1
Q
The Middle Ages (5th-15th Centuries)
A
- A period of significant scientific change
- Famine, plague, and war made populations vulnerable to the onslaught of epidemic disease.
- Healing was often sought through religious interventions such as by religious relics and by visiting sacred places.
- Nurses believed their duty was to God and to the spiritual rather than the need of the patient.
- Physical, emotional and comfort needs were set aside.
- Mental illness was viewed as possession by the devil or punishment for sins.
- Patients were chained, starved, kept under filthy conditions, and at times tortured.
2
Q
Renaissance (15th-17th centuries)
A
- Birth of scientific revolution and a new era in the healing arts.
- Cartesian philosophy resulted in a separation between the acts of caring and curing.
- Nurse’s role restricted to the caring realm of the healing arts.
- Caring was given lower priority than healing. Medicine overshadowed nursing++
- Nursing care provided by nuns
3
Q
reformation
A
- “Dark period of nursing” in Britain
- Nursing care removed from the nuns.
- Hospital care provided by convalescent patients, prostitutes, prisoners, and drunkards.
- Conditions in hospitals became deplorable.
- Much of Canada’s hospital care originated from France, not Britain
- Lay women such as Marie Hebert (arrived in Quebec in 1617) came from France to open hospitals and care for the Aboriginal populations
4
Q
The Modern Era
A
- Nursing as we know it today began to emerge in the modern era (18th-19th centuries).
- Nursing training schools emerged, social justice was fought for.
- Florence Nightingale (born in 1820, died in 1910) worked to free nursing from the bonds of the church; became a model for all nurses; described nursing as ‘caring for the mind and body’ (first reference to holistic nursing); and addressed moral and social issues.
5
Q
ethical philosophy
A
- The intense and critical examination of beliefs and assumptions
- offers principles for deciding what actions and qualities are most worthwhile
6
Q
philosophy of practice
A
-Includes assumption about norms and values
- Includes ethics, social and political philosophy, and philosophy of law.
- It is philosophy of practice, specifically moral philosophy, that provides the groundwork for discussion of many of the ethical dilemmas nurses must face
7
Q
moral philosophy
A
the philosophical discussion of what is considered good or bad, right or wrong, in terms of moral issues
8
Q
ethics
A
a formal process for making logical and consistent decisions, based upon moral philosophy
9
Q
morality
A
traditions or beliefs about right and wrong
10
Q
naturalism
A
- matter of feeling
- Ethics is dependent on human nature and psychology
- Differences in moral codes are a result of social conditions
- All people have similar underlying psychological tendencies, suggesting universality in moral judgment
- All people have tendency to make similar ethical decisions
- Sympathy/empathy is a motivating factor in moral decision making
- What is best in this case?
- Utilitarianism
11
Q
rationalism
A
- matter of reason
- All people have unique feelings and perceptions
- Ethical values have an independent origin in the nature of the universe and can become known to humans through the process of reasoning
- Truths about the world are universal and superior to what we receive from our senses and experiences
- Moral/ ethical rules originate from a higher source and are always true
- What is right always?
- deontology
12
Q
utilitarianism
A
- consequentialism
- based in naturalism
- Action is judged as good or bad in relation to the consequence, outcome, or end
- Right action is that which has the greatest utility or usefulness (no action is in itself good or bad, always depends on the end derived from them)
Forward looking
13
Q
deontology
A
- Kantianism
- based in rationalism
- Rightness or wrongness of an act depends upon the nature of the act, rather than its consequences.
- We must fulfill certain duties owed to others
- We must all act as members of a community of equal and autonomous individuals, and each member must treat all others as moral beings. Each person should have regard for the desires of others and allow for freedom of decision.
- backward looking- what is driving us? Motivating us?
- Most professional codes of ethics are based upon Kantian principles
14
Q
virtue ethics (character ethics)
A
- Actions of individuals are based on a certain degree of innate moral virtues
- Shifts our focus from the action (what we ought to do) to the actor (who we are, and what moral virtues we value)
- A person with moral virtue has consistently moral action and a morally appropriate desire
15
Q
5 focal virtues
A
compassion
discernment
trustworthiness
integrity
conscientiousness
16
Q
fundamental virtue
A
caring
17
Q
relational ethics
A
- Requires that we focus on the relationship as a significant and central aspect of health care ethics
1) Mutual respect (respect for an attention to difference)
2) Engagement (aim to strive for authenticity and connection)
3) Embodiment (holistic care, consideration of emotion and subjective experience alongside empirical knowledge)
4) Environment (how relationships connect us to larger social groups, systems, and communities)
18
Q
bioethics
A
- Support the improvement of client care by assisting clients, families, staff, physicians & volunteers resolve ethical issues.
