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Posts from the ‘Ethics’ Category

Caring in the Context of Risk

The first article in the current issue of ANS is titled “Caring in the Context of Risk: Moving Beyond Duty” authored by Darcy Copeland, PhD, RN. The article is available to download at no cost while it is featured! Dr. Copeland shared this important message about her work investigating workplace violence!

Discussion of ethics or ethical frameworks is extremely rare in workplace violence literature. I have been investigating workplace violence for many years and view the phenomenon, in part, as an occupational hazard. When healthcare systems across the country were faced with a novel occupational hazard (coronavirus infection), there was swift and relatively agreed upon guidance regarding provider obligations and duties in the face of this risk. A duty-bound approach to decision making in the context of infectious disease seemed to work. I wondered if a duty-bound approach to decision making regarding the provision of care in the context of risk posed by patient violence would be similarly helpful.

I determined that a duty-based framework was insufficient to capture the contextual nuances and moral complexity of providing nursing care to hospitalized patients who exhibit violent behavior. I propose that examination of professional duties is one framework that can be used to guide our actions but might be insufficient if used in isolation of other frameworks. In the article I describe additional ethical frameworks and explore how they may also be used to guide decision making in the context of risk associated with violent patient behavior. These frameworks include virtue ethics, ethics of the everyday, and care ethics.

Nursing has a very long history of using virtue ethics to inform appropriate professional behavior. Virtues are characteristics that make one a “good” person/nurse and are not dependent on roles or duties. An internalization of nursing values results in a lack of distinction between being a good person and being a good nurse. Decision making utilizing this framework focuses our attention on what behaviors would maintain individual and disciplinary character in given situations.

Ethics of the everyday implores us to utilize our conceptions of “right” behavior in normal, everyday work to inform our behavior in circumstances that we deem as extraordinary, or at least out of the ordinary. This framework reminds us that we enact values as we live our ordinary lives, that everyday living is morally significant. How we conceptualize nursing and the provision of nursing care under “normal” circumstances can be used to inform decisions about the provision of care when “big” issues arise.

Finally, given the centrality of caring for others in nursing the inclusion of care ethics as a framework was obvious. This framework situates caring as occurring in the context of a relationship between two people – a caregiver and a care recipient. This perspective recognizes care as a complex site of power dynamics; it also draws attention to the humanity, needs, and vulnerability of both people. Attention to these aspects of care draw attention away from rules or duties that may be difficult to implement in complex situations.

Workplace violence is a major issue in nursing. It is also a complex issue that does not lend itself to standardized, algorithmic approaches. The more tools nurses and nurse leaders have in their tool box to determine how to respond to this issue the better.

Ethical Nursing Care

The current ANS featured article is titled “A Critical Analysis of the American Nurses Association Position Statement on Workplace Violence: Ethical Implications” authored by Darcy Copeland, PhD, RN. Please visit the ANS website over the coming 2 weeks to download this thought-provoking article at no cost. Dr. Darcy provided this message reflecting on this work:

Darcy Copeland

“I have been researching workplace violence in nursing for several years.  Increasingly, I hear nurses in many settings describe violence directed towards nurses in very polarized ways.  For example, some nurses contend that violence is an inherent risk associated with our work while others contend that violence ought not be part of our jobs.  Amidst these polarized views are workplace policies reinforcing a zero tolerance to violence stance.  The American Nurses Association adopted such a stance in their position statement on workplace violence.  Such a position, however, is not in alignment with our ethical framework. Zero tolerance policies are absolutely appropriate with respect to family/visitor or employee violence.  They are not appropriate in the context of patients, however. Zero tolerance policies have a punitive and moralist history; they are also ineffective at actually preventing violence.  Adherence to zero tolerance policies in the context of patient violence has the potential to negatively impact the RN-patient relationship, erode public trust, and criminalize illness behavior.  After a critical analysis of the ANA’s position statement it is recommended that the ANA draft separate position statements. One addressing patient violence and a separate document addressing employee and visitor/family violence.  Nurses have very different duties, obligations and power in RN-patient relationships than in relationships with coworkers and relationships with families/visitors.  Those duties, obligations and power dynamics ought to inform our response to patient violence.”  

The Ultimate ANS “Ethics” Collection

“Ethical Practice, Quality Care,” is the theme for this year’s National Nurses’ Week, which begins on May 6, 2015.  To celebrate this week, we have compiled from the Journal archives the most groundbreaking, read and cited ethics articles that address ethical issues in nursing and health care!  The collection features classic ANS articles from the first 20 years – articles that remain relevant, timely and essential guides for discussion and dialog related to the pressing ethical issues of our discipline.  The authors of the twenty articles in the collection are among the most cited nursing scholars whose writings continue to shape ethical thought in nursing.

