The Central Competency of

Advanced Practice Nursing

Direct Clinical Practice: The Central
Competency of Advanced Practice
Nursing
Outline of Discussion

• Direct care versus Indirect care

• Six characteristics of direct care

practice of APNs
Direct care versus Indirect care
• Direct care and direct clinical
practice refer to the activities and
functions APNs perform within the
patient-nurse interface (Brown,
2005).
• Depending on the focus of an APN’
practice, the patient may, and often
does, include family
members/significant others.
Indirect Care Activities
• Advanced practice nursing activities
occurring before or adjacent to the
patient-nurse interface have a great
influence on the direct care that
occurs in the interface; either they
are not performed with an individual
patient or their main purpose is
tangential to the direct care of the
patients.
• Direct care is the central competency of
advanced practice nursing regardless of the
specific role of CNS, NP, CRNA, or CNM.
• To consult, collaborate, and lead clinical
staff and program effectively, an APN must
have clinical credibility.
• With deep clinical and systems
understanding that APNs possess, they
facilitate the care processes that ensure
achievement outcomes for individuals and
group of patients
 Examples of APN indirect care
activities
• Consultation with other health care
providers (physician, nurses, pharmacists)
• Writing prescriptions and orders
• Care coordination
• Communication with managed care and
insurance organizations
• Guidance of bedside nurse
• Unit rounds
 Six characteristics of direct
clinical are practice of APNs
• Use of a holistic perspective
• Formation of therapeutic partnerships
with patients
• Expert clinical thinking and skillful
performance
• Use of reflective practice
• Use of evidence as guide practice
• Use of diverse approaches to health
and illness management
1. Use of a holistic
perspective
THE HOLISTIC VIEW
 Holistic health
• “Health is a state of complete
physical, mental, and social well-
being and not merely the absence
of disease or infirmity.” (WHO)
• Holistic health views the physical,
intellectual, sociocultural,
psychological, and spiritual aspects
of a person’s life as an integrated
whole.
• A holistic health approach doesn't view
the body, mind and spirit as separate
entities and promotes drugs and
surgery only when absolutely essential
and after other solutions have been
sought.

• It looks for the underlying causes of

symptoms, rather than just covering up
the symptoms with a drug.
• Treatment approaches are highly
individualized for the unique needs
of each individual and the patient
and their practitioner make
decisions together as partners to
develop the health care plan.
• Being healthy does not necessarily
mean the absence of disease or
illness. It is about living as
completely and optimally as
possible with the hand you have
been dealt and the limits that you
face, while at the same time
pursuing options that will deal you
a better hand.
 HOLISTIC CARE
• National Institutes of Health
defines this as care that “considers
the whole person, including
physical, mental, emotional, and
spiritual aspects.”
• The nurse helps the client in
attaining the best state for healing
to occur.
Use of a Holistic Perspective
• Take into account the complexity of human life
• Recognize and address how social,
organizational, and physical environments
affect people.
• Consider the profound effects of illness, aging,
hospitalization, and stress
• Consider how symptoms, illness, and
treatment affect quality of life.
• Focus on functional abilities and requirements
2. Formation of therapeutic
partnerships with patients
Strategies for enacting
• Encouraging the patient to actively
participate in decision making.
• Look for potential cultural influences
on health care discourse
• Listen to the direct voices of patients
who are non-communicative
• Advocate the patient’s perspective
and concerns to others
Patient populations unable to
participate fully in partnership
• Infants and preverbal children
• Anesthetized patients
• Unconscious/comatose patients
• People with dementia
• People with congenital or acquired
cognitive limitations
• People whose primary language is
different from the provider’s
• Etc.
3. Expert clinical thinking
and skillful performance
• Knowledge
• Critical thinking
• Direct care and information
management
• Ethical reasoning
• Skillful performance
• Three main categories of knowledge
based for clinical judgment
• APNs’ specialize knowledge accrues
from: graduate and continuing education,
clinical experience, professional reading,
reflection, mentoring, and exchange
information and ideas with colleagues
within and outside nursing
4. Use of reflective practice
 Reflective Practice
• To continually grow and develop,
APNs must be reflective practitioners.
• Reflective practice is a way to take
the experiences a practitioner has
(positive or negative) and explore
them for the purpose of clarifying
meaning, critically analyzing, and
synthesizing and using learning to
improve practice (Atkins & Murphy,
1995).
• The goal is to turn experience into
personal knowledge by seeking
insights that are not available
with superficial recall.
• Can be done in a number of ways:
– self evaluation with a supervisor or
teacher, in a small group of
supportive colleagues.
5. Use of evidence as
guide practice
Research-based practice
• Is a more systematic, rigorous, and
precise way of translating research
findings into practice.
• Is used within an organization to design a
standard of care for a population of
patients
• May take to form of a clinical practice
guideline, a decision algorithm, a clinical
protocol, the component of a clinical
program, or change in policies or
procedures
• Evidence-based practice
• Theory-based practice
 6. Use of diverse
approaches to health and
illness management
• Use of interpersonal interventions to
influence patients
– Providing reassurance,
– Giving information, providing anticipatory
guidance
– Coaching,
– Guiding decision making
• Acquire proficiency in new ways of treating
and helping patients
– Telehealth, information technology
• Help patients maintain health and
capitalize on their strengths and
resources
• Provide preventive services
appropriate to your field of practice
– Preventive services in hospital and
home care
• Know what is allowed under managed
care contacts
• Negotiate with managed care managers
for non-covered services when
necessary
• Coordinate services among care sites
and multiple providers
• Acquire knowledge about
complementary and alternative
therapies
• A treatment approach can be
complimentary, alternative or
natural without necessarily being
holistic. However, most holistic
approaches are considered to be
complimentary, alternative or
natural.
SOME HOLISTIC MODALITIES
• Biofeedback • Journaling
• Exercise and • Massage
movement • Play therapy
• Goal-setting • Prayer
• Therapeutic touch
• Humor and
laughter • Meditation

