essentials of nursing leadership & management, 4th edition n246 leadership ethics & quality...

Essentials of Nursing Leadership & Management, 4th EditionEssentials of Nursing Leadership & Management, 4th Edition

N246 Leadership Ethics & Quality

S. Buckley, 2010

(Adapted from Nursing Leadership and Management,Whitehead, Weiss, Tappen)

In the beginning…

There were no antibiotics There were no ICUs There were no CT scanners and MRIs There were just physicians and nurses who

cared for people in sickness and in health Were there ethics?

Early nursing leaders

finances

Technological advances allowed for the development of intensive care units

New biomedical developments Advances in surgical techniques, such as

open heart surgery

Reasons for new inquiries in nursing

Technological advances created new questions for health-care professionals regarding the use of technology, RN role and outcomes

Changing views and perspectives on the concepts of life and death Dissatisfaction of RN’s with traditional manner of learning (mentoring)

and desire to have a scientific base for practice (professional scientists)

Interest by healthcare practitioners about application of values in professional practices, and how to discuss these issues.

Bioethics

A sub discipline of ethics The study of medical morality

Concepts of Ethics Ethics evolve from moral perspectives, which form

values and standards. Influenced by families, environment, social issues, culture, religion, cognition, law.

Ethical action depends, in part, on the ability of people to recognize that a moral issue exists in a given situation, knowing how to take appropriate ethical action if and when required, and on personal commitment and a genuine desire to achieve a moral outcome

(Johnstone, 1999, from:Ethics in Nursing Practice, 2nd ed, Fry, S.T,Johnstone, M.)

Value Systemsdefinitions

A set of related values Intrinsic values-located within, the real nature of a thing. Extrinsic values-from without Personal values Professional values Social principles, goals or standards held or accepted by

an individual class, society. That which is desirable or worthy of esteem for its own sake, thing or quality having intrinsic worth.

Historical values of nursing:

Nursing today Values in nursing

today:

Value Formation

Values are learned-therefore, influenced by family, culture, environment, cognition.

Values change with maturity and experience

The number of values an individual holds is not as important as what values they consider important

Types of Values Personal Cultural Religious professional

Values Clarification

Critical thinking Choosing Identifying-verbalizing? Acting

Belief Systems These are organized ways of thinking about

why people exist within the universe Their purpose is to explain such concepts

as: Life and death Good and evil Health and illness Individualism/rights

ETHICS AND MORALS

Morals An individual’s own code for acceptable

behavior Standards of goodness or rightness that

arise from an individual’s conscience They act as a guide for individual behavior Learned Capable of making a distinction between

right and wrong in conduct

Values Social principles, goals or standards held or

accepted by an individual class, society. That which is desirable or worthy of esteem for its own sake, thing or quality having intrinsic worth.

Standards Something established for use as a rule or

basis of comparison in measuring or judging quality, value, extent.

Laws Rule of conduct established and enforced

by the authority, legislation or custom of a given community, state, or other group.

May change with fluctuating social morals and viewpoints.

Ethics Having to do with moral standards,

conforming to the standards of conduct of a given professional group. Implies conformity with an elaborated, ideal code or moral principles.

Concerned with the motivation behind the behavior

Bioethics is the application of these principles to life-and-death issues

Ethical Theories

Deontological-based on duty to commitment, considers the intention of the action, not the consequences of the action. It is the individuals goodwill that determines worthiness, not the outcome.

Teleological-(utilitarianism)-what makes an action right or wrong is its usefulness. Right encompasses actions that have positive outcomes, wrong is composed of actions that result in poor outcomes.

Principalism-involved in biomedical issues, integrates ethical principles to resolve conflicts in situations.

