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The role of the nurse in ethical decision-making in intensive care units
fnfasiw and Cnfd Can Nursing (1993) 9, 191-194 @ Longman Group UK L:d 1993
The role of the nurse in ethical decision-making in intensive care units Christine Watson
This paper focuses on the nurses’ role in ethical decision-making in intensive care units (ICUs) of hospitals in the UK. There is a paucity of research on the topic, studies published are generally North American or Canadian in origin. The available literature suggests that although nurses are constantly at the intensive care patient’s bedside, often making complex decisions about treatment and care, their involvement in ethical decision-making is limited. This paper provides a review of the literature on how ethical decisions are made and the influences on nurses’ participation in this process.
INTRODUCTION Advances in technology and drug therapy mean that life can be extended and preserved for many critically ill people who, in past years, would have no hope of survival (Young 1988). When a patient’s condition becomes irrecoverable, however, rather than sustaining life, treatment may only be prolonging death. At this stage once competent patients may now be too ill to make decisions and others must assume that responsibility for them. Ethical decisions, particularly those involving withholding or withdrawing treatment, are therefore made on a regular basis in ICUs. The organisation of nursing care in these specialised units, often puts nurses in a unique position to contribute to this decision-making
Christine Watson RGN, ENB 100, BN(Hons), Lecturer in Nursing, University of the West of England, Bristol BS16 2JP, UK (Requests for offprints to CW) Manuscript LC.N.-
C
accepted 17 March 7993
process. There is a high nurse:patient ratio. One nurse may provide life-sustaining care, hour after hour, day after day, often forming a close relationship with both the patient and his or her family (Wlody 1990). This constant interaction allows opportunity to discuss the wishes of the individuals involved regarding the treatment regimen and their thoughts about death and dying. The nurse, therefore, may be the most appropriate person to facilitate the patient or family’s participation in ethical decision-making, or represent their views if they are unable or unwilling to participate. Indeed, nurses are required by their Professional Code of Conduct to assume an advocacy role, to ‘promote and safeguard the well-being of the patient’ (UKCC 1992). Although nurses are apparently well-placed to facilitate patient-centred decisions, the available evidence suggests that this role is not fulfilled. Holly (1989), studied 45 critical care nurses’ participation in ethical decision-making in relation to perceptions of environmental social support. She found that there were limited roles for patient, family or nurse participation in 191
192
INTENSIVE AND CRITICAL CARE NURSING
ethical decision-making and when nurses were involved, they were only supported by other nurses. 75% of the nurses surveyed reported that ethical decisions were made by doctors. Although the small study sample makes findings difficult to generalise, the study suggests that nurses lack the support and freedom to engage in ethical decision-making or to act in an advocacy role in such a situation. That this inability to participate in ethical decisions is preventing nurses from assuming the patient advocate role is supported by the findings of Rodney (1988) and expanded upon by Fenton (1988), who found that lack of participation causes feelings of anger, frustration and powerlessness. That nurses lack autonomy within the health care team is not a new proposition. In 1967 Stein described a stereotypic communication pattern he called the ‘doctor-nurse game’. In order to appear passive, the nurse gave recommendations about patient care in such a way that they appeared to be initiated by the doctor. In a recent re-evaluation of the doctornurse game, Stein et al (1990) assert that little has changed and that in many places the game is played as first described. It is doubtful, however, if this phenomenon is wholly applicable to the nurse-doctor relationship in ICUs. Critical care areas often require that nurses make rapid decisions under crisis situations when there has been a rapid change in the patient’s condition (Baumann & Bourbonnais 1982). Immediate action may be required in these situations and decisions cannot be postponed to await consultation with medical staff. This need to make rapid decisions based on sound rationale may be what differentiates the role of critical care nurses from their colleagues in less acute areas. Holly (1989) reports that critical care nurses are more assertive and function more autonomously than most. If this is so, why does the available evidence suggest that these nurses do not participate in ethical decision-making? It may be helpful here to examine what constitutes an ethical decision and what approach will enable a satisfactory resolution of an ethical dilemma. According to Benjamin & Curtis (1986), ethical decision-making is
