Runing head: ETHICAL CASE STUDY 1

Ethical Case Study #1

Vivian Nnazoba

Patty Hanks Shelton School of Nursing

Dimensions of Professional Nursing/NURS3224-324

Brandi Rougeux BSN

November 28, 2013

Runing head: ETHICAL CASE STUDY 1

Abstract

Case study one describes an ethical situation many nurses have to face every day. This

paper discusses different ways a nurse could handle a certain situation and how her decision can

affect her, the doctor,the patient and their family. The nurses are stuck between what they are

ordered to do and what they think is right, which is the ethical dilemma. The ethical dilemma

will be defined and applied in the case study. Key terms will be explained and defined. This

paper will give several options the nurse could take, which will include the advantages and

disadvantages. Evidence was collected from several articles found on a school library database to

support the case. After discussing the best approach/decision to this situation, the writer will

explain the reasons why she felt the decision made was the best one . Ethical principles

determines how the nurse makes the right decision. Finally, the conclusion will provide key

elements of the paper and the true explanation of the ethical dilemma.

Ethical Case Study # 1

Case study #1 tells a scenario of Bill Z a 76 year old man, who was admitted to a

medical center, and had been diagnosed 6 months previously with metastatic cancer that spread

from his lungs to his liver, GI system and Bones. The chemotherapy and the oral narcotics he

was on had little effect and he was becoming more and more weak that he couldnt take care of

himself anymore, so he was admitted to the hospital. The doctor decided that further

chemotherapy is useless and ordered Mr. Z to be kept comfortable with medication. So a

continuous morphine sulfate IV was started to help control his pain. The facility standards for

care for bedridden patients required that they be turned from side to side every 2 hours. Mr. Z
Runing head: ETHICAL CASE STUDY 1

yelled everytime he was turned, because the pain was overbearing. A conference was called to

decide what should be done. The head nurse clearly states that it Is a rule at the facility that a

bedridden patient be turned every 2hours to prevent skin breakdown. Melanie F, a nurse for

15yrs disagreed with the head nurse, stating that causing more pain to a man that is obviously

terminally ill does not help him. Susan B, a new graduate felt that a patient should have some say

about his own care. Ellen R, who had worked on the unit for 2 years felt that the physician

should make the decision and all the nurses should follow the order. This spikes a major ethical

dilemma between what is ethically right/wrong vs following/obeying the rules.

Explanation of Ethical Principles

Ethical principles provides a foundation for nursing practices. Nurses who practice in

today's health care system soon realize that making ethical decisions is a common part of daily

nursing care(Catalano, 2012).. There are several principles that define ethics. Ethics are

declaration of what is right or wrong, what a nurse should do and how it can affect their patients.

Ethics exists on several levels, ranging from the individual as a small group to the society as a

whole (Catalano, 2012).

Autonomy

According to Catalano, autonomy refers to the "client's right to make health-care

decisions for himself or herself, even if the health-care provider does not agree with those

decisions" (Catalano, 2012). In case study one, the nurse has an ethical decision to make. she

could follow the rules that states every bedridden patient should be turned every 2 hours,

disregarding the fact that the patient is in serious pain and terminally ill or listen to Susan B, a

new graduate nurse and "let the patient have a say about his own care", which addresses
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autonomy "the right of self-determination" (catalano 2012). Ethical principles ARE basis for

nurses’ decisions but also consider consequences when making these decisions.

Justice

Justice is defined as “the obligation to be fair to all people” (Catalano, 2012). All the

nurses had their own opinions on how the patient should be cared for, but they also should listen

to the patient's thoughts as well, play fair. The last suggestion by the nurse showed an example of

injustice. Saying that the physician should just make the decision and everyone has to follow is

unfair. She did not take into consideration the patient's feelings or even think about how the

nurse that is taking care of the patient would feel about that decision.

Fidelity

Fidelity is “the obligation of an individual to be faithful to commitments made to self and

others” (Catalano, 2012). Nurses make a commitment to do no harm to their patients, to help

patients get better and care for them. The nurse should take into consideration the pain she will

put the patient through and make some type of compromise to turn the patient maybe every 4 hrs

instead of 2 to minimize pain and restore happiness/comfort to the patient.

Beneficence

Beneficence views the "primary goal of health care as doing good for clients under their

care. Good care requires that the health care provider take a holistic approach to the client

including the clients's beliefs, feelings and wishes.."(Catalano, 2012). The nurses should take Mr.

