Nurses’ contributions to the resolution of ethical dilemmas Nichola Barlow Senior Lecture Professor Janet Hargreaves Dr Warren Gillibrand

Aim and Objectives Aim: To identify how nurses contribute to the resolution of ethical dilemmas in practice. Objective : To identify and discuss: –The beliefs that impact nurses’ decision ethical making moral action. –The values that influence nurses’ ethical decision making and moral action. –The contextual influences on nurses’ ethical decision making and moral action.

Literature Review : Themes Code of ethics –Codes of ethics provide principles rather than clear guidance. (Lere and Gaumnitz, 2003) –Globally nurses have a varying degree of knowledge of their professional codes. (Verpeet et al., 2005; Heikkinen et al., 2006) –Conflict within nurses ethical decision making and organisation. (Oberel and Hughes, 2001; Redman and Fry, 2000) –(

Literature Review : Themes Conflict –Doctors, and healthcare professionals. (Heikkinen et al., 2006; Oberel and Hughes, 2001; Ulrich et al., 2010) –Nurses values and those of patients, their families and the organisation. (Varcoe et al., 2004) –Conflict within ethical decision making and the organisation and it representatives. (Oberel and Hughes, 2001; Redman and Fry, 2000)

Literature Review : Themes Moral distress: – Occurs when conflict is experienced during ethical decision making. (Kain, 2007) – From nurses’ lack of involvement in decision making. (Dierchx de Casterle,et al., 2010; Long-Sutehall et al., 2011; Wolf and Zuxelo, 2007) –The consequences of moral distress are burnout, de- sensitisation and loss of nurses from the profession. (Corely, 2002: Ulrich et al., 2010)

Conceptualised Theoretical Moral Action Ethical Decision making DeontologyUtilityVirtue EthicsEthic of care Moral reasoning BeliefsValuesExpectations Ethical dilemmas Two or more equally unacceptable courses of action

Exploratory interpretive qualitative study design Ethical approval. Single NHS Trust multiple site. Semi-structured interview. Registered Nurses, variety of experience and current practice within secondary care. Thematic, and contextual analysis using Nvivo.

Data Collection Eleven interviews in total. Experience varied from 18months to 30years. Practice experience: surgery, vascular surgery, intensive care, medicine for the older person, stroke, Children's nursing. Audio recorded and transcribed semi-structured interview. Field notes.

Results: Themes Best for the patient: –‘I have had a few ethical dilemma at the end of the day I always considered the patients was uppermost and that justified my position’ Ross Advocacy: –‘I felt like no-one was listening. Like I come on duty and try and you know you're patients advocate.’ Nicky Standards of care: –‘...developing this area for the benefit of the patients and staff until I retire, so you know it isn't one thing’.Sam

Results: Themes Accountability –‘So then it was left for myself and some other members of staff to then explain the procedure to the patient. So then it is not necessarily my accountability, I suppose its more her accountability but I had to intervene because to me she just did not recognise that area of her accountability. She [the nurse who made the error] felt it was important to follow certain procedures in terms of the medical side of things but as to informing the patient and maybe the relatives it wasn’t considered important’. Drew

Results: Context Conflict –‘they could have sent the chief executive on the ward I would have stuck to my guns and did what I thought was best for these patients. And I know that there were two other patients that were in need of a bed but I actually had to look after the patients that were there then. So, you know, it did make me question, even now, I feel I made the right decision’. Ross

Results: Context Collaboration –‘I think we all sing from the same hymn sheet, and I think there are areas where what we do everybody does and yes I think it works. I think we know exactly where we're going. Once we've got that we know we're not giving non- essential medications, we're giving medications to be comfortable with, we're not filling them full of fluids which just you know hang around, we are just making them comfortable, and I think that's really important’. Charlie

