Morality in Nursing
Levine in 1989 stated that all nursing actions were a direct reflection on morality. Ethics tries to make sense of what is right and wrong. Who defines that in nursing? Is it in our nature to be ethical?
Kant believed that we need to act as everyone will act. If I am to do something, can I rationally expect everyone to act the same way? If the answer is no, then we should not perform that action, even if it may create some sort of minimal happiness. One must ask themselves … will the act have the good of humanity in mind, or will the action result in a benefit to the self. If the benefit of the action is only to the self, then one must not do that action, they need to find the action that would create the benefit to all.
The same rules apply in nursing. When we walk into work, and we begin our day, we must not think about the benefit of our actions resulting on ourselves. We must think about the nursing care that will benefit the good for all. When in the ER and an active resuscitation comes through the door, a consideration for all needs to be included before futile measures are executed. It may benefit your conscience to perform all medical interventions possible, but is it good for that poor soul that your are requiring to participate in the activities of this earth when they could move on to some other thing or place, even if it means to biodegrade. Does it benefit the next patient that comes in when you have used your last medication that could have saved their life on someone who has less than a 1% chance of surviving? No. It does neither patient any benefit, nor any benefit to your own morality.
The four concepts of ethics in nursing are:
1. The respect for autonomy
2. Nonmaleficence
3. Beneficence
4. Justice
These basic ethical concepts are not typically covered in nursing education. They need to be, because we are all to execute actions based on these concepts. This may be what distinguishes nurses from physicians because they are required to cover the ethical aspects of medicine. Does this mean that we are lesser thinkers because we do not require this in our basic education? Does this mean that we are just to execute the orders of physicians and not question the ethics of a situation because these concepts have not been introduced to us formally, or is it understood that we are already possess understanding of these concepts and we are above learning about them. It is essential for nurses to have a further understanding because we are not just order takers anymore, We are paving new paths for integrated thought and a higher level of human healing.
Sunday, January 3, 2010
Agnostic Ethics
Modern Bioethics: Morality from the Agnostic
Because we are not religious, does that mean that we are not ethical? Does it mean that I make my decisions differently than believers in a deity?
No. I am skeptical, maybe even noncommittal, but my reflection on an ultimate higher power are questionable. I am not an atheist, meaning that I do not completely deny that there might be a higher power, but as I live my life, I am not going to make decisions based on the belief in a higher power is going to control my life, and the hereafter.
In the words of Thomas Huxley, “Agnosticism is not a creed but a method, the essence of which lies in the vigorous application of a single principle... Positively the principle may be expressed as in matters of intellect, do not pretend conclusions are certain that are not demonstrated or demonstrable.”
He states, “I neither affirm nor deny the immortality of man. I see no reason for believing it, but, on the other hand, I have no means of disproving it. I have no a priori objections to the doctrine. No man who has to deal daily and hourly with nature can trouble himself about a priori difficulties. Give me such evidence as would justify me in believing in anything else, and I will believe that. Why should I not? It is not half so wonderful as the conservation of force or the indestructibility of matter...
It is no use to talk to me of analogies and probabilities. I know what I mean when I say I believe in the law of the inverse squares, and I will not rest my life and my hopes upon weaker convictions...
That my personality is the surest thing I know may be true. But the attempt to conceive what it is leads me into mere verbal subtleties. I have champed up all that chaff about the ego and the non-ego, noumena and phenomena, and all the rest of it, too often not to know that in attempting even to think of these questions, the human intellect flounders at once out of its depth.”
In the case of healthcare, or specifically nursing, where does one draw on to make their moral decisions if they are not relying on a deity to mold their decisions. Would it make a difference in the eyes of a believer to treat one of two patients first, if one had worked against the greater good of humanity throughout the course of their life, and the other worked for the benefit of good to all? The answer is that when we have patients come before us, there is no room to make such moral decisions, as the nature of our professional is to treat indiscriminately. I do not have to have GOD to tell me to do this, it is what is right.
Is it a postmodern concept to have no basis for decisions besides individual right and wrong? Zygmunt Bauman might think so. I don’t think so. Postmodern is antiquated, and unnecessary. Beautiful and descriptive in the most complex, yet utterly simple manner, postmodernism is for those who desire to have an excuse to blame their wrongs or rights. Postmodern is to be weak in mind and thought. It is much more powerful to understand how and why you think about your decisions, and not just to accept them because they happened.
Because we are not religious, does that mean that we are not ethical? Does it mean that I make my decisions differently than believers in a deity?
No. I am skeptical, maybe even noncommittal, but my reflection on an ultimate higher power are questionable. I am not an atheist, meaning that I do not completely deny that there might be a higher power, but as I live my life, I am not going to make decisions based on the belief in a higher power is going to control my life, and the hereafter.
In the words of Thomas Huxley, “Agnosticism is not a creed but a method, the essence of which lies in the vigorous application of a single principle... Positively the principle may be expressed as in matters of intellect, do not pretend conclusions are certain that are not demonstrated or demonstrable.”
He states, “I neither affirm nor deny the immortality of man. I see no reason for believing it, but, on the other hand, I have no means of disproving it. I have no a priori objections to the doctrine. No man who has to deal daily and hourly with nature can trouble himself about a priori difficulties. Give me such evidence as would justify me in believing in anything else, and I will believe that. Why should I not? It is not half so wonderful as the conservation of force or the indestructibility of matter...
