Critical care nurses' participation in ethical decision making

Critical care staff nurses' participation in ethical decision making was studied in relation to the perceptions of environmental social support of 45 female staff nurses. Data obtained measured perceived environmental social support from six organizational subgroups and individual participation in ethical decision making. Validity and reliability testing was done on the instrument. When involved in an ethical situation, critical care nurses perceived low levels of environmental social support from hospital administrators, nursing administrators, and physicians. Co-workers were consistently perceived as most supportive across all aspects of social support. The majority of the nurses surveyed (74%) reported that ethical decisions were made by physicians or with reference to hospital policy, and that there were limited roles for individual, family, or nurse participation in such decision making. It was concluded that critical care nurses perceive a lack of free agency necessary to engage in ethical decision making in hospital environments or to act in an advocacy role in such situations.     

Critical care nurses, ethical decision-making and stress

Considerable attention has focused on describing ethical issues that critical care nurses face in their practice; however, less attention has been directed at describing the process of ethical decision-making. Systematic research linking aspects of ethical-decision making and stress is lacking. This cross-sectional study examines the relationship between selected aspects of ethical decision-making, stress and selected nurse characteristics. Sixty-one critical care nurses completed the Nurse's Ethical Decision Making—ICU Questionnaire and the Health Professions Stress Inventory. Findings revealed that nurses who selected the patient advocacy model had significantly higher nurse autonomy scores, that perceived anxiety had a negative association with nurse autonomy, and that workplace restrictions and stress were related.     

Ethical issues in nursing leadership

Social transition causes shifts and changes in the relationship between health professionals and their patients. In their professional capacity, it is important today for nurses to handle ethical dilemmas properly, in a manner that fosters an ethical environment. This article investigates the ethical concerns and decision processes of nurses from a knowledge construction perspective, and examines such issues as patient needs, staff perceptions, organizational benefits, and professional image. The decision making methods commonly used when facing ethical dilemma explored in this study include the traditional problem solving, nursing process, MORAL model, and Murphy's methods. Although decision making for ethical dilemmas is governed by no universal rule, nurses are responsible to try to foster a trusting relationship between employee and employer, health care providers and patients, and the organization and colleagues. When decision making on ethical dilemmas is properly executed quality care will be delivered and malpractice can be reduced.     

Caring for one and all – Exploring ethical challenges in an ICU

This discussion paper explores some of the complex ethical and moral issues confronting contemporary critical care nurses. In contemporary healthcare discussions, there is an increased appreciation of the complexity of ethical challenges, the multiplicity of stakeholders and that a broad range of possible and practical outcomes exist. Furthermore, many scholars also acknowledge the limitations of principle based ethical frameworks. In seeking to build critical care nurses’ capacity to negotiate the complex – and often conflicting – ethical challenges, the authors have adopted a person-centred, values-based approach in this case study. Furthermore, by exploring these complex issues, this paper supports and builds upon critical care nurses’ decision making capacities in the clinical area. This case study has been purposefully left open-ended with the aim of inviting the reader to consider the questions posed in a collegial, collaborative manner within the particular context in which she/he is embedded.     

Nurses' responses to ethical dilemmas in nursing practice: meta-analysis

Title. Nurses’ responses to ethical dilemmas in nursing practice: meta‐analysis. Aim. This paper is a report of a study to explore nurses’ responses to ethical dilemmas in daily nursing practice. Background. Concern about nurses’ ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses’ ethical practice, little is known about how nurses involve themselves in ethical decision‐making and action in daily care. Method. A meta‐analysis of nurses’ ethical behaviour was conducted using data from nine studies in four countries (n = 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses’ ethical responses, based on an adapted version of Kohlberg’s theory of moral development. Data were analysed using random‐intercept regression analysis. Findings. All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision‐guiding criteria rather than patients’ personal needs and well‐being. Conclusion. Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses’ ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.     

