Ethical Caregiving
An introduction to ethics and the Elim ethical guidelines
for direct care staff
Outcomes

By the end of this module, you
will be able to:
◦ Identify language used to describe
ethical issues
◦ Describe what is meant by ‘moral
distress’
◦ Demonstrate how to identify an
ethical issue
◦ Navigate the Elim Stepwise Guideline
for Ethical Issues
Outcome: Identify language used to describe ethical issues
THE LANGUAGE
OF
ETHICS …
Caring Considerations
You are a care giver because you choose to
give care to others
 Often, giving care is a natural response that
feels right to all concerned (you, the
resident, family, other staff, and professional
and agency protocols)

Caring Considerations

Sometimes giving care and professional
practice must be learned and feels ‘odd’
until it becomes part of us
(remember the learning curve during your
education?)
Caring Considerations


Learning is one thing, but sometimes our
natural response is at odds with another care
giver’s natural response or our beliefs about
professional or moral care may clash;
Sometimes our natural or learned response
can be at odds with a resident, family, or even
agency protocol or policy
Ethical problems:
involve complex situations where values and
beliefs about care often collide
 cause us to question what is right or good
in a particular practice situation

Ethical problems:
can happen at an individual direct care
level, a unit level, between staff, between
residents, family, or at the policy and
protocol level of the agency
 often cause us uneasy feelings or feelings of
confusion or distress as our moral centre
feels off balance with our actions

Pop Quiz!
Which of the following statements are true?
Which are false?
1. Caring can feel difficult at times, such as
when a new skill is needed.
2. All caregivers agree on what care is
needed for residents in all situations.
3. Caregivers always share the same values
and beliefs about what is right and good.
4. An ethical problem can occur when
different values and beliefs collide.
Pop Quiz answer sheet!
The true statements are in green; the false
statements are in red. Please review the previous
slides if you are unsure of the correct responses.
1. Caring can feel difficult at times, such as
when a new skill is needed.
2. All caregivers agree on what care is needed
for residents in all situations.
3. Caregivers always share the same values
and beliefs about what is right and good.
4. An ethical problem can occur when
different values and beliefs collide.
Points to Ponder ...
Although individuals can differ in
personally held values and beliefs,
professions have ethical standards that are
agreed upon.
 The Canadian Nursing Code of Ethics is an
example of an ethical standard that all
nursing caregivers can agree to hold when
they provide care to residents.
 Fraser Health has a code of ethics that all
employees are held to ...

Fraser Health Code of Ethics
Here is a section of the Provincial Health Code of
Ethics. For the full ethics statement, visit the FHA website.
 Treating patients with respect, dignity, courtesy,
compassion, kindness, fairness, and optimism.
 Providing health and social services to patients
and their families with sensitivity and respect,
mindful of individual differences and cultural and
ethnic diversity.
 Respecting the autonomy of patients and the
right of those with capacity to make their own
decisions regarding their health care.
 Upholding the legal and ethical duty in
protecting patient privacy and confidentiality.
The Language of Ethics for Care

The Provincial Health Code of Ethics shares the
same language as the Canadian Nurses Code of
Ethics:
1.
2.
3.
4.
5.
6.
7.
Providing safe, competent care
Promoting health and well-being
Promoting and respecting informed decision-making
Preserving dignity
Maintaining privacy and confidentiality
Promoting justice
Being accountable
(Canadian Nursing Association http://cna-aiic.ca)

Although the wording may be different, all health
related professions share the following concepts …
And now, the
‘big’ words ...
Outcome: Identify language used to describe
ethical issues
Autonomy
The principle of autonomy
means that we honor the
resident’s right to make their
own decisions and direct
their own lives—including
their care.
 Advanced directives is one
way that autonomy can be
protected at the end-of-life.

Autonomy
Autonomy can come into conflict with care
if we believe that we know better than the
client about the care they ‘should’ receive.
This view, called ‘paternalism’ is the opposite
of client autonomy because it puts the care
provider in the position of making decisions
for the resident.
 Informed, collaborative decision making with
the resident is the way that autonomy and
the experience of the care giver can live in
harmony!

