendations for action; 9) take action if you are the decision maker and implementor of the decision(s) made; and 10) review and evaluate the situation after action is taken. In addition, Thompson et al.’s11 DECIDE model suggests to: 1) Define problems – what is an ethical issue?; 2) Ethical review – what principles are relevant to case?; 3) Consider options; 4) Investigate – ethical outcomes, costs and benefits; 5) Decide on action; and 6) Evaluate results. However, it is hard to say what are their strengths or weaknesses and which one is more greatly-accepted by clinicians. Therefore, the current study critically reviewed structured ethical decision-making models found via a systematic search of literature and suggested an integrated and comprehensive ethical decision-making model by synthesizing strengths of the different ethical decision-making models and by pilot-testing it. The suggested ethical decision-making model is meant to be prescriptive so that nurses may directly apply it in practice. Methods Peer-reviewed journal articles were searched using Medline and CINAHL databases. The following keywords and the subject headings were entered into the PubMed and CINHAL interface on 30 June 2010: (ethical OR moral) AND ((decision AND making) OR (decision AND model)). Four hundred and twenty-six articles from Medline and 202 additional articles from CINAHL were retrieved. NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses Their titles and abstracts were reviewed for potential relevance, and then the selected 78 articles were reviewed for their full-text. Studies were selected if (1) their authors originally developed an original ethical decision-making process or model, (2) the ethical decision-making process or model clearly presented steps for decision, and (3) they were written in English. Studies were excluded mostly 140 Park 141 because (1) the authors introduced or applied an ethical decision-making process or model developed by other people, (2) they described only a theoretical background of ethical decision making without a decision-making process, or (3) their ethical decision-making process or model were developed for non-healthcare practitioners or for non-clinical settings, such as business, information technology, education, or research. A report of an ethical decision-making process for family physicians of Canada18 was included after reviewing references of the selected articles. Twenty structured ethical decision-making processes were reviewed systematically. An integrated ethical decision-making model was developed and modified through a pilot test of its usability. In two nursing ethics courses, 67 second-year baccalaureate nursing students were asked to solve four cases of clinical ethical problems through a group discussion involving three or four people and to submit a report of their decisions. This was a regular classroom activity of a nursing ethics course taught by the author. To test the developed model, 22 student groups discussed an initial two cases before learning the model, and, after a brief orientation, a further two cases applying the model. After the discussion class, the students were invited to participate in this study as a group by submitting their reflective essay of how the use of the structured model influenced their decision-making process or outcomes. Twenty student groups voluntarily participated without revealing their names, and thus individual participants were not identifiable so as to protect the students. Accordingly, whether or not they participated in this study, their grades or student-teacher relationships were unaffected. Findings Reviews of ethical decision-making or problem-solving models Twenty different ethical decision-making models were classified into two groups and ordered by their publication year: ‘Nine ethical decision-making processes’ (Table 1) and ‘Eleven ethical problemsolving processes’ (Table 2). An ethical problem-solving process includes an ethical decisionmaking process, which refers mainly to a cognitive process, but goes further by adding implementing the decision and evaluating its results. However, the authors of the reviewed articles did not clearly distinguish this difference, and interchangeably used the two terms: ‘ethical problem solving’ and ‘ethical decision making’. Only two studies1,18 out of the 11 (Table 2) explicitly acknowledged the difference by mentioning it in their article titles. These two terms were differentiated in this study, as necessary; otherwise the term ‘ethical decision making’ is used to refer to both, and they are analyzed and discussed together. The reviewed 20 studies were published from 1976 to 2010: one in the 1970s, seven in the 1980s, four in the 1990s, and eight in the 2000s. They show that