Challenges in home care practice: a decision-making perspective

A qualitative approach using an ethnographic design was used to investigate the nature of clinical decision making in home care practice from home care nurses' perspective. In-depth interviews were conducted with experienced home care nurses (N = 16) in addition to observations of nurses during meetings and client visits. The findings indicate that the decision-making challenges involved in home care practice consisted of the following 4 major categories: (a) challenges that arise in the development of client-centered care plans, (b) challenges that arise from the home care practice environment, (c) challenges related to developing confidence in clinical decision making, and (d) challenges in ethical decision making. Education and practice recommendations for enhancing clinical decision making are also discussed.     

Exploring the heart of ethical nursing practice: implications for ethics education

The limitations of rational models of ethical decision making and the importance of nurses' human involvement as moral agents is increasingly being emphasized in the nursing literature. However, little is known about how nurses involve themselves in ethical decision making and action or about educational processes that support such practice. A recent study that examined the meaning and enactment of ethical nursing practice for three groups of nurses (nurses in direct care positions, student nurses, and nurses in advanced practice positions) highlighted that humanly involved ethical nursing practice is also simultaneously a personal process and a socially mediated one. Of particular significance was the way in which differing role expectations and contexts shaped the nurses' ethical practice. The study findings pointed to types of educative experiences that may help nurses to develop the knowledge and ability to live in and navigate their way through the complex, ambiguous and shifting terrain of ethical nursing practice.     

Revisiting nursing in a nontherapeutic environment

To address unanswered questions raised by a previous study of nurses' ethical decision making in the context of psychiatric-mental health nursing, a reinterpretation of the previous data was conducted. In the earlier study, the core category was found to be Moral Survival in a Nontherapeutic Environment, and involved the nurses in a precarious and somewhat unsatisfactory balance in meeting their patients' needs while attempting to elicit no harm to themselves and others. In this second interpretation, we considered the nurses' actions from two different ethical perspectives--an ethic of care and a critical feminist ethic--in order to gain a deeper understanding of how these mental health nurses balance ethical demands in a nontherapeutic environment, and to understand why the nurses did not express satisfaction with their work.     

Ethical dilemma for nurses who manage marital violence in clinical setting

Marital violence or intimate partner violence is a serious and recurring public health issue. In the clinical setting, battered women often seek medical advice, because of the health problems that result from marital violence. Thus, nursing staff are the first persons to come into contact with the battered women. Can nurses execute their notify responsibility to prevent continued injury before obtained the woman's agreement? Will this action violate the principle of autonomy or not? Nurses would face an ethical dilemma when they care for battered women. The purpose of this article is to use Aroskar's ethical decision making model to analyze and clarify the ethical dilemmas involved in managing marital violence, including: under the value systems of the person, the profession, and time to illustrate the basic information, decision theory dimensions, and ethical theories or positions. It is hoped that this article provides an ethical decision making model for the ethical dilemmas facing nurses who manage marital violence in the clinical setting.     

"Thinking aloud": data collection in the natural setting

Knowledge of how nurses make decisions is a desirable outcome of research. However, there currently exists an inadequacy in the techniques used to examine such decision making. In this article, the authors describe the techniques used in two studies incorporating "thinking aloud" to successfully examine the decision making of expert critical care practitioners in the natural setting. Both techniques of thinking aloud were found to provide useful information regarding decision making in the natural setting. No ethical implications were experienced in conducting these studies in the natural setting. In conclusion, the use of thinking aloud in the natural setting is an effective means of data collection.     

Research Article: Perceptions of Japanese patients and their family about medical treatment decisions

Internationally, nurses and physicians are increasingly expected to undertake roles in communication and patient advocacy, including in Japan, where the reigning principle underlying medical ethics is in transition from paternalism to respect for patient autonomy. The study reports the results of a survey in two Japanese teaching hospitals that clarified the perspectives of 128 patients and 41 family members regarding their current and desired involvement in health decision‐making. The commonest process that was desired by patients and their family was for patients to make decisions after consultation with both the physician and their family. The decision‐making preferences for competent patients varied among the participants, who believed that families have a crucial role to play in health‐care decision‐making, even when patients are competent to make their own decisions. The findings will inform health professionals about contemporary Japanese health‐care decision‐making and the ethical issues involved in this process, as well as assist the future development of a culturally relevant model to support patients' preferences for ethical decision‐making.     