It is no use to talk to me of analogies and probabilities. I know what I mean when I say I believe in the law of the inverse squares, and I will not rest my life and my hopes upon weaker convictions...
That my personality is the surest thing I know may be true. But the attempt to conceive what it is leads me into mere verbal subtleties. I have champed up all that chaff about the ego and the non-ego, noumena and phenomena, and all the rest of it, too often not to know that in attempting even to think of these questions, the human intellect flounders at once out of its depth.”
In the case of healthcare, or specifically nursing, where does one draw on to make their moral decisions if they are not relying on a deity to mold their decisions. Would it make a difference in the eyes of a believer to treat one of two patients first, if one had worked against the greater good of humanity throughout the course of their life, and the other worked for the benefit of good to all? The answer is that when we have patients come before us, there is no room to make such moral decisions, as the nature of our professional is to treat indiscriminately. I do not have to have GOD to tell me to do this, it is what is right.
Is it a postmodern concept to have no basis for decisions besides individual right and wrong? Zygmunt Bauman might think so. I don’t think so. Postmodern is antiquated, and unnecessary. Beautiful and descriptive in the most complex, yet utterly simple manner, postmodernism is for those who desire to have an excuse to blame their wrongs or rights. Postmodern is to be weak in mind and thought. It is much more powerful to understand how and why you think about your decisions, and not just to accept them because they happened.
evolution of nursing knowledge
Knowing in Nursing
The discipline of nursing has a unique body of knowledge that has patterns, forms, and structure. The growth of nursing knowledge since the beginning of the 21st century has increased significantly. Carper (1992, p. 73) reviewed nursing literature between 1964 and 1975 in “an effort to understand the kinds of knowledge comprising the discipline of nursing.” She published her results in a 1978 article that identified four fundamental patterns of knowing in nursing: empiricism, aesthetics, personal knowledge and ethics. It is important for members of the nursing profession to comprehend these patterns of information because it provides the type of knowledge that is most valuable to the discipline of nursing. The following is a discussion of Caper’s four fundamental patterns of knowing in nursing as well as Schultz and Meleis’ examination of nursing knowledge.
Empirics
The term empirics did not emerge into nursing verbiage until the 1950s. At this point in time, it became increasingly important to nursing theorist and researchers to develop a body of knowledge in nursing based on empirics (Polifroni, 1999). The empirics of nursing are the scientific aspects of nursing, which includes the verifiable data incurred from objective information (Hood, 2006). According to Carper, “Empirical data, obtained by either direct or indirect observation and measurement . . . are formulated as scientific principles, generalizations, laws, and theories that provide explanation and prediction” (Carper, 1992, p. 76). Chinn and Kramer stated that empirical knowledge is obtained through the human senses, and that it can be substantiated by others in the profession (Chinn & Kramer, 1999). This verified and credible data is then used communicate understanding, as well as explaining and structuring the knowledge obtained (Chinn & Kramer, 1999). Empirical data is essential to the discipline of nursing because it allows professionals to communicate across multiple disciplines in a basic and generalized format. Nurses from every background are required to obtain, comprehend, and act on empirical data. This is the reason it is imperative for empirical knowledge to be understood by all members of the profession.
Aesthetics
The esthetics of nursing is the concept of nursing as an art. The majority of literature on the development of nursing as a science is based on the factual and verifiable aspects of nursing. The concept of aesthetic knowing in nursing according to Chinn and Kramer (1999, p. 183) states, “the aspect of knowing that connects with deep meanings in a situation and calls forth inner creative resources that transform experience.”
Benner and Tanner (1987) described intuitive judgment in respect to the aesthetics of nursing. There are six aspects of intuitive judgment that should be employed by all nurses. The six aspects are:
1. Pattern recognition is the ability to recognize patterns and relationships without prior consideration of the separate components.
2. Similarity recognition is the ability to see similarities and parallels among patient situations, even when there are marked dissimilarities in objective features.
3. Common sense understanding is “a deep grasp of the culture and language, so that flexible understanding in diverse situations is possible. It is the basis for understanding the illness experience, in contrast to knowing the disease” (Benner & Tanner, 1987, p. 25). It is a way of “tuning in” to the patient and grasping the patient’s experience.
4. Skilled know-how is based on a combination of knowledge and experience that permits flexibility of actions and judgments.
5. A sense of salience makes it possible to differentiate what is particularly significant in a situation.
6. Deliberative rationality involves the use of analysis and past experience to consider alternative interpretations of a clinical situation.
The ability to adapt nursing care to meet the needs of every patient, as well as the recognition of the needs of the patient through interpreting behaviors is a part of the art of nursing. “The esthetic pattern of knowing in nursing involves the perception of abstracted particulars as distinguished from the recognition of abstracted universals. It is the knowing of a unique particular rather than an exemplary class” (Polifroni, 1999, p. 15). Caper stresses the significance of including aesthetic knowledge into the nursing process. She states that the experience of helping and caring, “must be perceived and designed as an integral component of its desired result rather than conceived separately as an independent action imposed on an independent subject” (Carper, 1978, p. 17). There is a need for nurses to allow a part of themselves to be expressed in nursing care. Through an understanding of aesthetics, and the above listed intuitive judgment, the nurse can provide clinical nursing that incorporate aesthetics.