Z's feelings into consideration and minimize the turns, but not completely dismiss the rules of

turning him to spare him pain. The nurse not dismissing the rule of turning a bedridden patient

will decrease the risk of pressure ulcers, which addresses both the do no harm to patient while

taking a holistic approach to client, by including his feelings and wishes.

Runing head: ETHICAL CASE STUDY 1

Veracity

Veracity is” the principle of truthfulness. It requires the health care provider to tell the

truth and not intentionally deceive or mislead clients” (Catalano, 2012). After the decision is

made the nurses should be truthful to the patient. Tell him the decision and why they chose it.

Sometimes nurses can give false reassurance, or tell the patient something different just to shut

the patient up or spare the patient from worrying too much.

Nonmaleficence

Nonmaleficence is “ethical principle that requires the professional to do no harm to the

client” (Catalano, 2012). The nurse has to do what is best for the patient, following the rule of

turning the patient every 2 hrs causes pain to the patient, which IS doing harm to a patient. So the

nurse should come to some compromise to keep the patient from getting bed sores but at the

same time keep the patient comfortable so he wont be in severe pain

Paternalism

Paternalism is described as a "dominant attitude of one over another.... providers who

were expected to make the best decision for the patient" (Camden, 2009). Some of the nurses

who has been with the facility for a long time expressed their opinion, which was "we follow the

rule, let the physician make the decision, we follow his order". This type of ethical principle can

be tricky sometimes. Because some physicians decisions/orders aren’t always the right decision.

Analysis of Ethical Issues in Case Study #1

Ethical Dilemma

“Ethical dilemma may exist when there is a conflict between the rights and values of the

people involved in the situation” (Perrin &McGhee, 2008). The head nurse felt that they needed

to obey the rule of the facility and go ahead and continue turning Mr. Z, regardless of pain. The
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other nurses disagreed otherwise, Susan B, the graduate nurse felt that the patient should have a

say about his own care. This clinical decision is about freedom versus control. Does the patient

have the right to make choices for himself that may result in harm or can the nurse take control

and do what benefits both her and the patient? The principle approach is examining the ethical

dilemma which are either to put everything aside and come to some type of compromise with the

critically ill patient whether it be minimizing the turns or turning him when he is ready to restore

comfort/happiness but keeping in mind that the nurse will be held responsible, if the patient

develops bed sores which can worsen his condition. OR the nurse can follow the rule of the

facility and disregard the patient's wishes/pain and continue to turn him every 2 hours. Keep in

mind that McGhee says that "The principle approach is concerned with what benefits each

individual person rather than what brings the greatest good to the most”(McGhee, 2008). The

nurse must analyze how her decision will affect her patient, herself, the faculty and the patient's

family. In the article "Ethical decision making and professional behavior among nurses", the

author states that "Ethical decision making is a rational process involving cognitive activity;

however it also involves moral judgement and justification of the decision (Cerit & Dinc 2013).

The nurse should do what is best for the patient, because at the end of the day your patient comes

first, it is all about the patient's health and well being.

Aditional Data

Although ethical values and principles guide oncology nursing practice, nurses often are

challenged to fulfill every professional core duty and responsibility in their everyday practice.

Nurses commonly encounter clinical situations that have ethical conflicts and they often have

difficulty recognizing and articulating them (Cohen & Erickson, 2006). The nurse will have to

apply her ethical decision making skills to solve this dilemma. Cerit and Dinc suggests that
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"individuals progress through three levels in the ability to make moral judgments: (a) the pre-

conventional level, when moral decisions are based on rewards and punishments and obedience

to authority; (b) the conventional level, when individuals recognize societal laws and rules and

are concerned regarding collective welfare and (c) the post-conventional level, when moral

decisions re based on internalized moral values and abstract principles"(Cerit, Dinc, 2013). The

pre conventional level clearly states that moral decisions are based on REWARDS, punishment

and obedience to authority. The nurse should do what is best for the patient but at the same time

obeying the law, by still turning the patient as the rule says but at the same time minimizing the

patient's pain by minimizing how often he is turn which rewards the patient with great comfort.

