Artigo Revisado por pares

Toward Everyday Ethics: Strategies for Shifting Perspectives

2017; Lippincott Williams & Wilkins; Volume: 28; Issue: 3 Linguagem: Inglês

10.4037/aacnacc2017406

ISSN

2149-0481

Autores

Aimee Milliken,

Tópico(s)

Palliative Care and End-of-Life Issues

Resumo

Jane's situation highlights the complexity of decision-making in an intensive care unit. Jane makes a recommendation regarding what she feels is best for her patient; however, there are other clinicians involved in her patient's care. When the resident does not follow Jane's recommendation, she is left feeling uncertain about the best course of action. Having norepinephrine infused through a peripheral IV puts Jane's patient at risk, but other factors (eg, the power differential between her and the resident/attending physician, her inability to effectively communicate her concerns, the time of day when the situation occurred) prevent her from taking further steps and she is left with a sense of unease. Although Jane may not label her predicament as an ethical problem, the decided plan of care is not in line with her professional goals (promotion of good and prevention of harm)—this predicament should be considered an ethical issue. Jane's case is used throughout this article to highlight the importance of recognizing problematic clinical situations that are ethical in nature. Additionally, strategies are provided for nurses to recognize and address these everyday ethical issues.Ulrich and colleagues1 define an ethical issue asRobichaux2 further describes situations containing ethical content as those in which the action "has the potential to harm or benefit others."2(p69) The term everyday ethics is "used to designate normatively important and pervasive issues in health care."3(p117) Everyday ethical issues are found in routine, day-to-day occurrences and are sources of uncertainty and conflict that can negatively affect patient care.Everyday ethics is fundamental in nursing codes of ethics4,5 and "central to nursing practice."6(p60) Jane faced an everyday ethical issue: the decision to infuse norepinephrine through a peripheral IV and not be more insistent that the patient receive a central line was subject to an evaluation of rightness or wrongness. When nurses like Jane take actions on behalf of patients, these actions are considered part of the nurse's role as a professional with a code of ethics.4,7,8 As such, all nursing actions can be assessed for their adherence to professional goals and standards7; therefore, all these actions are ethically important. If everyday ethical issues go unnoticed or unaddressed by clinicians, patients are in danger of receiving suboptimal care, which can lead to harm.Although everyday ethical issues can create distress for nurses in the clinical setting,1 these issues often go unrecognized by nurses and other health care practitioners.2,9,10 This lack of recognition may be because everyday ethical issues are underemphasized within traditional bioethical approaches, which focus on more "dramatic" ethical issues.3,10 These traditional ethical frameworks can lead to situations similar to Jane's, in which an everyday ethical problem is not recognized. Unrecognized everyday ethical issues are also a symptom of underdeveloped ethical awareness8—a component of moral sensitivity and the first step in the iterative process of moral action.11Ethical awareness—noticing ethical issues and their implications—is a prerequisite to ethical action. Jane's ethical awareness is underdeveloped; she is aware of a clinical problem but does not identify it as an ethical problem. Although Jane believes that the care plan recommended by the resident is not optimal, she is uncertain about how to exercise her agency for change: she advocated for her patient's needs but did not pursue further action after the resident dismissed her concerns. Jane was left with a sense of distress, and ultimately her patient was put at risk. Without ethical awareness, nurses will not act as moral agents.12This type of uncertainty in the face of ethical issues is highlighted in the nursing ethics literature.13 Nurses in practice often feel unprepared or ineffective when addressing ethical issues.1,14,15 This discomfort or constraint in taking action can lead to moral distress, defined as the "suffering that nurses and other health professionals experience when they act in ways that are inconsistent with deeply held ethical values, principles or commitments."16(p122) Jane may be experiencing moral distress because she acquiesced in the resident's decision to not call the attending physician.Despite barriers, critical care nurses like Jane have the ability to advocate for patients and address everyday ethics issues.17,18 Kristoffersen et al19 emphasize that nurses strive to do good in the face of everyday issues, whether or not these issues are labeled as ethical. However, some nurses report feeling ostracized because of their advocacy and seek covert mechanisms for moral survival.13By reframing ethics as an everyday issue, nurses are given the opportunity to evaluate troubling morally significant issues that negatively affect routine patient care. As Zizzo and colleagues3 suggest, an everyday ethics approach overcomesHaving an everyday ethics perspective gives nurses a more holistic approach to recognizing all ethical issues. By being aware that all nursing actions (even those considered routine or mundane) have potential ethical implications, nurses can promote ethical decision-making and actions.Strategies to increase everyday ethical awareness are vital for nurses in critical care environments. Ethical theory, for example, is a practical tool that could provide a framework for Jane to work through ethically challenging situations. There is a rich body of work in ethical theory and moral philosophy to aid nurses in making everyday ethical decisions. Nurses can use available ethical resources in their workplaces to work through ethically challenging situations,3 thus avoiding covert mechanisms for moral survival.Nurses have a professional obligation to recognize and address everyday ethical issues4,5; doing so is crucial for ensuring safe patient care and is a key way to mitigate nurses' moral distress. Several approaches can help nurses shift their thinking about everyday ethics in the critical care setting (see Table).20–31Ethical competence generally includes character strength, ethical awareness, moral judgment skills, willingness to do good,32 and the exemplification of one's values. Ethical competence and its components can be developed and strengthened in a variety of ways. Lechasseur and colleagues20 highlight multiple strategies for developing ethical competence including problem-based learning, which, unlike traditional lecture-based techniques, uses real clinical problems as a launching point for teaching and discussion.33 Problem-based learning can be used in an interdisciplinary team setting; it uses a small–group-based approach, in which the group is led by a tutor and each learner takes an active role.33 Lechasseur also discusses developing and strengthening decision-making and advocacy skills20 by using techniques such as role-playing, in which a problematic case is acted out among participants.23In order to develop moral sensitivity—another component of ethical competence—Weaver