Personal Knowledge
Personal knowledge in nursing is the nurse’s individual method of obtaining, organizing, understanding and applying information. “The pattern of personal knowing refers to the quality and authenticity of the interpersonal process between each nurse and each [client]” (Fawcett et al., 2001, p. 116). The personal knowledge a nurse possesses is dynamic, and will grow constantly throughout the lifespan. The nurse must be open to new experiences, thoughts and feelings. The nurse must be honest with themselves, and explore and interpret all knowledge obtained. Once this is completed, the nurse then should apply the comprehension of the data collected individually to meet the needs of the patient. Not all of the knowledge obtained will be easily interpreted. The nurse must be able to “accept ambiguity, vagueness, and discrepancies in what is essentially a subjective and existential process” (Hood, 2006, p. 98). Every nurse draws upon personal knowledge when interacting with patients. This concept incorporates both empirical data and aesthetics, and is essential to nursing practice.
Ethics: The Moral Component
Making decisions about the care of a patient often requires the nurse to determine which actions are morally right, and morally wrong. The problems that arise in healthcare that require moral decisions are typically vague in nature, with no clear connection to the standard code of ethics that is applied in the respect of human life. Nursing is bound to moral traditions that require, “valuable and essential social service responsible for conserving life, alleviating suffering, and promoting health” (Cody, 2006, p. 24).
This pattern of knowing requires a comprehensive understanding of different philosophies of morality. The ethical dilemmas that nurses encounter must first be reflected upon as concrete situations, then with consideration of the moral results of the actions taken. Reflection of different moral and ethical codes will provide the nurse with a greater understanding of how moral choices should be made. As technology progresses and a push for socialized medicine in the United States comes closer to reality, nurses will be faced with an increased amount of ethical dilemmas dealing with end-of-life situations. A thorough understanding of ethics and morality will assist the nurse in making the decisions that will benefit the patient as well as themselves.
Other Views of Patterns in Nursing
Schultz and Meleis (1988) examined Carper’s patterns of knowing, and felt that she left out a few very important practical concepts. They decided to include the following three patterns in nursing knowledge: clinical, conceptual, and empirical. The following is a description of these patterns in nursing, which need to be appreciated as an expansion of Caper’s four fundamental patterns of nursing.
Clinical knowledge refers to the nurse’s personal knowledge. The nurse employs multiple ways of knowing while they are addressing the problems of their patients. The clinical knowledge is observable when the nurse is practicing nursing, and is created from the unity of personal knowledge and empirical knowledge (Schultz P.R. & Meleis A. I, 1988).
Conceptual knowledge is derived from the objective and subjective data collected from multiple patient interactions. These interactions occur over a span of time and in multiple settings. The nurse will recognize the patterns that evolve from these experiences while expressing them as models and theories (Schultz P. R. & Meleis A. I, 1988). Propositional statements and concepts are formed and supported by empirical or anecdotal data, as well as logical reasoning (Schultz P. R. & Meleis A. I, 1988). This knowledge draws on information from nursing, as well as multiple other disciplines including sociology, psychology, etc. According to Schultz & Meleis, conceptual knowledge, “incorporates curiosity, imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that pertain to the discipline of nursing” (McEwan, 2007, p. 15).
The combination of experimental, historical, or phenomenological research is used to define the concept of empirical knowledge. This knowledge validates nursing actions and procedures. The validity of this knowledge is based upon the general acceptance by researchers within the field of nursing and the conclusions drawn from the evidence provided (McEwan, 2007). Schultz and Meleis stated that “empirical knowledge is evaluated through systematic review and critique of published research and conference presentations” (Schultz P.R. & Meleis A. I, 1988).
Summary
There is a need to recognize patterns of knowing in nursing. The recognition of these patterns will be used to validate the unique body of knowledge nursing owns. This unique body of knowledge is the justification of nursing practices. Understanding the patterns of knowing in nursing is crucial to teaching and learning nursing. The patterns of knowing will not expand nursing knowledge, but will answer the question of what it means to know, and how to identify the types of knowledge that are important to nursing. The recognition of these patterns of knowing assists to analyze the kind of knowledge that gives the discipline of nursing the meaning.
If you are interested in the full citations, please request an official copy of the paper.
The discipline of nursing has a unique body of knowledge that has patterns, forms, and structure. The growth of nursing knowledge since the beginning of the 21st century has increased significantly. Carper (1992, p. 73) reviewed nursing literature between 1964 and 1975 in “an effort to understand the kinds of knowledge comprising the discipline of nursing.” She published her results in a 1978 article that identified four fundamental patterns of knowing in nursing: empiricism, aesthetics, personal knowledge and ethics. It is important for members of the nursing profession to comprehend these patterns of information because it provides the type of knowledge that is most valuable to the discipline of nursing. The following is a discussion of Caper’s four fundamental patterns of knowing in nursing as well as Schultz and Meleis’ examination of nursing knowledge.
