Application of Quality and Safety Concepts

Case Report: Application of Quality and Safety Concepts
Introduction
This report will describe an ethical predicament situation encountered by a nurse in line of duty in an emergency department. The predicament will be analyzed using the algorithm for ethical decision making by Catalano’s (2009). A theoretical perspective is used in analyzing the ethical predicament. Several likely solutions to this predicament are discussed. Research instruments for solution evaluation are also identified.
There are many moral situations faced by people working in the nursing profession especially in relation to a growing technological and scientific environment in relation to the development of advanced treatment methods and diagnostic equipment (Range & Rotherdam, 2010). There are many conflicts emanating from the manner in which professionals handle users in hospital environments or in basic networks. Workers face difficulty while trying to solve conflicts due to being ignored by their leaders or due to lack of sufficient support while executing their duties and in professional autonomy. This is likely to cause the feeling of anger, guilt, outrage, sadness, frustration, hopelessness and impotence towards conflict situations (Corley, 2002).
There are four crucial responsibilities for any nurse and they are promotion of health, prevention of illness, alleviate suffering and restore health. The duties require a nurse to promote health, coordinate the care of patients, administer medication, and carry out medical examination, and other crucial such like duties. The process of nursing entails assessment, planning, diagnosis, evaluation and implementation (Parse, 1999).
A working nurse encounters conflict and moral issues in different situations while working. It is not possible to separate conflict from a nurse’s professional life. Among the many conflicting situations include absence of consent prior to handling a procedure, extension of a patient’s life without attention to the quality of that life, questionable or inhumane professional conduct, resource allocation inequalities, and fragmentation of decisions. Moral distress can become part of a nurse in light of the many conflict situations (Lunardi et al., 2009).
Problem Statement
The ethical dilemma encountered by the nurse working in the emergency wing relates to a patient who is 93 years old. The aged patient is moved from the extended care unit. This patient is suffering from Alzheimer’s disease. Due to her fading health she is unable to drink or eat anything, therefore, threatening her life. The patient is also not able to respond to touch or voice and is also non-verbal. The physician in charge of her has concluded that she is unable thrive. The granddaughter to this patient has been given the attorney powers over her grandmother. There is no advanced directive from the patient. The patient’s family emphasizes that their loved one must be taken to an emergency department in order to have her fed through some feeding tube. The family has been made to know that there is a chance that their loved one could survive with some feeding. The ethical dilemma for the nurse in charge of the patient is to identify the patient’s right to demise while balancing the same with the desires and wishes of her family members (Heiser, 2014).
Literature Review
Nurses have to make critical decisions most of the time throughout their practicing careers. The process of making decisions must be informed by the process of making ethical decisions. Ethical decisions involve education of nurses and the experiences gained through practical lessons. Culture and beliefs also inform decision making for nurses. Moreover, motivations, expectations, and different value systems also impact the decisions made by nurses. The code of ethics for nurses and mission statements’ framework support nurses in decision making. Any nurse will employ the ethical standards during decision making in light of the prevailing circumstances (Silva et al., 2014).
Nurses must have professional capacity to examine various situations and come up with spontaneous decisions having considered all possible alternatives characterizing ethical decision making (Silva et al., 2014). Nurses must be able to support their actions and decisions. For this reason a nurse must be confident in their ability to make good judgment in light of any situation by quickly differencing between right and wrong actions. Nurses must have sound moral perception, courage, sensitivity and imagination (Holt & Convey 2012). According to the suggestion of Grundstein-Amaro (1992) a nurse must place great value on the care perspective during decision making. This essentially means that a nurse has to be responsible and highly sensitive about the wishes of a patient during any decision making process.
