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Developing Ethical Skills: A Framework
CATHERINE ROBICHAUX
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Describe the role of personal values clarification in ethical skills development
Discuss how ethical sensitivity contributes to the interpretation of an ethical situation
Distinguish ethical from nonethical situations
Apply the components of an ethical decision-making model
Explain strategies to maintain ethical motivation and overcome personal/professional barriers to implementing an ethical decision
Discuss the purpose of reflection on and evaluation of an ethical decision
Nurses encounter ethical questions in their everyday clinical practice and often experience uncertainty about patient/family concerns related to informed consent, quality of life, surrogate decision making, and other issues. As members of an interdisciplinary health care team, nurses may also confront ethical situations in their professional relationships with peers. Increased challenges are posed when these issues occur in an environment with a deficient ethical climate that does not support the moral agency of the nurse. As a registered nurse, you may have had an ethics course or some content in your initial nursing preparatory program. However, you will find that more in-depth knowledge and skills will be very useful to assist you with effectively addressing the existing and potential ethical issues you face on a daily basis.
This chapter presents a framework for the development of ethical skills in nursing practice (Robichaux, 2012; Robinson et al., 2014): James Rest’s four-component model (FCM; 1986). The FCM describes the deliberative thought processes that occur from recognition of situation with ethical content, as in the Case Scenario, to implementation of a justifiable action. The FCM integrates the cognitive and affective processes that form an understanding of ethical nursing practice: sensitivity, judgment, motivation, and action. As with attainment of clinical skills and expertise, ethical skills can be experientially learned and refined over time through role modeling and other strategies that are presented.
CASE SCENARIO
John received his BSN after serving in the army as a medic. He has worked in the critical care unit (CCU) of a 400-bed community hospital in the Southwest for several years and recently attained certification as a critical care nurse (CCRN). John has become very familiar with Mr. T and his family as the patient has been admitted to the CCU three times within the last 6 months for exacerbations of severe heart failure (HF). On this admission, Mr. T’s condition deteriorated rapidly with episodes of hypotension and worsening renal function requiring use of inotropes, intubation, and dialysis.
Following 8 days of aggressive treatment, Mr. T is alert and showing signs of improvement and a decision is made to begin weaning him from the ventilator. After numerous unsuccessful weaning attempts over the next week, Mr. T is diagnosed with ventilator dependence and a decision is made to perform a tracheotomy. John has cared for Mr. T and his family during this hospitalization. He believes that Mr. T and his family do not fully understand various treatment options and possible implications despite discussing them in a family care conference.
VALUES AND ETHICAL SKILLS
Ethical behavior and action in nursing practice evolve from personal values that inform and direct our decisions in all aspects of our lives. An understanding of our values requires self-awareness and continual appraisal of our motivations in situations with ethical content. This understanding can be considered preliminary to the first component in developing ethical skills, ethical sensitivity.
“A value can be defined as a belief upon which one acts by preference” (Olpin & Hesson, 2016, p. 135). Values inform our actions and provide direction and meaning in life. Personal values are formed over time and can be influenced by family, culture, education, and the environment, among other factors. Certain values may be constant while others may change or evolve in response to experiences. Rokeach (2008) identified two types of values: instrumental and terminal. Instrumental values are personal characteristics that we possess or aspire to, such as being ambitious, caring, or intelligent. Terminal values are those that we consider most important or desirable and may include security, love, and independence. Instrumental values assist in attaining terminal values. As these core values become part of who we are, they may influence recognition of ethical situations and/or impact decision making in less than conscious ways.
Awareness of one’s values is an important first step in developing ethical skills and competence. This recognition also enables us to identify and articulate these values when they are challenged in professional and/or organizational contexts. Approaches to value clarification can involve the use of real or hypothetical situations, group or individual work, self-analysis, or other methods. It is a continual, reflective process that promotes alignment of our thoughts with our actions, thus enhancing personal integrity (Burkhardt & Nathaniel, 2014).
Developing self-awareness includes being actively conscious of our thoughts and physical/emotional reactions and questioning, in a nonjudgmental manner, why we are feeling that way. This awareness may enable us to identify the underlying value that is reflected or challenged in a given situation. It may also assist in developing the ability to step back and listen to others’ interpretations of the same situation. Listening to and discussing our reactions with others help us to articulate our own values and perhaps revise our perspectives (Olpin & Hesson, 2016).
CASE SCENARIO (CONTINUED)
Returning to the Case Scenario, John considers why he thinks that Mr. T and his family are not fully informed of treatment alternatives. He believes Mr. T would not want to be placed in a facility for ventilator-dependent patients, a likely outcome that was presented briefly during the family conference. John also has difficulty imagining a life dependent on a machine. Although he understands the benefits of technology in achieving therapeutic outcomes, he does not think that will happen for Mr. T. who had told John that he does not want to be a burden for his family.