- Case consultation
- Ethics education
- Policy development
- Research on ethical issues
19
Q
Jurisprudence exam
A
tests:
- Nursing regulation
- Scope of practice
- Professional responsibility and accountability
- Ethical practice
- The nurse-client relationship
150 multiple choice, 3 hours and 15 minutes
$40 fee
unlimited attempts, ($40 each time)
knowledge and comprehension
application
critical thinking
20
Q
ethical principles
A
basic and obvious moral truths that guide deliberation and action
Respect for autonomy
Beneficence
Non-maleficence
Veracity
Confidentiality
Justice
Fidelity
21
Q
paternalism
A
acting in a dominant manner, possibly on behalf of the patient.
22
Q
veracity
A
truth telling
23
Q
justice
A
fair, equitable, and appropriate treatment
24
Q
fidelity
A
- promise keeping
25
nurses have 4 fundamental responsibilities
to promote health,
to prevent illness,
to restore health
to alleviate suffering.
26
values
- Values are ideals, beliefs, customs, modes of conduct, qualities, goals preferred by people, groups and society
- Learned in conscious and unconscious ways, become ingrained and guide us in making decisions/choices
27
axiology
- Branch of philosophy that studies values
- Includes the study of aesthetics, or what is “right” or “wrong” in human relations and conduct
28
moral thought
individual cognitive evaluations of right and wrong, good and bad (what you think)
29
moral values
preferences or dispositions that reflect right or wrong in human behaviour (what you ought to do)
30
how are values acquired
- Developed over time, may stay with us or change in response to our development, experiences, education, and exposure to other perspectives
- What are the influences that help to shape our values?
- Conscious acquisition (instruction by parents, teachers, mentors, religious leaders, etc.)
- Unconscious acquisition (socialization and role-models)
31
moral autonomy
- The most important step in values formation is one’s freedom to choose those values most cherished and to relinquish those that have little meaning
- taking responsibility for our own values and beliefs
- stop embracing values of other and embrace our own values instead
32
self awareness
- Ethical relationships begin with self-knowledge and our willingness to express that awareness to others honestly and appropriately
- What we believe to be the truth is always coloured by our perceptions and surrounding contextual forces, and can change over time
- We must remain open to other perspectives, and attempt to understand the reasons others have for the decisions they make
- Self-knowledge is an ongoing, evolving process that requires us to make a commitment to know the truth about ourselves
33
values clarification
- process of becoming more conscious of and articulating what we value or consider worthy
- Reflection sheds light on our personal perspective and develops insight into our values which in turn improves our ability to make decisions
34
values conflict
When personal values are in conflict or at odds with a patient’s, colleague’s, or institution’s values interpersonal conflict may result.
35
moral integrity
authenticity: maintaining and articulating consistent fundamental values and beliefs over time
36
overt values (explicit values)
- explicitly communicated through documents or mission/vision/value statements
37
covert values (implicit values)
-implicit expectations not in writing, often only identified through the process of working through a challenging or centious situation, which highlights unspoken expectations or norms that are apart of the value system of that organization
38
moral distress
- Reaction to a situation in which there are moral problems that seem to have clear solutions, yet we are unable to follow our moral beliefs because of external restraints.
- Knowing the morally right action to take but being prevented from doing so by institutional constraints
- Evidenced by anger, dissatisfaction, frustration and poor performance in the work setting.
39
moral development
- Moral development (= human values development) is a product of the sociocultural environment in which we live and develop
- We learn what is right and wrong within the culture in formal/ conscious ways and informal/ unconscious ways
- Moral values are culturally relative, or learned/ developed in the context of a particular culture
40
Kohlberg's Ethics
- Both Kohlberg and Gilligan suggest developmental sequences in stages/ phases that are progressive. Each stage/ phase reflects greater depth of understanding, moral thinking, and moral reasoning.
