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Essentials of Nursing Leadership & Management, 4th Edition

N246 Leadership Ethics & Quality

S. Buckley, 2010

(Adapted from Nursing Leadership and Management,

Whitehead, Weiss, Tappen)


In the beginning…

There were no antibiotics

There were no ICUs

There were no CT scanners and MRIs

There were just physicians and nurses who cared for people in sickness and in health

Were there ethics?


Early nursing leaders


finances


1960s

Technological advances allowed for the

development of intensive care units

New biomedical developments

Advances in surgical techniques, such as

open heart surgery


Reasons for new inquiries in

nursing

Technological advances created new questions for health-care professionals regarding the use of technology, RN role and outcomes

Changing views and perspectives on the concepts of life and death

Dissatisfaction of RN’s with traditional manner of learning (mentoring) and desire to have a scientific base for practice (professional scientists)

Interest by healthcare practitioners about application of values in professional practices, and how to discuss these issues.


Bioethics

A sub discipline of ethics

The study of medical morality


Concepts of Ethics Ethics evolve from moral perspectives, which form

values and standards. Influenced by families, environment, social issues, culture, religion, cognition, law.

Ethical action depends, in part, on the ability of people to recognize that a moral issue exists in a given situation, knowing how to take appropriate ethical action if and when required, and on personal commitment and a genuine desire to achieve a moral outcome

(Johnstone, 1999, from:Ethics in Nursing Practice, 2nd ed, Fry, S.T,Johnstone, M.)


Value Systems

definitions

A set of related values

Intrinsic values-located within, the real nature of a thing.

Extrinsic values-from without

Personal values

Professional values

Social principles, goals or standards held or accepted by an individual class, society. That which is desirable or worthy of esteem for its own sake, thing or quality having intrinsic worth.


Historical values of

nursing:


Nursing today Values in nursing

today:


Value Formation

Values are learned-therefore, influenced by family, culture, environment, cognition.

Values change with maturity and experience

The number of values an individual holds is not as important as what values they consider important


Types of Values Personal

Cultural

Religious

professional


Values Clarification

Critical thinking

Choosing

Identifying-verbalizing?

Acting


Belief Systems These are organized ways of thinking about

why people exist within the universe

Their purpose is to explain such concepts

as:

Life and death

Good and evil

Health and illness

Individualism/rights


ETHICS AND MORALS


Morals An individual’s own code for acceptable

behavior

Standards of goodness or rightness that arise from an individual’s conscience

They act as a guide for individual behavior

Learned

Capable of making a distinction between right and wrong in conduct


Values Social principles, goals or standards held or

accepted by an individual class, society.

That which is desirable or worthy of esteem

for its own sake, thing or quality having

intrinsic worth.


Standards Something established for use as a rule or

basis of comparison in measuring or

judging quality, value, extent.


Laws Rule of conduct established and enforced

by the authority, legislation or custom of a

given community, state, or other group.

May change with fluctuating social morals

and viewpoints.


Ethics Having to do with moral standards,

conforming to the standards of conduct of a given professional group. Implies conformity with an elaborated, ideal code or moral principles.

Concerned with the motivation behind the behavior

Bioethics is the application of these principles to life-and-death issues


Ethical Theories

Deontological-based on duty to commitment, considers the intention of the action, not the consequences of the action. It is the individuals goodwill that determines worthiness, not the outcome.

Teleological-(utilitarianism)-what makes an action right or wrong is its usefulness. Right encompasses actions that have positive outcomes, wrong is composed of actions that result in poor outcomes.

Principalism-involved in biomedical issues, integrates ethical principles to resolve conflicts in situations.


