NURS 2513- Ethics and Health Equity York University

What is Nursing ethics?

•Expressed moral norms of the profession; values, virtues, and principles that the profession believes should guide nurses in everyday practice ​

What was Virginia Henderson's contribution to Nursing ethics?

•Human needs are central to nursing practice, nurses should care for patients until they can care for themselves​

"Patient care should be individualized...the nurse will seek constantly to help the patient meet their needs and live as normally as possible"

What was Sister M. Simone Roach contribution to Nursing ethics?

•Oversaw the development of the first code of ethics for RNs in Canada

What was Janet Storch​ contribution to Nursing ethics?

•Patient's Rights: Ethical and Legal Issues in Health Care and Nursing (1982)​

•Expectations for nurses based upon consumer rights; rights to be informed, to be respected, to participate in decision making, and to have equal access

What was Sara Fry contribution to Nursing ethics?

•Differentiation of nursing ethics; the nursing profession ought to focus on caring as a core ethical value​

•Focus on people versus abstract and idealized notions

Gender in Ethics of Nursing

•Historically, nursing has been predominantly dominated by those who identify as women ​

•Some argue that there is more emphasis on caring > curing ​

•Position of subordination, unquestioning obedience

Historical, Spiritual, and Religous practises in Nursing Ethics

•Middle Ages: women who entered nursing roles donated their property and wealth to the Christian church, devoting their lives to service ​

•A culture's belief system influences how its members accept health care practices; in this regard, people were more likely to accept healing through religious intervention​

•Women's status declined during this period; peasant women had generations of knowledge and improved practice by trial and error à seen as witchcraft ​

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•Renaissance and the Reformation: scientific era; shift from the church ​

•Nurses still held in lower regard, emphasis on caring​

•Canada: earliest records of nursing in the 17th century

What are the 3 components of Contemporary Bioethics and Nursing Ethics

Technological Developments​

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Research and Experimentation​

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Consumerism and Patient Rights

What are 3 models of the Nurse Patient Relationship?

The Contractual Model

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The Patient Advocate Model

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The Social Justice Advocacy Model

What are 3 knowledge bases of Ethics in Nursing

1.Moral Beliefs and Values​

2.Relevant Codes, Policies, and Laws​

3.Fundamental Concepts of Moral Philosophy

What is oughtness?

When we make a judgement, we do so from the point of what ought and ought not to be. ​To say that someone must be care for without bias means that it ought to be.​

What are Morality and Moral Reasoning made up of?

Oughtness and Moral Experience​ and Moral Virtues​

How do norms and ideals shape our live in terms of morality?

1.Guide our conduct and decision making​

2.Utilized to evaluate conduct and decision making

In terms of Morality and Ethical analysis, what situations may arise when it comes to moral complexity in Healthcare

1.Disagreement about moral norms and ideals​

2.Disagreement about the application of a moral norm given a situation ​

3.Moral norms/ideals may conflict

What is ethics in terms of morality and ethical analysis

Careful and systematic reflection and analysis about moral norms and ideals and how they bear on practical issues.

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•Moral norms/principles may be vague or unclear​

•There is often endorsement of moral principles without justification​

•Moral ideals/principles conflict with each other​

•Ethical analysis ensures all relevant considerations are entertained

What are the principles of the code of conduct of the CNO

1.Nurses respect clients' dignity​

2.Nurses provide inclusive and culturally safe care by practicing cultural humility.​

3.Nurses provide safe and competent care.​

4.Nurses work respectfully with the health care team to best meet clients' needs.​

5.Nurses act with integrity in clients' best interest.​

6.Nurses maintain public confidence in the nursing profession.

What are some overarching Principles

4. Entry level-RNs are prepared as generalists to practice safely, competently, compassionately, and ethically​

•In all situations of health and illness​

•With all people across the lifespan​

•With all recipients of care: individuals, families, groups, communities, and populations ​

•Across diverse practice settings​

•Using evidence-informed practice​

5. Entry level RNs have a strong foundation in nursing theory, concepts and knowledge, health and sciences, humanities, research and ethics from education at the baccalaureate level.​

6. Entry level RNs practice autonomously within legislation, practice standards, ethics, and scope of practice in their jurisdiction.​

What are some practise competencies that relate to Nursing Ethics?

1.Clinician: Registered nurses are clinicians who provide safe, competent, ethical, compassionate, and evidence informed care across the lifespan in response to client needs. Registered nurses integrate knowledge, skills, judgment and professional values from nursing and other diverse sources into their practice.​

2.Professional: Registered nurses are professionals who are committed to the health and well-being of clients. Registered nurses uphold the profession's practice standards and ethics and are accountable to the public and the profession.