Empirics
The term empirics did not emerge into nursing verbiage until the 1950s. At this point in time, it became increasingly important to nursing theorist and researchers to develop a body of knowledge in nursing based on empirics (Polifroni, 1999). The empirics of nursing are the scientific aspects of nursing, which includes the verifiable data incurred from objective information (Hood, 2006). According to Carper, “Empirical data, obtained by either direct or indirect observation and measurement . . . are formulated as scientific principles, generalizations, laws, and theories that provide explanation and prediction” (Carper, 1992, p. 76). Chinn and Kramer stated that empirical knowledge is obtained through the human senses, and that it can be substantiated by others in the profession (Chinn & Kramer, 1999). This verified and credible data is then used communicate understanding, as well as explaining and structuring the knowledge obtained (Chinn & Kramer, 1999). Empirical data is essential to the discipline of nursing because it allows professionals to communicate across multiple disciplines in a basic and generalized format. Nurses from every background are required to obtain, comprehend, and act on empirical data. This is the reason it is imperative for empirical knowledge to be understood by all members of the profession.
Aesthetics
The esthetics of nursing is the concept of nursing as an art. The majority of literature on the development of nursing as a science is based on the factual and verifiable aspects of nursing. The concept of aesthetic knowing in nursing according to Chinn and Kramer (1999, p. 183) states, “the aspect of knowing that connects with deep meanings in a situation and calls forth inner creative resources that transform experience.”
Benner and Tanner (1987) described intuitive judgment in respect to the aesthetics of nursing. There are six aspects of intuitive judgment that should be employed by all nurses. The six aspects are:
1. Pattern recognition is the ability to recognize patterns and relationships without prior consideration of the separate components.
2. Similarity recognition is the ability to see similarities and parallels among patient situations, even when there are marked dissimilarities in objective features.
3. Common sense understanding is “a deep grasp of the culture and language, so that flexible understanding in diverse situations is possible. It is the basis for understanding the illness experience, in contrast to knowing the disease” (Benner & Tanner, 1987, p. 25). It is a way of “tuning in” to the patient and grasping the patient’s experience.
4. Skilled know-how is based on a combination of knowledge and experience that permits flexibility of actions and judgments.
5. A sense of salience makes it possible to differentiate what is particularly significant in a situation.
6. Deliberative rationality involves the use of analysis and past experience to consider alternative interpretations of a clinical situation.
The ability to adapt nursing care to meet the needs of every patient, as well as the recognition of the needs of the patient through interpreting behaviors is a part of the art of nursing. “The esthetic pattern of knowing in nursing involves the perception of abstracted particulars as distinguished from the recognition of abstracted universals. It is the knowing of a unique particular rather than an exemplary class” (Polifroni, 1999, p. 15). Caper stresses the significance of including aesthetic knowledge into the nursing process. She states that the experience of helping and caring, “must be perceived and designed as an integral component of its desired result rather than conceived separately as an independent action imposed on an independent subject” (Carper, 1978, p. 17). There is a need for nurses to allow a part of themselves to be expressed in nursing care. Through an understanding of aesthetics, and the above listed intuitive judgment, the nurse can provide clinical nursing that incorporate aesthetics.
Personal Knowledge
Personal knowledge in nursing is the nurse’s individual method of obtaining, organizing, understanding and applying information. “The pattern of personal knowing refers to the quality and authenticity of the interpersonal process between each nurse and each [client]” (Fawcett et al., 2001, p. 116). The personal knowledge a nurse possesses is dynamic, and will grow constantly throughout the lifespan. The nurse must be open to new experiences, thoughts and feelings. The nurse must be honest with themselves, and explore and interpret all knowledge obtained. Once this is completed, the nurse then should apply the comprehension of the data collected individually to meet the needs of the patient. Not all of the knowledge obtained will be easily interpreted. The nurse must be able to “accept ambiguity, vagueness, and discrepancies in what is essentially a subjective and existential process” (Hood, 2006, p. 98). Every nurse draws upon personal knowledge when interacting with patients. This concept incorporates both empirical data and aesthetics, and is essential to nursing practice.
Ethics: The Moral Component
Making decisions about the care of a patient often requires the nurse to determine which actions are morally right, and morally wrong. The problems that arise in healthcare that require moral decisions are typically vague in nature, with no clear connection to the standard code of ethics that is applied in the respect of human life. Nursing is bound to moral traditions that require, “valuable and essential social service responsible for conserving life, alleviating suffering, and promoting health” (Cody, 2006, p. 24).
This pattern of knowing requires a comprehensive understanding of different philosophies of morality. The ethical dilemmas that nurses encounter must first be reflected upon as concrete situations, then with consideration of the moral results of the actions taken. Reflection of different moral and ethical codes will provide the nurse with a greater understanding of how moral choices should be made. As technology progresses and a push for socialized medicine in the United States comes closer to reality, nurses will be faced with an increased amount of ethical dilemmas dealing with end-of-life situations. A thorough understanding of ethics and morality will assist the nurse in making the decisions that will benefit the patient as well as themselves.
Other Views of Patterns in Nursing
Schultz and Meleis (1988) examined Carper’s patterns of knowing, and felt that she left out a few very important practical concepts. They decided to include the following three patterns in nursing knowledge: clinical, conceptual, and empirical. The following is a description of these patterns in nursing, which need to be appreciated as an expansion of Caper’s four fundamental patterns of nursing.
Clinical knowledge refers to the nurse’s personal knowledge. The nurse employs multiple ways of knowing while they are addressing the problems of their patients. The clinical knowledge is observable when the nurse is practicing nursing, and is created from the unity of personal knowledge and empirical knowledge (Schultz P.R. & Meleis A. I, 1988).