Meet Mary …
Mary is 92 years old and living in Residential
Care (RC). Upon admission to RC, Mary
decided on MOST2 (Medical Orders for
Scope of Treatment, level 2), meaning that for
any required medical interventions she would
remain at home, in RC.
Mary’s story continues ...
Mary has a stroke and has difficulty
communicating verbally.
Mary’s family wants her to be treated in
hospital: “I want everything done for my
mom,” says the eldest son.
What does Elim do?
Consider the ethical principle of autonomy ...
What is your response?
Hint:What does Mary want?
What ethical concept apply?
Autonomy
How do we ensure that Mary’s autonomy is
respected?

Consider Mary’s advanced directives ... these
speak for Mary when she cannot speak for
herself.
Informed Consent
 Informed


consent means that a resident
must understand the potential benefits and risks of
any medical treatment or nursing intervention
before ‘consent’ can be truly given.
Residents can choose to make their own medical
decisions, or can delegate decision-making authority
to another person.
Residents with assessed and documented cognitive
impairment retain the right to refuse care and may
‘assent’ to care (verbally agree), but will still require
the delegated decision-making authority to provide
legal and ethical consent.
About Mary …
The link between advanced directives, autonomy
and informed consent becomes clear when we
consider how and when Mary and her
physician met to discuss Advanced Directives
before she entered Residential Care. At that
time, Mary was fully informed about
implications of her decision.
Had Mary not met with her physician prior to
moving into Residential Care, the admitting
nurse would ensure that an Advanced
Directives discussion occurred.
Beneficence and non-Maleficence
 Beneficence means that we seek only to
give care that promotes the well-being of
residents.
 Non-maleficence means that we refuse to
perform actions that bring harm to a
resident.
 Can you think of examples of care where
these two principles may come into conflict?
 Can you think of examples where these
principles might come into conflict with the
concept of autonomy?
Meet Barry …
Barry moved into Independent Living five years
ago. His friends and neighbors say that Barry is
just ‘not the same’ in the last few weeks and
they are concerned. Barry has always been a
somewhat reclusive but tidy bachelor and has
no family. However, Barry could always be seen
on his daily walks through the garden. Now
Barry appears disheveled, disoriented, and pale.
When the nurse went in to check on him, the
fridge was standing open and empty. Barry
appeared quite ill.
Barry’s story continued ...
Barry refused to go to the hospital.
“It’s just my heart,” Barry says to the nurse.
“I just want it over—no hospital for me.”
What does the nurse do?
What ethical concepts apply?
Autonomy
 Informed Consent

Although Barry must be respected as an
person and considered to be competent
and able to direct care, the nurse considers
whether or not Barry understands his
situation ...
What ethical concepts apply?
Beneficence
 Non-Maleficence