- Kohlberg noted women tend to focus on relational stages, such as Stage 3. Men tend to focus on adherence to duty and the rules of authority, as highlighted in Stage 4.
- Kohlberg’s research also found that not everyone moves through all the stages, and that few people actually progress to the post-conventional level.
- suggests cognitive development is necessary though not sufficient for moral development (draws on Piaget)
- Choices are based on objective rules and principles to ensure fair treatment of all persons
- Focused on notions that are concerned with social conformity, principles, rules, and clear hierarchies
- Moral concern is with rights and responsibilities
41
Gilligan's Ethics
- noted women utilize an ethic of care in which the moral imperative is grounded in relationships with and responsibility for one another
- Gilligan’s research did not say most women think in the care perspective and most men in the justice perspective, but identified the default perspective women tend to use and feel most comfortable with.
- Gilligan noted all people can shift to the other (less dominant) perspective
- Choices are contextually bound, requiring strategies that maintain connections and a striving to hurt no one
- Approach that encompasses notions of relationships and responsibilities to others
- Moral concern is with competing needs and responsibilities in relationships
42
Kohlberg's Ethics of Justice Stages
1) preconventional - avoid getting in trouble
2) conventional - desire to fit in
3) post conventional - shared/universal moral principles
1. punishment and obedience
2. individual instrumental purpose and exchange
3. mutual interpersonal expectations, relationships, and conformity
4. social system and conscience maintenance
5. prior rights and social contract or utility
6. universal ethical principles
43
Gilligan Ethics of Care Stages
1) concern for survival
2) focusing on goodness
3) the imperative of care
44
Thomas's Level of Moral Response
1) expressive level - very superficial
2) pre-reflective level - blind following of standards
3) reflective level - reasons for moral views based on rules, values, principles
45
plurality
- Offering balance to each other, these perspectives broaden the view from which to see situations as a whole= a more comprehensive moral perspective
- The notion of a plurality of moral voices, which recognizes perspectives of both justice and care are factors in moral decision-making, is an important consideration for nursing
- Nursing may benefit from moving beyond current models of biomedical ethics to a model encompassing the concepts of care and justice
46
practical dilemmas
-claims of self-interest.
- Moral claims compete with non moral claims
- In decisions that involve practical dilemmas, moral claims have greater weight than non-moral claims.
47
moral uncertainty
- senses moral problem but does not know the morally correct action
- “Uncomfortable with the situation, but can’t articulate a specific problem”
48
moral dilemma
-2+ conflicting moral claims
-No satisfactory solution
-All solutions have equal outcomes
49
moral distress
-Right action is clear, but you cannot do it due to limitations in the institution or system
-linked to “burnout”
-can cause moral disengagement
-Can cause erosion of a nurse’s values and affect confidence and self-esteem
50
moral outrage
- Shares the same common feeling of powerlessness as moral distress
- Feel powerless to do the right thing
- Don't know what to do anymore
51
moral residue
- Moral residue: when nurses find they are being asked to compromise their values time and time again
- Moral residue can be the result of moral distress over time
- Can result in feelings of guilt, inadequacy, and powerlessness
- “Compassion fatigue”
52
moral disengagement
- Moral disengagement: a problem that can occur if the “ethical commitments” of nurses are repeatedly devalued or ignored
- When nurses work in environments where they feel their views, contributions, and ethical concerns are not valued by the institution, they can, over time, become disengaged or far less invested in their nursing role and practice
- Nurses may express a lack of caring about outcomes and/or express lack of interest or lack of engagement in what they do
- May progress into feelings of resentment, demonstrated by being unkind or uncaring towards patients and colleagues
53
moral courage
- To have moral courage is to stand up for what one believes in, even in the face of opposition or adversity
- related to steadfastness
54
moral resilience
The ability to tolerate threats, stressors, and challenges while also maintaining ones integrity and moral stamina
55
The Nursing Process as a Decision Making Model
- Assessing and describing the situation to identify the ethical problem, values involved, and any rules or policies that apply
- Making plans/ deciding on an approach to solve the problem or address the situation
- Implementing plans/ taking action (even if that means doing nothing), communicating clearly and consistently, and providing ongoing support for those affected
- Evaluation of decisions made and resulting outcome
56
laws
- Many laws affect the practice of nursing