What are the Ethical Responsibilities and and values of being a Nurse?

1.Providing Safe, Compassionate, Competent, and Ethical Care​

1.Promoting Health and Well-Being​

2.Promoting and Respecting Informed Decision-Making​

3.Honouring Dignity​

4.Maintaining Privacy and Confidentiality​

5.Promoting Justice​

6.Being Accountable

what is the ethical analysis and NUrsing process?

Assessment​

•Recognize an ethical/moral issue and form an assessment and interpretation​

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Planning​

•Identify and plan options; which is considered morally best​

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Implementation​

•How to implement the option in a sensitive and effective way​

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Evaluation ​

•Review how the process unfolded in the interest in learning from the situation

What are the 3 categories of ethics?

Metaethics, Applied, and Normative ethics

What is metaethics

Examines origin and meaning of moral values, language, and principles

"what is morality?"

What is applied ethics?

Constructs solutions to controversial and moral issues by applying philosophical tools

What is normative ethics?

Analyzes moral standards of right and wrong

Utilitarianism, consequentialism, virtue ethics are examples of normative theories

What is ethical theory

Branch of moral philosophy that studies social values and the application of moral philosophy

Expands our understanding about how "we ought and ought not to act (do) or to be"

"Oughtness" is socially constructed, conditioned and reinforced (power) on others; helping us to make decisions

Examines underlying thinking about "judgements, actions, duties, and obligations" (Bouchal & Astle, 2023, p. 112) and the reasons/rationales or judgements to support our moral claims (decisions)

Includes a premise/idea about values

Facilitates understanding of the world

Deontological Ethics

Health care providers adhere to traditional ethical theories based on moral duties, principles, and imperatives. This system focuses on actions and principles that are considered "right" or "wrong" regardless of outcomes, with moral agents like nurses identifying and fulfilling their duties. Individuals bear responsibility for their decisions and must act in accordance with reason, without duties being imposed by others.

Categorical Imperitive

All duties are evaluated using a single categorical imperative, a rule developed when considering an action (such as always telling the truth). The Universalizable-test is used to determine if everyone could reasonably follow the same rule in a given situation. If not reasonable, the rule is not suitable for moral action. This rule must be followed at all times and is binding on everyone in society.

Categorical imperitve pt.2

Upholding the categorical imperative means following universal human reason, not someone else's will. It asks what is right to do, considers the consequences of everyone acting the same, and urges us to treat others as we would want to be treated. It is a moral guideline that should guide our actions.

Deontological ethics pt.2

Autonomy involves creating or following self-imposed laws or the categorical imperative. Ethical decision-making involves justice, autonomy, and beneficence. Moral claims can translate to moral rights, such as a nurse's duty to tell the truth to Mrs. Smith can be seen as Mrs. Smith's right to know the truth.

Ethical theories in nursing(Kant)

Shared understanding and acceptance of ethical principles is crucial in nursing, with a focus on respect, universality, and fulfilling duties. Kant's theory of ethics aligns with nursing values, emphasizing the importance of choosing between principles and duties in ethical dilemmas. Professional codes of nursing ethics are derived from Kantian principles to preserve patient dignity and autonomy.

Kant:Criticisms of theory

Kant focuses on moral conflict between duty and self-interest, believing there cannot be conflicting duties, but conflicts often arise between different moral duties. Pluralistic deontology, as proposed by Ross, allows for multiple moral duties such as nonmaleficence, beneficence, fidelity, reparation, gratitude, self-improvement, and justice. Conflict can arise between these duties, but Kant's categorical imperative can help resolve them. This theory emphasizes the binding nature of moral rules without considering consequences, as seen in the conflict over disclosing harmful information to a patient. Kant argues that the right decision, such as telling the truth, is independent of projected consequences, opposing utilitarianism's focus on maximizing overall happiness.

Utilitarianism/Consequentialism by John Stewart Mill

Moral rightness is determined by the good or benefit of an action's consequences, following the teleological philosophy. It argues that actions are morally right when they bring good or benefit to the majority. Utilitarianism values happiness as the greatest good for all, guiding decisions to maximize overall happiness. The Principle of Utility states actions should aim for the most happiness for all. The fundamental imperative is to act in a way that brings the most good to the world.

