all right so we are nearing the end of your foundations course this is one of the last pre- lectures that you will have in preparation for your course today's topic is ethics and values we'll be spending a fair amount of time on this in class as well but we will look a little bit here so you have a little bit of background information it also ties really well with legal which is the topic that we're going to be doing in class as well so you'll really get to see how ethics values and legal all sort of work together I love this quote here you know I love some Florence Nightingale that the very first requirement in a hospital is that it should do the sick no harm so certainly we can all agree with that I think all right so we're going to go ahead and look at our objectives first so the first thing I want you guys to be able to do is just look at some basic terms when we're speaking about nursing ethics and understand what those terms mean so that's an important piece of this being able to discuss the role of Ethics in professional nursing absolutely and then I want each of you to spend some time examining and clarifying your personal values and we spent a little bit of time on this uh earlier in the semester as well but it really is important to be able to distinguish what our values are so that we then can enter into ethical issues being aware of that we're going to discuss some contemporary ethical issues it was actually interesting as I was getting ready to record this this morning uh on my news feed came something that I thought wow that is absolutely an ethical issue so I'll have a little video for you at the end of this that we can look at and kind of see wow what would you do in that situation and then being able to apply critical thinking to ethical dilemmas is certainly another objective with this material so when we look at ethics and values we need to be able to define those and be able to separate how those are different so if you look at the grid that I inserted on on the right of the screen here on the second bar down you'll see under ethics it says professional and under values it says personal I think that really is the big distinction in that values are your personal beliefs your attitudes your Customs or your patients Customs beliefs attitudes however ethics is really the determining what is good or valuable for the group at large so our professional nursing ethics are different from your personal values hopefully they coincide really well because that that makes for an easier career for you um but that that's the difference there is that one is considered professional one is considered personal and one can really VAR very much within individuals and the other one is more within professions all right so we're also going to look at some basic terms here so when we talk about autonomy we're really referring to the commitment to include our patients in decisions in all aspects of their care and acknowledging and protecting a patient's independence so with that being said sometimes a patient is going to refuse treatment and maybe that goes against your values but if your patient doesn't want something done then they have the right as long as that's an informed refusal so they understand you've explained to them let's say it's a patient who doesn't want to have a blood transfusion you've explained to them how a blood transfusion Works you've explained to them what's going to happen to them if they don't have the blood transfusion usion and they've said nope you know what that goes against my values I'm not going to have a blood transfusion then based on the principle of autonomy they have the right to make that decision when we look at beneficence this is really fundamental to the practice of Nursing and it really implies that the best interests of the patient are more important than your own self-interests so you are looking out for your patient and and that's what's important with beneficence there uh when we look at non maleficence we really have to look at maleficence first which means to harm or hurt so then non-maleficence would be the positive side of that meaning we are avoiding harm or hurt an example of that that I can think of that nurses do several times every shift I think is when we evaluate our patients so doing a health assessment like you're learning how to do in your other course and you find your patient has a heart rate that is fairly low let's say a patient's heart rate is about 45 and they have medications that were ordered by The Physician and it says give this blood pressure medication at such and such a time and you know that medication and you know wow not only does it decrease the blood pressure but it also really decreases the heart rate if I were to give this to my patient that would drop their heart rate to a point where perhaps that's too low and it's going to harm my patient so at that point I'm using the principle of non-maleficence to decide wow I'm not going to give this medication to my patient I'm going to go ahead and call the physician and say this is what the heart rate was I chose not to give this medication is there a different type of blood pressure medication that you would like to give this patient so just because something's ordered doesn't mean I'm going to do it because of that principle of non-maleficence if doing what was ordered is going to cause my patient harm then I have to think independently and say okay I'm not going to do that based on that principle if you're looking at Justice really now we're referring to healthc Care Resources so a lot of it is distribution of resources things like are we you know the person with insurance getting the same care as the person without insurance a if you're treating you know are you treating patients the same based on their backgrounds their ethnicity are you treating one patient better than a different patient um you know so looking at all those aspects and then Fidelity is huge within nursing so really it is exactly like it says on the slide here it is the agreement to keep promises so as a nurse you need to keep your promises by following through on your actions or interventions so if you're saying to your patient I'm going to be back in an hour then you're going to be back in an hour or you're going to find somebody else to go back and check on them but