‘the application of various skills of ethical analysis and reasoning in an attempt to reach a well-grounded solution to an ethical problem’. It is difficult to determine British intensive care nurses’ level of skill in ethical analysis and moral reasoning due to the lack of available research. In their integrative review of American research in this area, Ketefian & Ormond (1988) state that the relationship between education and moral reasoning remains ambiguous, mainly due to research design limitations. However, educational preparation of nurses may give an indication of present practice. Curriculum content varies from college to college and on examination of course documentation (Bristol Polytechnic 1987, Leeds College of Nursing 1991, Avon College of Health 1990 etc.) although ethics are taught in both pre-registration programmes and post-registration intensive care courses, the development of practical skills in ethical analysis is not addressed. Two current approaches to moral education in nursing curricula, namely, putting ethics into the same context as a study of professional codes of conduct and imparting moral theories as the basis for action, are strongly rejected by van Hooft (1990). He argues for a process he calls ‘empowerment’ which develops nurses’ conlidence and sensitivity in the making of difficult decisions, by attitudinal change and reflective practice. While this seems a commendable approach, it is difficult to see how ‘well-grounded’ decisions (Benjamin & Curtis 1986), can be made without the study of ethical theory. A combination of teaching methods, including the study of ethical theory and empowerment, may facilitate nurses’ participation in the ethical decision-making process. What actually happens during this process is difficult to determine due to the lack of research in the area. There are, however, several models available which propose a structure for resolving ethical dilemmas. One such model, Curtin (1992), is particularly succinct and is therefore readily applied to critical care situations, where time may inhibit lengthy deliberation. The model is summarised below: 1. Background
information.
Information
is
INTENSIVE
2.
3.
4.
5.
6.
gathered, organised and ranked in order of relevance of the decision to be made, thus determining the problem(s). Identification of ethical component. The problem is analysed to see if it fits the definition of an ethical problem. It is then analysed in terms of ethical theory to determine moral rights, duties, obligations and principles involved. Identification of individuals to be involved. All people involved in the decision, their level of competence and how they are involved is identified. Lines of authority and resonsibility should be clarified. Conflicting human rights must be identified and ranked. Identify options. Alternative courses of action are identified, with the consequences for each projected. Reconciling facts and principles. Alternatives are examined in terms of values and ethical theory. Resolution. An attempt is made to achieve consensus of all parties involved. Curtin (1982) states that legal requirements and social expectations may influence the decision but should not dictate it.
As previously mentioned there is no evidence to suggest that this type of approach, or indeed any formal structure is used in this country to aid ethical decision-making. However, the model does illustrate the complexity of the decisionmaking process and it could be postulated that it is nurses’ lack of educational preparation which is an inhibiting factor to their involvement in such processes. According to Grundstein-Amado (1992), nurses’ participation in ethical decision-making would humanise the process. She found that nurses placed the highest value on the ‘caring’ perspective, which entails sensitivity to the patients’ wishes. In contrast, doctors value patients’ rights and a scientific approach concerned with disease and its cure. Although again this study sample was small (n = 18) making findings difficult to generalise, sociological research in nursing substantiates the idea that the two professions act from different points of
AND CRITICAL
CARE NURSING
1%
reference (Salvage 1985, Bush & Kjervik 1979, Melia 198 1). A joint approach, based on mutual participation by doctors and nurses, may enable a more balanced resolution of these difficult dilemmas. To conclude, although nurses are constantly at the patients’ bedside, often making complex decisions about treatment and care in ICUs, the available evidence suggests that their involvement in ethical decision-making is limited. Traditionally, doctors appear to have professional dominance over nurses and thus some nurses are socialised into passive roles. Nurses’ lack of educational preparation in the areas of moral reasoning and ethical practice may be a further inhibitant to their participation in what appears to be a complex cognitive process. However, the suggestion is that nurses desire involvement in ethical decision-making and their professional code requires this of them. Furthermore, their caring perspective may facilitate a more patient-centred approach to the resolution of ethical problems.
