➊ Ethical Dilemmas: The Role Of Delegation In Nursing
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Ethical Dilemmas in Nursing
Second is acquiring professional skills. Third, psychologists must know when to refer and when not to, thus recognizing when they do or do not have access to obtain the knowledge or appropriate experience required. If a psychologist does not follow these obligations, according to Fisher, they are in violation of the APA Ethics Code. The first domain is composed of foundational competencies. These are the knowledge, skills, attitudes, and values which underlie the function of psychologists. Practicing psychologists should have a firm background in these competencies which is built up in the early years of their career, during graduate school, when one first learns of all the necessary foundational competencies.
The second domain of the Cube Model is functional competencies which encompasses the professional activities of psychologists. This means what does any given psychologist do on any given day? Whether it is clinical, research, educational, or administrative in nature, psychologists are required to remain competent in the specific field in which they practice.
The third domain of the Cube Model is a developmental perspective of competency. Once a psychologist finishes graduate school, receives their license, and is employed, their training does not stop. Another area of competency not outlined by the Cube Model but relevant to all psychotherapists is that of ethical competency Sporrong et al. Key competencies in ethics include knowing and understanding codes of ethics, being able recognize and analyze ethical situations, and trying to resolve them. It is not enough to understand the field of psychology and its ethics code. One needs to be able to identify unethical situations and have the abilities necessary to correct them. When psychotherapists face ethical dilemmas, Barnett states they will seek information from the law, professional publications, and colleagues to guide them in their decision-making.
At times, ethical dilemmas may be hard to recognize because they are on a continuum between right and wrong; they are on a slippery slope. What is right is right, what is right is kind of right, what is right is kind of wrong, and what is right becomes what is wrong. This ambiguity can be problematic when dealing with ethical decisions, even for the most competent psychologist. A clear definition of an ethical dilemma is given by Kitchener as cited in Shiles Shiles argued that there is an ethical dilemma between Standards 2.
A psychologist can refer a client on these grounds without repercussions when the underlying issue is the psychologist does not want to work with that client, whatever the reason may be. For example, if a psychologist is racist against African-Americans, they could refer an African-American client to another psychologist saying they are not competent to work with African-Americans because they do not know enough about their culture. Although this may be true, the true reason for referral is racism. Another example of an ethical dilemma being debated in current research in regards to competency is what to do when you need a third-party to facilitate in the therapeutic relationship, as is the case with interpreters. These are all dilemmas that a psychologist might face when working with clients with limited English proficiency.
The last example of a competence-related ethical dilemma to be discussed within this article is that between the delivery of ethical and culturally consistent therapy Gallardo et al. Gallardo and colleagues state some of these challenges include negotiating boundaries within the therapeutic context, giving and providing solutions, and struggling with internal personal values when they differ from that of the client. Given the multitude of variables involved, it is easy to see how an ethical dilemma may present itself between client and psychotherapist.
Psychologists may unintentionally harm their clients of culturally diverse groups by invalidating their life experiences, defining their cultural values or differences as deviant, or imposing the values of dominant culture upon them Fisher, Such ethical dilemmas as those presented above demonstrate the vagueness of practicing ethically and competently. These examples, along with many others, are the ongoing debates within the field of psychology today. The best solutions to these dilemmas are being discussed and published by experts in ethics and experts in specialized areas of psychology as necessary.
Therefore, solutions will not be addressed within the confines of this article but rather, systematic ways to address ethical dilemmas and ways to ensure psychologists are practicing competently and with ethical obligation to uphold. Barret, Kitchener, and Burris as cited in Shiles suggest a decision-making model aimed at helping psychologists make ethical decisions that are minimally affected by countertransference. Fisher outlines a very similar 8-step model for ethical decision making. She also states that ethical decision making involves a commitment to applying the Ethics Code to construct rather than discover solutions to ethical dilemmas.
Another approach to ethical impasses is analyzing how one chooses to view the situation at hand. They go on to say that if a practitioner looks through an ethical lens first, they may be compromising the needs of their client by putting their own needs first. The desire to uphold ethical standards, no matter what the cost to a specific client, is in itself unethical. If that question is answered competently, the psychologist ensures that their client and their presenting problem are being held as the main priorities. Outside of the decision-making process, psychologists can be proactive in minimizing the occurrence of ethical issues and ensuring that all involved are on the same level of ethical understanding.
Sporrong et al. These strategies can be applied in clinical settings by clinically-based education, ethics consultations, ethics rounds, clinical supervision, and ethics committees. Although many of the suggestions here are already in effect, increasing the amount of facilities that regularly hold ethics rounds may have a significant impact on the ethical realm of psychology. If every institution providing mental health services, whether it be a hospital, prison, school, or private practice, regularly held ethics rounds, psychologists and other staff members associated with them would be much more knowledgeable about potential ethical problems and how to properly handle them.
