Clinical Ethics Handbook for Nurses: Emphasizing Context, Communication and Collaboration (The International Library of Bioethics, 93)

This handbook provides tools for nurse educators, ethics educators, practicing nurses and allied health professionals for developing confidence and skill in ethical decision making in interdisciplinary settings such as acute and chronic care hospitals and clinics. It is useful for all healthcare personnel who face ethical issues in the course of their work and who work with nurses to resolve these issues. While the content is based on a US context, the concerns of nurses internationally are discussed and emphasized. Nurses working in acute and chronic care settings face many obstacles to providing good care and are often the first line of defense related to patient safety and meeting the needs of patients and their families. Some of the obstacles to optimal patient care are institutional, some sociocultural, and others the result of inadequate communication. Evidence points to the idea that while nurses do have the knowledge and skills to address practice problems of various sorts, they may not be confident in their skills of ethical decision making and advocacy actions. This is a resource to develop moral agency on behalf of individuals and to address broader barriers to good care raised at the local, community, or social levels. Preface Acknowledgements Contents Part I Foundations of Professional and Clinical Ethics 1 Introduction 1.1 The Challenges of Contemporary Healthcare Environments 1.2 A Practical Strategic Resource for Point of Care Nurses, Nurse Educators and Leaders 1.3 Clarifying Concepts and Terms 1.3.1 The Meaning of Health 1.3.2 Connecting and Distinguishing Bioethics, Professional Ethics, Medical Ethics and Nursing Ethics 1.4 Problems Faced by Nurses: Major Themes in the Literature 1.4.1 Moral Distress 1.4.2 Complexity in Contemporary Practice Environments 1.5 Knowledge, Skills and Attributes Needed for Nurse Moral Agency 1.5.1 Disempowered Nurses 1.5.2 Status of Nurse Perception of Power Internationally 1.5.3 Attributes Needed for Nurse Moral Agency 1.6 Summary References 2 Developing Ethical Awareness and Ethical Sensitivity 2.1 Foundations for Ethical Nursing Practice 2.2 Challenges in the Ethical Preparation of Nurses 2.3 Developing Ethical Awareness 2.4 Ethical Sensitivity and Rest’s Four Component Model of Moral Action 2.4.1 The First Component is Ethical (Moral) Sensitivity 2.4.2 The Second Component is Moral Judgment 2.4.3 The Third Component is Moral Motivation 2.4.4 The Final Component of the Four Component Model Involves Moral Character 2.5 Moral Agency, Advocacy, and Moral Distress: Implications for Good Patient Care 2.5.1 Moral Agency 2.5.2 Advocacy 2.5.3 Moral Distress 2.6 The Nurse’s Role in Interdisciplinary Contexts and Moral Communities 2.7 Self-Reflection and Reflective Practice 2.8 Summary 2.9 Exercise: Practicing Self-Reflection References 3 The History, Language and Tools of Ethics: Application in Healthcare Settings 3.1 History of Bioethics: Role of Philosophy and the Humanities 3.1.1 History of Medicine: Goods and Harms 3.1.2 Scientific Advances and the Beginnings of Modern Medicine 3.1.3 Professional Ethics 3.1.4 The Beginnings of Bioethics 3.2 Relationship of Moral Philosophy and Moral Theory to Healthcare and Nursing Goals 3.3 Moral Theory and Ethical Principles: Purpose, Scope and Limits in Healthcare 3.3.1 Deontology 3.3.2 Consequentialism 3.3.3 Moral or Ethical Principles in Healthcare Decision-Making 3.3.4 The Georgetown Principles 3.4 Other Ethical Perspectives: Care, Feminist, Narrative, Virtue 3.5 Decision-Making Frameworks 3.6 Summary 3.7 Discussion Questions References Part II Essential Knowledge and Skills for Ethical Deliberations 4 Effective Communication—Improving Communication Skills 4.1 Introduction: The Ethical Importance of Good Communication 4.2 Foundations of SAVI 4.2.1 The Challenge of Communicating: Noise 4.2.2 Understanding SAVI: The Shift from Analyzing People to Analyzing Behavior 4.2.3 The Structure of SAVI 4.2.4 Moving from Yellow Light to Green Light 4.2.5 Using the Rows in Conversation 4.2.6 The Columns: Personal, Factual, Orienting 4.2.7 The Squares 4.2.8 Putting it All Together: A Dynamic Systems Perspective 4.3 SAVI IN PRACTICE 4.4 Summary and Case Examples 4.5 Exercises References 5 Models of Ethics Deliberation and Consultation 5.1 History of Healthcare Ethics Committees and Consultation 5.1.1 Landmark Cases 5.1.2 The Evolution of HECs 5.2 Healthcare Ethics Committees Description and Functions 5.2.1 Clinical Ethics Consultation 5.2.2 Ethics Education 5.2.3 Ethics Policy Development 5.2.4 Healthcare Ethics Committees: Composition 5.2.5 Access 5.3 Ethical Frameworks and Consultative Approaches 5.3.1 Practical Approaches to Ethical Deliberation 5.4 Organizational Ethics Consultative Models 5.4.1 Organizational Ethics: Case Examples 5.5 Preventive Ethics 5.5.1 Models of Preventive Ethics 5.5.2 Palliative Care, Nursing, and Preventive Ethics 5.5.3 Advance Directives and Advance Care Planning 5.6 Summary Appendix A: Example Discussing Advance Care Planning With a Patient References 6 Cultural, Religious, Language and Personal Experiences: Influences in Ethical Deliberations 6.1 Introduction 6.2 Perspectives on Ethics and Culture 6.3 Culture, Value, and Meaning 6.3.1 Culture as a Vehicle for Meaning 6.3.2 Important Definitions 6.3.3 Checking Assumptions—Avoiding Stereotypes 6.3.4 Situate Responsibilities in Nursing Goals and Perspectives. 