When is the nurse acting to promote the
wellbeing of Barry and when is the nurse’s action
reducing the risk of harm to him?
... Let’s consider another principle that may help
us help Barry ...
Veracity (Truth telling)
 Veracity means that we are
transparent in our actions and honest
in our intent and our words. It is to be
truthful in word and deed!
 There are times when veracity and
other ethical principles can conflict.
For example, consider that some
cultures prefer not to be told about
terminal conditions.
 But for now, consider how veracity
and informed consent might clash in
Barry’s case?
About Barry …
The nurse understands that there may be a
treatable underlying cause to Barry’s change in
demeanor. The nurse discusses with Barry the
possibilities of what might be causing his current
distress. This is veracity in action and helps Barry
make an informed decision and act
autonomously.
Barry agrees to be seen by his physician.
Barry is treated for a urinary tract infection, returns
home, and is soon back into his regular routine.
Pop Quiz!
Which of the following statements are true?
Which are false?
 By practicing veracity, the nurse gave
Barry the opportunity to make the best
choice for himself.
 By practicing veracity, the nurse was giving
care that promoted beneficence for Barry.
 By practicing veracity, the nurse was giving
care that promoted non-maleficense.
Pop Quiz Answer Sheet!
The true statements are in green; the false
statements are in red. Please review the previous
slides if you are unsure of the correct responses.
 By practicing veracity, the nurse gave Barry
the opportunity to make the best choice for
himself.
 By practicing veracity, the nurse was giving
care that promoted beneficence for Barry.
 By practicing veracity, the nurse was giving
care that promoted non-maleficense.
Justice, Vulnerability and Fidelity
 Justice means that we fairly and equally
distribute our time and resources to all
residents, regardless of perceived ‘social
worth’ or pleasing personality.
 Some groups of patients and residents are
deemed to be more vulnerable than others
because they may need consideration to
ensure they truly are receiving equitable care
and resources.
 Fidelity involves a covenant, or promise to
care for our residents. It speaks to being loyal,
trustworthy, and advocating for residents
when they cannot be heard.
Confidentiality
 Confidentiality is the promise held between
the professional care giver and resident that
communications will ‘stay in the room’ and that
the resident’s personal concerns will not
become small talk and gossip.
 Confidentiality can come into conflict with
the principles of beneficence and nonmaleficence. For example, if a resident were to
tell a care giver that they were going to harm
themselves or another, keeping confidentiality
would result in harm to the resident or
another person.
Revisiting Mary and Barry …
Residents like Mary and Barry in their most
vulnerable states want respect and to have their
voices heard. They also want caregivers who act
fairly and in their best interest by providing
information so that they can collaborate in
decision making.
This means that a professional caring relationship is
founded upon the ethics of veracity and fidelity and
that the resident can rely upon safe communication
that is confidential and care that is competent.
Ethical issues can be complex



If you are thinking that Mary and Barry
were difficult cases you are right!
In the examples of Mary and Barry, you can
see that ethical issues can be complex.
Often ethical issues are difficult to
describe:
◦ You may only sense that something is ‘not right’
◦ Issues of moral distress will be discussed later in
this module
Ethical issues in practice

Some ethical issues are easier to see, such
as demeaning or belittling residents verbally
or by acting badly or ignoring residents. For
example:
◦ Using ‘elder speak’ (speaking to elders as if they
are babies or small children)
◦ Ignoring personality differences and choices,
such as when seating residents at tables or
including/excluding them in certain activities or
responding to choices in music, TV shows,
movies
Ethical issues and the law

Other ethical issues are considered elder
abuse, such as
◦ Bullying or threatening residents
◦ Physical, verbal, financial, or sexual abuse
◦ Neglect
Elder abuse results in acts that are illegal,
such as assault, theft, etc.
 Elder abuse must be reported to your
Director of Care who will follow Fraser
Health procedures and protocols.

What will you do?

Steps for Elim direct care staff:
1. Speak with the Director of Care for any ethical
issue.
2. Your Director of Care will work with you and
your team to resolve practice issues involving
ethical issues.
3. If the ethical issue cannot be resolved at the
unit level, the Director of Care will initiate the
Elim Village Ethics Committee
4. The Elim Village Ethics Committee meets and
reviews the ethical issue and may call in outside
experts as needed. Involved staff may be invited
to participate in the process.
Elim Ethical Issues Guideline
The Elim Ethical Issues Guideline directs
staff to practice with ethical integrity
 The Ethical Issues Guideline provides
steps to take if an ethical issue is
identified

