Nursing Ethics While most hospitals seem to be well-run and most situations and scenarios are planned for in advance when it comes to what nurses should be doing, should not be doing and why, this is not always the case. Just one example of this would be situations where palliative care is probably or definitely called for in a given situation but there is not a defined or clear protocol as to when the palliative path should be started and what criteria should be used. Indeed, patients that are facing such a situation are typically terminal or they at least cannot be treated for what is ailing them. An easy example to point to would be a cancer patient whose disease is beyond what medicine can do for them. When there is an absence of leadership when it comes to palliative care protocols, it falls to nurses to collaborate, work together and initiative the proper care levels when no one else will step up.

Analysis

As suggested by the introduction, a palliative care scenario is when care is limited to managing comfort and limiting pain. Cancer patients, those with incurable chronic pain conditions and others would all qualify. Of course, it would be optimal and a sign of leadership for hospitals, hospice centers and so forth to have defined and definite protocols when it came to initiating palliative care protocols and how they progress once they start. However, not all health centers are that mindful on the subject. Quite often, nurses are left to make these decisions including the initiation of a palliative care path and what happens as the patient progresses on that path.

There are a number of ethical challenges and dimensions that should be mentioned when covering this subject. First, the doctors and leaders of a healthcare location that deals with palliative care should be defining what should be done, when and why. It should not be left to nurses, at least in the opinion of the author of this report. Second, when it comes to pain management, there are some major potential pitfalls that have to be addressed because narcotics and similar medicines can be addictive. This may not matter much if a patient's death is imminent but there is an entirely different set of considerations when the patient's pain-filled status is more perpetual and longer in nature. However, the potential issues and concerns even go beyond that. For example, medical care can sometimes be extremely segmented. The term that gets thrown around a lot is "silo." A good example would be that the pain management imperatives and patterns that an emergency room nurse would follow are likely going to be different than for a nurse that works in a hospice situation. The former is typically concerned with saving lives first with pain management being done if possible. When it comes to hospice care, reducing pain is often one of the few things that can be done as the patients involved are typically going to die within a few days once they are there. However, all of the nurses at a given facility and in the same situation (e.g. palliative care) need to be singing from the same proverbial hymnal. Further, the leaders and subject matter experts (SME's) of a facility should take advantage of "teachable moments" and examples of what was done well, what was not done well and the reasoning behind these evaluations. Leaving a void and leaving nurses to fend for themselves and make palliative care calls is simply a bad idea all around. It reduces consistency and it reduces the focus on gaining the best outcomes for the patient even if that refers to pain experience immediately before death (Lennon-Dearing, Lowry, Ross & Dyer, 2009).

As for how to deal with an absence of leadership and proper examples, one person that had something to say about the subject is Jodie Gary. In her 2014 treatise titled The Wicked Question Answered, she talks about nurses and their potential or actual acts of deviance. While this may imply that the nurses are doing wrong, it actually refers to what is known as positive deviance. Indeed, there is such a thing. The background given by Ms. Gary makes it clear what she is referring to. As noted at the onset of her report, "how nurses respond when faced with the dilemma of providing patient-centered care in the absence of patient-centered practice guidelines remains relatively unreported" (Gary, 2014). Indeed, a healthcare facility without a defined palliative care protocol and that leaves such decisions and frameworks to the nurses would be such a dilemma. At the same time, the controls and requirements...

This is also mentioned by Ms. Gary when she says "complexity science is useful for examining the complex, adaptive, and self-organizing system for healthcare deliver, where attempts at rigid control increase problems and unintended consequences requiring individuals to work around or deviate from controls that are not flexible enough to allow for individual or circumstantial differences" (Gary, 2014). In short, there should be a system in place for palliative care at this hospital. At the same time, both controls specific to palliative care and general to the facility should not overly constrict and restrict what nurses and other professionals are allowed to do. Indeed, having a firm procedure that is very defined and specific is all well and good. However, there are situations where following the same script is not the right way to go and it is often fairly easy to see when a patient situation is playing out that way. Consistency is good but being willing to be flexible and malleable in one's approach is better. Leadership is much the same way in that the good leaders are able to enter the "mode" that is applicable and needed for the situation. Being firm and extremely assertive may be off-putting in more casual situations but it can be very useful when a patient crashes and the stakes are high (Gary, 2014).
When collaboration is entered into due to a void of defined procedure and consistency, this is generally a good thing. Even so, there are ethics involved in this general practice and nurses should be careful to keep the proper general ethical standards when making spontaneous decisions about any form of patient care. To state the obvious, the primary reason for such collaboration should be the improvement and perfection of patient care. If it is about anything else, then something is probably amiss. For example, focusing too much on costs and such can lead to the diminishing of patient outcomes and the general safety of both patients and professionals. As a very generic example, not buying new mops may save money but not keeping the floor clean presents a bacterial and aesthetic nightmare. Given all of the above, it is important that there be a defined procedure and framework for every expectable outcome or happenstance. However, nurses should be empowered to make decisions and create exceptions when the situation calls for it. However, the focus of these workflows and outcomes should always be on the safety of both the professionals involved as well as the patient. There are many stakeholders involved in a medical care location and the patient should be the number one stakeholder considered when it comes to just about everything. Even so, there are other important stakeholders to consider including the employees/staff of the location, the surrounding community that relies on that hospital or medical care location being there even if it is not needed right that second and so on. This is not to say that costs and appearances are not important. However, quality of patient care and outcomes should not take a back seat to anything (Engel & Prentice, 2013).

To state the obvious, the ethical standards of differing people and professionals can differ. This paradigm and happenstance is presciently explained by Ewashen (2013) when she states "ethical inter-professional collaboration becomes especially relevant and necessary when inter-professional practice decisions are contested" (Ewashen, McInnis-Perry & Murphy, 2013). Even with the extremely long historical arc of different providers and nurses working together as both medical professionals and stakeholders when it comes to the outcomes of the patient, there are situations where sensible minds can disagree about the proper course or ethics of a situation. This could be because of the personal and professional ethics of a person intermixing but it could really be a dilemma that lacks a clear and concise answer, for whatever reason. Ewashen and her colleagues assert that the best way to avoid major dilemmas is to be "oriented to action, high moral conviction, and the lowest level of bias" (Ewashen, McInnis-Perry & Murphy, 2013). Further, it is asserted that there should be an "integrated model of coherence or reflective equilibrium, a reflective testing and reconsidering of moral beliefs, principles, and theoretical postulates applicable to the case" ((Ewashen, McInnis-Perry & Murphy, 2013). Lastly, there should be a single…