Conceptual knowledge is derived from the objective and subjective data collected from multiple patient interactions. These interactions occur over a span of time and in multiple settings. The nurse will recognize the patterns that evolve from these experiences while expressing them as models and theories (Schultz P. R. & Meleis A. I, 1988). Propositional statements and concepts are formed and supported by empirical or anecdotal data, as well as logical reasoning (Schultz P. R. & Meleis A. I, 1988). This knowledge draws on information from nursing, as well as multiple other disciplines including sociology, psychology, etc. According to Schultz & Meleis, conceptual knowledge, “incorporates curiosity, imagination, persistence, and commitment in the accumulation of facts and reliable generalizations that pertain to the discipline of nursing” (McEwan, 2007, p. 15).
The combination of experimental, historical, or phenomenological research is used to define the concept of empirical knowledge. This knowledge validates nursing actions and procedures. The validity of this knowledge is based upon the general acceptance by researchers within the field of nursing and the conclusions drawn from the evidence provided (McEwan, 2007). Schultz and Meleis stated that “empirical knowledge is evaluated through systematic review and critique of published research and conference presentations” (Schultz P.R. & Meleis A. I, 1988).
Summary
There is a need to recognize patterns of knowing in nursing. The recognition of these patterns will be used to validate the unique body of knowledge nursing owns. This unique body of knowledge is the justification of nursing practices. Understanding the patterns of knowing in nursing is crucial to teaching and learning nursing. The patterns of knowing will not expand nursing knowledge, but will answer the question of what it means to know, and how to identify the types of knowledge that are important to nursing. The recognition of these patterns of knowing assists to analyze the kind of knowledge that gives the discipline of nursing the meaning.
If you are interested in the full citations, please request an official copy of the paper.
medical futility in the ER
Medical Futility and Moral Distress in Emergency Nursing
Introduction
Medical futility is an emerging problem to Emergency Room nurses. As a result, ER nurses experience high levels of moral distress. The consequential moral distress leads to emotional and physical problems by the affected nurse, negative impact on patient care, burnout, and high turnover. Attention to the affect of moral distress and medical futility on other nursing specialties has been explored, however the specialty of emergency nursing has been neglected.
This article is aimed at examining the phenomenon of moral distress caused by medically futile practices in the ER. Focus will include the importance of recognizing this phenomenon as well as efforts to address it.
Defining Moral Distress
Andrew Jameton described nursing moral distress as the painful feelings and psychological upset that occurs when nurses face ethical dilemmas, and are unable to react in the manner they deem ethically appropriate (Corley, 2002). Institutional policies, lack of time, unsupportive supervisory staff or legal limitations may prevent the nurse from acting the way they think is necessary (Corley, 2002).
Jameton described a distinction between initial and reactive moral distress. Initial moral distress happens when nurses experience anger, frustration, and anxiety as the ethical dilemma presents itself, and the nurse cannot react to it as they believe is ethical (Corley, 2002). Reactive distress occurs after the nurse is unable to act according to their personal ethical guidelines (Corley, 2002). There is also a difference in moral dilemmas and moral distress. A moral dilemma has more than one right action, but acting on one prohibits action on the others (Corley, 2002). The action of doing the right thing is also doing something wrong, because of the inability to do the other right things. Webster and Bayliss recently broadened the definition of moral distress by stating it is the failure to engage in doing the right thing, or failure to do the right thing according to personal values because of an error in judgment, or circumstances beyond control (Corley, 2002). This moral distress can result in compromised personal values, and moral residue.
Impact of Moral Distress on Nurses
The majority of study on the moral distress that affects nurses has been done in the intensive care and acute care settings (McCarthy, 2008). The research has indicated that the majority of moral distress has come from aggressive treatments of critically ill patients, treatments that are deemed futile, unequal power balances amongst colleagues, or inadequate or incompetent coworkers (McCarthy, 2008). The research has been conducted by a series of qualitative studies with the exception of Corley, who developed the Moral Distress Scale in order to validate the research with empirical data.
Corley’s study in 2001 indicated that many nurses experience a high level of moral distress which has resulted in 15% or the nurse participants to leave positions due to the moral distress they experienced (McCarthy, 2008). Moral distress has been associated with feelings of frustration, anger and anxiety. The manifestations of moral distress includes anger, frustration, guilt, loss of self worth, depression, nightmares, suffering, anger resentment, sorrow, anxiety, helplessness, and powerlessness (Zuzelo, 2007).
Another study found that new graduate nurses experienced levels of moral distress due to disappointment, doubt, and blame once they realized they were not accomplishing the goals they had set for themselves in nursing schools (McCarthy, 2008). The methods of coping with their distress was to leave the unit they were working in search of better working conditions, cutting down on the amount of hours worked, changing their career entirely, or blaming the nursing administration or hospital system (McCarthy, 2008). A study that collaborated with the one mentioned above described the emotions that nurses felt when experiencing moral distress. The emotions ranged from emotional exhaustion, abandonment, lack of respect, or lack of belonging (McCarthy, 2008).
Moral distress is a significant problem in nursing, and can lead to a compromise in personal integrity, or a wounded moral conscience. The compromise of personal integrity results in an irreversible alteration of self. Hanna states, “moral distress involves a perceived violation for the person [that] can produce a disconnection from self and others (Hanna, 2004, p. 76). According to Webster and Baylis, the compromise of one’s integrity can lead the nurse to underestimate or deny that anything is wrong. The nurse may then “compartmentalize” the self in order to deflect the compromise experienced in the workplace is recognized as not changing the personal self (McCarthy, 2008). Consequently, Some people may lose their perspective on their own morals, and act on the basis of fear of repercussion.
