Nursing Ethics and Ethical Decision-Making in Patient Care

Introduction

Nurses are required to make many immediate decisions in the course of their assigned duties. Unfortunately, in recent years, patient care has often been compromised as a nursing shortage crisis has escalated to epidemic proportions. Increased patient loads have resulted in hasty nursing decisions as responsibilities and hours worked have both grown. Although precious time must be spread thin to accommodate higher numbers of patients, nurses must exercise their morals through consistency in ethical behavior. According to Peggy Chinn (1), "Many ethical issues, such as end-of-life decision making, have increased in complexity. Other issues, such as advocacy and choice, have changed in certain respects but are more clearly centrally situated within nursing's ethical domain."

As a result, nurses are held accountable for a variety of decisions in nursing practice, and in many instances a patient's life depends on those decisions. Gastmans (496) states that "Generally, the goal of nursing activity is described as the promotion of the well-being of the patient by providing good care in the wider meaning of the word (i.e., the physical as well as the psychological, relational, social, moral, and spiritual levels). Nurses participate in an ethical practice. In each particular situation, they have to make personal choices and decisions based on the good that nursing practice sets as a goal. The ethical practice becomes concrete through the personal relationship between the nurse and the patient. The quality of nursing care must always be seen in the light of the relationship between a unique nurse and a unique patient. The patient cannot be considered as a passive object to which a core strategy is to be applied."

The following discussion examines nursing ethics and the situations that often lead to a compromise of quality patient care and difficult ethical decision-making processes in nursing practice. Conclusions are drawn regarding the ways in which ethical dilemmas can be resolved.

Data Collection and Assessment

Patients often encounter incidents where they require additional care and treatment. Unfortunately, in those times of need, other patients are sometimes neglected because full attention is required elsewhere. As a result, shortcuts are often taken in daily nursing practice with regard to patient needs. A primary concern of nurse administrators is the allocation of resources to provide the best possible patient care during periods when staffing shortages are highly prevalent: "Nurse administrators are faced with several difficulties in allocating resources. A conflict exists between nurses' perceived need to contain costs and the need to do what is reasonably possible to promote the health of an individual" (Sarikonda-Woitas and Robinson 75). As a result of limited resources and excessive responsibilities, nurses are constantly faced with situations requiring their immediate attention. Nursing responsibilities are often spread too thin, and a lack of control over patient practice frequently results in mistakes and errors. This lack of control over nursing practice is the central ethical dilemma discussed in the remainder of this paper.

A fictional situation is presented here that can easily be mirrored in real-life circumstances. A nurse begins her assigned shift at 7:00 AM. She arrives at 6:40 AM to prepare for the day and to review her assigned patient load. She is dismayed to discover that she will be responsible for seven patients because two nurses have called in sick. She immediately recognizes that she must manage her time well throughout the day.

At 9:00 AM, she encounters her first distress call as a patient rings for assistance. The nurse enters the room and finds the patient experiencing chest pain. She performs an assessment and recognizes that she requires help from other staff. In the meantime, she has forgotten that five minutes earlier, another patient with a history of mental instability requested assistance with his IV because it was bothering him. She had promised to return to fix the problem but became distracted by the patient with chest pain. As another nurse and a patient care assistant arrive, the chest pain patient's condition worsens and she eventually stops breathing. A code blue is called and a physician arrives shortly thereafter. Unfortunately, after several minutes of resuscitation efforts, the patient dies.

The nurse is visibly disturbed by the turn of events and leaves the room so that nursing assistants can properly attend to the deceased patient. Over an hour has passed since she last visited the patient with the IV problem, and she finally recalls that he still needs attention. When she enters his room, the patient is very displeased at having been ignored. The nurse apologizes and attempts to explain that an emergency required her attention. She replaces the IV and notices excessive bruising: in his agitation over the soreness in his arm, the patient had attempted to remove the IV himself during the interim. Once the situation is resolved, the nurse is troubled by her failure to check on him sooner. She documents the IV change and the bruising, but she does not acknowledge the lapse in patient attention in the chart — meaning she does not record the reason the bruising occurred. Although this omission is not an extreme action, the nurse is plagued with guilt over her decision to withhold that information.