- Binding and enforced rules of action or conduct
- Define rights and obligations and enforce penalties for people who violate them
- Built upon a moral foundation
57
5 basic functions of law in society
1) to maintain order in all aspects of our lives
2) to provide solutions that can help resolve conflicts between individuals, groups, and organizations
3) to help bring about social change and change in behaviours and norms
4) to outline the civil rights of individuals and to protect those rights
5) to reflect and express social norms and expectations for individuals, groups, and organizations
58
purpose of the law
-ensure safety of citizens
-protect property
-prohibit discrimination
-regulate the professions
-provide for the distribution of goods and services
-protect the economic and environmental interests of society
59
constitutional law
- Written in several documents including the Constitution Act
- Part 1: Charter of Rights and Freedoms (values of the nation)
- British north america act → constitution act → canada act
- Formal set of rules and principles that describes the powers of the government and the rights of people
60
statutory/legislative law
- Formal laws written and enacted by federal or provincial legislatures
- Parliament passes these laws
- Laws set out by government through acts, statutes, codes, or laws
61
administrative law
- Involves operation of government agencies (such as education, social welfare, public health units, LHINs, CNO).
- Legal powers are granted to administrative agencies
- Rules set out by CNO carry the same weight as other law
- CNO - protect the public
62
common law (foundation)
-Laws created and enforced in judicial system by courts and judges
-More room for interpretation (by a judge for example) than statutory laws, but this is controlled by precedent (establishing principles on a case by case basis by which courts and judges make decisions in subsequent cases)
63
public law
- Aka criminal law
- Breaking the law
- People + government
- Crimes and actions considered harmful to society
- Federal government
- Nurses may be accused of:
Injuring a patient
Falsifying narcotic records
Failure to renew licenses
Fraudulent billing
64
private law
- Aka civil law
- People + people
- A person’s legal rights and obligations in activities that involve other people
- Includes contract law and tort law, property, labor, family, inheritance, small business, privacy
- Tort- negligence/malpractice - harm suffered because of someone elses action (intentional or unintentional)
- Employment contract (expressed contract)
- Nurse-client relationship (Implied contract)
- An act or omission causing unintended injury or harm to another person, usually negligence (unintentional tort)
65
capacity to consent
-A person is capable if the person is able to understand the information that is relevant to making a decision and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision
-capacity depends on treatment
-capacity depends on time
-return of capacity
-wishes
-later wishes prevail
-consent may be withdrawn at any time
66
elements of consent
1. The consent must relate to the treatment.
2.The consent must be informed.
3.The consent must be given voluntarily.
4.The consent must not be obtained through misrepresentation or fraud.
67
elements of informed consent
1.The nature of the treatment.
2.The expected benefits of the treatment.
3.The material risks of the treatment.
4.The material side effects of the treatment.
5.Alternative courses of action.
6.The likely consequences of not having the treatment.
68
emergency treatment without consent
(a) there is an emergency; and
(b) the delay required to obtain a consent or refusal on the person’s behalf will prolong the bodily harm.
(c) language barrier or disability will delay consent and cause harm
(c) steps that are reasonable in the circumstances have been taken to find a practical means of enabling the communication to take place, but no such means has been found;
(d) the delay required to find a practical means of enabling the communication to take place will prolong the suffering that the person is apparently experiencing or will put the person at risk of sustaining serious bodily harm; and
(e) there is no reason to believe that the person does not want the treatment.
69
substitute decision makers
- the persons guardian
- the persons power of attorney
- representative appointed by the board
- spouse or partner
- child or parent of the person
- childrens aid society
- brother or sister
- relatives
70
substitute decision makers must be:
(a) capable with respect to the treatment;
(b) at least 16 years old, unless he or she is the incapable person’s parent;
(c) not prohibited by court order or separation agreement from having access to the incapable person or giving or refusing consent on his or her behalf;
(d) available
(e) willing to assume the responsibility of giving or refusing consent
71
PHIPA
- Sets rules for the collection, use and disclosure of personal health information.
- These rules will apply to all health information custodians operating within the province of Ontario and to individuals and organizations that receive personal health information from health information custodians.