Medical Futility Defined
Currently medical futility refers to interventions that are not likely to produce any significant benefit for the patient. There are two types of futility distinguished, qualitative and quantitative. Qualitative futility refers to the quality of the benefit an intervention will produce is exceedingly poor, and quantitative refers to the likelihood that an intervention will benefit the patient is exceedingly poor (Jecker, 1998). Both definitions refer to the benefit to the patient that a patient is able to appreciate.
In a widely cited article by Schneiderman et al proposed a definition of medical futility in both the quantitative and qualitative aspects, but include the belief that “ a treatment is deemed futile if empirical data demonstrates less than 1% chance of success” (Schneiderman, 1990) or if the treatment produces chronic unconsciousness or fails to end critical care support.
Since there is a wide range of definitions and no consensus amongst health care professionals to find specific meaning in futility, a legal and ethical movement must be accomplished in order to prevent undue moral distress in healthcare professionals.
Medical Futility in the Emergency Room
The emergency room requires rapid decision making in regards to treatments. The decisions are made with the expected risks and benefits to the patient, family, and society. With some treatments, the expectation of benefit is low, or considered medically futile. The decision made in regards to the benefit of treatment should be based on empirical evidence, societal and professional standards. These decisions should not be made on individual prejudice. Currently here is no ethical or legal obligation to healthcare providers to provide medical treatments they deem futile. Judgments made in the ER have special significance because of the considerable consequences of administering or withholding interventions.
Special considerations of the emergency room is that there is often a lack of information about the patient on arrival, surrogates are unavailable, or the presenting information is incorrect. Because of these circumstances, nurses are required to make decisions based on evidenced based practice, patient and family wishes, and professional judgment. In consideration of withholding interventions, the risks and benefits should be carefully weighed by the nurse. The ultimate goal of the intervention is to prolong death, and restore the patient to health, with this in mind, circumstances may arise that blur the lines of the benefit to the patient. The family members of the patient may become involved, and reassurance, guilt resolution, and the provision of additional time to accept poor prognosis may be necessary. Patient and family care should continue to be provided even if certain medical treatments are withheld. Support, guidance, and palliative care may be more beneficial to the patient and family than that of technological advances.
In the emergency room, there are four concepts of futility in regards to resuscitative efforts that were discovered by Brody and Halevy. The first is physiologic futility meaning failure to produce and physiologic response. The second is imminent demise futility, which is failure to prevent death in the near future. The third is lethal condition futility, which is failure due to underlying lethal condition that will result in death in the distant future. The fourth is qualitative futility which is failure to lead to an acceptable quality of life. As the progression of the types of futility one would experience in the emergency room, each type becomes broader in concept and toward a more controversial group of patients (Brody, 1995).
Medical Futility Causing Moral Distress
Many physicians have admitted in the past to have ordered treatments that are medically futile (Mohammed, 2009). Medical futility raises concerns for healthcare providers. The care that is ordered is often aggressive, and can be viewed as cruel and inhumane. It may not be in the best interest of the patient, and moral integrity can be questioned as a result. Because of the negative effects of futility on nurses, there is a need to address new standards of treatments, and evaluate end-of-life care.
Participating in medically futile acts causes moral distress on healthcare providers, and it has been shown that nurses are more effected by this than are physicians (Mohammed, 2009). However, institutional constraints bind nurses to act in ways that do not reflect their own personal values. Nurses are also exposed to the death and dying process around the clock, and are required to deal with invasive technologies, and their impact on the dying human body.
Medical futility is widely practiced, and will only continue to increase in frequency as the move in healthcare is toward socializing medicine. There is a great need for why these practices continue when it has been proven to cause moral distress and burden patients and families. These practices continue because of the social need for such treatments to continue when facing death and dying.
A common practice in the ER is t perform CPR. Depending on the age of the patient, the co morbidities, the chances of being successful with CPR are so low, it can be considered futile. Peberdy et al. reported that only 1-6% of hospitalized patients survive CPR, and only 17% of the survivors lived long enough to be discharged out of the hospital (Peberdy M, 2003).
Proposed Future Research
A measure of the amount of moral distress on emergency room nurses would be beneficial to the profession. As the move in politics is gaining momentum on socialized medicine, there will be fewer resources available to patients in ERs due to the increased demand for emergency care. Moral distress will become a larger problem in the future, and the nursing shortage may increase, Methods of reducing moral distress in the emergency room will help decrease nursing burnout and increase retention.
The impact of nursing moral distress on patient outcomes is essential to the improvement of healthcare in the emergency room. With recognition that end-of-life issues arise, and cause nurses to act in ways they find morally disturbing, methods can be devised so that patient care is not compromised. A study on how nurses with moral distress affects the impact on patient care in the emergency room would assist in the recognition that a reduction of moral dilemmas is essential.
The value of educating the public on realistic expectations of morbidity and mortality in relation to the emergency room can assist in decreasing the demand for care that patients, families and care givers request that may be futile. Research regarding the education provided to the general population before and after end-of-life situations will allow the recognition of where disparities exist.
