N246 Ethics, Quality of Care, IOM PP

Essentials of Nursing Leadership & Management, 4th Edition
N246 Leadership
Ethics & Quality

S. Buckley, 2010

(Adapted from Nursing Leadership and Management,
Whitehead, Weiss, Tappen)

In the beginning
There were no antibiotics
There were no ICUs
There were no CT scanners and MRIs
There were just physicians and nurses who
cared for people in sickness and in health
Were there ethics?
Early nursing leaders
finances
1960s
Technological advances allowed for the
development of intensive care units
New biomedical developments
Advances in surgical techniques, such as
open heart surgery
Reasons for new inquiries in
nursing
Technological advances created new questions for health-care
professionals regarding the use of technology, RN role and outcomes
Changing views and perspectives on the concepts of life and death
Dissatisfaction of RNs with traditional manner of learning (mentoring)
and desire to have a scientific base for practice (professional
scientists)
Interest by healthcare practitioners about application of values in
professional practices, and how to discuss these issues.

Bioethics
A sub discipline of ethics
The study of medical morality

Concepts of Ethics
Ethics evolve from moral perspectives, which form
values and standards. Influenced by families,
environment, social issues, culture, religion,
cognition, law.
Ethical action depends, in part, on the ability of
people to recognize that a moral issue exists in a
given situation, knowing how to take appropriate
ethical action if and when required, and on
personal commitment and a genuine desire to
achieve a moral outcome
(Johnstone, 1999, from:Ethics in Nursing Practice, 2
nd
ed, Fry,
S.T,Johnstone, M.)
Value Systems
definitions

A set of related values
Intrinsic values-located within, the real nature of a thing.
Extrinsic values-from without
Personal values
Professional values
Social principles, goals or standards held or accepted by
an individual class, society. That which is desirable or
worthy of esteem for its own sake, thing or quality having
intrinsic worth.

Historical values of
nursing:

Nursing today
Values in nursing
today:
Value Formation
Values are learned-therefore, influenced by
family, culture, environment, cognition.
Values change with maturity and
experience
The number of values an individual holds is
not as important as what values they
consider important
Types of Values
Personal
Cultural
Religious
professional
Values Clarification
Critical thinking
Choosing
Identifying-verbalizing?
Acting
Belief Systems
These are organized ways of thinking about
why people exist within the universe
Their purpose is to explain such concepts
as:
Life and death
Good and evil
Health and illness
Individualism/rights
ETHICS AND MORALS
Morals
An individuals own code for acceptable
behavior
Standards of goodness or rightness that
arise from an individuals conscience
They act as a guide for individual behavior
Learned
Capable of making a distinction between
right and wrong in conduct
Values
Social principles, goals or standards held or
accepted by an individual class, society.
That which is desirable or worthy of esteem
for its own sake, thing or quality having
intrinsic worth.
Standards
Something established for use as a rule or
basis of comparison in measuring or
judging quality, value, extent.
Laws
Rule of conduct established and enforced
by the authority, legislation or custom of a
given community, state, or other group.
May change with fluctuating social morals
and viewpoints.
Ethics
Having to do with moral standards,
conforming to the standards of conduct of a
given professional group. Implies
conformity with an elaborated, ideal code or
moral principles.
Concerned with the motivation behind the
behavior
Bioethics is the application of these
principles to life-and-death issues
Ethical Theories
Deontological-based on duty to commitment, considers
the intention of the action, not the consequences of the
action. It is the individuals goodwill that determines
worthiness, not the outcome.
Teleological-(utilitarianism)-what makes an action right or
wrong is its usefulness. Right encompasses actions that
have positive outcomes, wrong is composed of actions
that result in poor outcomes.
Principalism-involved in biomedical issues, integrates
ethical principles to resolve conflicts in situations.