Steps in making moral decisons according to utilitarianism

Step 1: Project the possible actions and consequences of each action

Step 2: Calculate the amount of happiness (+ve) or balance above unhappiness (-ve) that will be produced by each possible action and consequence

Step 3: Select balance or action that will result in the greatest amount of happiness for the greatest number of people

-Follows a method of trial and error or cost-benefit analysis so that the greatest good can be determined

Challenges with Utilitarianism

Predicting and balancing consequences of actions against happiness can be challenging. In some cases, sacrificing the happiness of a few individuals for the greater good of the collective may be justified. This could be seen in healthcare decisions like organ transplants, where the happiness of many is prioritized over the few. This approach challenges fundamental moral principles and requires maximizing utility for the benefit of the majority, setting aside personal interests.

Response to Challenges of Utilitarianism: Act and Rule Utilitarianism

Act-utilitarianism: Choose actions that increase overall good in each situation, allowing for different and opposing actions as guidelines rather than strict rules, ie. kidnapping and organ harvesting acceptable if benefits greater number.Rule-utilitarianism: Follow rules that maximize overall good, prioritize happiness of greatest number and diminish unhappiness.

Summary of Deontology and Consequenialism

Both deontology and consequentialism center around moral rules and principles guiding decision-making. Moral life is defined by adherence to either the greatest happiness principle or categorical imperative, as well as other unalterable moral guidelines.

Virtue Ethics- Aristole

Aristotle, the Father of Value Ethics, believed that moral character is shaped by practicing virtuous behavior. Moral virtues, which are both habits and character traits, help individuals achieve happiness and are socially valued. Variance in virtues is present, but they should be practiced in moderation to become consistent habits. Virtues are gained through moral education to reach full potential and contribute positively to the community.

Common questions pertaining to virtue ethics

Morally valued traits include purity, faith, loyalty, devotion, trustworthiness, and temperance. Virtue ethics can be learned in places like nursing, where Florence Nightingale believed it was important. Context affects ethical decision-making.

Biomedical Ethics and Bioethics

Health care professionals use virtue ethics to align their character with doing good for the community. Biomedical ethics involves moral reasoning using four principles (autonomy, beneficence, nonmaleficence, and justice) to prioritize actions in individual situations. The Bioethical Theory by Oberle & Raffin Bouchal incorporates these principles in health care ethics.

Focal virtues

Virtue ethics in healthcare focuses on virtues like caring, compassion, discernment, trustworthiness, integrity, and conscientiousness in providers' actions.

Ethic to care(Feminst appraoch)

Response to Kohlberg's Stage Theory of Moral Development includes pre-conventional, conventional, and post-conventional stages. Pre-conventional involves fear of punishment and desire satisfaction. Conventional is about pleasing others and obeying authority. Post-conventional emphasizes autonomy and independent thinking. Women scored lower than men in moral development in this theory.

Ethic of care: Carol Gilligan

Females and males differ in their approach of moral problems-differences that were not superior or subordinate to the ethic of care

Female problem-solving uses a contextual approach called "ethic of care" focusing on kindness, concern, and values relatedness and sensitivity in addressing the needs of individuals and the community. Nurses play a vital role in this perspective.

Men apply abstract justice principles disregarding unique circumstances. Ethic prioritizes deontology and utilitarianism, silencing nurses.

Concerns with Ethic of Care

Nursing is seen as a women's profession that reinforces gender stereotypes and promotes occupational segregation, raising questions about compatibility with justice.

Feminist Ethics

An offshoot of Ethics of Care, this approach seeks to reshape traditional ethics, initially addressing women's issues and challenging gender stereotypes. It now explores broader topics like sexism, discrimination, and advocacy for change.

Feminist Ethics: Three Overlapping Features

Gender plays a significant role in societal roles and group identities, with ongoing patriarchal structures and gender prejudices leading to male privileges. Attention to power dynamics is crucial, considering who holds power, vulnerability, and impact on redistributing power. Sensitivity to context and relatedness, particularly in power and prejudice, challenges norms and expands analysis scope. Nursing professionals advocate for social justice issues such as human rights violations, war, world hunger, gender inequities, and climate change.

Relational Ethics

Relational ethics complements existing theories by emphasizing relationships, commitments, and interactions. It shifts focus to self-awareness and how we relate to others, with key themes being environment, embodiment, mutual respect, engagement, and uncertainty.

Relational Ethics: Environment

The healthcare organization's environment impacts nurse's work and relationships with other providers. The system is interconnected with direct and indirect relationships. Nurses prioritize broader context influenced by power dynamics and politics.