Two additional aspects or research that should be addressed are the perception of medical futility in the ER from the nurses perspectives, and the impact or treatment withdrawal of medically futile treatments on the nursing staff, the patients, families and caregivers. All of this information will assist in developing methods to reduce moral distress in ER nurses. With a reduction of moral distress will come an improvement in patient care, less nursing burnout and turnover, as well as improvement in psychological equilibrium.
If you are interested in the full list of references, please ask for a copy of the paper and the full list will be provided.
Introduction
Medical futility is an emerging problem to Emergency Room nurses. As a result, ER nurses experience high levels of moral distress. The consequential moral distress leads to emotional and physical problems by the affected nurse, negative impact on patient care, burnout, and high turnover. Attention to the affect of moral distress and medical futility on other nursing specialties has been explored, however the specialty of emergency nursing has been neglected.
This article is aimed at examining the phenomenon of moral distress caused by medically futile practices in the ER. Focus will include the importance of recognizing this phenomenon as well as efforts to address it.
Defining Moral Distress
Andrew Jameton described nursing moral distress as the painful feelings and psychological upset that occurs when nurses face ethical dilemmas, and are unable to react in the manner they deem ethically appropriate (Corley, 2002). Institutional policies, lack of time, unsupportive supervisory staff or legal limitations may prevent the nurse from acting the way they think is necessary (Corley, 2002).
Jameton described a distinction between initial and reactive moral distress. Initial moral distress happens when nurses experience anger, frustration, and anxiety as the ethical dilemma presents itself, and the nurse cannot react to it as they believe is ethical (Corley, 2002). Reactive distress occurs after the nurse is unable to act according to their personal ethical guidelines (Corley, 2002). There is also a difference in moral dilemmas and moral distress. A moral dilemma has more than one right action, but acting on one prohibits action on the others (Corley, 2002). The action of doing the right thing is also doing something wrong, because of the inability to do the other right things. Webster and Bayliss recently broadened the definition of moral distress by stating it is the failure to engage in doing the right thing, or failure to do the right thing according to personal values because of an error in judgment, or circumstances beyond control (Corley, 2002). This moral distress can result in compromised personal values, and moral residue.
Impact of Moral Distress on Nurses
The majority of study on the moral distress that affects nurses has been done in the intensive care and acute care settings (McCarthy, 2008). The research has indicated that the majority of moral distress has come from aggressive treatments of critically ill patients, treatments that are deemed futile, unequal power balances amongst colleagues, or inadequate or incompetent coworkers (McCarthy, 2008). The research has been conducted by a series of qualitative studies with the exception of Corley, who developed the Moral Distress Scale in order to validate the research with empirical data.
Corley’s study in 2001 indicated that many nurses experience a high level of moral distress which has resulted in 15% or the nurse participants to leave positions due to the moral distress they experienced (McCarthy, 2008). Moral distress has been associated with feelings of frustration, anger and anxiety. The manifestations of moral distress includes anger, frustration, guilt, loss of self worth, depression, nightmares, suffering, anger resentment, sorrow, anxiety, helplessness, and powerlessness (Zuzelo, 2007).
Another study found that new graduate nurses experienced levels of moral distress due to disappointment, doubt, and blame once they realized they were not accomplishing the goals they had set for themselves in nursing schools (McCarthy, 2008). The methods of coping with their distress was to leave the unit they were working in search of better working conditions, cutting down on the amount of hours worked, changing their career entirely, or blaming the nursing administration or hospital system (McCarthy, 2008). A study that collaborated with the one mentioned above described the emotions that nurses felt when experiencing moral distress. The emotions ranged from emotional exhaustion, abandonment, lack of respect, or lack of belonging (McCarthy, 2008).
Moral distress is a significant problem in nursing, and can lead to a compromise in personal integrity, or a wounded moral conscience. The compromise of personal integrity results in an irreversible alteration of self. Hanna states, “moral distress involves a perceived violation for the person [that] can produce a disconnection from self and others (Hanna, 2004, p. 76). According to Webster and Baylis, the compromise of one’s integrity can lead the nurse to underestimate or deny that anything is wrong. The nurse may then “compartmentalize” the self in order to deflect the compromise experienced in the workplace is recognized as not changing the personal self (McCarthy, 2008). Consequently, Some people may lose their perspective on their own morals, and act on the basis of fear of repercussion.
Medical Futility Defined
Currently medical futility refers to interventions that are not likely to produce any significant benefit for the patient. There are two types of futility distinguished, qualitative and quantitative. Qualitative futility refers to the quality of the benefit an intervention will produce is exceedingly poor, and quantitative refers to the likelihood that an intervention will benefit the patient is exceedingly poor (Jecker, 1998). Both definitions refer to the benefit to the patient that a patient is able to appreciate.
In a widely cited article by Schneiderman et al proposed a definition of medical futility in both the quantitative and qualitative aspects, but include the belief that “ a treatment is deemed futile if empirical data demonstrates less than 1% chance of success” (Schneiderman, 1990) or if the treatment produces chronic unconsciousness or fails to end critical care support.
Since there is a wide range of definitions and no consensus amongst health care professionals to find specific meaning in futility, a legal and ethical movement must be accomplished in order to prevent undue moral distress in healthcare professionals.