interest in ethical decision-making process has been ongoing and that new models are being constantly developed even today. A chronological pattern of change was not found in ethical decision-making or problemsolving models. Among the reviewed 20 models, seven were developed for RNs or nurse practitioners, five for health professionals in general, four for physicians, two for psychologists, one for social workers, and one for a neonatal intensive care unit. Theoretical backgrounds and contextual factors. NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses Most authors suggested ethical pluralism applying diverse ethical theories and perspectives in decision making as one ethical theory or perspective was unlikely to be a panacea for every ethical problem. Ethical pluralism seems to be natural in modern societies that are experiencing an increasing diversity of values.3 By adopting various theoretical alternatives, nurses are more likely to have a comprehensive moral vision.16 Deontology (principle-based approach) and consequentialist theory (teleology, ends-based approach) were predominantly adopted by the authors of the models, whereas some models were based on a single ethical theory: consequentialism.7,15,19 141 142 Bunting and Webb (1988)23 Haddad (1992)24 8 stages of decision theory component (continued) 2. Gather information 1. Respond to the sense or feeling that something is wrong 5 stages Health professionals, long-term care givers Utilitarianism & deontology Ethical reasoning structure of a professional (individual value), Psychological factors influencing decision: bounded rationality, contextual component (the projection, mixed motives or decision maker’s relationship competing demands with the client, the health care system) Health professionals Grundstein-Amado (1991)21 1. Problem perception Identification of the ethical problem Identification of the medical problem 3. What further information do 2. Information processing you require about either of the Gathering medical-technical information above in order to make a Seeking other sources of judgment? information 4. Who are the persons who will 3. Identification of the patient be affected by the decision? preferences 5. What are the values of the involved parties? 1. What are the health issues? 2. What are the ethical issues? Physicians (Perinatologists & Nurse practitioners neonatologists) Consequentialism & deontology Consequentialism & nonconsequential ethical theory Substantive structure: 1) philoso(deontology, codes of ethics, phy of the physician-patient the patient’s bill of rights) relationship, 2) interpretation of ethical principles, 3) ethical theories, 4) ultimate sources of our morality 5 stages of procedural structure 10 stages Pellegrino (1987)6 1. Establish a data base 1. Establish the Facts 2. Determine what is in the patient’s best interests 6 stages Teleology & deontology (rights and duties of involved persons) RNs Curtin and Flaherty (1982)29 Table 1. Nine studies of ethical decision-making processes 143 Pellegrino (1987)6 7 stages RNs Consequentialism Decision analysis model DeWolf Bosek (1995)15 6. Reach resolution Grundstein-Amado (1991)21 Kaldjian et al. (2005)9 8. What are the alternatives available? 9. What are the ethical justifications for each alternative? 10. What are the probable outcomes of each alternative? 7 stages Neonatal intensive care unit Collaborative decision (Consequentialism approach) Individual value system & the core values of the unit (continued) 5. Work with others to determine a course of action 7. The choice 8. Justification Baumann-Holzle et al. (2005)14 4. Seek a resolution/ determine option 3. Identify the ethical problem Haddad (1992)24 5. Listing the alternatives 6. Listing the consequences 6. What are the conflicts between 4. Identification of the ethical issues values or ethical principles? 7. Must a decision be made and, if so, whose decision is it? Bunting and Webb (1988)23 Physicians Social workers Ethical pluralism including conseTeleology & deontology quentialism & deontology Value system or preference of the decision maker, context of the environment, individual decision making styles 7 stages 6 stages 1. State the problem plainly Mattison (2000)13 4. NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses State your decision in concrete terms 5. Justify the decision 3. Define the ethical issues and 2. Identify and clarify principles the ethical components 3. Determine the rights, duties, authority and capabilities of the decision makers 4. Determine possible causes of action 5. Reconcile facts and values; hold multiple values in tension Curtin and Flaherty (1982)29 Table 1 (continued) 144 Kaldjian et al. (2005)9 Baumann-Holzle et al. (2005)14 1. Background information /case details 2. Separating practice considerations and ethical compounds 4. Decision (consensus) 5. Planning the discussion with the parents 6. Discussion with the parents 1. Description of the child’s 2. Gather and organize data: medical information, care and medical facts, medical goals, social situation patient’s goals and preferences, 2. Different aspects of evaluation context the infant’s chances of survival the infant’s chances of dying if mechanical ventilation and other critical assistance are continued/withdrawn the infant’s actual suffering the infant’s possibility to live independently in the future without developing severe handicaps 3. Ask: Is the problem ethical? 