- The legislation balances individuals’ right to privacy with respect to their own personal health information with the legitimate needs of persons and organizations providing health care services to access and share this information.
- With limited exceptions, the legislation requires health information custodians to obtain consent before they collect, use or disclose personal health information. In addition, individuals have the right to access and request correction of their own personal health information.
72
problem solving in conflict situations
1) remain attentive to personal values
2) clarify obligations
3) determine the nature of the problem
4) consider and weigh alternatives
5) develop respectful solutions
73
workplace bullying and incivility
- Balance loyalty to other nurses with loyalty to the patient and the institution.
- Nurses have an ethical and professional responsibility to report unsafe, harmful or unethical behaviour of another professional nurse.
- Workplace incivility includes horizontal or lateral violence, bullying, harassment, oppression, sabotage, and “nursing eating its young”.
- Harassment - any behaviour that demeans, humiliates, or embarrasses a person
74
relationships with physicians
- Important factor in quality of patient care.
Generally reflect the prevailing gender roles in a society.
- Complex within the institutional setting
- No chain-of-command relationship, yet nurses often must follow physicians’ orders.
- The ideal: mutual respect and collegiality.
75
organizational ethics
- Principles and goals by which the organization operates; their ethical behavior
- Aimed at preventing ethical problems rather then reacting to them
- Aimed at producing a positive ethical climate where policies, procedures integrate patient, business and professional perspectives that reinforce the organizations mission and vision
76
nurses relationships with organizations
- Hospitals are hierarchical and bureaucratic institutions that expect nurses’ loyalty.
- Difficulties arise when there is conflict between the goals of nurses and patients and those of the institution.
- Need to:
Balance professional obligations with personal commitments.
Value one’s self in order to value others.
77
professional status
Expertise
Accountability
Presence of a systemic theory
Ethical codes
A professional culture
Altruistic service orientation
Competency testing
Established Standards
Scope of Practice
Credentialing
Licensure
78
expertise
- Expertise is the characteristic of having a high level of specialized skill and knowledge.
- Primary distinguishing difference between the professional and nonprofessional.
- Expertise is gained through:
Extensive educational requirements
Intense guided practice
Examination for licensure
Certification
Mandatory continuing education
79
nursing and autonomy
- Autonomy literally means self-governing.
- Because it self-regulates, the profession is autonomous.
- Autonomy has two levels:
Autonomy of the profession.
Autonomy of the individual practitioner.
80
accountability
- Accountability means to be answerable to oneself and others for one’s own actions.
- Related to both responsibility and answerability.
- Mechanisms of Accountability
Codes of Nursing Ethics. (primary goals and values of nursing)
Standards of Nursing Practice. (minimum expectations for safe nursing care)
Scope of Practice Statutes. (what members of a profession can do)
Nursing theory and practice derived from nursing research. (creates a unique body of knowledge
81
authority
- The authority for nurses to practice is granted by statute based upon the contract the profession has with society.
- Nursing is a self regulated profession where the government grants authority to the professional colleges and associations of nursing
- Is contingent upon the nurse’s continuing to uphold the established standards of nursing.
82
unity
- A defining characteristic of a profession.
- Nurses work together toward shared goals
- The profession’s ability to organize for the purpose of fulfilling the promises made to society.
- The relationships that nurses have with one another.