Ethical Principles
Autonomy
Nonmaleficence
Beneficence
Justice
Fidelity
Confidentiality
Veracity
Accountability
Autonomy
The freedom to make decisions about
oneself
Nurses need to respect clients rights to
make choices about health care
Nonmaleficence
Requires that no harm be caused to an
individual, either unintentionally or
deliberately
This principle requires nurses to protect
individuals who are unable to protect
themselves
Beneficence
This principle means doing good for
others
Nurses need to assist clients in meeting all
their needs
Biological
Psychological
Social
Justice
Every individual must be treated equally
This requires nurses to be nonjudgmental
Fidelity
Loyalty
The promise to fulfill all commitments
The basis of accountability (moral concept that
involves acceptance by a professional nurse of
the consequences of a decision or action)
Confidentiality
Anything stated to nurses or health-care
providers by clients must remain
confidential
The only times this principle may be
violated are:
If clients may indicate harm to themselves or
others
If the client gives permission for the information
to be shared
Veracity
This principle implies truthfulness
Nurses need to be truthful to their clients
Veracity is an important component of
building trusting relationships
Accountability
Individuals need to be responsible for their
own actions
Nurses are accountable to themselves and
to their colleagues
Ethical Codes
These are formal statements of the rules of
behavior for a particular group of
individuals
Ethical codes are dynamic
Most professions have a code of ethics to
guide professional behavior
Organizational Ethics

Focus on the workplace
Ethical culture makes a difference
Senior leadership must promote an ethical
culture-do they?
Ethical Dilemmas
Occur when a problem exists between
ethical principles
Deciding in favor of one principle usually
violates another
Both sides have goodness and badness
associated with them
Ethical decision making
Consider cause, variables, precipitating events
and implications
Reflect upon ones own perspective and values
Explore options for action:
ANA code of ethics, facility standard and ethics,
nurse practice act (BRN), legal issues, rights.
Select appropriate plan. Understand
consequences of the plan.
Implement
Evaluate results
Current Ethical Issues
Issues to Consider
Assisted suicide
Technology issues-as RN, as patient.
Gene therapies, genetic counseling
Designer babies, fertility issues, fetal success
Organizational climate
Family planning
Social responsibility
Immigration policies
Resource management.
Stem cell research
DNR status
Conclusion
An issue is not an ethical issue for the
nurse unless he or she has been asked
Always gather the facts prior to decision-
making
Consider your personal beliefs and values
Quality issues
What is it??
The degree of excellence that distinguishes
one thing from another
Relates to education and practice;
professionals perceive that they are
providing high-quality nursing education
and patient care.
Why do we need it?
* current health care system is fragmented,
poorly organized, inefficient use of
resources.
*New technologies, availability of
information (it), decreasing resources,
increasing chronic disease states mandate
a change.
* consumer dissatisfaction with current
system
Quality improvement
Also known as performance improvement,
focuses on processes or systems that
significantly contribute to client safety and
effective client care outcomes; criteria are
used to monitor outcomes of care and to
determine the need for change or improve
the quality of care.(Saunders NCLEX review, 5
th
edition, Silvestri, L.,2011)
Professional organizations that focus on
quality
* Joint commission on Accreditation of
Healthcare Organizations (JACHO)
* American Nurses Association (ANA)
*Institute of Medicine (IOM)
IOM essential competencies
Provide patient centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Use informatics
Aims of IOM quality of care
Safe
Effective
Patient centered
Timely
Efficient
equitable
IOM- cost of inefficiency
44,000-98,000 die each year
$17-29 billion in total costs
Nursing errors:
*Medication
*knowledge
*procedure

Continuous Quality improvement (CQI)

Identify indicators
Collect ongoing data on indicators
Analyze and evaluate data
Implement change
(utilize evidence based practice)
How to monitor quality of care
Guidelines
Protocols
Algorithms
Standards of care
Critical pathways
How does structured care methodologies
work?
Link process of care (issue) and outcome
Determine method of measurement
Clarify responsibilities of interdisciplinary
team
Facilitate communication among team
members
Document, apply systematic approach to
measurement.
Root cause analysis
Process of learning from consequences;
Determine influences, establish linked
chains of influences, determine necessary
influences, analyze root (initial) cause.
Currently used to analyze errors and
mistakes; attempts to evaluate series of
events that may lead to errors (safety
errors) and determine causative reason for
error (process), rather than punitively
blame a person
Risk management
part of QA
Identify potential problems, risks
Incident investigation
Sentinel events
Anticipate outcome, prevent recurrence
conclusion
To enhance quality of care;
Think critically
Plan and report outcomes
Make introductory rounds
Plan partnership with the client
Communicate plan
Evaluate progress

N246 Ethics, Quality of Care, IOM PP

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Essentials of Nursing Leadership & Management, 4th Edition

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