ELIM VILLAGE
STANDARDS and CRITERIA
TOPIC:
ETHICS
DEPARTMENT:
Administration
APPROVED BY:
Executive Director
DATE:
June 26, 2014 by the Elim Ethics Committee
LAST REVIEWED DATE*:
June 2014
* see Table of Contents for last reviewed date
1.0
Purpose:
To provide direct care staff with a framework of how ethical issues are addressed at Elim Village.
2.0
Standard:
Elim Village shall have a process to help facilitate discussion and decision-making related to ethical
issues in residential, assisted living, and community care.
3.0
Key Functions:
3.1
3.2
3.3
3.4
3.5
To provide supportive direction from the Elim Ethics Committee to direct care staff
To provide a process for staff to obtain support, education and communication on ways to deal
with ethical issues and moral distress
To promote an awareness of ethical issues in older adult care
To provide orientation and continuing education with resource material on ethics and ethical
decision-making
To provide a process whereby direct care staff with ethical concerns can share their concerns
with the Elim Ethics Committee.
Note: The Elim Ethics Committee does not make decisions regarding family matters, but offers
education, support and recommendations to staff on ways to deal with specific ethical issues. Any
decision about care, treatment, or personal rights rests with the resident, their legal representative, and
the interdisciplinary professional care team.
4.0
Definitions:
Ethics: “Branch of philosophy dealing with values relating to human conduct, with respect to the
rightness and wrongness of certain actions and to the goodness and badness of the motives and ends
of such action” (dictionary.com).
Biomedical ethics: “A discipline dealing with the ethical implications of biological research and
applications especially in medicine” (Merriam-webster.com).
Moral Distress: “is the psychological disequilibrium that occurs when a person believes he or she
knows the right course of action to take, but cannot carry out that action because of some obstacle,
such as institutional constraints or lack of power” http://www.azbioethicsnetwork.org/education/definitions/
5.0
Procedure:
Conflicts in Care!

In complex situations, like Mary and Barry,
you can see that ethical principles can come
into conflict:
◦ Even when all professional care givers are
practicing ethically
◦ Even when all professional care givers have the
best interest of the resident at heart
 Ethical
dilemmas can cause moral distress
for all involved: residents, family members,
staff, and administrators.
Outcome: Describe what is meant by moral distress
MORAL DISTRESS …
AN UNCOMFORTABLE PLACE TO BE
What is moral distress?
 ‘moral distress’ describes the feeling when as
care givers we feel helpless to do the right
thing because:
 Every action seems to result in a conflict in ethical principles
 There are barriers to us doing the right thing (barriers can
be other staff, agency policy, lack of resources, family
members, or the resident themselves)
 The cost of doing the right thing seems insurmountable (will
it cost us our job? Our license? Our credibility? Our core
belief?)

In some circumstances, our own personal
competing values make us uncertain about
what is truly ‘right’ … or we may question
whether or not this is really ‘an issue’ or ‘just
me’ …
Situations causing moral distress
A resident is nearing death and experiencing restlessness
and appears to be uncomfortable.The family wants their
loved one to be ‘with them’ to the end and is morally
opposed to the use of medications.
 You believe that a care protocol on your floor is resulting
in practice that is demeaning and disrespectful to
residents.
 A resident’s family asks you to carry on with life
prolonging interventions for a resident who has told you
that she is ‘ready to go.’
 A resident often appears emotionally distressed and
withdrawn and routinely becomes very upset during
morning care.You suspect she might be in pain but others
insist, ‘that’s just the way she always is.’You feel bad
continuing a plan of care that is not working for this
resident but don’t know what else to do.

Responding to moral distress

Reacting the four A way!
 Ask
 Affirm
 Assess
 Act
ASK!
The first ‘A’ is Ask

Ask yourself:

“Am I feeling distressed or showing
signs of suffering? Is the source of
the distress work-related? Am I
observing symptoms of distress in
others I work with?”
Your goal in the first ‘A’ is to
become aware that moral
distress is present.
AFFIRM!
The second ‘A’ is Affirm

Affirm your distress:
Validate your feelings and
perceptions with an experienced
care giver you trust.
 Affirm your professional obligation
to move to the next step.
Your goal in the second ‘A’ is to
make a commitment to address
your moral distress.

ASSESS!
The third ‘A’ is Assess

Identify sources of your distress:
◦ Personal and internal (my values)
◦ Environmental (external considerations)

Determine the severity of your distress
and who needs to become involved in
your personal assessment process:
◦ Personal or Pastoral Counselor
◦ Unit staff and team leader
◦ Director of Care
Your goal in the third ‘A’ is to prepare to
make a plan of action as you collect the
appropriate team to support you.
ACT!
The fourth ‘A’ is Act

Personally and professionally prepare for
action:
◦ Action may be to pursue counseling and personal support
options
◦ Action may be to initiate a change with the team you’ve
gathered in your Assess phase
◦ Action may be to take this issue to the next level following
the Elim Step by Step Ethical Response Plan

