Case Report: Application of Quality and Safety Concepts Introduction

This report will describe an ethical predicament situation encountered by a nurse in line of duty in an emergency department. The predicament will be analyzed using the algorithm for ethical decision making by Catalano’s (2009). A theoretical perspective is used in analyzing the ethical predicament. Several likely solutions to this predicament are discussed. Research instruments for solution evaluation are also identified.

There are many moral situations faced by people working in the nursing profession especially in relation to a growing technological and scientific environment in relation to the development of advanced treatment methods and diagnostic equipment (Range & Rotherdam, 2010). There are many conflicts emanating from the manner in which professionals handle users in hospital environments or in basic networks. Workers face difficulty while trying to solve conflicts due to being ignored by their leaders or due to lack of sufficient support while executing their duties and in professional autonomy. This is likely to cause the feeling of anger, guilt, outrage, sadness, frustration, hopelessness and impotence towards conflict situations (Corley, 2002).

There are four crucial responsibilities for any nurse and they are promotion of health, prevention of illness, alleviate suffering and restore health. The duties require a nurse to promote health, coordinate the care of patients, administer medication, and carry out medical examination, and other crucial such like duties. The process of nursing entails assessment, planning, diagnosis, evaluation and implementation (Parse, 1999).

A working nurse encounters conflict and moral issues in different situations while working. It is not possible to separate conflict from a nurse’s professional life. Among the many conflicting situations include absence of consent prior to handling a procedure, extension of a patient’s life without attention to the quality of that life, questionable or inhumane professional conduct, resource allocation inequalities, and fragmentation of decisions. Moral distress can become part of a nurse in light of the many conflict situations (Lunardi et al., 2009).

Problem Statement

The ethical dilemma encountered by the nurse working in the emergency wing relates to a patient who is 93 years old. The aged patient is moved from the extended care unit. This patient is suffering from Alzheimer’s disease. Due to her fading health she is unable to drink or eat anything, therefore, threatening her life. The patient is also not able to respond to touch or voice and is also non-verbal. The physician in charge of her has concluded that she is unable thrive. The granddaughter to this patient has been given the attorney powers over her grandmother. There is no advanced directive from the patient. The patient’s family emphasizes that their loved one must be taken to an emergency department in order to have her fed through some feeding tube. The family has been made to know that there is a chance that their loved one could survive with some feeding. The ethical dilemma for the nurse in charge of the patient is to identify the patient’s right to demise while balancing the same with the desires and wishes of her family members (Heiser, 2014).

Literature Review

Nurses have to make critical decisions most of the time throughout their practicing careers. The process of making decisions must be informed by the process of making ethical decisions. Ethical decisions involve education of nurses and the experiences gained through practical lessons. Culture and beliefs also inform decision making for nurses. Moreover, motivations, expectations, and different value systems also impact the decisions made by nurses. The code of ethics for nurses and mission statements’ framework support nurses in decision making. Any nurse will employ the ethical standards during decision making in light of the prevailing circumstances (Silva et al., 2014).

Nurses must have professional capacity to examine various situations and come up with spontaneous decisions having considered all possible alternatives characterizing ethical decision making (Silva et al., 2014). Nurses must be able to support their actions and decisions. For this reason a nurse must be confident in their ability to make good judgment in light of any situation by quickly differencing between right and wrong actions. Nurses must have sound moral perception, courage, sensitivity and imagination (Holt & Convey 2012). According to the suggestion of Grundstein-Amaro (1992) a nurse must place great value on the care perspective during decision making. This essentially means that a nurse has to be responsible and highly sensitive about the wishes of a patient during any decision making process.

A nurse will become twice as much distressed when there are staffing problems than when there are other issues. To the contrary Woods, Rodgers, Towers and La Grow (2015) contend that moral distress mainly comes from situations where maximum care is affected for reasons of reducing costs occasioned by poor continuity from provider and working alongside incompetent colleagues. In circumstances where a nurse differs with the orders given by a physician and is required to conduct unnecessary treatments and tests making the nurse to feel as though the process of death has been extended unnecessarily then they can become morally distressed. Futile care is also considered a source of moral distress. The suggestion by Molloy, Evans and Coughlin (2015) is that nurses will often suffer moral distress when showing support for distressed family members to infants who is critically ill. In the opinion of the nurse when their situation is dismissed they will become emotionally distressed. This will make the nurse feel powerless and frustrated to make any changes.
It is possible to predict burnout through moral distress. A nurse with higher levels of moral distress will most likely leave their current institution for a less stressful working environment or even abandon their nursing profession all together. The findings of Corley et al. (2001) reveal that 15% of nurses had quit their positions due to distress. According to Hamaideh (2014) high moral distress levels can be associated with the lack of sufficient skills and enough knowledge from the nurse to handle situations that are morally challenging. The suggestion by Pye (2013) is that experience level may positively influence the ability of nurses to manage moral distress skillfully.

The findings by Ulrich et al. (2010) indicate that at times nurses aren’t in the know of the choices they have when challenged with a situation that presents some ethical dilemma. Ulrich et al. (2010) further found that often nurses are inadequately prepped for handling ethical dilemmas. In addition to this Musto and Schreiber (2012) found that nurses contend with moral distress if they question their decision and doubt their practice. These doubts surface when nurses overthink solutions to problematic situations.

Theoretical Perspective and Case Description

Catalano’s (2009) algorithm on ethical decision is applicable in the description and analysis of the current ethical dilemma situation (Blais & Hayes, 2011).

1st step: Highlight the ethical dilemma, collect data and interpret it

2nd step: State ethical dilemma

3rd step: Gather necessary facts

4th step: Potential solution

Catalino’s (2009) asserts that decision making begins with an assessment of the algorithms in the ethical dilemma situation. First it is important to identify the likely ethical dilemma situation, then collect data and interpret it. Decisions entail making a determination about the party that will be impacted the most following the decision. Step number 2 involves stating the dilemma. The nurse is in a dilemma to meet the wishes of the family and at the same time give the patient some dignified death. Step 3 entails gathering of facts including potential risks to the life of the patient. The information gathered is important in generating outcome (Deshpande, 2009).

In accordance with the 1st step, the wishes of this family were evaluated. Information on the hands of the nurse indicates that the person with power of attorney wants the grandmother to receive some feeding tube. The granddaughter informs the nurse that she has information that the feeding tube at the emergency department will help her grandmother get better. The assessment of the nurse indicates that the family to the patient isn’t aware that Alzheimer’s is a progressive disease. Alzheimer’s is a type of Dementia that cannot be reversed (Porth, 2010). The family, according to the nurse, didn’t have information that the effect of Alzheimer’s on the patient’s quality of life at this point would not improve through nutrition. It is the responsibility of the nurse to consider the patient’s physical condition. The patient is incapable of making decisions or even communicating. She is suffering from stage 3 decubitus Coccyx ulcer. By placing some feeding tube this would not help improve the life quality for the patient.

The 2nd step presents the dilemma of having to take care of the desires of the family or alternatively to support the right of the patient to dignified death. The 3rd step presents some possibilities including getting the feeding tube fitted on the patient by some…