Relational Ethics: Embodiment

The integration of mind and body is essential for healing. Nurses must balance scientific knowledge and compassion to assist patients in exploring their emotions. Mutual respect in the nurse-patient relationship is crucial for promoting health and well-being through embracing emotional experiences.

Relational Ethics: Mutual Respect

Healthy nurse-patient relationship where both benefit and respect each other's ideas, leading to new understandings. Requires willingness from both parties and no judgement.

Relational Ethics: Engagement

Nurse forms relationship with patient focusing on trust, openness, responsiveness, and understanding. Nurse shows care and respect while exploring patient's needs. Relationship has professional boundaries limiting engagement.

Autonomy

Individual autonomy in health care decisions relies on providers respecting patients' ability to set goals and plans. Patients must possess the competence to make rational decisions, understand consequences, and act on choices. Consent includes the ability to refuse treatment.

Beneficence

"Bene"=well, good

"Facio"=to do

Doing good for someone else's well-being

For nurses-actions benefit patients

Medications, vaccines

Overlaps with caring ethics

Beneficent acts are morally and legally demanded by our profession

Beneficence and Nursing Practice: Two Components

Acting in a manner that upholds beneficence involves nurses prioritizing the best interests of the patient while setting aside their own self-interests. This is achieved by understanding patient needs, working collaboratively with patients to meet those needs, and actively preventing harm or evil in various situations such as strikes or pandemics. The main goal is to do good and remove harm.

Non-maleficence

Primum non nocere

"First, do no harm"

Veracity

The moral value of telling the truth.

Hierarchy of values

In the past, benefiting the patient and doing no harm was more important than truthfulness

"What would be best for the patient's own good"

Shift in attitudes, with more physicians now stating their policy is to disclose information; truth telling is the accepted norm

Veracity(Truthfulness and Autonomy)

•Respect for autonomy and informed decision making

•The critical question is, does the patient want to know?

Veracity and Trust

Truthfulness and Trust

Trust requires partners in the relationship are truthful to each other

Deception endangers the nurse-client therapeutic relationship

CNO Code of Conduct (2023)

5. Nurses act with integrity in clients' best interests

In this principle, nurses are honest and fair practitioners, who strive to build a trustworthy, therapeutic nurse-client relationship.

Veracity and the Practitioner-Patient Knowledge Gap

Differences in knowledge and ability to understand information between health care providers and patients

Lack of clarity, inability to predict outcomes

Good Judgement

A factually true statement may not be truthful, and truthfulness is honesty is valued more than accuracy

Communicating "Bad News"(SPIKES)

Setting

Perception

Invitation/information

Knowledge

Empathy

Summarize/strategize

Communicating "Bad News"(PEWTER)

•Prepare

•Evaluate

•Warning

•Telling

•Emotional response

•Regrouping preparation

Truth-Telling and Culture

Cultural humility and truthfulness

Some research suggests deference to autonomy is a Western way of thinking

"Collusion"

Truthfulness and the Circle of Care

The 'Circle of Care'

•Potential for conflict

Nursing scope of practice limitations

CAN communicate test results, assessment findings

•CANNOT communicate a diagnosis

Technology

Patients often receive results independently; nursing and physician roles have shifted to education rather than informing

Confidentiality

: the character of knowledge or information about someone that is confided or acquired in special relationships; respect for confidentiality is a duty of someone which whom such information has been shared

Privacy

broader term, pertains to information, bodies, and personal space

Personal Health Information Protection Act (PHIPA)

Any identifying information about clients that is in verbal, written or electronic form. This includes information collected by nurses during the course of the therapeutic nurse-client relationship.

Physical or mental health, including family history;

Care provided;

A plan of service;

Payments or eligibility for health care;

Donation of body parts or substances or information gained from testing these body parts or substances;

A person's health number; or

That name of the client's SDM

CNO Standards

Personal health information practices

Knowledgeable consent and substitute decision-makers

The client's right to access and amend his/her personal health information

Potential for harm

Disclosure without consent

Digitalization and Social Media

Digitalizing health care

Pros and cons

Privacy, confidentiality, and social media

Boundary between professional and private lives

Explain the difference between personal values and societal values.

Personal values are individual beliefs and principles, while societal values are shared beliefs and norms that are accepted by a group or society

How can culture influence the development of values?

Culture shapes values through traditions, beliefs, and practices that are passed down through generations, affecting how individuals perceive and prioritize different aspects of life.

Describe the role of group presentations in the course.

Group presentations account for 20% of the course grade, require a maximum of 5 members for topics and 6 for debates, and attendance is mandatory to receive participation credit.

Discuss the implications of values conflict in nursing care.