In exploring his reactions to the situation, John realizes that he highly values his ability to engage in and enjoy many different sports and be independent. He is very physically fit, similar to his father and brothers. John discusses his thoughts with Jackie who has been a nurse for over 10 years and was his preceptor. Jackie asks if Mr. T, who is Japanese American, and his family have discussed possible future outcomes. She also suggests that culturally they may have a more communal approach to making these decisions. John states, “Mrs. T is not well and her two daughters live out of town. She has said that she can’t care for Mr. T at home and would not be able to visit him very often. I don’t think he would want to live that way. No one has talked with the family enough about the possible need for long-term care.”
As nurses increasingly work with both patients and providers from different cultural backgrounds, awareness of personal values and understanding those of others are essential to ethical practice. This understanding is also considered an essential Quality and Safety Education for Nurses (QSEN) competency for both undergraduate and graduate nurses, as presented in Table 2.1. Because values are learned within the context of a particular culture, a value such as respect for individual autonomy may not be shared in a culture that is relationship centered and prefers communal decision making. The provision of patient centered care that is culturally sensitive does not require the provider to ignore his/her values. It does, however, emphasize relationships and understanding of the cultural worldview of others rather than simply offering a choice to participate in clinical decisions about what treatments to forgo or accept. This cross-cultural reflection is especially important when exploring potential end-of-life care (Johnstone, 2012).
Question to Consider Before Reading On
You can begin to determine your personal values by answering general questions such as:
1. Where would I like to be in 5 to 10 years or what would I like someone to say about me in my eulogy?
ETHICAL SENSITIVITY
Ethical sensitivity involves the ability to interpret and identify with the reactions and feelings of others. This skill involves an awareness of how our actions or inactions in a given situation may affect others and, in so doing, assume a sense of responsibility or obligation. It can be said that all nursing actions and interactions are inherently ethical in nature as they are aimed at achieving good for patients, families, and all those who are recipients of care. Ethical sensitivity is also relevant in our relationships with peers and coworkers. As Benner (2003) has observed, “It is not an exaggeration to say that in every clinical encounter, there may ethical issues at the personal, provider, and social levels” (p. 375).
How do we distinguish between ethical situations or problems and those that are nonethical, what Burkhardt and Nathaniel (2014) refer to as “practical dilemmas” or “decisional conflicts”? Routine problems are generally those that focus on preference, expediency, and economy. They can usually be resolved with appropriate information and resources. In contrast, ethical problems are described by terms such as harm, benefit, right, wrong, and so on, and have elements of uncertainty, value, and conflict. A situation may have ethical content when an action freely performed or not performed has the potential to harm or cause considerably less benefit to others. Harms can include death, pain (physical, emotional, spiritual), loss of freedom, opportunity, or loss of dignity or self-esteem (Gert, 2005).
Table 2.1
Developing Ethical Skills: Relevant QSEN Competencies
Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values information, communication, and education. (Knowledge) Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. (Skills) Communicate patient values, preferences, and expressed needs to other members of health care team. (Skills) Value seeing health care situations “through patients’ eyes.” (Attitudes) Respect and encourage individual expression of patient values, preferences, and expressed needs. (Attitudes) Willingly support patient-centered care for individuals and groups whose values differ from own. (Attitudes) Describe basic principles of consensus building and conflict resolution. (Knowledge) Participate in building consensus or resolving conflict in the context of patient care. (Skills) Value continuous improvement of own communication and conflict resolution skills. (Attitudes) Value the perspectives and expertise of all health team members. (Attitudes) Respect the centrality of the patient/family as core member of any health care team. (Attitudes) Act with integrity, consistency, and respect for differing views. (Skills) Use effective practices to manage team conflict. (Skills) |
Source: AACN (2012); Cronenwett et al. (2007).
Practical dilemmas or decisional conflicts may arise in situations in which moral claims compete with nonmoral claims that are characterized by self-interest or based on personal values (Burkhardt & Nathaniel, 2014). For example, in the Case Scenario, John may have been required to work overtime when caring for Mr. T during his initial admission crisis. John may have perceived a practical dilemma or a conflict of duties if he had promised his father that he would accompany him to a football game. This personal duty, however, does not have the same moral obligation as that of caring for Mr. T.
Sensitivity to situations that may contain ethical content can help nurses avoid erroneously identifying some issues as strictly clinical or administrative. As examples, nurse fatigue (ANA, 2014) and an inadequate number of registered nurses (Duffield et al., 2011) have been associated with a higher incidence of medication errors and increased patient mortality rates. In addition, fatigue impacts the health and safety of nurses resulting in a host of potential physical disorders and injury risk factors related to drowsy driving (ANA, 2014). Box 2.1 presents an application of Rest’s FCM to a case of nurse fatigue.