and Mitcham21 recommend discussing real-world cases that mimic the complexities of practice to develop a fundamental understanding of ethical principles and theories. Nurses who become familiar with ethical principles and theories are better able to identify ethical issues in specific situations, thus enhancing their moral sensitivity.21 Strategies to develop moral sensitivity and ethical competence can be implemented in the clinical setting through ethics rounds, inservice training, formal ethics training, or interprofessional educational opportunities. Ideally, multiple opportunities using a variety of learning strategies geared toward strengthening the cognitive and affective components of ethical competence should be available to nurses on an ongoing basis.22In addition to developing ethical competence, nurses must take ethical action, which involves moral agency and moral resilience. Moral agency is the understanding of professional moral responsibilities and the ability to fulfill these responsibilities.34 A moral agent, as outlined in nursing professional codes of ethics,4,5 is capable of acting with integrity within the context of the health care system and local practice environment.35 Thus, moral agency involves identifying oneself as capable of taking ethical action, understanding professional goals and responsibilities, and being able to recognize and act on situations in which ethical action is required.Jane made a moral judgment that infusing norepinephrine peripherally was the wrong approach. She exercised moral agency by telling the resident that the patient needed a central line. She believed herself to be constrained from further action by the resident's comments and decision. Jane, like other nurses, could develop her moral agency in several ways: by practicing communication skills, through role playing,22,23 or by having safe discussions about issues as they arise—giving Jane the opportunity to apply ethical frameworks to analyze problems and identify institutional resources to address the issues.24Moral agency is strengthened by moral resilience—defined by Rushton25 as "the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress, or setbacks."25(p112) Developing moral resilience is one way nurses can preserve their professional identity in challenging situations and combat feelings of moral distress. Strategies to bolster moral resilience include fostering self-awareness, developing moral sensitivity, and contributing to a culture of ethical practice.25Jane could develop moral resilience by reflecting on the situation, assessing her own perspective, and verifying the facts of the case. She then could evaluate whether she has exhausted all options to achieve what she believes is the best plan of care for her patient. This reflection might lead Jane to consider other possible options such as going up the chain of command to her charge nurse or accessing further resources. A morally resilient approach would help Jane face any feelings of distress or upset she may have experienced; she can use her personal resources and support from others to mitigate her negative feelings.25Organizational culture can profoundly influence nurses' perceptions about ethical issues.36 Thus, strategies to shift focus toward everyday ethics also must involve the community within which nurses practice.9,36 Changing workplace culture is a complicated and multifaceted endeavor. The various strategies discussed in this article are not intended to be exhaustive.One way of shifting nurses' attention to everyday ethics issues is through interprofessional education, which emphasizes communication, mutual respect, and shared planning or decision-making in ethics curricula.27 In this approach, nurses, physicians, and other health care providers are brought together for formal or informal learning opportunities, improving interdisciplinary communication and, ultimately, patient care.27,28 Interprofessional education can be used to broaden clinicians ideas of what constitutes an ethical problem, helping clinicians identify everyday ethical issues.The development of moral spaces (or moral communities) is another strategy for shifting culture. Liaschenko and Peter26 describe a moral community as a place where ethical discourse regularly occurs, formally and informally. Hamric and Wocial29 recommend that moral spaces contain ethics resources that are (1) informative, (2) available at any time of day, (3) well known to health care providers, and (4) sanctioned by clinical and administrative leadership. A moral space provides nurses and other clinicians with a place where there is time, resources, and permission to reflect upon ethical issues that have occurred in the workplace.As part of a shift in workplace culture, nurse leaders must be attuned to the organizational and unit-specific issues that are sources of everyday ethics stress for nurses at the bedside (eg, staffing issues).1 Identifying specific systemic stressors and working with staff nurses to ameliorate these stressors are practices the nurse leader should highlight when shifting the workplace culture.Preventive ethics is a proactive approach to recognizing and managing everyday ethical challenges and identifying potential triggers of ethical conflict.30 This method differs from traditional approaches for managing ethical challenges, which tend to be reactive and often neglect to address systems issues.30The earlier potential sources of conflict are identified, the more proactive nurses can be in addressing them. Preventive ethics interventions can be implemented at the organizational, unit, and individual levels to aid in shifting the ethical climate. Ultimately, preventive ethics serves as a tool for identifying everyday ethical issues.30The Veteran's Health Administration (VA) is an example of a health care system that uses a preventive ethics approach.31 The VA's Integrated Ethics (IE) model includes a preventive ethics component that uses a step-by-step process called ISSUES (Identify issue, Study issue, Select strategy, Undertake plan, Evaluate and adjust, Sustain and spread).31 Moreover, this IE model includes tools and resources to facilitate implementation, and all VA medical centers are required to have a preventive ethics team.31The process is designed to address gaps in quality. Once an issue is identified, the preventive ethics team selects an ethical standard that applies to the situation and then drafts an operational definition of best practices to be used in future situations. Current practices are then compared to the new standard as a baseline for improvement31 to prevent similar issues from recurring. The VA's IE model has been applied in a variety of clinical and organizational ethics settings, resulting in measurable improvements in ethical practices.31Reframing ethics as an everyday issue keeps its presence at the forefront of patient care. In critical care environments, nurse leaders and nurses at the bedside can make changes at the organizational, unit, and individual levels to help foster an everyday ethics perspective. Ultimately, recognizing the ethical implications of everyday issues can help nurses identify and resolve conflict before crises occur, resulting in less ethics-related stress for nurses and better outcomes for patients.

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