Ethical Decision-Making 5
Running Head: Using Ethical Decision-Making Model In Clinical Practice
Using Ethical Decision-Making Model In Clinical Practice
Carmilo Vannucci
NURS3013_29122S Issues and Trends in Nursing, Jill Hasley, MNSc., RN
Southern Arkansas University School of Nursing
March 10, 2013
This papers purpose is to illustrate a scenario in which a nurse uses the ethical decision making model outlined on pages 128-134 from the book Ethics and Issues in Contemporary Nursing 3rd Edition (Burkhardt & Nathaniel, 2008). The scenario is in fact real, however no actual names, dates or places shall be used and any reference to such places whether actual or fictional is coincidence and in noways referring to those specified. Outline for the ethical decision-making model was derived from figure 6-1 page 131 from Ethics and Issues in Contemporary Nursing 3rd Edition (Burkhardt & Nathaniel, 2008). The model stages itself in stepwise manner as such: Articulate the Problem, Gather Data, Explore Strategies, Implement Strategies, and Evaluate Outcomes (Grundstein-Amado, 1993).
The scenario takes place in a emergency room, the narrator (me-author) was primary registered nurse in the emergency room and observer, other observers included; 1 RN-secondary, 1 PCT, 1 Ward Clerk, 1 ER-Physician, 1 Primary Physician, 1 Patient Father, 1 Patient Mother, 2 Transporting Paramedics, 1 House Supervisor, 1 Radiology Technician, 1 Laboratory Technician, 1 Pediatric Patient. The primary nurse caring for the pediatric patient was I, the patient was admitted during the previous shift with primary diagnosis of pneumonia secondary to failure to thrive. History included age: 3.5 years, with chronic esophageal spasms causing aspiration pneumonia. Vitals were all WNL for age except Temperature which at time of shift change was 103.7 degrees F rectally with no previous doses of APAP. Patients family was distraught at time of first clinical interaction because of stated wait time. During shift change entire ER staff is new including physician, nurses and ancillary staff, because of this and patients age and health status entire new assessment with history was performed by RN and physician. The physician orders included fluids, APAP administration per protocol for temperature control, antibiotics IV azithromycin per recommended dosing for age and weight, transfer to ACH via ground transport. The antibiotic order was called in to the house supervisor since the emergency room did not carry the IV prepared vial. Upon arrival of antibiotic the primary nurse was coordinating ground transport, the house supervisor with the antibiotic volunteered to administer dose and proceeded to do so. After transportation was coordinated and patient was accepted to ACH it was found that the antibiotic dose was given by incorrect route IM instead of IV and suspected incorrect dose. Questioning of the house supervisor included medication dosage, and route. Also, failure to report error to physician, family and primary physician occurred. The patient was later denied admission to ACH because of legal issues but was treated in their emergency room until shift change. Adverse reaction to the antibiotic included pain, swelling at site with residual parasthesis to extremity (right vastus lateralis) causing deficient use.
During problem articulation it was found that the antibiotic was given by wrong route and suspected wrong dose. Two ethical dilemmas arise, Competence vs. Incompetence and Truth-telling vs. Deception (Norberg, & Hirschfeld, 1987). The desired goal was for proper pharmacological intervention to facilitate healing, which would be more effective intravenously rather than intramuscular. The situation became a dilemma because of the offending parties obligation to report incident and failure to do so (Windsor, & Cappel, 1999). The most important facts are medication dosage used, injection site, residual parasthesis, and failure to report error. Gaps in information were the actual dosage used and the site of injection. Key participants would include: house supervisor, ER physician, primary RN of patient, parents of the patient, transporting paramedics, primary patient physician. Other considerations such as nurse-patient ratio of 1:8 should be taken into account creating another ethical dilemma (Doane, Pauly, Brown, & McPherson, 2004). Ethical principles relating to the above said dilemmas would include: Autonomy, beneficence, non-maleficence, veracity, fidelity, and justice (Hough, 2008). The ethical issues involved are inappropriate orders, disproportionate power, fear of retaliation, feeling of helplessness, professional accountability, being a whistle-blower, inadequate unit staffing (Berggren, da Silva, & Severinsson, 2005). Lack of communication between staff, management incompetence and lack of professional accountability contributed to the patients poor outcome (Ito, Tanida, & Turale, 2010). Prompt recognition and treatment would have lessened the damage done to the patient.
Data gathered about the event included patient health and history record, emergency room staff, census at time of incident, transferring party, accepting party, patient outcome, patient prognosis, time of stay, and witnessing parties. Review of orders and protocols taken, consulting physicians obtained and attorney review of applicable litigation obtained. It was found that prompt identification and reporting of incident was made not by offending person but by the patients primary nurse. Report of incident was made to ER physician, primary physician of patient and the offending party also the house supervisor. Follow-up on patient outcome was made the next day by primary nurse through questioning of transferring paramedics, accepting nurse at ACH and primary nurse of the patients physician. Conclusions found were that patient developed parasthesis in the injection site limb (right upper leg) and that admission to ACH was denied upon litigation concerns. Follow-up reporting was made to the nursing department head and the chief executive officer of the hospital. Subsequent evidence was collected by legal department of offending hospital and actions taken included dismissal of offending party (house supervisor) and referral to Arkansas State Board of Nursing for clinical review of case.
Strategies explored to help resolve future cases included clear communication, yearly testing of competence of all staff including nurse management, protocol review, physician competence review and incident reporting protocol review.
Implementation of clear communication protocol including handing off of written orders to acting agents. Yearly competency testing for all nurses and nurse management implemented. New protocols for incident reporting and follow-up written. Physician competence review testing at yearly basis initiated.
Outcomes to implementation one year after incident yielded no additional concurrences of specific events and increased recognition of offending parties to sentinel events. Making the process of incident reporting more whistle-blower friendly increased the amount of reporting during the next year. If nurses and patients don't fear retaliation from the established caregivers then reporting occurs at a lower incident level than would be otherwise considered.
In conclusion, ethical dilemmas explored above included competence vs. incompetence and truth-telling vs. deception. Strategies implemented were incident reporting protocol revision, physician and nurse yearly competency testing, clear communication protocol implementation which included handing of off written orders to acting agents, and new protocols for incident follow-up review. Outcomes to strategies included increased incident reporting during the next year, less sentinel event occurrences and improved outcomes of adverse incidents.
Ethical Decision-Making 11
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Ethical Decision Making Paper Grading Rubric
Criteria / Points Possible / Points EarnedConcise & thorough description of situation (1 ½-2 pages) / 10 / 10
Each of the five steps (see table 6-1) thoroughly addressed / 50 / 40
Analysis demonstrates sound reasoning and depth of thought / 20 / 15
Appropriate introduction (5 points) & closing (5 points) / 10 / 10
Correct grammar/spelling & references are cited in proper APA format / 4 / 2
References (2 points each) / 6 / 6
Total / 100 / 83
Carmilo,
I’m glad to hear that the situation worked out and that measures were put into place to ensure this mistake doesn’t happen again. You mentioned that you were going to utilize the Ethical Decision-Making Model to analyze the ethical situation in your paper. However, I couldn’t see how you used it though. The steps of the model were not addressed nor were examples of each step. Your opening and closing paragraphs were good and interesting. You listed 29 references, but only six or seven in the paper. Please remember to credit the information in your paper with the reference that you obtained it from. You had some APA and grammar errors…just some advice, if you can have someone proof your next papers prior to submitting them, it would help your grade (it is often hard to see our own mistakes – I have to have someone proof mine!). Please take all of my comments as constructive, as they are meant to be.
Thanks Carmilo,
JH