Essentials of Nursing Leadership & Management, 4th Edition
N246 Leadership
Ethics & Quality
S. Buckley, 2010
(Adapted from Nursing Leadership and Management,
Whitehead, Weiss, Tappen)
Essentials of Nursing Leadership & Management, 4th Edition
In the beginning…
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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?
Essentials of Nursing Leadership & Management, 4th Edition
Essentials of Nursing Leadership & Management, 4th Edition
Essentials of Nursing Leadership & Management, 4th Edition
Essentials of Nursing Leadership & Management, 4th Edition
Early nursing leaders
Essentials of Nursing Leadership & Management, 4th Edition
Essentials of Nursing Leadership & Management, 4th Edition
Essentials of Nursing Leadership & Management, 4th Edition
finances
Essentials of Nursing Leadership & Management, 4th Edition
1960s
 Technological advances allowed for the
development of intensive care units
 New biomedical developments
 Advances in surgical techniques, such as
open heart surgery
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
Bioethics
 A sub discipline of ethics
 The study of medical morality
Essentials of Nursing Leadership & Management, 4th Edition
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.)
Essentials of Nursing Leadership & Management, 4th Edition
Value Systems
definitions
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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.
Essentials of Nursing Leadership & Management, 4th Edition
 Historical values of
nursing:
Essentials of Nursing Leadership & Management, 4th Edition
Nursing today
 Values in nursing
today:
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Types of Values
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Personal
Cultural
Religious
professional
Essentials of Nursing Leadership & Management, 4th Edition
Values Clarification
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Critical thinking
Choosing
Identifying-verbalizing?
Acting
Essentials of Nursing Leadership & Management, 4th Edition
Belief Systems
 These are organized ways of thinking about
why people exist within the universe
 Their purpose is to explain such concepts
as:
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Life and death
Good and evil
Health and illness
Individualism/rights
Essentials of Nursing Leadership & Management, 4th Edition
ETHICS AND MORALS
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
Standards
 Something established for use as a rule or
basis of comparison in measuring or
judging quality, value, extent.
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
Ethical Principles
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Autonomy
Nonmaleficence
Beneficence
Justice
Fidelity
Confidentiality
Veracity
Accountability
Essentials of Nursing Leadership & Management, 4th Edition
Autonomy
 The freedom to make decisions about
oneself
 Nurses need to respect clients’ rights to
make choices about health care
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Beneficence
 This principle means “doing good” for
others
 Nurses need to assist clients in meeting all
their needs
 Biological
 Psychological
 Social
Essentials of Nursing Leadership & Management, 4th Edition
Justice
 Every individual must be treated equally
 This requires nurses to be nonjudgmental
Essentials of Nursing Leadership & Management, 4th Edition
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)
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Veracity
 This principle implies “truthfulness”
 Nurses need to be truthful to their clients
 Veracity is an important component of
building trusting relationships
Essentials of Nursing Leadership & Management, 4th Edition
Accountability
 Individuals need to be responsible for their
own actions
 Nurses are accountable to themselves and
to their colleagues
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Organizational Ethics
 Focus on the workplace
 Ethical culture makes a difference
 Senior leadership must promote an ethical
culture-do they?
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Current Ethical Issues
Essentials of Nursing Leadership & Management, 4th Edition
Issues to Consider
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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
Essentials of Nursing Leadership & Management, 4th Edition
Conclusion
 An issue is not an ethical issue for the
nurse unless he or she has been asked
 Always gather the facts prior to decisionmaking
 Consider your personal beliefs and values
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
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, 5 edition, Silvestri, L.,2011)
th
Essentials of Nursing Leadership & Management, 4th Edition
Professional organizations that focus on
quality
 * Joint commission on Accreditation of
Healthcare Organizations (JACHO)
 * American Nurses Association (ANA)
 *Institute of Medicine (IOM)
Essentials of Nursing Leadership & Management, 4th Edition
IOM essential competencies
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Provide patient centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Use informatics
Essentials of Nursing Leadership & Management, 4th Edition
Aims of IOM quality of care
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Safe
Effective
Patient centered
Timely
Efficient
equitable
Essentials of Nursing Leadership & Management, 4th Edition
IOM- cost of inefficiency
 44,000-98,000 die each year
 $17-29 billion in total costs
Nursing errors:
*Medication
*knowledge
*procedure
Essentials of Nursing Leadership & Management, 4th Edition
Continuous Quality improvement (CQI)
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Identify indicators
Collect ongoing data on indicators
Analyze and evaluate data
Implement change
(utilize evidence based practice)
Essentials of Nursing Leadership & Management, 4th Edition
How to monitor quality of care
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Guidelines
Protocols
Algorithms
Standards of care
Critical pathways
Essentials of Nursing Leadership & Management, 4th Edition
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.
Essentials of Nursing Leadership & Management, 4th Edition
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
Essentials of Nursing Leadership & Management, 4th Edition
Risk management
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part of QA
Identify potential problems, risks
Incident investigation
Sentinel events
Anticipate outcome, prevent recurrence
Essentials of Nursing Leadership & Management, 4th Edition
conclusion
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To enhance quality of care;
Think critically
Plan and report outcomes
Make introductory rounds
Plan partnership with the client
Communicate plan
Evaluate progress