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Suzanne Rolls

Professional Nursing Advisor

NZ Nurses Organisation

June 2014

36th Enrolled Nurse Section Conference 2014

Nursing Ethics

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NZNO Code of ethics, 2010

The need for knowledge on ethics, ethical issues

and ethical decision making has never been greater. Nursing is undertaken in complex professional practice environments. Nurses daily face situations where they are challenged by under-resourcing, time pressures, short staffing and unhealthy roster patterns. Nurses with a knowledge of ethics, ethical frameworks and processes are better prepared for situations requiring ethical judgements.

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NZNO code of ethics 2010

Each situation is unique and exists in its own context. The most important values from the framework will be specific to the particular situation. Any one value is not always an over-riding value; the balance of values and their inter-relationships may change, not only with each situation, but also within each situation.

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The four‐box method

Is a useful tool for addressing clinical

ethical issues by asking us to allocate

specific items of information within four

boxes that each focus on different

aspects of care planning for individual

patients.

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The four-box method

CLINICAL ISSUES PATIENT PREFERENCES

The principles of beneficence and nonmaleficence

What is the patient’s medical history/

diagnosis/prognosis?

What are the treatment options?

What are the goals of treatment?

What is the benefit to the patient?

The principle of respect for autonomy

What are the patient’s expressed preferences for treatment?

Is the patient competent?

What would they want done?

What is in their best interests?

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4 box - QUALITY OF LIFE CONTEXTUAL FEATURES

The principles of beneficence and nonmaleficence and respect for autonomy

Prospects of survival with and without treatment?

Various effects of patient of treatment?

What are the plans for comfort and palliative care?

The principles of loyalty and fairness

How does this affect others: family

whānau and team?

Cost to Central health system?

Cultural/religious issues?

Law and Policy?

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Not making a decision, is not morally

neutral and is itself open to moral

appraisal, and there is a need to find a

way through that will lead to a decision

that we can agree is rational and

ethical (Godlovitch as cited in Keenan,

2010).

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The four-box method builds on the

recognition that even after reflection

we can and do still disagree on which

moral theory is ultimately correct.

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Truth telling & integrity

The right to be fully informed

Open disclosure

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Nurse’s Registration Cancelled For Dishonest

and Negligent Conduct HPDT359/nur10/160Pr

The Tribunal note that “honesty and

documentation are essential tools for a

nurse. Honesty in documentation is an

even more essential tool”

And that falsification of observations was “potentially a

great risk to patient safety”

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Research in NZ - Nurses

Job dissatisfaction

Burnout

Moral distress

- Martin Woods (2012)

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Moral distress – Woods 2012

“moral distress occurs when

professionals cannot carry out what

they believe to be ethically appropriate

actions because of internal or external

constraints”

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The five key areas:

Concerns they were not delivering good care due to pressures

from management to reduce costs.

Watching patient care suffer because of a lack of continuity in

who was providing treatment.

Working with other professionals who were not competent

enough to provide the care needed.

Carrying out physician's orders for what was considered to be

unnecessary tests and treatments.

Carrying out extensive life-saving actions when the nurse

thought they were unnecessarily prolonging the dying process.

Martin Woods, 2012

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Care rationing – a matter of

ethics?

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Care rationing debate in NZ

Care rationing (CR) uncovered in CCDM reports

SSHW hosts a CR symposium in 2012

April 2013 SSHW convenes a CR advisory; 2013 HVDHB/WDHB report CR; Media interest in CR – community speaks out;

Nov 2013 CR advisory disbanded by SSHW. Modifications to terminology suggested by SSHW Unit

2014 NZNO position on Care rationing developed and public campaign developed

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Terms

Missed care

Failure to rescue

Care left undone

Prioritisation

Errors of omission

Allocation of resources

Adverse events

Care rationing

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Pick a definition to best describe care

rationing

Option

A

“any aspect of required patient care that is omitted (either in part or whole) or delayed.”

Option

B

“the withholding or failure to carry out necessary nursing

tasks due to inadequate time, staffing level, and/or skill

mix.”

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Who is to blame when care is delayed or

omitted?

Who will be held accountable?

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Who is to blame when the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level, and/or skill mix?

Who will be held accountable?

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Care rationing

Care rationing as defined by

Schubert et al is ‘the withholding or

failure to carry out necessary nursing

tasks due to inadequate time, staffing

level, and/or skill mix,‘

2008

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Research questions - Kalisch et al 2009

1. To what extent is nursing care missed?

2. How does missed nursing care vary across

hospitals?

3. What are the reasons for missed nursing

care?

4. Do reasons for missed care vary across

hospitals?

5. Do nurse staffing levels predict missed

care?

6. Does missed nursing care predict job

satisfaction?

7. Does missed nursing care predict intent to

leave and/or turnover

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Most frequently rationed Kalish et al 2009

76%

66% 64%60% 59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ambulation

Interdisciplinary care

conference attendance

Mouth care

Timely medication

administration

Turning

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Failure to ambulate linked to:

New onset delirium

Pneumonia

Delayed wound healing

Pressure ulcers

increased length of stay and delayed

discharge

increased pain and discomfort

muscle wasting and fatigue

Physical disability

Kalisch et al 2009

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What happens when care becomes

habitually rationed?

Does it become the “ new normal?”

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Inadequate nurse

staffing

Failure To rescue/Care Rationing

Poor patient

outcomes

Moral distress

High nurse turnover

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Care Rationing – failure to

prioritise or work

smarter??????

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Sacrificing Decisions • reduce demand (cancel/defer) – affects productivity & volumes

• increase capacity by using unbudgeted resources tagged for future activity (extras, overtime) – impacts financially and on future service provision

• increase capacity by cancelling planned non clinical activity (e.g. education or leave) – impacts on workforce & ultimately service quality

• Require extraordinary work effort

• reduce quality of service

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Impact of sacrificing decisions • Budget over run

• Queuing

• Production delays

• Service cancellation

• Care rationing

• Harm/error incidents/adverse events

• Poor patient placement

• Increased staff discretionary effort (missed breaks/overtime)

• Staff fatigue/anxiety or distress

• Staff feeling professionally compromised

• Avoidable patient deaths

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Intelligent information

Forces problem

recognition

Results in accurate diagnosis

Stimulates appropriate

action

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NZNO to focus on Care

rationing

Position paper underdevelopment

Educate members to escalate

concerns

Members to highlight areas of concern

Support groups to speak up

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To the public:

This is systemic

Nurses are not deliberately withholding care – not resourced enough

Nurses are not being irresponsible

We have the solution (CCDM)

Nurses leave their working day very stressed

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NZNO resources

Incident debriefing

http://www.nzno.org.nz/LinkClick.aspx?fileticket=D1LS31jlskY%3d

Incident reporting

http://www.nzno.org.nz/Portals/0/publications/Incident%20Reporting4.pdf

Investigations - your rights and responsibilities

http://www.nzno.org.nz/LinkClick.aspx?fileticket=YbPfSZB0kdU%3d

Serious and sentinel events

http://www.nzno.org.nz/LinkClick.aspx?fileticket=a2MlvORxjS8%3d