The nurse has always practiced with the utmost ethical judgment throughout her five years of service. However, she faces significant pressures in her daily activities, and the stress on this particular day became too great to manage fully. The healthcare organization has consistently set the standard for quality and ethical behavior in the local area, and its status as a Magnet hospital for nursing excellence has demonstrated its ability to attract and retain a pool of highly qualified nurses. Nevertheless, no matter what the circumstances may be, nurses are often compelled to prioritize responsibilities in ways that compromise quality care.

The primary ethical issue in this scenario involves the failure to check on a patient with an IV problem — a patient who ultimately took matters into his own hands when his assigned nurse did not return as promised because she was occupied with a life-threatening emergency. As a result, the nurse departed from her ethical framework when she documented the bruising caused by the patient's self-removal of the IV without reporting the time lapse in care that produced those physical consequences. The patient is not likely to suffer permanent damage from the incident, but the physical effects are apparent for the remainder of his hospital stay.

Problem Identification

Unfortunately, incidents such as this are relatively common during a nursing shortage, when responsibilities and demands are excessive and patient care ultimately suffers. According to Judith A. Erlen, "Nurses feel overwhelmed by this [nursing] shortage. They are exhausted because they are carrying demanding patient loads and are working overtime. There are not enough nurses to provide the quality of patient care that is needed; the number of staff is inadequate. Hospitalized patients are more acutely ill; nurses have more patients in their caseload. Eight-hour shifts are often becoming 16-hour shifts. These factors are taking their toll. Nurses are fearful that they will make mistakes, will harm patients, and will harm themselves" (62).

In this particular situation, the nurse was so overwhelmed by the emergency that she failed to recognize the importance of also attending to the IV patient and did not think to ask another nurse to check on him. This can be attributed to the urgency of assisting the patient with chest pain, but the nurse might have been able to alert a colleague on her way to the other room. As it stands, the IV patient is left with temporary bruising causing soreness and discomfort. The nurse feels responsible but is ashamed to admit her neglect in formal charting, and so she does not disclose this information as she is required to do.

Many external factors contribute to the problem, including the overall design of the healthcare delivery system and the excessive demands placed on fewer available nurses. It is possible that the nurse will experience long-term consequences as a result of her decision: "The goal of nursing is to provide respectful, competent care to protect the welfare of patients. Yet, most nurses are employees of an institution. As a result, conflicts arise for nurses because the institution's policies and the needs of the patient may be at odds" (Erlen 77). Care is often compromised by the necessity of managing a large number of patients simultaneously, and this situation opens the door to a variety of ethical considerations.

In relation to utilitarian principles, both the potential health of the affected patient and the overall well-being of the nurse are in question. The nurse is experiencing feelings of guilt over her chart omission, but she does not want to risk jeopardizing her nursing career through disciplinary action. Furthermore, the patient's bruising is likely to heal in time, and it appears that no further internal damage to the arm veins has occurred. Therefore, this incident is unlikely to affect the patient's overall recovery from abdominal surgery. However, the nurse's decision is likely to affect her future choices regarding patient care, and she will need to develop a priority system for managing her workload more effectively.

Conclusion

The situation described in this paper is a relatively minor incident that did not impose any long-term effects on the patient's overall well-being, nor did it result in damage to the nurse's career. However, many incidents occur in nursing practice that do result in detrimental consequences, including death. Nurses face a significant amount of stress and responsibility in their daily activities. As patient loads increase and the severity of patient illness grows, additional attention must be paid to each individual to ensure the best possible care. It is not surprising that many nurses experience considerable ethical dilemmas in their attempts to provide quality care for all of their assigned patients — and that some of these circumstances involve ethical dimensions that must be evaluated within the nurse's personal and professional ethical framework.