References Avon College of Health 1990 Unpublished Project 2000 curriculum Baumann A and Bourbonnais S F 1986 Nursing decision-making in critical care areas. Journal of Advanced Nursing 7: 435-446 Benjamin M and Curtis J 1986 Ethics in nursing, 2nd edn. Oxford University Press, New York .. Bristol Polvtechnic 1988 Unnublished BSc (Hans) Nursing’with RGN, tours; curriculum document Bush M A and Kjervik D K 1979 Women in stress - a nursing perspective. Appleton-Century-Croft, New York Curtin L 1982 No rush to judgement. In: Curtin L and Flaherty M J (eds) Nursing ethics theories and pragmatics. Robert J Brady Co, Maryland, pp 57-63 Fenton M J 1988 Moral distress in clinical practice: implications for the nurse administrator. Canadian Journal of Nurse Administration 1 (10): 8-l 1 Grundstein-Amado L 1992 Differences in ethical decision-making processes among doctors and nurses. lournal of Advanced Nursing 17: 129-137 Holly C 1989 Critical care nurs&’ participation in ethical decision-making. Journal of the New York State Nurses Association 20 (4): 9- 12 Ketefian S and Ormond J 1988 Moral Reasoning and Ethical Practice in nursing: an integrative review. National League for Nursing, New York Leeds College of Nursing 1990 Unpublished Project 2000 Nursing curriculum document
194
INTENSIVEANDCRITICALCARENURSING
Melia K M 1981 Student nurses accounts of their work and training: a qualitative analysis. Unpublished PhD Thesis, University of Edinburgh Rodney P A 1988 Dealing with ethical problems. Canadian Critical Care Nurses lournal8 (1): 8-10 Salvage J 1985 The politics of nursing. Heine’mann, London Stein L 1967 The doctor-nurse game. Archives of General Psychiatry 16: 699-703 Stein L, Watts D, and Howell T 1990 The doctor-nurse game re-visited. New England Journal of Medicine 322(8): 546549
UKCC 1992 Code of Professional Conduct. United Kingdom Central Council for Nursing, Midwifery and-Health Visiting Van Hooft S 1990 Moral education for nursing decisions. Journal of Advanced Nursing 15:>10-215 Wlody G S 1990 Ethical issues in critical care: a nursing model. Dimensions in Critical Care Nursing 9 (4): 224230 Young E W D 1988 Decisions to limit therapy in terminal or critical illness part 1. Current Reviews in Respiratory & Critical Care 11 (2): 1O- 15.
The role of the nurse in ethical decision-making in intensive care units Christine Watson
This paper focuses on the nurses’ role in ethical decision-making in intensive care units (ICUs) of hospitals in the UK. There is a paucity of research on the topic, studies published are generally North American or Canadian in origin. The available literature suggests that although nurses are constantly at the intensive care patient’s bedside, often making complex decisions about treatment and care, their involvement in ethical decision-making is limited. This paper provides a review of the literature on how ethical decisions are made and the influences on nurses’ participation in this process.
INTRODUCTION Advances in technology and drug therapy mean that life can be extended and preserved for many critically ill people who, in past years, would have no hope of survival (Young 1988). When a patient’s condition becomes irrecoverable, however, rather than sustaining life, treatment may only be prolonging death. At this stage once competent patients may now be too ill to make decisions and others must assume that responsibility for them. Ethical decisions, particularly those involving withholding or withdrawing treatment, are therefore made on a regular basis in ICUs. The organisation of nursing care in these specialised units, often puts nurses in a unique position to contribute to this decision-making
Christine Watson RGN, ENB 100, BN(Hons), Lecturer in Nursing, University of the West of England, Bristol BS16 2JP, UK (Requests for offprints to CW) Manuscript LC.N.-
C
accepted 17 March 7993
process. There is a high nurse:patient ratio. One nurse may provide life-sustaining care, hour after hour, day after day, often forming a close relationship with both the patient and his or her family (Wlody 1990). This constant interaction allows opportunity to discuss the wishes of the individuals involved regarding the treatment regimen and their thoughts about death and dying. The nurse, therefore, may be the most appropriate person to facilitate the patient or family’s participation in ethical decision-making, or represent their views if they are unable or unwilling to participate. Indeed, nurses are required by their Professional Code of Conduct to assume an advocacy role, to ‘promote and safeguard the well-being of the patient’ (UKCC 1992). Although nurses are apparently well-placed to facilitate patient-centred decisions, the available evidence suggests that this role is not fulfilled. Holly (1989), studied 45 critical care nurses’ participation in ethical decision-making in relation to perceptions of environmental social support. She found that there were limited roles for patient, family or nurse participation in 191
192
INTENSIVE AND CRITICAL CARE NURSING