you're not going to leave them for five hours and come back and say oh you know I was kind of busy and I got tied up with things because that's not their problem you promised them you would be back you need to keep that promise based on the ethical principle of fidelity on the next slide here we're going to take a look at the professional code of ethics for nursing so this is our Collective professions state M of what is it's nursing's understanding of its own commitment to society if that makes any sense so it really is our framework for our nursing practice and it gives us direction as far as how our ethical relationships our nursing responsibilities what are appropriate behaviors and really making day-to-day practice decisions it was developed by the American Nurses Association and there are nine Provisions in class we will spend a little bit of time looking at each of those and seeing what that means to each of you as nurses but it really is um a nice succinct statement again of our ethical obligations it's considered non-negotiable within nursing meaning this is these are our standards everybody looks to the American nurs Association code of ethics to look at what our standards are and then there are some different um you know emphasis so there's emphasis on advocacy how many times have we talked about that already this semester responsibility accountability confidentiality so all words that you all have heard many many times and really you're starting to see the big picture of how this is part of everything that we do um so definitely we'll look at that with the code of ethics as well all right so when we look at ethics and philosophy there's a couple of terms that you may or may not be familiar with already so I'm not going to spend a whole lot of time on this but just so that when these words kind of float by you have an understanding of what they what they are so dim ology really just defines actions as right or wrong when we look at utilitarianism that's when we're really looking at the value of something based on its usefulness So within uh medicine I would say we're looking more at the greatest good for the greatest number of people is sort of the guiding principle behind this system if that's how we're looking at it and then ethics of care really emphasizes the importance of understanding relationships and being willing to commit to that relation ship with our patient that based on ethics of care we have committed that we are going to care for this patient and we need to then get to know who they are and support them whether that is supporting their autonomy whether that is Fidelity on our part but that's that relationship that we have entered into with them when we look at nursing and values then we start thinking about ethical dilemmas and almost always when we have ethical dilemmas it's because of conflict values so nursing practice requires you to be in contact with your patients physically emotionally physiologically spiritually and you you don't always get a choice of who your patient is right so in your other relationships whether it's your spouse or your friendships you get to choose which relationships you're going to enter into and a lot of times we enter into relationships with people and tend to gravitate towards people who have the same values as us but as a nurse You're agreeing to provide care to your patient solely on the basis of their need for your services so it's not because you like them or because you share values uh and so sometimes some ethical dilemmas can result of that um as a nurse you need to show you need to respect your own values but you also need to respect the values of your patients and the fact that those may be different so that's again where some of these ethical dilemmas come up you need to be able to distinguish between personal values things that are absolute fact and then opinion because those three are not interchangeable and sometimes people you'll come across you probably come across people like this all the time where they have such strong values or opinions that they sort of believe them to be facts and so that becomes a little bit difficult because we are going to have different values we're going to have different opinions but we're only going to have one set of facts so with that it becomes a little bit difficult and again we end up with some of those ethical dilemmas sometimes people are so passionate about their values that it ends up with some conflict there and so again these are some of the things that could come up for you as a nurse in your career some of the examples that I can think of straight up as um professional examples would be let's say you feel very strongly that abortion is absolutely a never event uh it's ethically wrong to you you really have your values just say this is really not something that I can participate in however you work in a hospital that performs abortions and they have just said they're short staffed in the O and they need you to come in and this is the case that you're now helping with that would absolutely be an ethical dilemma so we'll look a little bit later as well at what are some of the things what are some of the resources that you have so that you can resolve some of these ethical dilemmas first however we're going to look at values clarification I really like this here because I think it does a nice job of looking at the fact that uh values and feelings can vary between people right so the values in this exercise are sort of neutral terms but you can see how there may not be a right or wrong in this it's just different values so if I were to say to you that addressing someone by his or her first name shows friendliness but you however feel that addressing someone by his or her first name is disrespectful that means we have different values so you're going to view me as dis disrespectful and I'm going to view me as friendly so those are two different things so if you look down at each of these you know something as simple as showing direct eye contact in our Western society that shows interest however there's other societies where direct eye contact is considered intrusive so what are you conveying and what is it that you wish to convey all right we're going to go ahead and then now look at some of the resources that you have available to you so in institutional