Medical Futility in the Emergency Room
The emergency room requires rapid decision making in regards to treatments. The decisions are made with the expected risks and benefits to the patient, family, and society. With some treatments, the expectation of benefit is low, or considered medically futile. The decision made in regards to the benefit of treatment should be based on empirical evidence, societal and professional standards. These decisions should not be made on individual prejudice. Currently here is no ethical or legal obligation to healthcare providers to provide medical treatments they deem futile. Judgments made in the ER have special significance because of the considerable consequences of administering or withholding interventions.
Special considerations of the emergency room is that there is often a lack of information about the patient on arrival, surrogates are unavailable, or the presenting information is incorrect. Because of these circumstances, nurses are required to make decisions based on evidenced based practice, patient and family wishes, and professional judgment. In consideration of withholding interventions, the risks and benefits should be carefully weighed by the nurse. The ultimate goal of the intervention is to prolong death, and restore the patient to health, with this in mind, circumstances may arise that blur the lines of the benefit to the patient. The family members of the patient may become involved, and reassurance, guilt resolution, and the provision of additional time to accept poor prognosis may be necessary. Patient and family care should continue to be provided even if certain medical treatments are withheld. Support, guidance, and palliative care may be more beneficial to the patient and family than that of technological advances.
In the emergency room, there are four concepts of futility in regards to resuscitative efforts that were discovered by Brody and Halevy. The first is physiologic futility meaning failure to produce and physiologic response. The second is imminent demise futility, which is failure to prevent death in the near future. The third is lethal condition futility, which is failure due to underlying lethal condition that will result in death in the distant future. The fourth is qualitative futility which is failure to lead to an acceptable quality of life. As the progression of the types of futility one would experience in the emergency room, each type becomes broader in concept and toward a more controversial group of patients (Brody, 1995).
Medical Futility Causing Moral Distress
Many physicians have admitted in the past to have ordered treatments that are medically futile (Mohammed, 2009). Medical futility raises concerns for healthcare providers. The care that is ordered is often aggressive, and can be viewed as cruel and inhumane. It may not be in the best interest of the patient, and moral integrity can be questioned as a result. Because of the negative effects of futility on nurses, there is a need to address new standards of treatments, and evaluate end-of-life care.
Participating in medically futile acts causes moral distress on healthcare providers, and it has been shown that nurses are more effected by this than are physicians (Mohammed, 2009). However, institutional constraints bind nurses to act in ways that do not reflect their own personal values. Nurses are also exposed to the death and dying process around the clock, and are required to deal with invasive technologies, and their impact on the dying human body.
Medical futility is widely practiced, and will only continue to increase in frequency as the move in healthcare is toward socializing medicine. There is a great need for why these practices continue when it has been proven to cause moral distress and burden patients and families. These practices continue because of the social need for such treatments to continue when facing death and dying.
A common practice in the ER is t perform CPR. Depending on the age of the patient, the co morbidities, the chances of being successful with CPR are so low, it can be considered futile. Peberdy et al. reported that only 1-6% of hospitalized patients survive CPR, and only 17% of the survivors lived long enough to be discharged out of the hospital (Peberdy M, 2003).
Proposed Future Research
A measure of the amount of moral distress on emergency room nurses would be beneficial to the profession. As the move in politics is gaining momentum on socialized medicine, there will be fewer resources available to patients in ERs due to the increased demand for emergency care. Moral distress will become a larger problem in the future, and the nursing shortage may increase, Methods of reducing moral distress in the emergency room will help decrease nursing burnout and increase retention.
The impact of nursing moral distress on patient outcomes is essential to the improvement of healthcare in the emergency room. With recognition that end-of-life issues arise, and cause nurses to act in ways they find morally disturbing, methods can be devised so that patient care is not compromised. A study on how nurses with moral distress affects the impact on patient care in the emergency room would assist in the recognition that a reduction of moral dilemmas is essential.
The value of educating the public on realistic expectations of morbidity and mortality in relation to the emergency room can assist in decreasing the demand for care that patients, families and care givers request that may be futile. Research regarding the education provided to the general population before and after end-of-life situations will allow the recognition of where disparities exist.
Two additional aspects or research that should be addressed are the perception of medical futility in the ER from the nurses perspectives, and the impact or treatment withdrawal of medically futile treatments on the nursing staff, the patients, families and caregivers. All of this information will assist in developing methods to reduce moral distress in ER nurses. With a reduction of moral distress will come an improvement in patient care, less nursing burnout and turnover, as well as improvement in psychological equilibrium.
If you are interested in the full list of references, please ask for a copy of the paper and the full list will be provided.
Modern bioethics, from nursing to atheism
Modern bioethics is such a powerful and significant thing. We cannot be health care providers, or receivers without consideration for bioethics. Today's ethical dilemmas in health care are unique as people are living longer, access to care is more readily available, and interventions are saving lives for people who before would have passed.
Nursing is a new beast. Before it was the execution of physicians orders, now it has morphed into an independent science and pattern of thought. Nursing research as emerged as cutting edge in medical science, and is now integrated with philosophy as much as science. As health care has emerged from modernism and postmodernism, a new era in health care is upon us.
Nursing is a new beast. Before it was the execution of physicians orders, now it has morphed into an independent science and pattern of thought. Nursing research as emerged as cutting edge in medical science, and is now integrated with philosophy as much as science. As health care has emerged from modernism and postmodernism, a new era in health care is upon us.
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