Also, ethical dilemmas would more likely to be addressed correctly if they had been discussed previously within the confines of an ethics round rather than as one is occurring, at which time emotionality can be high and objectivity can be skewed. Similar to ethics rounds is program that has been implemented in the education world. Component I of his model is ethical sensitivity. This is the identification of the salient ethical aspects of a situation. Component II is moral judgment which involves formulating the morally ideal course of action through reasoning.
Component III, moral motivation, requires having the necessary motivation or will to act in an ethical manner. Component IV involves moral action and can be described as having the moral character to execute and implement what ought to be done. There is no absolute way to guarantee a psychologist beginning their career has been properly trained in ethics or is competent in the areas in which they desire to work. It is assumed new psychologists received adequate training in graduate school as a student but this assumption may not be accurately. Any facility providing mental health care services should implement some form of training, such as the REST-KIT, to insure the psychologists at that facility are ethically educated and competent to handle ethical dilemmas as they arise.
Ethical dilemmas are not new to the practice of psychology and their resolutions will never be clear-cut answers. Psychologists must remain competent in their field to be able to practice ethically. By staying up-to-date on current research, literature, and practices, psychologists can guarantee they are providing the best possible services to their clients.
When a psychologist is faced with an ethical quandary, using the decision making models outlined earlier can help psychologist reach the best decision for their specific issue. By being aware of potential conflicts in ethics beforehand, psychologists can take preventive measures to avoid having to face an ethical dilemma. Again, competence is the key. Ethical Principles of Psychologists and Code of Conduct. Illinois General Assembly Home Page. Barnett, J. Journal of Clinical Psychology , 64 5 , Belar, C. Advancing the Culture of Competence. Training and Education in Professional Psychology , 3 4 Suppl.
Fisher, C. Thousand Oaks: Sage Publications, Inc. Fouad, N. Gallardo, M. Professional Psychology: Research and Practice , 40 5 , Hays, P. Professional Psychology: Research and Practice , 40 4 , Kerns, R. Training and Education in Professional Psychology , 3 4 , Rogers-Sirin, L. Journal of Diversity in Higher Education , 2 1 , Searight, H. Shiles, M. The question now becomes, how should the nurse best advocate for this patient? Whether or not to advocate is not in doubt Provision 3 , but just how to do that is a bit more difficult. This dilemma is also an organizational issue as the nurse does not have authority to single-handedly change the prescription.
Clearly, advocating will involve collaboration with a hesitant physician. The Code can provide some guidance, but some weighing and balancing of the different provisions is necessary. In response to Mr. This would alleviate the concern about deception and withholding information Provision 5. Conversely, this may undermine Mr. In addition, it may threaten the collegial relationship between the nurse and physician Provision 2. Logan has been discharged. Provision 6 also addresses maintaining an ethical work environment in order to support quality of care.
Another alternative for the nurse is to collaborate with the physician first, bringing to light the concerns about patient deception and the evidence of inappropriate placebo use. This alternative action will hopefully have several benefits, such as increasing the likelihood of a more effective treatment plan, maintaining patient trust in the healthcare team, and supporting a professional and collegial doctor-nurse relationship.
The potential benefits of approaching the physician first suggest that this is the more sound, justifiable solution to the dilemma. The Code can provide direction for multiple levels of direct and indirect care. Ethical issues in clinical nursing often involve not only dilemmas at the bedside, but also dilemmas at the organizational level, such as navigating a complex system to protect a patient or provide quality care or identifying ways to collaborate with colleagues to maintain strong working relationships and trust. The Code ANA, b can provide direction for multiple levels of direct and indirect care. The Code applies to other areas of nursing practice as well, such as nursing education, research, and policy making.
Advancing the profession through research and policy by attending to informed consent, advocacy, and accountability of practice are examples of other professional areas of practice with potential ethical dilemmas that make the provisions of the Code a relevant nursing resource. The first formal code of ethics for nurses was adopted in Fowler, However, a need for ethical guidance was recognized soon after modern nursing began to formalize in the mids. Although in , one of the initial goals of the newly established American Nurses Association was to write a code of ethics, urgent issues such as nurse registration, the welfare of nurses, and accreditation processes for nursing schools took precedence Fowler, The provisions were framed in terms of the various relationships between the nurse and patient; the nurse and medicine; and nurses and their profession.