This collection will be prominently displayed on the ANS Web site all week.  But it is available now so that you can have a head start in preparing for the many discussion that will focus on ethics during the week of celebration.  Click here to go to the collection.  ANA-NNW2015-Logo

Challenges of Ethical Conflict and Moral Distress

The current ANS “Editor’s Pick” article presents a feasibility study to assess the usefulness of an innovative ethics screening tool for nurses who are dealing with critical ethical situations.  The article, titled “Barriers to Innovation: Nurses’ Risk Appraisal in Using a New Ethics Screening and Early Intervention Tool” is by Carol L. Pavlish, PhD, RN, FAAN; Joan Henriksen Hellyer, PhD, RN; Katherine Brown-Saltzman, MA, RN; Anne G. Miers, MSN, RN, ACNS, CNRN; and Karina Squire, MPH, BS, RN.  This team of authors has provided this message for ANS readers:

Have you ever stood at a patient’s side and wavered precariously between believing in the treatments you provide and

Carol L. Pavlish

Carol L. Pavlish

dreading the painful consequences? Have you ever hoped with all your heart that these treatments will work while the experienced voice inside worries they most likely will not? Have you ever turned away from yourself…your true self… just so you can come back to work the next day?

One of the most commonly-occurring ethical dilemmas that nurses encounter is silently weighing their moral obligations to patients while facing uncertainty, being surrounded by unwavering hope, and finding themselves squarely in the middle of a healthcare culture that dis-incentivizes difficult conversations. Silence is the powerful perpetrator of that culture – and we as nurses are too often its accomplice.

 Joan Henriksen Hellyer

Joan Henriksen Hellyer

When researching the feasibility of applying an evidence-based ethics screening tool that encourages nurses to express concerns, we were surprised at the tenacity of their silence. We found that some nurses “let it slide” because systems see no profit in ethical deliberation and place certain demands on exactly how nurses should use their time. Hierarchical power structures can drive nurses to avoid “being the troublemaker”. Furthermore, some nurses “questioned themselves” instead of turning the question outward – outward to structures that concentrate power in the hands of a few making it all the more difficult to “query the gatekeepers.”

Speaking up is not a risk-free action in health care. As a result, concerns become “unspeakable.” Jane Georges warns us that compassion becomes more difficult and even impossible when concerns are “unspeakable.”

Katherine Brown-Saltzman

Katherine Brown-Saltzman

Without compassion, nursing care becomes mechanical at best – dangerous and alienating in its worst form. Our research seems to indicate that nurses who bring innovations to health care cannot just focus on preparing nurses for new roles. We must also challenge and change systems that find comfort in the status quo. As Peggy Chinn says in her editorial, “The time has come for nurses to come together as never before to revive some of the innovative models that existed in the past and to creatively forge ahead into uncharted territory.” We have a rich tradition of moral courage in nursing – from Florence Nightingale to Lillian Wald and many others – all of whom challenged the “unspeakable” and created conditions where health and human flourishing can actually happen.


Anne Meirs

Part of moral courage is reclaiming that heritage and finding our own voice to ask four key questions: a) What is wrong with this picture? b) Who benefits? c) What are the barriers to freedom from what is

Karina Squire

Karina Squire

wrong? and finally, d) What needs to change? Chinn and Kramer posed this four-question framework in Integrated Theory and Knowledge Development in Nursing (2011). The framework moves us beyond the “unspeakable” and strengthens our voices to participate actively in creating innovative systems of care – where clinicians appreciate value-laden contexts, challenge each other to dialogue about ethical concerns, and ultimately provide focused goals that honor what healthcare providers in good conscience can provide for patients.

While it is featured, this article is available to download at no cost. Then come back here and post your comments and questions  here … the authors and I want to hear from you, and we will respond!

Disaster preparedness

The Washington Post had a story yesterday that should raise some concerns, for a day or two:  “US Health Care System Unprepared for Major Nuclear Emergency, Officials Say”Disaster Relief

As I suggested in another post, it is difficult, if not impossible to be prepared for a catastrophe when our health care facilities are barely handling routine loads.

Disaster preparedness requires tremendous redundancies: Extra staff, extra supplies, extra equipment, extra medications, extra food, and alternative energy sources. Read more

The “Cs” of Scholarship

Several years ago I created a kind of template to use in talking about some of the mysteries of good scholarship.  The handout I used made its way around the world and with some regularity I received requests for copies of the handout!  So in mythe letter C Editorial in ANS Vol 22, No 2, I published a version of this handout.  With permission of our publisher, I am presenting this once again here, along with yet another pair of “C’s”!

The “C’s” in this list represent contrasting traits that we seek in the best of scholarship.  Some of the pairs seem like contradictions, but in fact, they have a Read more

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