If these people are not yet on your team,
now is the time to meet with the:
◦ Unit team leader and RN
◦ Director of Care
Your goal in the fourth ‘A’ is to move ahead with
a plan of action with the appropriate team to
support you.
Outcome: Identifying ethical issues
FOLLOW THE CLUES
What if I’m still unsure …
Is this really an ethical issue or is it ‘just me’?
Wondering if we are all alone in this is one of the
biggest causes of distress! Don’t let it stop you cold!
The four A plan will help you sort this out safely—
with a supportive team.
 If you are feeling distress, there is an issue—follow
the A plan!
 Some clues to distress are:
◦ Emotional (depressed, cynical, feeling overwhelmed, grief,


confusion, fear, hurt)
◦ Physical (fatigue, headaches, weight changes, lethargy,
impaired sleep and memory)
◦ Behavioral (the need to be ‘right’, sarcasm, apathy, victimbehavior, blaming others, powerlessness)
◦ Spiritual (loss of meaning, crisis of faith, loss of selfworth, disconnection with others)
What if I’m still unsure …
Is it ‘safe’ to include certain people on my
‘assessment and support’ team? What if they
are part of the problem?
 If you believe that certain staff or team
leaders are part of the issue or will be
unsupportive of you go to the next level.
Don’t let moral distress stop you in your
tracks!

Moral courage trumps moral distress



Moral courage is seen in individuals who, when they
uncover an ethical dilemma, explore a course of
action based on their ethical values, and follow
through with a decision as to the right course of
action regardless of the possible consequences this
course of action might present.
Moral courage generally occurs when individuals
with high ethical standards face acute or recurring
pressures to act in a way that conflicts with their
values (Clancy, 2003; Miller, 2005).
Moral courage requires a continuous commitment
to, and reflection upon personal values and moral
behaviors that influence ethical decision making
(Clancy, 2003; Kidder, 2005).
Outcome: Navigating the Elim Ethical Issues Guideline
STEP BY STEP …
Elim Ethical Issues Guideline
The Elim Ethical Issues Guideline directs
care staff to practice with ethical integrity
 The Ethical Issues Guideline provides
steps to take if an ethical issue is
identified

ELIM VILLAGE
STANDARDS and CRITERIA
TOPIC:
ETHICS
DEPARTMENT:
Administration
APPROVED BY:
Executive Director
DATE:
June 26, 2014 by the Elim Ethics Committee
LAST REVIEWED DATE*:
June 2014
* see Table of Contents for last reviewed date
1.0
Purpose:
To provide direct care staff with a framework of how ethical issues are addressed at Elim Village.
2.0
Standard:
Elim Village shall have a process to help facilitate discussion and decision-making related to ethical
issues in residential, assisted living, and community care.
3.0
Key Functions:
3.1
3.2
3.3
3.4
3.5
To provide supportive direction from the Elim Ethics Committee to direct care staff
To provide a process for staff to obtain support, education and communication on ways to deal
with ethical issues and moral distress
To promote an awareness of ethical issues in older adult care
To provide orientation and continuing education with resource material on ethics and ethical
decision-making
To provide a process whereby direct care staff with ethical concerns can share their concerns
with the Elim Ethics Committee.
Note: The Elim Ethics Committee does not make decisions regarding family matters, but offers
education, support and recommendations to staff on ways to deal with specific ethical issues. Any
decision about care, treatment, or personal rights rests with the resident, their legal representative, and
the interdisciplinary professional care team.
4.0
Definitions:
Ethics: “Branch of philosophy dealing with values relating to human conduct, with respect to the
rightness and wrongness of certain actions and to the goodness and badness of the motives and ends
of such action” (dictionary.com).
Biomedical ethics: “A discipline dealing with the ethical implications of biological research and
applications especially in medicine” (Merriam-webster.com).
Moral Distress: “is the psychological disequilibrium that occurs when a person believes he or she
knows the right course of action to take, but cannot carry out that action because of some obstacle,
such as institutional constraints or lack of power” http://www.azbioethicsnetwork.org/education/definitions/
5.0
Procedure:
Elim Ethical Issues Guideline cont