ethical decision-making and when nurses were involved, they were only supported by other nurses. 75% of the nurses surveyed reported that ethical decisions were made by doctors. Although the small study sample makes findings difficult to generalise, the study suggests that nurses lack the support and freedom to engage in ethical decision-making or to act in an advocacy role in such a situation. That this inability to participate in ethical decisions is preventing nurses from assuming the patient advocate role is supported by the findings of Rodney (1988) and expanded upon by Fenton (1988), who found that lack of participation causes feelings of anger, frustration and powerlessness. That nurses lack autonomy within the health care team is not a new proposition. In 1967 Stein described a stereotypic communication pattern he called the ‘doctor-nurse game’. In order to appear passive, the nurse gave recommendations about patient care in such a way that they appeared to be initiated by the doctor. In a recent re-evaluation of the doctornurse game, Stein et al (1990) assert that little has changed and that in many places the game is played as first described. It is doubtful, however, if this phenomenon is wholly applicable to the nurse-doctor relationship in ICUs. Critical care areas often require that nurses make rapid decisions under crisis situations when there has been a rapid change in the patient’s condition (Baumann & Bourbonnais 1982). Immediate action may be required in these situations and decisions cannot be postponed to await consultation with medical staff. This need to make rapid decisions based on sound rationale may be what differentiates the role of critical care nurses from their colleagues in less acute areas. Holly (1989) reports that critical care nurses are more assertive and function more autonomously than most. If this is so, why does the available evidence suggest that these nurses do not participate in ethical decision-making? It may be helpful here to examine what constitutes an ethical decision and what approach will enable a satisfactory resolution of an ethical dilemma. According to Benjamin & Curtis (1986), ethical decision-making is
‘the application of various skills of ethical analysis and reasoning in an attempt to reach a well-grounded solution to an ethical problem’. It is difficult to determine British intensive care nurses’ level of skill in ethical analysis and moral reasoning due to the lack of available research. In their integrative review of American research in this area, Ketefian & Ormond (1988) state that the relationship between education and moral reasoning remains ambiguous, mainly due to research design limitations. However, educational preparation of nurses may give an indication of present practice. Curriculum content varies from college to college and on examination of course documentation (Bristol Polytechnic 1987, Leeds College of Nursing 1991, Avon College of Health 1990 etc.) although ethics are taught in both pre-registration programmes and post-registration intensive care courses, the development of practical skills in ethical analysis is not addressed. Two current approaches to moral education in nursing curricula, namely, putting ethics into the same context as a study of professional codes of conduct and imparting moral theories as the basis for action, are strongly rejected by van Hooft (1990). He argues for a process he calls ‘empowerment’ which develops nurses’ conlidence and sensitivity in the making of difficult decisions, by attitudinal change and reflective practice. While this seems a commendable approach, it is difficult to see how ‘well-grounded’ decisions (Benjamin & Curtis 1986), can be made without the study of ethical theory. A combination of teaching methods, including the study of ethical theory and empowerment, may facilitate nurses’ participation in the ethical decision-making process. What actually happens during this process is difficult to determine due to the lack of research in the area. There are, however, several models available which propose a structure for resolving ethical dilemmas. One such model, Curtin (1992), is particularly succinct and is therefore readily applied to critical care situations, where time may inhibit lengthy deliberation. The model is summarised below: 1. Background
information.
Information
is
INTENSIVE
2.
3.
4.
5.
6.
gathered, organised and ranked in order of relevance of the decision to be made, thus determining the problem(s). Identification of ethical component. The problem is analysed to see if it fits the definition of an ethical problem. It is then analysed in terms of ethical theory to determine moral rights, duties, obligations and principles involved. Identification of individuals to be involved. All people involved in the decision, their level of competence and how they are involved is identified. Lines of authority and resonsibility should be clarified. Conflicting human rights must be identified and ranked. Identify options. Alternative courses of action are identified, with the consequences for each projected. Reconciling facts and principles. Alternatives are examined in terms of values and ethical theory. Resolution. An attempt is made to achieve consensus of all parties involved. Curtin (1982) states that legal requirements and social expectations may influence the decision but should not dictate it.