Box 2.1
Application of the Four-Component Model to a Nurse Fatigue Case Scenario
Carmen and Charles have worked together on the pediatric oncology unit of a large, academic medical center for about 5 years. Recently, Charles has begun working the night shift, 7 p.m. to 7 a.m., so he can attend school during the day to finish his BSN. Carmen has received report from Charles and assumed care of his patients on the day shift on several occasions. In the past 2 weeks, Carmen notices that Charles appears very exhausted during morning report. She also found him dozing in the break room while his patient’s infusion device was alarming and noticed several errors in his documentation. Today, Charles reported to Carmen that he rescheduled several medications for one patient because he had overlooked administering them at the proper time.
ETHICAL SENSITIVITY
Carmen thinks about the possible patient harm that could occur from Charles’s fatigue but wonders if it might be temporary until he adjusts to the night shift. She is aware of her primary ethical obligation to the patients but also considers her professional relationship with Charles and the potential impact to his career if she reports the incidents. Carmen decides to first share her concerns with Charles who states: “Well, nothing really happened. I’ll get used to the hours.”
ETHICAL JUDGMENT
Carmen considers the components of the ethical decision-making framework. The questions assist her in recognizing her principal responsibility to protect the patients as presented in the Code of Ethics (2015), which is also consistent with maintaining her moral integrity. However, she also values her professional relationship with Charles and his usual consistent ability to provide excellent patient care. Carmen realizes that there is a conflict between the principles of beneficence (supporting Charles) and nonmaleficence (avoiding patient harm). She decides to talk with Charles once again before discussing the issue with the nurse manager.
ETHICAL MOTIVATION
In Carmen’s second conversation with Charles about his fatigue and the potential for patient harm, he again states that he will get accustomed to the hours soon and she is not to worry. Carmen thinks about the next step and wonders if she will alienate Charles and the other nurses if she brings her concerns to the nurse manager. She does not want to jeopardize the cohesive nursing teamwork on the unit and is generally not a person who “speaks up” or “makes waves.” Carmen discusses her hesitation with the nurse educator who agrees to go with her to speak with the nurse manager.
ETHICAL ACTION
After the nurse manager listens to Carmen’s concerns, she and the nurse educator agree to speak with Charles about the possible consequences of his fatigue. They also know that the issue of nurse fatigue is not limited to Charles and there have been several “near misses” on the unit. The manager and nurse educator decide to present a class integrating the American Nurses Association (ANA) position statement on nurse fatigue (2014) and related evidence-based strategies designed to promote patient safety and the health of the nurse. One of these practices, creating a respite room where night nurses are encouraged to nap or rest, will be instituted immediately. The nurse manager will also work with Charles and other nurses to ensure that they do not work more than 12 hours a day or more than 40 hours in 7 days (Trossman, 2015).
Recognition of a situation with ethical content can be especially challenging in the present health care environment where the primary focus is often on efficiency and cost savings. Research suggests that professional socialization and organizational structures may impact nurses’ and other providers’ ability to be sensitive to the moral content of their practice. Insufficient or unsupportive coworkers and lack of time to provide adequate care may lead to perceptions of inadequacy and failed expectations resulting in erosion of ethical sensitivity and dulling of moral conscience (Gustafson, Eriksson, Strandberg, & Norberg, 2010).
Ethical sensitivity involves an understanding of alternate courses of action and how each might affect patients, family members, coworkers, administration, and others. This understanding may also avoid moral certainty, which can result in insensitivity to new information or alternative solutions. Moral certainty compels one to act on a chosen resolution to an uncomfortable situation but does not guarantee a positive outcome (Wurzbach, 2005). Respect for alternative perspectives, such as Jackie’s and the surgeon’s, is necessary if constructive dialogue is to occur and contribute to developing and sustaining a moral community. Gallagher and Tschudin (2010) describe a moral community as one in which values are made clear and shared, where these values direct ethical action, and where all feel safe to be heard.
Emotion and empathy are central in developing ethical sensitivity. To discriminate appropriately in an ethical situation, the nurse must be able to put himself or herself in the other’s position as noted in the QSEN competency, “Value seeing health care situations ‘through the patients’ eyes’” (Table 2.1). Overidentification and the influence of personal motives must be avoided, however. This skill can be enhanced through self-knowledge, critical reflection, and awareness of individual values, biases, and assumptions.