Winding roads and faded signs: ethical decision making in a postmodern world

We are living in an era, sometimes referred to as "postmodern," exemplified by complex change related to vast increases in information and technology and exposure to diverse people and ideas. Society as a whole is experiencing dissonance in solving ethical dilemmas, and nurses' ethical dilemmas are never far removed from the social context in which nurses practice. This article explores aspects of postmodernism that complicate ethical decision making. It is hoped that this discussion may aid nurses in understanding how world values, especially those of postmodernism, complicate ethical decision making in health care. Suggestions melding aspects of the postmodern with traditional approaches to ethical decision making are presented.     

Ethical decision-making processes used by health care providers

This paper reports the results of a study conducted with 18 health care providers (HCPs) in two Toronto hospitals The study examined and assessed how these HCPs make clinical–ethical decisions in the light of a theoretical model of clinical–ethical decision making Nine nurses and nine doctors were interviewed through two-phased, in-depth, semi-structured interviews The results suggest that, in relation to the two major elements of the model, namely the ethical component and the decision theory component, the HCPs did not follow a consistent and systematic pattern of ethical decision making Differences emerged between their actual self-reported behaviour and their potential moral capability (i e their abstract thought process) The general picture that emerged was that decisions were made in a narrow, habitual manner, through the elimination of the most significant and demanding elements of the process HCPs' ethical approaches affected the entire process of the decision making their perception of the problem, their search for and selection of information and evidence, and their development of alternatives and resultant consequences It is suggested to (a) further investigate and understand the subjective realities of the individuals involved in the decision making processes, their values and the meaning they ascribe to their choices, and (b) to establish extensive educational programmes to enhance HCPs' decision-making capacity and subsequently promote an effective and responsible professional practice     

A review of clinical decision making: models and current research

Aims and objectives. The aim of this paper was to review the current literature clinical decision‐making models and the educational application of models to clinical practice. This was achieved by exploring the function and related research of the three available models of clinical decision making: information‐processing model, the intuitive‐humanist model and the clinical decision‐making model. Background. Clinical decision making is a unique process that involves the interplay between knowledge of pre‐existing pathological conditions, explicit patient information, nursing care and experiential learning. Historically, two models of clinical decision making are recognized from the literature; the information‐processing model and the intuitive‐humanist model. The usefulness and application of both models has been examined in relation the provision of nursing care and care related outcomes. More recently a third model of clinical decision making has been proposed. This new multidimensional model contains elements of the information‐processing model but also examines patient specific elements that are necessary for cue and pattern recognition. Design. Literature review. Methods. Evaluation of the literature generated from MEDLINE, CINAHL, OVID, PUBMED and EBESCO systems and the Internet from 1980 to November 2005. Results. The characteristics of the three models of decision making were identified and the related research discussed. Conclusions. Three approaches to clinical decision making were identified, each having its own attributes and uses. The most recent addition to the clinical decision making is a theoretical, multidimensional model which was developed through an evaluation of current literature and the assessment of a limited number of research studies that focused on the clinical decision‐making skills of inexperienced nurses in pseudoclinical settings. The components of this model and the relative merits to clinical practice are discussed. Relevance to clinical practice. It is proposed that clinical decision making improves as the nurse gains experience of nursing patients within a specific speciality and with experience, nurses gain a sense of saliency in relation to decision making. Experienced nurses may use all three forms of clinical decision making both independently and concurrently to solve nursing‐related problems. It is suggested that O'Neill's clinical decision‐making model could be tested by educators and experienced nurses to assess the efficacy of this hybrid approach to decision making.     