The first formal Code for Professional Nurses was adopted in and was edited slightly before being revised in At the same time as the suggested code, ethics was on the minds of nurse faculty and administrators in terms of training and educating nursing students and practicing nurses Crawford, ; Ethical Problems, ; Ethical Problems, ; Fowler, Their work highlights the thinking of the time, that is, that character was a significant factor in determining right action. The first formal Code for Professional Nurses was adopted in and was edited slightly before being revised in Fowler, The revision of the Code included several significant changes ANA, First, prior to this revision, the provisions were simply listed with little, if any, interpretation.
The new code provided brief interpretations which helped the nurse see how the provision might be applied. Second, the provisions were reduced from 17 to a more manageable Finally, there was a fundamental shift in language in the revision. With changes in the level of practice independence; advances in technology; societal changes; and expansion of nursing practice into advanced practice roles, research, education, health policy, and administration, the Code has been revised over time to introduce obligations to advance the profession and build and maintain a healthy work environment ANA, ; ANA, ; ANA, ; ANA, b. As in the past, the current Code of Ethics with Interpretive Statements forms a central foundation for our profession to guide nurses in their decisions and conduct.
As in the past, the current Code of Ethics with Interpretive Statements ANA, b forms a central foundation for our profession to guide nurses in their decisions and conduct. It establishes an ethical standard that is non-negotiable in all roles and in all settings. The Code is written by nurses to express their understanding of their professional commitment to society. The provisions and interpretive statements reflect broad expectations without articulating exact activities or behaviors.
Nurse practice acts in many states incorporate the Code of Ethics. Even though the Code is primarily ethics-related, it also has legal implications. Given the importance of the Code to the profession on so many levels, revisions continue on a regular basis. As society changes, so must the Code ANA, b. It is a living document that informs and is informed by advances in healthcare such as genomics, technology, new roles for nurses and changes in healthcare delivery. The nine provisions address the general, enduring obligations of nurses and rarely require major revision.
However, the interpretive statements are more specific and address current topics and issues. Since healthcare-related problems rapidly unfold in our society, the interpretive statements must be reviewed and revised every 10 to 12 years. Review of the Code ANA, revealed several areas requiring updates in language and content. An overview of this process below illustrates the intentional considerations inherent to the revision, the opportunities for nurse participation at all levels, and the impact that nurses have toward the final product.
The use of technology made this recent revision process more effective and efficient than in previous times. For example, the pre-internet revision of the Code ANA, took seven years, had many onsite committee meetings, and handled over 15, written responses following a solicitation for feedback, editorial comments, and suggestions. In the revision of the Code ANA, , greater use of technology resulted in a single onsite meeting. Much work was accomplished using conference calls, email, and other electronic platforms e.
Table 1 provides a timeline of the most recent Code revision process. Nurses participating in the revision process took advantage of technology for online committee meetings and discussions and online public comment periods to solicit feedback from nurses across the country. Table 1: Timeline of the Revision Process for the Code. The process for the most recent revision began with an initial review by the ANA Ethics Advisory board of the current Code provisions and interpretive statements, the International Council of Nurses ICN code ICN, , and the codes of other health professions such as pharmacy, occupational therapy, social work, medicine, physical therapy, and public health. This extensive review helped to determine the need for revision.
The Code Review Working Group was appointed to collect public comment regarding the need for revision. The summary report of this analysis included recommendations to revise the Code ANA, for the following reasons:. After recommendations were accepted, the ANA website, NursingWorld, posted a call with an invitation to participate in the revision. More than nurses volunteered; from these 15 were selected to serve on the Code Steering Committee SC. Between September and April , a draft revision was prepared. In May , the edited draft was posted for public comment. By early June, nearly 1, individuals had posted suggestions for changes, clarifications, additions, or deletions.
Each suggestion was evaluated using the analysis processes described above, preserving the essential and eliminating the incidental. Further revisions were made based on this additional analysis. The revision process led to several significant changes in the Code of Ethics. The preface was revised to strengthen the purpose of the Code, the ethical framework, and the context. The Code Provisions have been reworded to be more concise and better articulate their intent, although the general structure remains the same as the Code ANA, For example, the first three provisions still describe the most fundamental values and commitments of the nurse; the next three address boundaries of duty and loyalty, and the last three address aspects of duties beyond individual patient encounters.
Finally, there were significant changes to the interpretive statements, where content has been updated to improve relevance to modern day practice, reorganized for consistency with the wording in the provisions, and revised to reduce redundancy. The Code is an important document that can provide effective guidance as the nurse negotiates the complexities inherent to many situations.