Clor (2001), Corley, Elswick, Gorman and Clor (2001) opine that a nurse contends with high moral distress levels when the staffing is low to the level that caring becomes insufficient. A nurse will become twice as much distressed when there are staffing problems than when there are other issues. To the contrary Woods, Rodgers, Towers and La Grow (2015) contend that moral distress mainly comes from situations where maximum care is affected for reasons of reducing costs occasioned by poor continuity from provider and working alongside incompetent colleagues. In circumstances where a nurse differs with the orders given by a physician and is required to conduct unnecessary treatments and tests making the nurse to feel as though the process of death has been extended unnecessarily then they can become morally distressed. Futile care is also considered a source of moral distress. The suggestion by Molloy, Evans and Coughlin (2015) is that nurses will often suffer moral distress when showing support for distressed family members to infants who is critically ill. In the opinion of the nurse when their situation is dismissed they will become emotionally distressed. This will make the nurse feel powerless and frustrated to make any changes.
It is possible to predict burnout through moral distress. A nurse with higher levels of moral distress will most likely leave their current institution for a less stressful working environment or even abandon their nursing profession all together. The findings of Corley et al. (2001) reveal that 15% of nurses had quit their positions due to distress. According to Hamaideh (2014) high moral distress levels can be associated with the lack of sufficient skills and enough knowledge from the nurse to handle situations that are morally challenging. The suggestion by Pye (2013) is that experience level may positively influence the ability of nurses to manage moral distress skillfully.
The findings by Ulrich et al. (2010) indicate that at times nurses aren’t in the know of the choices they have when challenged with a situation that presents some ethical dilemma. Ulrich et al. (2010) further found that often nurses are inadequately prepped for handling ethical dilemmas. In addition to this Musto and Schreiber (2012) found that nurses contend with moral distress if they question their decision and doubt their practice. These doubts surface when nurses overthink solutions to problematic situations.
Theoretical Perspective and Case Description
Catalano’s (2009) algorithm on ethical decision is applicable in the description and analysis of the current ethical dilemma situation (Blais & Hayes, 2011).
1st step: Highlight the ethical dilemma, collect data and interpret it
2nd step: State ethical dilemma
3rd step: Gather necessary facts
4th step: Potential solution
Catalino’s (2009) asserts that decision making begins with an assessment of the algorithms in the ethical dilemma situation. First it is important to identify the likely ethical dilemma situation, then collect data and interpret it. Decisions entail making a determination about the party that will be impacted the most following the decision. Step number 2 involves stating the dilemma. The nurse is in a dilemma to meet the wishes of the family and at the same time give the patient some dignified death. Step 3 entails gathering of facts including potential risks to the life of the patient. The information gathered is important in generating outcome (Deshpande, 2009).
In accordance with the 1st step, the wishes of this family were evaluated. Information on the hands of the nurse indicates that the person with power of attorney wants the grandmother to receive some feeding tube. The granddaughter informs the nurse that she has information that the feeding tube at the emergency department will help her grandmother get better. The assessment of the nurse indicates that the family to the patient isn’t aware that Alzheimer’s is a progressive disease. Alzheimer’s is a type of Dementia that cannot be reversed (Porth, 2010). The family, according to the nurse, didn’t have information that the effect of Alzheimer’s on the patient’s quality of life at this point would not improve through nutrition. It is the responsibility of the nurse to consider the patient’s physical condition. The patient is incapable of making decisions or even communicating. She is suffering from stage 3 decubitus Coccyx ulcer. By placing some feeding tube this would not help improve the life quality for the patient.
The 2nd step presents the dilemma of having to take care of the desires of the family or alternatively to support the right of the patient to dignified death. The 3rd step presents some possibilities including getting the feeding tube fitted on the patient by some surgeon. The other option is offering hospice care for the patient and the family. The third option is clearing the ailing woman medically and taking her back to the emergency care facility (ECF). All the gathered information must be carefully considered. This will allow the nurse to find a solution to the dilemma. Any further decision from the nurse will be dependent upon the outcomes and solutions to the current dilemma.
Proposed Solutions
Blais & Hayes (2011) said that intelligent ethical reasoning entails rational thinking. A sound ethical decision must never be informed by emotions, inflexible precedents and policies, or intuition (p.61). It is important for the nurse to consider the ethical standards outlined and espoused by the civil laws and principal authorities which are set in place by government and society (Blais & Hayes, 2011). The Nurse’s international council recognizes that health promotion, illness prevention, and minimizing suffering are some fundamental nurses’ responsibilities. The nurse has to make sure that there is a healthy and safe healthcare environment for patients.