6.3.5 Shared Trauma and Microaggression 6.4 Reflection on Personal Beliefs And Values And The Role Of Bias, Implicit Bias, And Prejudice 6.4.1 Conscientious Objection 6.5 Religious and Spiritual Influences on Ethical Decision-Making 6.5.1 Belief in Miracles and Effects on Patient ‘Good’ 6.5.2 Surrogate Acting Against Patient Preferences 6.5.3 Conflicts of Conscience 6.6 Language and Interpretation Difficulties 6.6.1 Risks to Patients and Family 6.6.2 Appropriate Nurse Actions 6.7 Strategies for Nurses to Use 6.7.1 Improving Sensitivity to Cultural Differences and Language Difficulties 6.7.2 Virtues of Biomedical Ethics 6.7.3 Principles of Shared Decision Making 6.8 Summary References Part III Ethical Issues Associated with Practice and Research 7 Neonatal and Pediatric Acute and Palliative Care 7.1 Introduction 7.2 The Historical Development of Neonatal Intensive Care Units and Seminal Cases 7.3 Principles of Parental and Team Decision-Making for Premature and Critically Ill Neonates 7.3.1 Moral Status 7.3.2 Medically Ineffective Treatments and Care Redirection 7.3.3 Providing Parental Support 7.4 Issues in the Care of Children and Adolescents 7.4.1 Balancing Autonomy and Beneficence 7.4.2 Children’s Involvement in Decision-Making 7.5 Engaging in Self-Reflection, and Reflection on Practice 7.6 Summary References 8 Genetics: Nurses Roles and Responsibilities 8.1 Introduction 8.2 Genetic Screening and Testing: U.S. and International Perspectives 8.2.1 Prenatal Genetic Screening and Testing 8.2.2 Newborn Screening 8.2.3 Genetic Testing for Children and Adults 8.2.4 Direct to Consumer Testing 8.3 Impact of Genetic Information 8.3.1 Informed Consent 8.3.2 Privacy and Confidentiality 8.3.3 Eugenics 8.3.4 Discrimination 8.3.5 Access: Genetic Workforce Issues 8.4 Genetic Research and Biobanks 8.5 Summary References 9 Ethical Issues in Psychiatric and Mental Health Care 9.1 Stigma and Implicit Bias 9.1.1 Mindfulness 9.2 Access to Care 9.2.1 Social Determinants of Mental Health 9.2.2 Health Insurance and Mental Health Parity 9.2.3 Open Notes and Cures Act 9.3 Privacy and Confidentiality 9.3.1 Mandated Reporting 9.3.2 Stigma, Privacy and Data Sharing 9.3.3 Telepsychiatry 9.3.4 Therapeutic Use of Self as a Nurse 9.4 Restrictions on Autonomy 9.4.1 Involuntary and Voluntary Treatment 9.4.2 De-escalation 9.4.3 Chemical and Physical Restraints 9.5 Collaborative Recovery 9.5.1 Trauma-Informed Care 9.5.2 Patient-Centered Care 9.6 Psychological Impacts of COVID-19 on Nurses 9.6.1 Secondary Trauma 9.6.2 Mental Health Workforce 9.7 Case Studies 9.7.1 Case 1: Implicit Bias 9.7.2 Case 2: Therapeutic Use of Self 9.8 Summary References 10 Research on Human Subjects: Nurses Roles and Responsibilities 10.1 Introduction 10.1.1 Subject Versus Participant 10.1.2 Research Benefits, Burdens and Injustice 10.2 A Brief History of Biomedical Research Ethics and Associated Regulations 10.2.1 Defining Human Subjects Research 10.2.2 Human Rights 10.2.3 Barriers to Honoring Human Rights 10.2.4 Nursing and Human Rights 10.2.5 Human Rights Infractions: Insights from Cognitive Psychology 10.2.6 A Very Brief History of Human Rights Abuses in Research 10.2.7 Ethical Principles Guiding Human Subjects Research 10.3 Common Problem in Research Settings 10.3.1 Respect for Persons 10.3.2 Beneficence 10.3.3 Justice 10.4 Nurses Roles and Advocacy Strategies 10.4.1 Questions to Ask Before Entering a Study 10.4.2 Examples of Problems and Strategies for Resolution 10.5 Thought Experiment 10.6 Suggestions and Questions 10.7 Summary References 11 Organizational Influences on Ethical Action 11.1 Introduction 11.2 Institutional Mission, Vision, and Values 11.3 Supportive Unit Structures 11.3.1 Moral Spaces 11.3.2 Interdisciplinary Collaboration 11.4 Nursing Ethics and Institutional Policy 11.5 Strategies for Change: Cases for Discussion 11.6 Summary References 12 Social Justice, Structural Disparities and Nursing Responsibilities 12.1 Introduction 12.2 Perspectives on Social Justice 12.2.1 Ancient to Contemporary Theories of Justice 12.3 Health and Healthcare as Human Rights’ Issues: Disparities and Nursing Advocacy 12.3.1 Defining Health and Healthcare 12.4 Structural Injustice and Health Disparities 12.4.1 Structural Injustices Local and Global 12.4.2 COVID-19 and Injustices 12.4.3 Common Injustices Recognizable By Nurses 12.5 Strategies for Nursing: Identifying and Addressing Injustices 12.5.1 Nurses’ Contributions to Just Environments and Policies 12.6 Chapter Summary 12.7 Book Summary References Index