3. Identifying value tensions 4. Identifying principles in the code 4. Ask: Is more information or dialogue needed? of ethics which bear on the case 3. Developing at least three 5. Identify possible courses of different scenarios action (benefit/cost, projected outcomes) Mattison (2000)13 6. Identify the best action 6. Assessing which priority/obliga- 5. Determine the best course of action and support it with tion to meet foremost and jusreference to one for more tifying the choice of action sources of ethical value: ethical 7. Resolution principles, rights, consequences, comparable cases, professional guidelines, conscientious practice 7. Evaluate the action 6. Confirm the adequacy of the 7. Evaluation of the decision choice (justification) conclusion making process 3. Identify possible actions 4. Assign probabilities 5. Calculate expected values 1. Identify desired outcomes 2. Assign utilities DeWolf Bosek (1995)15 Table 1 (continued) 145 RNs Consequentialism & deontology Aroskar (1986)25 Psychologists Consequentialism Tymchuk (1986)7 6. Implementation (continued) 9. Participate actively in resolving the issue 10. Apply state/federal laws governing nursing practice 11. Evaluate the resolutive action taken 4. Determination of which alternative to 8. Choose and act on a resolutive action implement 5. Review procedures 9. Follow the situation until you can see 7. Reviewing the process to learn what 7. Evaluation needs to be changed in dealing with the actual results of your decision, and future ethical situations in patient care use this information to help making future decisions 5. Consider as many possible alternative 4. Seeing what help may be gained by looking at the alternatives from the decisions as you can perspective of ethical theories and 6. Consider the longand short-range concepts consequences of each alternative decision 5. Making a decision 7. Reach your decision 8. Consider how this decision fits in with your general philosophy of patient care 6. Taking action 11 stages 1. Identify the moral aspects of nursing care RNs & nursing students Code of ethics, ethical principles Cassells and Redman (1989)26 2. Gather relevant facts related to a moral issue 3. Clarify and apply personal values 4. Understand ethical theories and principles 5. Utilize competent interdisciplinary resources 6. Propose alternative actions 2. Determination of available 7. Apply nursing code(s) of ethics to alternatives help guide actions 3. Determination of who should decide which alternative to implement 7 stages 7 stages 1. Distinguishing a predominantly ethical situation from one, for example, that is primarily a communication issue 1. Determination of who should 2. Gathering an adequate information 3. State who’s involved in making the participate in the decision base decision 4. Identify your role (quite possibly, your 3. Identifying the value conflicts role may not require a decision at all.) Clinicians in general (The University of Colorado Medical Center) Consequentialism 9 stages 1. Identify the health problem. 2. Identify the ethical problem. Murphy and Murphy (1976)19 Table 2. Eleven studies of ethical problem solving processes 146 1. Identification of ethically relevant issues and practices 1. Perceive the situation as having ethical 1. Review the situation and identify a) concerns health problems, b) decision(s) needed, and c) key individuals involved 10 stages Psychologists Teleology, deontology, existentialism, synthesis of different ethical theories Individual influences: level of cognitive moral development, ethical orientation, demographic profile Issue specific influences (moral intensity): temporal immediacy, magnitude of consequence, proximity, concentration of effect, probability of effect, and social consensus Significant other influences (family, friends, coworkers, peers, and/or a wide variety of extraneous stakeholders) Situational influences: culture/climate and p … NSG426 Phoenix Integrated Ethical-Decision-Making Model for Nurses Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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