|
Back to Article List
July 13, 2001
By
Jill E. Winland-Brown, EdD, ARNP
Julie has worked in various med-surg settings for almost 20 years. She pretty much keeps to herself, as she is so involved in her ‘outside life’. Recently, however, issues at work have been ‘invading’ her thoughts outside of work and she is increasingly feeling caught in the middle. Michelle, another RN, has frequently asked Julie to witness her wasting ˝ of a narcotic when she is only to give ˝ of the required dose. Michelle suspects that she is giving double the ordered dose, as her patients seem to be very docile after Michelle medicates them. Because of the pace on the unit, Julie never seems to witness the actual ‘wasting’—it is always after the fact. She doesn’t feel like she can refuse, because this is a common practice. The least of her worries is her co-workers accusing her of bringing this to someone’s attention if it turns out to be inaccurately perceived on her part.
While this scenario may sound ‘bland’, if it is bothering a nurse and is constantly on her mind, it is of concern. In our every day professional life we are confronted with dilemmas requiring ethical analysis. A dilemma is any situation that arises where either there is a conflict between what is ‘right’ and other duties and obligations, or where there are two equally unsatisfactory alternatives. The conflict may be internal when two ethical principles that the nurse may hold seem to be in opposition as in the case of maintaining confidentiality while being honestly truthful with a patient. In the scenario above with Julie, she is concerned that patients may be getting double doses of medications without physicians’ awareness. She is also concerned that Michelle is lying about this. In addition, Julie is concerned that if caught, she will be responsible for the errors being made as she is signing the narcotic book.
Just as clinical competence takes years to develop, so does ethical competence. With caring as the essence of nursing, both types of competence are equally important. In order to practice from an ethical base, a nurse must incorporate principles of ethics in everyday reasoning. There are seven ethical principles that nurses must consider although each situation may only call for several of them. The ethical principles include; autonomy (respect for all persons); beneficence (action promoting good); nonmaleficence (doing no harm); veracity (truth telling); confidentiality, fidelity (keeping promises); and justice (fairness).
A framework is suggested for analyzing dilemmas that provides a systematic method for considering which choice of action might be the most ethical and allow the nurse to apply reason to the situation rather than just acting on emotion or his/her usual first impulse. Using the mnemonic ‘ETHICAL’ and following these 7 steps in a dilemma will assist the nurse in arriving at an ethical decision.
E Examine the data
T Think about which person(s) should be making the decision
H Humanize the options by constructing a decision tree
I Incorporate the ethical principles, legal statutes, standards of care, and hospital policies
C Choose an action
A Act
L Look back and evaluate
The above scenario will be considered using this ETHICAL framework. In examining the data, Julie feels like she has perceived things accurately. She has made a note of several instances where this happened, then went back and reviewed the nurses’ notes on those patients who received the ‘double dose’ and found that all the patients slept for the next 4-8 hours or even longer. Julie is also concerned that if Michelle is lying about this aspect of her nursing care—what other illegal things is she doing and lying about. Julie thinks that initially she is the decision maker and must bring this information to her immediate supervisor. In humanizing this situation, Julie thought about four options with resulting consequences available to her. A decision tree allows one to visualize the many choices available with the potential consequences resulting from each action.
Decision Tree to Humanize the Options
| Options | Consequences |
| Confront Michelle | Michelle could denyMichel could say Julie is out to ‘get her’Michelle would be more cautions with future ‘wasting’ of narcotics and neverask Julie again
| | Do Nothing |
Turmoil inside Julie would continueContinue to suspect Michelle and question her other nursing actions
| | Approach co-workers |
Co-workers may wonder why Julie has so much time to make up accusations
Think Julie is paranoid
Agree with her and state they thought it was only them who suspected wrongdoing
| | Approach supervisor |
Accuse Julie of ‘meddling’
Ignore her
Begin to investigate data
|
In incorporating the ethical principles, Julie respects Michelle’s autonomous practice but feels that beneficence requires that she pursue some action. She is required by the Code for Nurses to report unethical care of which she has first hand knowledge. Julie has decided to choose to notify her supervisor as she felt that this action supported the ethical principles, legal statutes, and Code for Nurses. The action might not make her popular with her co-workers, but she will be able to live with herself knowing that she acted in patients’ best interests. As Julie looks back and evaluates the situation after the fact, she realizes that if she had to choose all over again, she would take the same action. This truly reflects an ethical action!
The American Nurses Association (ANA) Code of Ethics for Nurses sets forth the values and ethical principles that guide the clinical decisions of all practicing nurses. The code also provides guidance for nurses in justifying differences between personal and professional values. The Code sets the ethical standards for nursing while the Nurse Practice Act of each state established the legal standards. The newest version of the Code of Ethics (last revised in 1985) will be voted on this summer in the House of Delegates at the ANA convention.The ANA also has developed many position statements related to practice as well as other areas of nursing that may assist nurses in developing policies in their own institutions to guide an ethical practice. The website for The Center for Ethics and Human Rights of the American Nurses Association (http://www.ana.org/ethics/) provides resources in this area.
While developing ethical competence takes time and energy, it becomes second nature, and becomes interwoven in the fabric of the nurses being. While there are no ‘cut and dried’ answers to any dilemma, following this process will ensure that the nurse acted ethically and applied reason rather than emotion in resolving a dilemma. The end result is that the nurse no longer feels caught ‘between a rock and a hard place’.
References
Winland-Brown, J. (2001). Ethical and Legal Issues of a Caring-based Practice,
Chap. 26 in Dunphy, L. & Winland-Brown, J. (Ed). Primary Care- The Art and Science
of Advanced Practice Nursing. Phila: FA Davis.
|
|
 |
Corporate