83
CNO Practice Standard: Ethical Commitments
- Commitments to Client: provide safe, effective and ethical care according to client wishes and standards
- Commitments to Self: know your values while providing ethical care
- Commitments to Colleagues: respect for eachother
- Commitments to Profession: act professional, self-regulate
- Commitments to Team and Colleagues: respect for all HCPs
- Commitments to Quality Practice Settings: advocate for quality
84
forms of abuse
Financial
Verbal and emotional
Physical
Sexual
Neglect
85
CNO mandatory reporting
-Process ensures CNO is alerted if there is a concern that a nurse is not practicing safely
- Allows CNO to take action to protect the public
- Discipline committee or fitness to practise committee review and respond to issues of professional misconduct, sexual abuse, incapacity, or incompetence
86
duty to report to CNO
-Facility operators*, employers* (and nurses) are required to file a report to the CNO if they believe a nurse has sexually abused a client, is incompetent, or incapacitated
-Required to report termination of a nurse’s employment for reasons of professional misconduct, incompetence, or incapacity
-A nurse must report sexual abuse of clients and self-report any offences using the Self-Reporting Form
87
Sexual Abuse occurs when a HCP:
-Has physical sexual relations with a client
-Touches a client in a sexual manner
-Behaves in a sexual manner with a client, and/or
-Makes remarks of a sexual nature to a client
88
incompetence
-Must relate to the nurse’s professional care of a client
-The nurse must display a lack of knowledge, skill or judgment, and
-Any deficiencies must demonstrate the nurse is unfit to continue to practice, or that practice should be restricted
89
incapacity
- The member must have a physical or mental condition
- The condition must warrant that the member not be permitted to practice, or that practice should be restricted
90
intimate partner violence - screening
- Early identification of the problem can reduce its consequences and decrease the likelihood of further victimization
- Evidence shows an increase in disclosure when asked “the question”
- Research shows that women have to be asked 6 – 8 times before they will disclose.
91
intimate partner violence - how do we help
- Women living with abuse tend to be isolated.
- Health concerns are often the only legitimate reason a woman can seek assistance from community professionals of any kind.
- The health care system may be the only entry point, her only access to information about abuse and the resources available to her.
- Health care providers must be accountable to the process, not the outcome
- The role of the health care provider is not to rescue the woman or tell her what to do or what decision to make but to support her through validation and empowerment, to listen to her and provide safety and resource information
- Validation has been identified as essential to the healing process
92
Domestic Violence/Women Abuse/IPV
- Nurses should screen for woman abuse for all females 12+ years of age
- Nurses should develop skills to foster an environment that facilitates disclosure
- Nurses should develop screening strategies and initial responses taking into account differences based on race, ethnicity, class, religious/ spiritual beliefs, age, ability, or sexual orientation
- Nurses should know what to document when screening for and responding to abuse
- Nurses should know their legal obligations when a disclosure of abuse is made
- Under Section 266 of the Criminal Code of Canada, it is against the law for anyone to abuse their spouse, common-law partner, or girlfriend/ boyfriend
93
Woman Abuse: Role of the Nurse
1) Ask the question
2) Acknowledge the abuse
3) Validate the woman’s experience
4) Assess immediate safety
5) Explore options
6) Refer to violence against women services at the woman’s request
7) Document the interaction
94
Reporting: Woman Abuse/Child Abuse
- Nurses do not have a mandatory obligation to report woman abuse to the police
- It is the woman’s right to choose if she wishes to involve police and must consent to this involvement before the nurse initiates such action
- Nurses must respect the woman’s decision and advocate for her right to choose
- Age of consent for sexual activity is 16, but there are close age exceptions
- According to the Criminal Code of Canada, young women over the age of 12 are able to consent to sexual activity:
- When she is between the ages of 12-13 and the age difference between the 2 persons is less than 2 years older and there is no relationship of trust, authority or dependency or any other exploitation of the young person
- When she is between the ages of 14-15 and the age difference between the 2 persons is less than 5 years older and there is no relationship of trust, authority or dependency or any other exploitation of the young person
- When the young person is 16+ and the other person is not in a position of trust or authority
A report to CAS is required
- When the young woman is under 16 and the alleged abuser is a person in a caregiving role or a role of authority or trust
95
child abuse
-Under the Child and Family Services Act, everyone, including members of the public and professionals who work closely with children, is required by law to report suspected cases of child abuse or neglect. If you have reasonable grounds to suspect that a child is or may be in need of protection, you must report it to CAS
- Failure to report may result in a fine of $1000
- Duty to report overrides professional confidentiality
96
when to report elder abuse in LTC
Improper or incompetent treatment or care
Abuse of a resident by anyone
Neglect of a resident by a staff member or the owner of the home
Illegal conduct
Misuse or fraud involving the resident’s money
Misuse or fraud involving public funding provided to a LTC home
**In Ontario, nurses must report elder abuse for residents of retirement homes and LTC facilities
97
code of nursing ethics
An explicit declaration of primary goals and values of the profession that indicates the “profession’s acceptance of the responsibility and trust with which it has been invested by society”
Nurs 2213
flashcards
Decks in class (2)
# Cards
