Fundamentals of Nursing and Midwifery 2e

Unit II Foundations of nursing and midwifery practice

206

Cost-effectiveness and allocation The increasing awareness of how difficult it is to make valued and scarce health resources available to all in need has resulted in new appreciation for the moral relevance of cost-effectiveness. Nurses and midwives who are committed to patient advocacy bridge the sometimes overwhelming needs of patients and their families and the limited resources available to professional carers. Justice is the principle of bioethics that speaks to distributing the benefits and burdens of healthcare delivery fairly. Nurses and midwives are uniquely positioned within the interdisciplinary team to speak to what it means to give people ‘their due’. Issues of cultural and/or religious variation Since many conflicts about what ought to be done are rooted in different cultural or religious beliefs and values, nurses and midwives who are sensitive to the cultural and/or religious identity of patients and carers can help mediate these conflicts. Considerations of power Differences in power underlie many of the ethical challenges encountered in clinical practice. Injury and illness create vul- nerabilities in the most sophisticated healthcare consumer and mandate vigilance on the part of the nurse and other carers to challenge any abuses of power by clinicians. Clinicians who believe they lack power to influence care settings and deliv- ery may also experience ethical conflict and distress. Final note about trustworthiness Common to all of the standards discussed above is the obligation for nurses and midwives to be competent and willing to use their competence to secure the health and well-being or good dying of the person. When nurses or midwives become aware that something is interfering with people getting the care they need, they are responsible for responding within the scope of their power and responsi- bility. If they cannot independently resolve the problem, they are responsible for alerting the appropriate party, who may be the attending doctor, a nursing supervisor or a medical director. While some believe ‘the problem is out of their hands’ once they notify the next person in the chain of command, ethically, the problem does in fact remain theirs until appropriate action is taken. Thus, you should know and use the chain of command, and continue to refer a problem upwards until it is resolved and the person’s needs are met. Examples of ethical problems Ethical problems commonly arise for nurses and midwives between nurses and patients, midwives and women, nurses and doctors, midwives and obstetricians, nurses and other nurses, and nurses, midwives and their employing institu- tions. Moreover, nurses and midwives are often most

conflicted when good practice seems to require acting against their personal moral convictions. It is at this point that the concept of moral distress can arise. Moral distress is increasingly recognised within clinical practice as a situ- ation that occurs when one is aware of the correct action but is constrained in this action by other factors. Examples are witnessing incompetent practices, judgemental behaviour towards patients and families, witnessing unnecessary suf- fering, and compromised care due to understaffing and other system failures. Moral distress has the potential to cause residual impact on nursing staff, who feel disempowered to individually change the situation. Varcoe et al. (2012) suggest that moral distress is a potentially useful concept in which resolution can provide an opportunity for reflection and growth in ethical practice (see Research in practice: Moral distress and clash of personal values). As you read through the following minicases, try to determine how you would respond. The process of ethical decision making described above should prove helpful. Clinicians and patients Troublesome clinician–patient situations that can result in ethical problems for nurses include paternalism (acting for patients without their consent to secure good or prevent harm), deception, confidentiality, allocation of scarce nursing resources, informed consent, and conflicts between the patient’s and clinician’s values and interests. Paternalism An alert older resident who lives in a nursing home and who is now at high risk for falls refuses to call the nurse for assis- tance when getting out of bed. The nurse must decide whether to obtain an order to restrain the resident. Does preventing potential harm justify violating the resident’s right to auton- omy, and make it acceptable for the nurse to act as a ‘parent’ and choose an action the resident does not want because the nurse believes it to be in the resident’s best interest? Deception A postoperative patient asks the student nurse, who is about to administer an intramuscular injection for pain, ‘Is this your first injection?’ It does happen to be the student’s first injection and the student is anxious. Would the student’s intent to decrease the person’s anxiety justify telling the them, ‘No, I’ve given several before’? Confidentiality A 9-year-old child confides in you that her father touches her in her private area and she doesn’t like it. She doesn’t want you to tell anyone. What is the ethical dilemma here and how would you explain your subsequent actions to the child? Allocation of scarce health resources A nurse has just been pulled from your unit, leaving it understaffed. Among your patients is a 33-year-old man recovering from a heart attack who is being discharged in the morning (he tells you he still has many questions); an