resources there usually is ethics committees within hospitals especially your larger hospitals some of your smaller hospitals may not have that in-house and that might be something that they Outsource I've never worked in a hospital that didn't have an Ethics Committee but I don't know that every hospital has the resources to have that usually the ethics committees are let's I'm trying to think of who who all sits on the Ethics Committee so usually there are nurses Physicians social workers we I've always worked for institutions that have included pastoral care in that um and so all these team members are then sitting down and looking and we can have things that we call like an Ethics consult so if we're having an ethical dilemma then we can request that the Ethics Committee sit down and look at the facts the values all of this that's involved with it and help us come to some type of a resolution and I will show you in class I have sort of a book that I got from one of the hospitals that I work at that actually just has a grid that you work through for some of these different dilemmas I have a more simplified one on the next page as well but it really working in an institution that has an Ethics Committee has been really really beneficial to me it's it's something that I very much appreciate having access to so here is what I was talking about this a little bit fuzzy here um but this is just sort of a very simple grid so the second bar down where it says refer to ready reference grid that's what I'm going to bring in to class that you can see that because it really does break down these different ethical dilemmas and kind of point you in a direction as far as what which direction should we head with that so I'll kind of let you glance at this one here more more so just as an informational I don't need you to memorize anything that's on here I'm not going to ask you you know step seven who are you supposed to involve that's that's not a fair test question but just an awareness and also when you go into clinical next semester you know is this something that you see in the unit have you seen anybody utilize this kind of keep your eyes out for that one of the things that as nurses I really appreciate is that we are really able to collaborate with other professionals and that becomes sort of that Collective wisdom so that's going to guide a group to the best possible decision is that it's not just the nursing perspective it's not just the family perspective it's not just the physician's perspective it is all of us working together to try and come to a resolution and as nurses we have a really unique point of view in this in that we're the ones who are spending time with the patients at the bedside day in and day out and very often patients will tell you something that they won't tell their family they won't tell their physician and a lot of times I found especially in critical care situations that patients will tell me things that they're too scared to tell their family or don't want to admit to their physician and so I've had patients tell me I don't want to do this anymore I don't want to keep having dialysis every day and I understand that my outcome is going to be a much shorter life if I don't do this but this is unbearable and I don't want to do this anymore I need to then find out from that patient are you telling me this because you don't feel comfortable telling anybody else and you want me to be your voice and tell them that or how is how is this going through the ethical dilemma for me would be if the patient says okay but you can't tell anybody cuz I'm just going to keep doing it for my family but I mean I don't want to do this it's absolutely just the worst thing for me but I I don't know how to tell my family and I don't want you to tell them then that's when I start having an ethical dilemma because I now know what my patient wants however I see what is happening is not what they want um so that's a time when then perhaps I would pull the team together and we would really sit and look and you know include the patient and say okay how can we go about making some some kind of resolution of this to where you feel like your needs are being met uh and we're not going against what it is that you value so I think I sort of got off track there a little bit but I think I got everything all right so some of the issues in health care ethics that you may have looked at perhaps in some of your other classes I'm not sure but if we're looking at quality of life you know we talk about end of life decisions this is something I came up with very against very often often in critical care I think I've probably said this to you already but one of my strongest beliefs is that just because we can keep somebody alive doesn't mean we should so it and that sounds kind of harsh and I hopefully I've explained that to you enough that you understand what I'm saying um but if somebody does not wish to have these things done but their family says it should then that's a that's a difficult situation so really looking at quality of life what does your patient want what is important to them so a lot of times you know physician assisted suicide do not resuscitate do not attempt to resuscitate those all become sticky sticky issues genetic screening absolutely so you know genetic screening we've come a long way with this but I when I was pregnant I chose not to have genetic screening done because I knew I wasn't going to terminate the pregnancy irregardless of what they were going to find so in that case I didn't want to be stuck in that dilemma I didn't want to have that whole dilemma of they say something's wrong but what if something's not wrong and it goes against my values and I can't do this so for me that was something I chose not to do and again that's based on my personal values no right or wrong there at end of Life Care absolutely uh again something I've seen a great deal of in critical care situations is are we just pushing off death are we you know just keeping them alive longer but in a horrible situation or is it something that's truly going to benefit that patient and then access to care something I've become more and more aware of recently is you know absolutely there's a very very inequitable access to care and as a nurse that's very very frustrating to see that