One of the possible answers to the ethical dilemma in this situation is to fit the patient with a feeding tube according to the family’s wishes. The family will become satisfied and would have reason to believe that their loved one will be alive for longer. It is the expectation of the family that their loved one will get better through nutrition. The fact, however, is that there is no improvement since the patient has Alzheimer’s disease. Interventions of nutrition will not achieve any good. The family isn’t aware that it is a natural process for a patient to seize drinking and eating when they approach their demise (Dreyer, Forde, & Nortvedt, 2009). A feeding tube is a given to calm the patient’s family although it does no good for the patient.
The hospice option is another possible solution. It is the duty of the nurse to seek consent from the patient’s family (Gladding, 2000). The nurse has to communicate this with the family in the presence of the responsible social worker, physician and possible a chaplain since the patient isn’t able to express her wishes. With regard to this decision the POA will make the final decision. In some situations, the family of the patient is brought in late in the day hence the presence of many emotions at the time (Dreyer et al., 2009). An ideal situation is where the decision of this nature is arrived at when patient is in facility for extended care. This happens rarely though. The best solution for this patient is to consider hospice care. Another last option is to send this patient to ECF. It would not be of any help to the family or the patient. It would make the family unhappy because they would assume their loved one has been neglected the duty of care. This would also delay necessary care for the needs of the patient. This option isn’t appropriate or sufficient in the sight of the nurse since it denies the patient necessary care (Heiser, 2014).
The patient centered approach was used by the nurse (Swider, Mcelmurry & Yaling, 1985). The approach highlights the duties of the nurse towards the patient and the patient’s family as well as their best interests and rights. In accordance to the approach the nurse has a moral duty to exercise authority as would any other professional in healthcare. She understands her duty to take good care for this patient and to assist in the facilitation of meeting the patient’s every need even when this means overlooking hospital administration decisions or instructions.
Research Instrument Identification
The McAlpine, Kristjanson and Poroch (1997) ERT (Ethical Reasoning Tool) is applicable when evaluating proposed solutions. ERT was innovated as a way of classifying ethical responses in a case study into 3 levels of professional response. The response levels include:
1st level: Traditional response: This thinking conspicuously highlights the application of conventional reasoning on issues of morality, personal beliefs and moral values.
2nd Level: Reflective or conventional response: Entails practical considerations are quite important although their combined application alongside reflective reasoning entertains the consideration of fundamental ethical issues as well as the need to consider some other issues apart from personal beliefs.
3rd level: Reflective Response: Thinking critically concerning ethical issues entails the application of the ethical framework in clarifying, evaluating, and justifying different perspectives.
The tool is founded on the attitude theory. Decision examination through the attitude theory offers some important insights into the likely external and internal constraints that might impede the growth of the thoughts reflective levels. A strong attitude may cause some emotional responses, allow for better stability and move a person closer to change, as well as have some significant impact on processing of information. Strong attitudes can also result to strong behavior (Eagly & Chaiken, 1993). The instrument proves that there is a promising avenue of measuring ethical issues and professional responses. This tool is also strong in that responses come from the respondents without any external influence. The tool established uninfluenced ethical thinking concerning the dilemma hence clarifying on assumed versus real professional cognitions.
Conclusion
It is naïve for anyone to think that any method or system is likely to solve all moral situations. Principles are general in their nature and definition. Ethical disputes on the other hand are unique and private. In the bioethics field the presence of tradeoffs delay decision implementation. More so, in the nursing field, every case is unique. The correct decision may not determine before the situation arises. For every situation, it’s fundamental to examine relevant data more so because there is no telling what the variables might be in the new situation. The consequences must be considered through the decision. Ethics are important for the analysis, study and assessment of relationships existing between empirical data sourced from unique situations where death or life of a person is involved. Sound professional ethics calls for systematic formulas resulting in moral institution and successful decisions which offer some fitting framework for adoption in ethical decisions. This ensures that decisions are made under consideration of relevant data and clarification of duties and rights. It is also crucial for patients alongside their families to reflect carefully on every decision to avert any consequences from a distrustful element (Trout & Rivkin, 2000).
References
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