Ethical Principles Autonomy Nonmaleficence Beneficence Justice Fidelity Confidentiality Veracity Accountability

Autonomy

The freedom to make decisions about oneself

Nurses need to respect clients’ rights to make choices about health care

Nonmaleficence

Requires that no harm be caused to an individual, either unintentionally or deliberately

This principle requires nurses to protect individuals who are unable to protect themselves

Beneficence This principle means “doing good” for

others Nurses need to assist clients in meeting all

their needs Biological Psychological Social

Justice

Every individual must be treated equally This requires nurses to be nonjudgmental

Fidelity

Loyalty The promise to fulfill all commitments The basis of accountability (moral concept that

involves acceptance by a professional nurse of the consequences of a decision or action)

Confidentiality Anything stated to nurses or health-care

providers by clients must remain confidential

The only times this principle may be violated are: If clients may indicate harm to themselves or

others If the client gives permission for the information

to be shared

Veracity

This principle implies “truthfulness” Nurses need to be truthful to their clients Veracity is an important component of

building trusting relationships

Accountability

Individuals need to be responsible for their own actions

Nurses are accountable to themselves and to their colleagues

Ethical Codes These are formal statements of the rules of

behavior for a particular group of individuals

Ethical codes are dynamic Most professions have a “code of ethics” to

guide professional behavior

Organizational Ethics

Focus on the workplace Ethical culture makes a difference Senior leadership must promote an ethical

culture-do they?

Ethical Dilemmas

Occur when a problem exists between ethical principles

Deciding in favor of one principle usually violates another

Both sides have “goodness” and “badness” associated with them

Ethical decision making Consider cause, variables, precipitating events

and implications Reflect upon one’s own perspective and values Explore options for action: ANA code of ethics, facility standard and ethics,

nurse practice act (BRN), legal issues, rights. Select appropriate plan. Understand

consequences of the plan. Implement Evaluate results

Current Ethical Issues

Issues to Consider

Assisted suicide Technology issues-as RN, as patient. Gene therapies, genetic counseling “Designer babies”, fertility issues, fetal success Organizational climate Family planning Social responsibility Immigration policies Resource management. Stem cell research DNR status

Conclusion

An issue is not an ethical issue for the nurse unless he or she has been asked

Always gather the facts prior to decision-making

Consider your personal beliefs and values

Quality issues What is it?? The degree of excellence that distinguishes

one thing from another Relates to education and practice;

professionals perceive that they are providing high-quality nursing education and patient care.

Why do we need it? * current health care system is fragmented,

poorly organized, inefficient use of resources.

*New technologies, availability of information (it), decreasing resources, increasing chronic disease states mandate a change.

* consumer dissatisfaction with current system

Quality improvement Also known as performance improvement,

focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change or improve the quality of care.(Saunders NCLEX review, 5th edition, Silvestri, L.,2011)

Professional organizations that focus on quality * Joint commission on Accreditation of

Healthcare Organizations (JACHO) * American Nurses Association (ANA) *Institute of Medicine (IOM)

IOM essential competencies Provide patient centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Use informatics

Aims of IOM quality of care Safe Effective Patient centered Timely Efficient equitable

IOM- cost of inefficiency 44,000-98,000 die each year $17-29 billion in total costs

Nursing errors:

*Medication

*knowledge

*procedure

Continuous Quality improvement (CQI)

Identify indicators Collect ongoing data on indicators Analyze and evaluate data Implement change (utilize evidence based practice)

How to monitor quality of care Guidelines Protocols Algorithms Standards of care Critical pathways

How does structured care methodologies work? Link process of care (issue) and outcome Determine method of measurement Clarify responsibilities of interdisciplinary

team Facilitate communication among team

members Document, apply systematic approach to

measurement.

Root cause analysis Process of learning from consequences; Determine influences, establish linked chains

of influences, determine necessary influences, analyze root (initial) cause.

Currently used to analyze errors and mistakes; attempts to evaluate series of events that may lead to errors (safety errors) and determine causative reason for error (process), rather than punitively blame a person

Risk management part of QA Identify potential problems, risks Incident investigation Sentinel events Anticipate outcome, prevent recurrence

conclusion To enhance quality of care; Think critically Plan and report outcomes Make introductory rounds Plan partnership with the client Communicate plan Evaluate progress

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