Factors influencing ethical decision making in the home setting.

The process of ethical decision making does not differ according to the patient care setting. However, various factors in home care affect the way in which decisions are made. The factors to consider are the amount of time needed to make a decision, the involvement of the patient and family, the need for support systems, the difficulties with interdisciplinary communication, and the lack of an ethics committee. Recognizing the ways in which these variables affect the decision making can help home healthcare nurses resolve the ethical dilemmas they face. In addition, staff education programs, the use of consultants, and the development of ethics committees are possible strategies to facilitate ethical decision making.     

Ethical components of caring

The meanings of caring that emerge from the ethics literature are professional value; personal value; understanding humankind's existence; understanding meaning of values, choices, and priority systems; moral decision making; dignity; worth; healing powers within; being treated as a person; and partners in treatment. These meanings of caring are incorporated into the practice realm of critical care nurses. Clients in the critical care units demand a nurse who will treat them with respect, understanding, dignity, worth, partnership; provide choices; understand their values; guide them in moral decision making; and empower their healing capacities. As technology continues to explode, more and more ethical dilemmas will evolve and the critical care nurse will need to bridge the advancing technology with human caring. Then her expert nursing care will make the empowering difference in the client's care.     

Informed consent and the elderly. An ethical challenge for critical care nursing

Nursing ethics was long reticent about ethical challenges that elderly patients pose for critical care nursing. One of these, the legal doctrine of informed consent, has important implications for critical care nursing ethics. Deriving from the principle of respect for persons and intended to preserve their autonomy, informed consent represents both a duty and an ideal for care givers to implement in the process of ethical decision making. All too often the ideal is lost, however, and the doctrine reduced to a sterile and bureaucratic procedure. When elderly patients are unable to give an adequately informed consent, advance directives can enable them to express their wishes by prior choosing. If they become cognitively impaired, however, it is much more difficult to determine what, if any, preferences such a patient might express if able to do so. Medical empowerment of the elderly, a laudable social goal, can be as contradictory as informed consent itself and many elderly patients may opt out of their own decision making. The resultant moral distress of such a complex process is still another ethical challenge that faces the critical care nurse. Because nursing holds a position of moral centrality among the health care professions, critical care nurses cannot avoid the prospect that issues like those identified in this article will continue to challenge and confront them in the coming decade. By turning to colleagues in nursing as well as other professions, nurses can best strengthen and consolidate their vital role as mediators of meaning and morality in life-and-death situations.     

Practice of expert critical care nurses in situations of prognostic conflict at the end of life.

BACKGROUND: Prolonging the living-dying process with inappropriate treatment is a profoundly disturbing ethical issue for nurses in many practice areas, including the intensive care unit. Despite the frequent occurrence of such distressing events, research suggests that critical care nurses assume a limited role in end-of-life decision making and care planning. OBJECTIVES: To explore the practice of expert critical care nurses in end-of-life conflicts and to describe actions taken when the nurses thought continued aggressive medical interventions were not warranted. METHODS: A qualitative design was used with narrative analysis of interview data that had a temporal ordering of events. Interviews were conducted with 21 critical care nurses from 7 facilities in the southwestern United States who were nominated as experts by their colleagues. RESULTS: Three recurrent narrative plots were derived: protecting or speaking for the patient, presenting a realistic picture, and experiencing frustration and resignation. Narratives of protecting or speaking for the patient concerned preventing further technological intrusion and thus permitting a dignified death. Presenting a realistic picture involved helping patients' family members reframe the members' sense of the potential for recovery. Inability to affect a patient's situation was expressed in narratives of frustration and resignation. CONCLUSIONS: The transition from curative to end-of-life care in the intensive care unit is often fraught with ambiguity and anguish. The expert nurses demonstrated the ability and willingness to actively protect and advocate for their vulnerable patients even in situations in which the nurses' actions did not influence the outcomes.