Post on 02-Jun-2020
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Suzanne Rolls
Professional Nursing Advisor
NZ Nurses Organisation
June 2014
36th Enrolled Nurse Section Conference 2014
Nursing Ethics
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NZNO Code of ethics, 2010
The need for knowledge on ethics, ethical issues
and ethical decision making has never been greater. Nursing is undertaken in complex professional practice environments. Nurses daily face situations where they are challenged by under-resourcing, time pressures, short staffing and unhealthy roster patterns. Nurses with a knowledge of ethics, ethical frameworks and processes are better prepared for situations requiring ethical judgements.
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NZNO code of ethics 2010
Each situation is unique and exists in its own context. The most important values from the framework will be specific to the particular situation. Any one value is not always an over-riding value; the balance of values and their inter-relationships may change, not only with each situation, but also within each situation.
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The four‐box method
Is a useful tool for addressing clinical
ethical issues by asking us to allocate
specific items of information within four
boxes that each focus on different
aspects of care planning for individual
patients.
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The four-box method
CLINICAL ISSUES PATIENT PREFERENCES
The principles of beneficence and nonmaleficence
What is the patient’s medical history/
diagnosis/prognosis?
What are the treatment options?
What are the goals of treatment?
What is the benefit to the patient?
The principle of respect for autonomy
What are the patient’s expressed preferences for treatment?
Is the patient competent?
What would they want done?
What is in their best interests?
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4 box - QUALITY OF LIFE CONTEXTUAL FEATURES
The principles of beneficence and nonmaleficence and respect for autonomy
Prospects of survival with and without treatment?
Various effects of patient of treatment?
What are the plans for comfort and palliative care?
The principles of loyalty and fairness
How does this affect others: family
whānau and team?
Cost to Central health system?
Cultural/religious issues?
Law and Policy?
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Not making a decision, is not morally
neutral and is itself open to moral
appraisal, and there is a need to find a
way through that will lead to a decision
that we can agree is rational and
ethical (Godlovitch as cited in Keenan,
2010).
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The four-box method builds on the
recognition that even after reflection
we can and do still disagree on which
moral theory is ultimately correct.
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Truth telling & integrity
The right to be fully informed
Open disclosure
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Nurse’s Registration Cancelled For Dishonest
and Negligent Conduct HPDT359/nur10/160Pr
The Tribunal note that “honesty and
documentation are essential tools for a
nurse. Honesty in documentation is an
even more essential tool”
And that falsification of observations was “potentially a
great risk to patient safety”
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Research in NZ - Nurses
Job dissatisfaction
Burnout
Moral distress
- Martin Woods (2012)
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Moral distress – Woods 2012
“moral distress occurs when
professionals cannot carry out what
they believe to be ethically appropriate
actions because of internal or external
constraints”
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The five key areas:
Concerns they were not delivering good care due to pressures
from management to reduce costs.
Watching patient care suffer because of a lack of continuity in
who was providing treatment.
Working with other professionals who were not competent
enough to provide the care needed.
Carrying out physician's orders for what was considered to be
unnecessary tests and treatments.
Carrying out extensive life-saving actions when the nurse
thought they were unnecessarily prolonging the dying process.
Martin Woods, 2012
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Care rationing – a matter of
ethics?
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Care rationing debate in NZ
Care rationing (CR) uncovered in CCDM reports
SSHW hosts a CR symposium in 2012
April 2013 SSHW convenes a CR advisory; 2013 HVDHB/WDHB report CR; Media interest in CR – community speaks out;
Nov 2013 CR advisory disbanded by SSHW. Modifications to terminology suggested by SSHW Unit
2014 NZNO position on Care rationing developed and public campaign developed
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Terms
Missed care
Failure to rescue
Care left undone
Prioritisation
Errors of omission
Allocation of resources
Adverse events
Care rationing
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Pick a definition to best describe care
rationing
Option
A
“any aspect of required patient care that is omitted (either in part or whole) or delayed.”
Option
B
“the withholding or failure to carry out necessary nursing
tasks due to inadequate time, staffing level, and/or skill
mix.”
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Who is to blame when care is delayed or
omitted?
Who will be held accountable?
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Who is to blame when the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level, and/or skill mix?
Who will be held accountable?
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Care rationing
Care rationing as defined by
Schubert et al is ‘the withholding or
failure to carry out necessary nursing
tasks due to inadequate time, staffing
level, and/or skill mix,‘
2008
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Research questions - Kalisch et al 2009
1. To what extent is nursing care missed?
2. How does missed nursing care vary across
hospitals?
3. What are the reasons for missed nursing
care?
4. Do reasons for missed care vary across
hospitals?
5. Do nurse staffing levels predict missed
care?
6. Does missed nursing care predict job
satisfaction?
7. Does missed nursing care predict intent to
leave and/or turnover
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Most frequently rationed Kalish et al 2009
76%
66% 64%60% 59%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ambulation
Interdisciplinary care
conference attendance
Mouth care
Timely medication
administration
Turning
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Failure to ambulate linked to:
New onset delirium
Pneumonia
Delayed wound healing
Pressure ulcers
increased length of stay and delayed
discharge
increased pain and discomfort
muscle wasting and fatigue
Physical disability
Kalisch et al 2009
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What happens when care becomes
habitually rationed?
Does it become the “ new normal?”
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Inadequate nurse
staffing
Failure To rescue/Care Rationing
Poor patient
outcomes
Moral distress
High nurse turnover
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Care Rationing – failure to
prioritise or work
smarter??????
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Sacrificing Decisions • reduce demand (cancel/defer) – affects productivity & volumes
• increase capacity by using unbudgeted resources tagged for future activity (extras, overtime) – impacts financially and on future service provision
• increase capacity by cancelling planned non clinical activity (e.g. education or leave) – impacts on workforce & ultimately service quality
• Require extraordinary work effort
• reduce quality of service
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Impact of sacrificing decisions • Budget over run
• Queuing
• Production delays
• Service cancellation
• Care rationing
• Harm/error incidents/adverse events
• Poor patient placement
• Increased staff discretionary effort (missed breaks/overtime)
• Staff fatigue/anxiety or distress
• Staff feeling professionally compromised
• Avoidable patient deaths
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Intelligent information
Forces problem
recognition
Results in accurate diagnosis
Stimulates appropriate
action
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NZNO to focus on Care
rationing
Position paper underdevelopment
Educate members to escalate
concerns
Members to highlight areas of concern
Support groups to speak up
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To the public:
This is systemic
Nurses are not deliberately withholding care – not resourced enough
Nurses are not being irresponsible
We have the solution (CCDM)
Nurses leave their working day very stressed
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NZNO resources
Incident debriefing
http://www.nzno.org.nz/LinkClick.aspx?fileticket=D1LS31jlskY%3d
Incident reporting
http://www.nzno.org.nz/Portals/0/publications/Incident%20Reporting4.pdf
Investigations - your rights and responsibilities
http://www.nzno.org.nz/LinkClick.aspx?fileticket=YbPfSZB0kdU%3d
Serious and sentinel events
http://www.nzno.org.nz/LinkClick.aspx?fileticket=a2MlvORxjS8%3d