there are many people who need access to care who just don't have it and people who are dying because they don't have the resources that they need and so that could also cause uh some issues and and ethical dilemas we've talked a fair amount already about culturally competent care but but with this again some of the same things I'll say it again because it's important but I know we've already talked about this respecting cultural differences being willing to negotiate and compromise when our World Views differ being aware of your own again your own values and biases and then using those communication skills so that you can communicate with your patient and can you know show them the empathy that you have knowing cultural practices again in the patients that you generally see and not assuming anything about anybody but having some kind of an awareness and then really truly understanding that all patients are individuals so with that um you know we have to look at them as individuals they may be part of an ethnic group but they're also individuals so we want to uh encourage autonomy but we do have some cultures where the preference is that the oldest son makes a decision or the oldest daughter and the patient doesn't want to be involved in this at all so that is based on their cultural beliefs and so we have to support that as well even though it's not how we choose to live our lives when we look at moral distress here we're really talking about the anguish that you would experience when you feel like you're unable to act clo uh according to your closely held values and moral distress is something that I think you would be hardpressed to find a nurse who doesn't feel like they've had moral distress at some point or other in their careers there was actually a study done that highlighted that both for nurses and Physicians the highest level of distress were experienced when cargivers felt pressured to continue unwarranted aggressive treatments for patients in the ICU and I would absolutely 100% agree with that that that's a very very difficult situation to be in and it's really important for nurses not to become jaded to these situations and not to pass judgment the video that I talked about at the beginning that will be at the end of this is something where it looks to me as if it's an ER physician who has just completely become jaded to the patient population that is coming through the ER and is just making huge assumptions about why this patient is there and what it is that they're trying to get when they're there and is there for treating the patient very very badly in my opinion in order to um alleviate moral distress we really want to look at learning about our ethical resource is learning having conversations about it sharing stories with our other professionals and then increasing the opportunity for collegial practice such as like multi-disciplinary rounds being able to call in the employee assistance program so really being able to kind of talk through it at the bottom of the slide here where it talks about moral distress being a shared experience that's where things like an employee assistance program so if everybody on the unit let's say I'm working in labor and delivery Heaven Help me I'm not but let's say I'm working in labor and delivery and we have a stillborn baby that's a very distressing event for the for the people involved we can call the employee assistance program and we can have them come in and debrief all of us because everyone on that unit experienced that so being able to work through that so that we're not taking that with us and encouraging kind of constructive conversation about that then that's going to help decrease the amount of moral distress that we're having when we look at aging that's another area where there are some ethical issues absolutely so sometimes and I've probably said this before as well some of our older patients they're not as familiar with the concept of autonomy so if I look at like my in-laws if the physician said something that was sort of the the rule you know if the physician says you go do this then you go do that and even if you don't understand why you're doing it or it doesn't make you feel good to do it you're going to do it because that's the boss and the physician said to go do that and so sometimes we have older patients who really perhaps are just different in the concept of autonomy from how our younger Generations are and they don't question the Physicians and they believe the physician always knows best even if it's not really the treatment that they wish to have and then as people age there are also conditions that you've already been learning about in health assessment that affect the communication process so if you have somebody who has become incapacitated by stroke or disease you know how are they able to communicate their needs did they communicate their needs to somebody before this happened is there a spokesperson that can speak for that patient and then also patients taking multiple medications poly Pharmacy is a huge issue and so is that affecting their cognitive skills and are they not able to make decisions the way that they would so it's very difficult I think to come to a consensus about medical goals for the the older adults and it's something that I think we're going to keep dealing with because our older population is growing and growing and as they enter into our health care environment we're going to have to figure out how to support them and how to ethically deal with these situations uh let's see what I have here all right I think that's good all right so we're getting close to the end here so I want to now give you a little bit of a tool as far as how to look at processing and ethical dilemma so keeping in mind that ethical dilemmas they cause distress both for the patient and the caregiver so it's not just you that's affected but resolving an ethical dilemma in um many ways is sort of similar to the nursing process that we've already talked about it really requires a deliberate and systematic plan and a process for resolving ethical dilemmas that respects the differences of opinion of all the participants really helps to provide and resolve conflict about those actions so these seven steps here will guide you through basically the assessment planning implementation evaluation