Results: Context Concern for others – ‘ I even used to think about Doctors doing it I mean Doctors feel or appear to be quite blasé about it they were quite happy to do it. I used to think how do they feel prescribing a drug for a patient they have never clapped eyes on, how do they know – they are very trusting themselves.’Lee ‘I even used to think about Doctors doing it I mean Doctors feel or appear to be quite blasé about it they were quite happy to do it. I used to think how do they feel prescribing a drug for a patient they have never clapped eyes on, how do they know – they are very trusting themselves. Trusting is the word for it these weren’t doctors that regularly worked on my ward so they did not know my capabilities and could not trust my capabilities they did not know me. I might have been a really poor nurse for all they knew, who did not recognise these things.’Lee

Results: Relationships –Nurses demonstrated through their accounts that the relationships they maintain are the key to achieving moral action. –The context did present barriers as identified in both the research data and literature review –The most important is that with the patient, the patients family –Doctors –Other health professionals

Reconceptualised Theoretical Framework Moral Action Ethical Decision making Virtue ethicsEthic of careUtilityDeontology Moral reasoning BeliefsValuesExpectations Ethical dilemmas Two or more equally unacceptable courses of action RELATIONSHIPSRELATIONSHIPS Nurse patient relationship With other patients, families, health and social care team members With other patients, families, health and social care team members In partnership

Limitations This is relatively small sized study exploratory. Nurse participants worked in the same organisation The study is limited to secondary care context.

Conclusion and Recommendations Nurses’ professional relationships are central to nurses’ contributions to the resolution of ethical dilemmas. Support is required for nurses to acquire the skills to develop and maintain professional relationships for addressing ethical dilemmas in practice. Nurses need to be involved in the development of organisational policy and individual patient decisions, which place obligation on them. Research is required to explore this phenomenon in other geographical areas and professional settings.

References Corley M.C. (2002) Nursing Moral Distress: A proposed Theory and Agenda Nursing Ethics 9 (6) pp Dierckx de Casterlé B. Denier Y. De Bal N. and Gastmans C. (2010) Nursing care for patients requesting euthanasia in general hospitals in Flanders, Belgium Journal of Advanced Nursing 66 (11) pp 2410 – Heikkinen, A. Lemonidou, C. Petsios, K., Sala, R. Barazzetti, G. Radaelli, S. and Leino-Kilpi, H. (2006) Ethical codes in nursing practice: the viewpoint of Finnish, Greek and Italian Nurses. Journal of Advanced Nursing 55(30 pp

References Kain, V. (2007). Moral distress and providing care to dying babies in neonatal nursing. International Journal of Palliative Nursing 13(5) pp Lere J.C. and Gaummitz, B.R. (2003) The impact of codes of ethics on decision-making Some insights from information Economics. Journal of Business Ethics 48 pp Long-Sutehall, T. Willis, H. Palmer, R. Ugboma, D. Addingham-Hall, J. and Coombs, M. (2011) Negotiated dying: A grounded theory of how nurses shape withdrawal of treatment in hospital critical care units. International Journal of Nursing Studies 48(12):

References Oberle, K. and Hughes, D. (2001) Doctors’ and nurses’ Perceptions of ethical problems in end of life decisions. Journal of Advanced Nursing 33(6) pp Redman, B.K and Fry, S.T (2000) ‘Nurses Ethical Conflict: what is really known about them?’ Nursing Ethics, 7(4), pp Ulrich, C. M., Taylor, C., Soeken, K., O'Donnell, P.,Farrar, A., Danis, M. & Grady,C. (2010), Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66: 2510–2519.

References Varcoe,. C. Doan, G. Pauly, B. Rodney, P. Storch, J. Mahoney, K. McPherson, G. Brown, H. and Starzonomski, R.( 2004).Ethical practice in nursing: working the in-betweens. Journal of Advanced Nursing 45(3)pp Verpeet, E. Dierckx de Casterlé B. Van der Arend, A. and Gastmans, C.A.E. (2004). Nurses views on ethical codes: a focus group study. Journal of Advanced Nursing 51 (2) Wolf, Z. R. and Zuzelo, P. R. (2007) ‘Never Again’ Stories of Nurses: Dilemmas in Nursing Practice. Qualitive Research 16(9) pp