Ethical Principles

Autonomy

Nonmaleficence

Beneficence

Justice

Fidelity

Confidentiality

Veracity

Accountability


Autonomy

The freedom to make decisions about

oneself

Nurses need to respect clients’ rights to

make choices about health care


Nonmaleficence

Requires that no harm be caused to an

individual, either unintentionally or

deliberately

This principle requires nurses to protect

individuals who are unable to protect

themselves


Beneficence This principle means “doing good” for

others

Nurses need to assist clients in meeting all

their needs

Biological

Psychological

Social


Justice

Every individual must be treated equally

This requires nurses to be nonjudgmental


Fidelity

Loyalty

The promise to fulfill all commitments

The basis of accountability (moral concept that involves acceptance by a professional nurse of the consequences of a decision or action)


Confidentiality Anything stated to nurses or health-care

providers by clients must remain confidential

The only times this principle may be violated are:

If clients may indicate harm to themselves or others

If the client gives permission for the information to be shared


Veracity

This principle implies “truthfulness”

Nurses need to be truthful to their clients

Veracity is an important component of

building trusting relationships


Accountability

Individuals need to be responsible for their

own actions

Nurses are accountable to themselves and

to their colleagues


Ethical Codes These are formal statements of the rules of

behavior for a particular group of

individuals

Ethical codes are dynamic

Most professions have a “code of ethics” to

guide professional behavior


Organizational Ethics

Focus on the workplace

Ethical culture makes a difference

Senior leadership must promote an ethical

culture-do they?


Ethical Dilemmas

Occur when a problem exists between

ethical principles

Deciding in favor of one principle usually

violates another

Both sides have “goodness” and “badness”

associated with them


Ethical decision making Consider cause, variables, precipitating events

and implications

Reflect upon one’s own perspective and values

Explore options for action:

ANA code of ethics, facility standard and ethics, nurse practice act (BRN), legal issues, rights.

Select appropriate plan. Understand consequences of the plan.

Implement

Evaluate results


Current Ethical Issues


Issues to Consider

Assisted suicide

Technology issues-as RN, as patient.

Gene therapies, genetic counseling

“Designer babies”, fertility issues, fetal success

Organizational climate

Family planning

Social responsibility

Immigration policies

Resource management.

Stem cell research

DNR status


Conclusion

An issue is not an ethical issue for the

nurse unless he or she has been asked

Always gather the facts prior to decision-

making

Consider your personal beliefs and values


Quality issues What is it??

The degree of excellence that distinguishes

one thing from another

Relates to education and practice;

professionals perceive that they are

providing high-quality nursing education

and patient care.


Why do we need it? * current health care system is fragmented,

poorly organized, inefficient use of

resources.

*New technologies, availability of

information (it), decreasing resources,

increasing chronic disease states mandate

a change.

* consumer dissatisfaction with current

system


Quality improvement Also known as performance improvement,

focuses on processes or systems that

significantly contribute to client safety and

effective client care outcomes; criteria are

used to monitor outcomes of care and to

determine the need for change or improve

the quality of care.(Saunders NCLEX review, 5th edition, Silvestri, L.,2011)


Professional organizations that focus on

quality * Joint commission on Accreditation of

Healthcare Organizations (JACHO)

* American Nurses Association (ANA)

*Institute of Medicine (IOM)


IOM essential competencies Provide patient centered care

Work in interdisciplinary teams

Employ evidence-based practice

Apply quality improvement

Use informatics


Aims of IOM quality of care Safe

Effective

Patient centered

Timely

Efficient

equitable


IOM- cost of inefficiency 44,000-98,000 die each year

$17-29 billion in total costs

Nursing errors:

*Medication

*knowledge

*procedure


Continuous Quality improvement (CQI)

Identify indicators

Collect ongoing data on indicators

Analyze and evaluate data

Implement change

(utilize evidence based practice)


How to monitor quality of care Guidelines

Protocols

Algorithms

Standards of care

Critical pathways


How does structured care methodologies

work? Link process of care (issue) and outcome

Determine method of measurement

Clarify responsibilities of interdisciplinary

team

Facilitate communication among team

members

Document, apply systematic approach to

measurement.


Root cause analysis Process of learning from consequences;

Determine influences, establish linked

chains of influences, determine necessary

influences, analyze root (initial) cause.

Currently used to analyze errors and

mistakes; attempts to evaluate series of

events that may lead to errors (safety

errors) and determine causative reason for

error (process), rather than punitively

blame a person


Risk management part of QA

Identify potential problems, risks

Incident investigation

Sentinel events

Anticipate outcome, prevent recurrence


conclusion To enhance quality of care;

Think critically

Plan and report outcomes

Make introductory rounds

Plan partnership with the client

Communicate plan

Evaluate progress

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