of an ethical dilemma so first thing you have to look at is finding out is there even an ethical dilemma right and then gather your information don't jump to conclusions uh make sure that you have relevant information so that you can kind of look at the big picture then clarify values and find out what is the problem verbalize what that problem is you're then going to identify different courses of action there's not one choice right so for it to be a dilemma there are several choices so what are those different choices and then negotiating a plan and evaluating that plan how is how is this going to work I'm going to give you an example on the next page that I hope we don't run run into but let's say here so let's say now you're in your sophomore semester you're in clinical and while you're at lunch not while you're on the unit you take out your phone and you're just kind of checking through your social media and all of a sudden you notice that one of your classmates and also your friend has tweeted the following message within the hour so it says last day of clinical rotation would rather die than be a patient on this unit worst Hospital ever the nurses suck my patient's better off at the homeless shelter where he came from so now we're going to look at do we have an ethical dilemma or not hopefully you can kind of already f figure the step on that so is there an ethical dilemma and why is there an ethical dilemma so in this this is your friend right so your friend has done something you know your friend shouldn't have done how do you then process through this so you're Gathering your information and you're thinking about it you're thinking wow she was at clinical she was using her phone when she shouldn't have been she commented on the patient being homeless she's badmouthing the hospital she's badmouthing the nurses uhoh this is really really not good right so now you're looking at values you're looking at your values you're thinking about the patient you're thinking about the nurses you're thinking about the hospital so you're really looking at the big picture there and then you are verbalizing the problem so what is the problem I would say the problem is she's being unethical by using her phone by talking about the hospital breaking the code of conduct so I could go on and on I think there's quite a few things that are the problem here so when it comes down to of action I would say you really have two options right maybe three say something do something or don't right so these you can try and ignore it or you can do something about it so when we talk about negotiating a plan maybe you could tell her to remove it and if she doesn't that you're going to tell your instructor maybe you're going to go straight to your instructor because you don't want to be involved in this at all so these are your choices these are different plans no one can tell you which one is right or wrong but you have to make a decision as far as what you would do with that and then you're going to evaluate your plan you know what is the best solution that you can come up with for this one all right so that's a quick example now we get to the video that I was telling you about so it's unfortunate it's a little bit long but like I said I just saw it this morning as I was getting this ready and I thought wow this is really something relevant to what we're doing it's going to take me a second to pull it over because it always comes muted and then I have to fix it here so give me just a second to get this up again this is an ER phys physician who is assessing a patient and I'm not sure if they tell you up front but it's a patient who had an anxiety attack and uh is now in the erti nightmare so this is the physician with the patient here on his camer her Sam at must are youing I was Justus Samuel says he was rushed by ambulance Hospital in lascas after colling during basketball practice on Monday numb and in a lot of pain Samuel says he suffers from debilitating anxiety attacks it's just heart you know I've seen him and out ofous father Donald his then they wait while theor they claim and with the nurses the nures a security guard in to I was just like why would there be security that's when Samuel asked his father to get his and they this I'm sorry sir were sick of all the people are here who are ding you want to yourne at any point did you raise your voice did you agressive did you say anything to her that would frustrate her I was completely calm the whole time a spokesperson forino told k we are saddened and disappointed by the Phan untion cont I think she needs to terminated on top of the hospital needs to be investig Sam and his father think that theor believed they were there just forars but he was eventually treated dehydra fluids antiy andever Mar Medina all right so the dilemma I would have you look at with that is let's say I I don't know if you saw it on the video but a couple times there was somebody who walked in behind the physician there so I don't know whether it was a tech it was a nurse I have no idea but let's just say that was a nurse and the nurse was you and you're seeing the way that this physician is treating this patient would that be an ethical dilemma for you would that go against your values and then what would you do so you really would have to work through that same grid of figuring out what are you going to do are you going to directly have a conversation with this physician are you going to go find your manager and say this is not acceptable I don't understand why this is happening in our ER figuring out what would be your way to deal with this I just thought instead of letting this go on or maybe that's your other option is somebody's Behaving Badly treating patients badly and are you just going to ignore it completely so really just looking at those things because these ethical issues come up all the time so really being able to look at those and try and come up with some solutions of how you would work through something like that so again hopefully not something that you will come up against but you you never know all right so that is the end of this one here there will be a pre-lecture quiz I think I included the pre-lecture quiz for evidence-based practice and ethics together but um I will have a note for you on blackboard so you'll know what the questions