Values conflict can lead to ethical dilemmas in nursing care, affecting decision-making and the ability to provide patientcentered care, necessitating careful navigation of differing values.

Describe how values are learned according to the content.

Values are learned in both conscious and unconscious ways from other people, including parents, friends, society, organizations, and professions.

Define moral values and their significance.

Moral values are a special type of value that helps individuals decide what to do or not do during dilemmas, guiding ethical decision-making.

How do values influence our behavior and choices?

Values influence our choices, behavior, and standards, shaping who we are as individuals and providing direction and meaning to life

Explain the concept of moral autonomy.

Moral autonomy is the process of reflecting on the approach used to determine choices of values, taking responsibility for our choices, and engaging in decisions that lead to the development of our freedom of choice.

Discuss how values can be expressed.

Values can be expressed directly through verbalization or written standards, and indirectly through nonverbal behavior and cognitive evaluations of right and wrong

What is the role of values in decision-making?

Values play a crucial role in decision-making by influencing our preferences and behaviors, although we may not always be aware of their impact

How might values differ between individuals in a group setting?

lues may differ among individuals in a group setting due to personal, societal, professional, or organizational influences, leading to varied perspectives on what is important.

Describe the exercise involving item selection during a natural disaster scenario.

Participants must choose three items of personal importance to bring to an evacuation, then discuss how their values influenced their choices and the items they selected.

How do values influence the removal of items in a group exercise?

Values influence the decision-making process when removing items from a list, as individuals consider the importance of items based on their own values and the values expressed by others.

Describe the impact of age, culture, and family on personal values.

Age, culture, family, and individual differences significantly influence what we hold as most important, leading to a unique set of values for each person.

How does values clarification contribute to professional identity

Values clarification helps individuals identify their values of worth, make decisions about which values to keep or modify, and understand the perspectives of others, contributing to their professional values and identity

Define the process of self-awareness in relation to values.

Self-awareness involves becoming more conscious of and articulating what we value, which is an ongoing process grounded in reflective and self-directed behavior.

How can journaling enhance self-awareness regarding values?

Journaling provides multiple possibilities for reflection, helping individuals explore and articulate their values, leading to greater self-awareness.

Explain the significance of moral integrity in value clarification

Moral integrity involves upholding moral norms such as trustworthiness and truthfulness, ensuring that one's values and beliefs are consistently maintained over time

Discuss the importance of understanding others' realities in values clarification.

Understanding others' realities, experiences, cultures, and environments is crucial in values clarification as it helps individuals appreciate diverse perspectives and influences.

What are the ethical values of the CNA and CNO?

The CNA and CNO ethical values include providing safe and competent care, promoting client well-being, respecting informed decision-making, maintaining privacy, and promoting justice.

How can group discussions aid in clarifying personal values?

Group discussions allow individuals to share and compare their top-ranked values, identify similarities and differences, and reflect on which values are being met or unmet.

What role does integrity play in living up to one's values?

Integrity involves consistently applying one's morals over time, which is essential for 'walking the talk' and living in alignment with one's values.

Describe the importance of self-awareness in understanding others' values.

Self-awareness allows individuals to appreciate their own values, which is essential for understanding and respecting the values of others.

How can one become more self-aware?

Self-awareness can be enhanced through managing emotions and thoughts, introspection, observation, reflection, meditating, journaling, and engaging in arts-based activities

Define values conflict in a nursing context.

Values conflict refers to an internal or interpersonal conflict between the values of the nurse and those of their patients, colleagues, or the institution, which can negatively impact patient care.

How should a nurse respond to differences in values?

A nurse should identify the differences in values, respond with understanding, and seek common ground to uphold integrity

Describe a scenario that illustrates values conflict in nursing.

In the case of Ryder, a terminally ill child, there is a conflict between the parents' desire for aggressive treatment and the doctor's recommendation for comfort care, highlighting differing values regarding end-of-life care

What are some potential impacts of incongruent personal and institutional values?

Incongruent values can lead to disagreements, control issues, decreased job satisfaction, and negatively affect patient care.

How can moral distress arise in a healthcare setting?

Moral distress occurs when a healthcare professional knows the right course of action but is prevented from taking it due to institutional conflicts or constraints.

Identify specific nursing interventions to manage values conflict.

Nursing interventions may include adhering to nursing practice standards, following codes of ethics, and facilitating open communication among all parties involved.

What role do institutional values play in nursing practice?

Institutional values, both overt and implicit, guide the philosophy, policies, and ethical standards of care, influencing how nurses approach patient care and decisionmaking.