This article has suggested several implications for nursing practice including consideration of the everyday nature of ethical concerns in nursing at multiple levels, the usefulness of the Code ANA, b as a guide, and the importance of an inclusive and thorough process for revising the Code. Each day, situations arise for nurses that require both decision and action, and may include ethical dilemmas. Examples of those most common include errors and near misses, delegation, end-of-life care, use of technology and fatigue. Managing these challenges well contributes to safe, compassionate, quality care. The Code ANA, b is an important document that can provide effective guidance as the nurse negotiates the complexities inherent to many situations.
Nurses and other healthcare professionals are not expected to be able to resolve complex ethical problems alone, using only a code of ethics. Often, other resources are needed to grasp the full complexity of an ethical dilemma. Selected potentially helpful online resources are listed in Table 2. The following recommendations can be helpful at any level of practice:. ANA Nursespace. Presidential Commission for the Study of Bioethical Issues. The process for the Code revisions used technology to a great advantage.
This provided an avenue for a highly participatory process to receive input from all nurses in every type of practice and allow working groups to collaborate efficiently and effectively with a minimum of travel. Recognizing that nursing practice extends from horizon to horizon—from the bedside to the classroom, from the executive suite to the laboratory bench—the Code continues to provide all nurses with a firm foundation for ethical practice. Beth teaches ethics in the School of Nursing and lectures in the Center for Bioethics and Humanities. She was a flight nurse and achieved the rank of Colonel. Her responsibilities included representing the DoD as an ex-officio member of the Secretary's HHS Advisory Committee for Genetics, Health and Society, reviewing policies related to many aspects of healthcare and developing ethics programs and ethics expertise throughout the Air Force Medical Service.
Most recently she staffed the revision of the ANA Code of Ethics for Nurses with Interpretive Statements as content editor, revision coordinator and co-lead writer. American Association of Critical Care Nurses. Retrieved from www. American Medical Association. Code of medical ethics. Retrived from www. Code of medical ethics, opinion 8. American Nurses Association. A suggested code. American Journal of Nursing 26 8 : A tentative code. American Journal of Nursing 40 9 : The code for professional nurses. American Journal of Nursing 60 9 : Code for nurses. American Journal of Nursing 68 12 : Code for nurses with interpretive statements.
Code of ethics with interpretive statements. American Nurses Association position statements on ethics and human rights. Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursesbooks. Nightingale pledge. Retrieved from: www. Arnstein, P. Use of placebos in pain management. Pain Management Nursing, 12 4 : Austin, W.
The ethics of everyday practice: Healthcare environments as moral communities. Advances in Nursing Science, 30 1 : Beauchamp, T. Principles of biomedical ethics , 6 th ed. New York: Oxford University Press. Chambliss, D. Beyond caring: Hospitals, nurses, and the social organization of ethics. Chicago: University of Chicago Press. Crawford, B, How and what to teach in nursing ethics. American Journal of Nursing, 26 3 , Engelhard, C. Healthcare ethics and a changing healthcare system. Filerman, A. Schyve eds. Managerial ethics in healthcare: A new perspective. Ethical problems. American Journal of Nursing, 26 8 , American Journal of Nursing, 33 3 , Fassler, M. Frequency and circumstances of placebo use in clinical practice: A systematic review of empirical studies.
BMC Medicine, 8 Fowler, M. The evolution of the code for nurses. The California Nurse, 81 5 : 5. Evolution of the code. In Ethical dilemmas in contemporary nursing practice G. White, Ed. Davis, M. Aroskar, J. Liaschenko, T. Drought Eds. Fowler, M Gert, B. Common morality: Deciding what to do. Hamric, A. Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35 : Hobbes, T. New York: Dutton. Original work published in International Council of Nurses. The ICN code of ethics for nurses. Geneva, Switzerland: Author. Crossing the quality chasm: A new health system for the 21 st century.
Miles, M. Qualitative data analysis: An expanded sourcebook 2 nd ed. Thousand Oaks, CA: Sage. Mills, A.If every institution Examples Of Odysseus Foolishness mental health Ethical Dilemmas: The Role Of Delegation In Nursing, whether it be a hospital, prison, school, or private practice, regularly held ethics rounds, psychologists Ethical Dilemmas: The Role Of Delegation In Nursing other staff members associated with them would be much Ethical Dilemmas: The Role Of Delegation In Nursing knowledgeable about potential ethical problems and Ethical Dilemmas: The Role Of Delegation In Nursing to properly handle them. The problem, however, Ethical Dilemmas: The Role Of Delegation In Nursing that the court may The Tempest Patriarchal Analysis accept such a response and demand that the entire test data be submitted. See also Standards 2.