Steps for staff:
1. If you are experiencing moral distress you are
encouraged to go directly to your Director of Care.
2. Your Director of Care will guide you through the
Four A process (Ask, Affirm, Assess, Act).
Alternatively, if you are more comfortable, you can go
through the Ask and Affirm steps with a trusted
friend before going to the Director of Care.
3. The Director of Care will work with you and your
team to help resolve the issue.
4. If the ethical issue cannot be resolved at the unit
level, the Director of Care will initiate the Elim Village
Ethics Committee
5. The Elim Village Ethics Committee meets and reviews
the ethical issue and may call in outside experts as
needed. Involved staff may be invited to participate in
the process.
Elim Ethical Issues Committee
The Elim Ethical Issues Committee uses the ethical
framework authored by Bashir Jiwani, ethicist and
Director of Ethics Services and Diversity Services for
Fraser Health:
The Clinical Ethics-Based Decision-Making Workup (Jiwani,

http://www.incorporatingethics.ca/clinicians.php )


This framework directs the committee in an in-depth
analysis of facts and values to make the best decision
reflecting Elim’s ideals while seeking to understand
and advocate for the voice of the resident
The committee does not do its work in isolation, but
invites staff, family, and outside experts as needed
Post test
GET READY TO SHINE!
Which of the following should be reported to the Director of Care:
1.
a)
b)
c)
d)
e)
True or False. ‘Elder speak,’ or speaking ‘baby talk’ to older adults is
not respectful communication.
Elim direct care staff are required to:
2.
3.
a)
b)
c)
d)
e)
4.
5.
Suspected Elder Abuse by a family member
Suspected Elder Abuse by a staff member
An ethical situation causing moral distress
Any ethical issue, potential elder abuse, or any situation causing moral
distress
All of the above
Be familiar with the Elim Ethical Issues Guideline
Be familiar with the steps to take if an ethical issue is encountered in
practice at Elim
Immediately confront a family member or staff person suspected of elder
abuse
Give care that is respectful, promotes dignity and autonomy
A, B, and D
True or False. The feelings associated with moral distress may signal
that you are experiencing an ethical issue.
True or False. The 4-A response to moral distress (Ask, Affirm,
Assess, Act) is a supportive way to address ethical concerns.
Post test answers are in green
Which of the following should be reported to the Director of Care:
1.
a)
b)
c)
d)
e)
True or False. ‘Elder speak,’ or speaking ‘baby talk’ to older adults is
not respectful communication.
Elim direct care staff are required to:
2.
3.
a)
b)
c)
d)
e)
4.
5.
Suspected Elder Abuse by a family member
Suspected Elder Abuse by a staff member
An ethical situation causing moral distress
Any ethical issue, potential elder abuse, or any situation causing moral
distress
All of the above
Be familiar with the Elim Ethical Issues Guideline
Be familiar with the steps to take if an ethical issue is encountered in
practice at Elim
Immediately confront a family member or staff person suspected of
elder abuse
Give care that is respectful, promotes dignity and autonomy
A, B, and D
True or False. The feelings associated with moral distress may
signal that you are experiencing an ethical issue.
True or False. The 4-A response to moral distress (Ask, Affirm,
Assess, Act) is a supportive way to address ethical concerns.
Resources and References








http://www.cna-aiic.ca/en/improve-your-workplace/nursing-ethics/
http://www.nursingethics.ca/
http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_D
istress.pdf
http://nursingworld.org/MainMenuCategories/EthicsStandards/Courageand-Distress
Jiwani, B. (n.d.) Clinical ethics-based decision-making workup. Retrieved
from http://www.incorporatingethics.ca/clinicians.php
Jiwani, B. (n.d.) Leading with integrity. Retrieved from
http://www.incorporatingethics.ca/leadership.php
Murray, J. S. (Sept 30, 2010) Moral courage in healthcare: Acting ethically
even in the presence of risk. OJIN:The Online Journal of Issues in Nursing
15(3), Manuscript 2
LaSala, C. A. (2010) Creating workplace environments that support
moral courage. OJIN:The Online Journal of Issues in Nursing 15(3).
Retrieved from http://www.medscape.com/viewarticle/737896