Options

The nurse has several options with advantages and disadvantages. First advantage and

disadvantage being the nurse could put patient first and disregard the rule of the facility and not

turn the patient at all every 2 hours and restore comfort to the patient. The disadvantage being

she might lose her job because she disobeyed the rule. Another advantage and disadvantage is

the nurse can come to some type of compromise with the patient and minimize the turns, so at

the same time she is obeying the rule and preventing patient from having skin breakdown. A

Disadvantage of this option is the minimized turns did not prevent pressure ulcers, so with that

being said the patient develops a sore. Another option is the nurse could listen to the last nurse

that gave her opinion and let the physician decide what to do, which then takes the pressure of

the nurse and it is now in the physician's hands, but the disadvantage is the nurse then has a

guilty conscious because the physician's decision could have a bad consequence. The last

possible option is the nurse can do whatever she wants to do, disregarding the other nurses, the

patient, patient's family and physician and just do what She feels is best. Disadvantage of this
Runing head: ETHICAL CASE STUDY 1

option is her instinct or her judgment could be wrong causing the patient harm and lose her

license as a nurse in the process.

Decision

The nurse should take into consideration all the nurses opinions but still put the patient

first. Nurse should obey the rule of the facility by turning the patient as required but minimize

the turns and just monitor the patient more frequently to prevent skin breakdown but at the same

providing comfort to the critically ill patient.

Act

I would do what is best for the patient but at the same time keep in mind that i have a job

to do and I need to follow the rules and regulations. I would still turn the patient as required, but i

will minimize how often i turn the patient, monitor the patient closely to prevent skin breakdown

or worsening of his condition while still providing great comfort for the patient.

Evaluate

I made this decision because this choice will prevent harm to the patient, provide comfort

for the patient but at the same time it still falls into the rule of turning a bedridden patient.

Conclusion

In conclusion, nurses face ethical dilemmas every day regardless of where they practice.

They are faced with ethical decision that can affect them and their patients. It is important that

nurses know how to manage those decisions so that client's ethical rights are honored without

dismissing the nurse's own morals and conscience. We try to base our practices on ethical

principle but there will be times when we question our decisions, whether it is the right one or

not, but we have to keep in mind that the patient comes first. The goal is to not cause harm to the

patient and do what is best/beneficial for the patient. Difficult decisions are faced on a daily
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basis. By standing by our morals and knowing what nursing ethics are while keeping in mind the

consequences that comes with it, we will have a better understanding on how to make tough

decisions and change in the process.

References

Camden, susan gallagher. (2009). "Ethical realities of bariatric nursing: a case study approach to

real-world dilemmas...". Beriatric Nursing and surgical patient care. vol. 4 issue 3, p. 185.

Catalano, Joseph , T. (2012). Nursing Now! TODAY’S ISSUES, TOMORROW’S TRENDs.

Philadelphia: F.A. Davis Company.

Cerit, B., & Dinç, L. (2013). Ethical decision-making and professional behavior among nurses:

A correlational study. Nursing Ethics, 20(2), 200-212. Doi: 10.1177/0969733012455562

Cohen, jeryl S, Erickson, Jeanne M. "Ethical dilemmas and moral distress in oncology nursing

practice". Clinical journal of Oncology Nursing. Dec 2006. Vol, 10 issues 6. p 775-782.

Perrin, Ouimet Kathleen (2008). Ethics and Conflic: SECOND EDITTION. Canada: Jones and

Barlett Publishers.
Runing head: ETHICAL CASE STUDY 1

Patty Hanks Shelton School of Nursing

Bachelor of Science in Nursing Program
NURS 324/33224 – Dimensions of Professional Nursing
Grading Rubric for Ethics Paper
Summer 2013

Student Name:_________________________________________________

Criterion Possible Earned Comments

Points Points
INTRODUCTION 5
EXPLANATION OF ETHICAL 35
PRINCIPLES
• Autonomy (5)
• Justice (5)
• Fidelity (5)
• Beneficence (5)
• Veracity (5)
• Nonmaleficence (5)
• Paternalism (5)
ANALYSIS OF ETHICAL ISSUES 35
IN SELECTED CASE STUDY (
Table 5-2, p. 133)
• Clarify the Ethical Dilemma (5)
• Gather additional data (5)
• Identify at least 4 options
including the advantages and
disadvantages of each option
(10)
• Make a decision (5)
• Act (5)
Runing head: ETHICAL CASE STUDY 1

• Evaluate (5)
CONCLUSION 10
APA FORMAT 10
5 References 5
TOTALS 100

Faculty:___________________________ Date:___________________