As previously mentioned there is no evidence to suggest that this type of approach, or indeed any formal structure is used in this country to aid ethical decision-making. However, the model does illustrate the complexity of the decisionmaking process and it could be postulated that it is nurses’ lack of educational preparation which is an inhibiting factor to their involvement in such processes. According to Grundstein-Amado (1992), nurses’ participation in ethical decision-making would humanise the process. She found that nurses placed the highest value on the ‘caring’ perspective, which entails sensitivity to the patients’ wishes. In contrast, doctors value patients’ rights and a scientific approach concerned with disease and its cure. Although again this study sample was small (n = 18) making findings difficult to generalise, sociological research in nursing substantiates the idea that the two professions act from different points of
AND CRITICAL
CARE NURSING
1%
reference (Salvage 1985, Bush & Kjervik 1979, Melia 198 1). A joint approach, based on mutual participation by doctors and nurses, may enable a more balanced resolution of these difficult dilemmas. To conclude, although nurses are constantly at the patients’ bedside, often making complex decisions about treatment and care in ICUs, the available evidence suggests that their involvement in ethical decision-making is limited. Traditionally, doctors appear to have professional dominance over nurses and thus some nurses are socialised into passive roles. Nurses’ lack of educational preparation in the areas of moral reasoning and ethical practice may be a further inhibitant to their participation in what appears to be a complex cognitive process. However, the suggestion is that nurses desire involvement in ethical decision-making and their professional code requires this of them. Furthermore, their caring perspective may facilitate a more patient-centred approach to the resolution of ethical problems.
References Avon College of Health 1990 Unpublished Project 2000 curriculum Baumann A and Bourbonnais S F 1986 Nursing decision-making in critical care areas. Journal of Advanced Nursing 7: 435-446 Benjamin M and Curtis J 1986 Ethics in nursing, 2nd edn. Oxford University Press, New York .. Bristol Polvtechnic 1988 Unnublished BSc (Hans) Nursing’with RGN, tours; curriculum document Bush M A and Kjervik D K 1979 Women in stress - a nursing perspective. Appleton-Century-Croft, New York Curtin L 1982 No rush to judgement. In: Curtin L and Flaherty M J (eds) Nursing ethics theories and pragmatics. Robert J Brady Co, Maryland, pp 57-63 Fenton M J 1988 Moral distress in clinical practice: implications for the nurse administrator. Canadian Journal of Nurse Administration 1 (10): 8-l 1 Grundstein-Amado L 1992 Differences in ethical decision-making processes among doctors and nurses. lournal of Advanced Nursing 17: 129-137 Holly C 1989 Critical care nurs&’ participation in ethical decision-making. Journal of the New York State Nurses Association 20 (4): 9- 12 Ketefian S and Ormond J 1988 Moral Reasoning and Ethical Practice in nursing: an integrative review. National League for Nursing, New York Leeds College of Nursing 1990 Unpublished Project 2000 Nursing curriculum document
194
INTENSIVEANDCRITICALCARENURSING
Melia K M 1981 Student nurses accounts of their work and training: a qualitative analysis. Unpublished PhD Thesis, University of Edinburgh Rodney P A 1988 Dealing with ethical problems. Canadian Critical Care Nurses lournal8 (1): 8-10 Salvage J 1985 The politics of nursing. Heine’mann, London Stein L 1967 The doctor-nurse game. Archives of General Psychiatry 16: 699-703 Stein L, Watts D, and Howell T 1990 The doctor-nurse game re-visited. New England Journal of Medicine 322(8): 546549
UKCC 1992 Code of Professional Conduct. United Kingdom Central Council for Nursing, Midwifery and-Health Visiting Van Hooft S 1990 Moral education for nursing decisions. Journal of Advanced Nursing 15:>10-215 Wlody G S 1990 Ethical issues in critical care: a nursing model. Dimensions in Critical Care Nursing 9 (4): 224230 Young E W D 1988 Decisions to limit therapy in terminal or critical illness part 1. Current Reviews in Respiratory & Critical Care 11 (2): 1O- 15.