CASE SCENARIO (CONTINUED)
John thinks about his conversation with Jackie and her perspectives on the situation. He reflects on his motivation and still believes that Mr. T and his family do not fully understand treatment options and possible outcomes. John discusses his concerns with the surgeon performing the tracheotomy who states, “They seemed to understand everything during the care conference. I know the intensivist wants to move ahead with the trach quickly so the patient can be moved out of the ICU.” John replies, “I don’t think they completely understand the possibility that he will eventually be placed in a ventilator dependent facility or the chances that he may never be able to breath on his own. I understand the need to move the patient out of the ICU but the family requires more information like the option of terminal weaning.” “You will have to speak to the intensivist about that,” responds the surgeon, “I doubt that he will discuss that with the family.”
Questions to Consider Before Reading On
1. Can you describe a situation in which you or a class peer/colleague “overidentified” with a patient and/or family member?
2. What skills may be needed to maintain ethical sensitivity while avoiding overidentification?
ETHICAL JUDGMENT
The second component of the Rest’s framework, ethical judgment or decision making, has been widely studied in nursing and other disciplines (Page, 2012; Park, 2012). This deliberative process should reflect knowledge of ethical principles, theories, and professional codes. As with the decision-making model developed by Craig Klugman (see Table 2.2), used in this chapter and in several others in this text, most have elements that outline an approach to reaching a judgment through identifying and organizing facts so one can reflect on the issues. Use of a systematic and comprehensive process serves to improve the quality of ethical decisions (Grace, 2014).
Some decision-making models are linear while others revisit previous steps, as necessary with the overall goal of making a prudent choice, not achieving certainty. Most models integrate diverse ethical theories and approaches, as one alternative is not applicable for every ethical situation. Issues that arise during daily practice may not need in-depth consideration of all elements in a model. Others may be more complex such as in the Case Scenario and require careful evaluation (Robichaux, 2012).
The decision-making model can be applied at different stages in an ethical situation. It can be used by an individual nurse or the interdisciplinary team and patient/family to think through an ethical decision. In the Case Scenario, John may or may not be involved in the final decisions about Mr. T’s treatment and placement. However, he can use the model to guide judgment regarding his concern about the patient’s and family’s lack of knowledge about treatment options and outcomes, as presented in Table 2.2.
The decision-making model presented in Table 2.2 contains specific questions to consider that relate to the four principles of bioethics: autonomy, beneficence, justice, and nonmaleficence. Those questions associated with virtue and care ethics acknowledge the moral integrity of the nurse and his or her caring relationship with the “other,” in this case, the patient and his family. Every question in the model may not be relevant in every situation. In reality, there may never be enough information to ensure that a decision is perfect; however, it is possible to gain sufficient insight by considering the questions posed.
Questions to Consider Before Reading On
Recall an ethical situation that left you feeling concerned. Explore this situation with a class peer or colleague using the decision-making framework in Table 2.2.
1. What insights did you gain?
2. Would you or your class peer or colleague have done things the same or differently?
Table 2.2
Application of Ethical Decision-Making Model (developed by Craig Klugman)
VIRTUE | CARING |
Yes, by acting in accordance with professional value of advocacy.
Yes, by presenting action to all stakeholders.
No.
Has not called for ethics consult before but discussed action with nurse mentor. |
By ensuring that patient and family are aware of all options and potential outcomes.
All stakeholders will be involved in the ethics consultation.
The family believes in communal decision making and respect for elders.
Yes, and will be discussed during the ethics consult. |
AUTONOMY | BENEFICENCE |
Yes.
Yes.
The patient and his family.
Yes, to a certain extent but perhaps not entirely.
A purpose of the consult is to clarify the patient’s preferences. |
I believe the ethics consult will help clarify options/outcomes for the patient/family.
As mentioned previously, hopefully, it will help them make better informed choices.
The patient/family will have better understanding as will the care providers.
What is best is what the patient/family wants, but they should know all the options. |
NONMALEFICENCE | JUSTICE |
I would not want to be dependent on a machine and live in a long-term care facility. I think that the patient/family should have all the information unless they say otherwise.
If the patient/ family have already made up their minds, we should not try to impose our opinions
I have talked with the patient/family about the purpose of the ethics consult and they have agreed.
The patient has the tracheotomy without being aware of alternatives and possible outcomes. The patient is informed of alternatives and outcomes and chooses the tracheotomy or no intervention. |
The patient has been in the ICU for 2 weeks. He has end-stage HF and is ventilator dependent. There is a possibility that he will be transferred to an LTC facility. • If applicable, should these scarce resources be used on this patient? This may be discussed during the consult.
The patient does not have long-term care insurance.
• Legal obligations • Institutional policy • Public health interests Not noted at this point. |
HF, heart failure; ICU, intensive care unit; LTC, long-term care.
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