• Imagery
SIX CORE COMPETENCIES
of Advanced Practice
Nursing
I.Expert Coaching and
Guidance: An APN Role
Competency
Vu Van Dau, RN, PhD,
 Outline of Discussion

• Definition of Coaching
• Coaching in Nursing and Health Care
• APN Coaching
• Coaching Process/Model
Definitions of Coaching
• The word coach is derived from the Middle
English word coche, meaning “wagons or
carriage”, a means of conveyance from one
destination to another.
• Modern used of coach to mean a teacher is apt:
a coach facilitates the safe passage of a person
in transition from one situation to another.
• Can be applied to nurse-patient, faculty-student,
preceptor-student, and mentor-protégé
relationship.
• Patient education is a central and well-
documented function of all nurses in any
setting, and evidence of its effectiveness is
well-established.
• Patient education provided by APNs is
best conceptualized as interpersonal
processes of expert coaching and
guidance through life transitions such as
illness, childbearing, and bereavement.
• Vale et al. (2002):
– Coaching as a method of training patients to
take responsibility for the achievement and
maintenance of target levels of their modifiable
risk factors. Developed “Coaching Cycle”
• Dowd et al (2003):
– “a supportive actions taken by health
professionals that empowers patient to
participate in the achievement of mutually
identified goals.
• Spross and colleagues (Clarke & Spross,
1996 in Hamric, Spross, & Hanson, 1996)
– Develop a model of coaching
– Is a complex, dynamic, collaborative, and
holistic interpersonal process that is mediated
by the APN-patient relationship and the APN’s
self-reflection skills
Expert Coaching and Guidance
• Traditional strategies for motivating patient
behavior change that rely on education
and persuasion, or even coercion, have
not been the most effective.
• Coaching is an successful strategy in
motivating people toward personal and
professional goal.
• Coaching is an NP strategy for improving
patient health outcomes.
• Coaching is an NP educational
competency mandate by the National
Organization of Nurse Practitioner
Faculties.
 Coaching in Nursing
• Nurse-Nurse coaching:
– Nurse career coaches
– Coach leaders
– Executive coaches
– Peer coaches
to assist other nurses to improve their
effectiveness, transition to new work
environments, or manage career development in
hospitals, clinic, and other health care venues.
• Nurse-patient/family coaching
– An approach to patient care (interventions).
• An approach to patient care.
– eg.,Whittermore et al. (2004) proposed the
adaptation model of Diabetes Model as a
framework for guiding nurse-coaching
interventions for helping patients to integrated
diabetes care into their lives.
 Steps in the Coaching Process
• Step1: Goal Definition
– Definition of coaching goals.
• Step 2: Analysis
– What is the present situation?
• Step 3 Exploration
– What are the different options aimed at obtaining the
goal?
• Step 4 Action
– Moving forward; identify and commit to a course of
action.
• Step 5 Learning:
– Implementation of the agreed-on actions
• Step 6 Feedback: What has been learned?
6. Recognizes that people are whole and
resourceful, free to make choices, yet
they are accountable for the
consequences
7. Recognizes the unique understanding
and experience of the client: The client is
the expert of this or her own situation
 The Coaching Model
Vale et al. (2002)

Asking questions for

knowledge, attitude,
belief

Reassessment Explanation
and rational

Goal setting Assertiveness

training
 The APN Coaching Model
Spross (1996)
• Coaching Assessment:
– To establish and build a relationship
– To collect data
• Coaching process:
– Coaching process by APNs focus on fostering
involvement, choice, and independence.
• Coaching outcome
– Primary focus or target
– The APN coach does not set goals for patient or
coerce. The patient sets his or her own goals, and the
APN’s role is to support, encourage, cheer the
patient, and celebrate success.
 APN Expert Coaching and Guidance of
Patients, Families, and Team

Self-Reflection

Technical Clinical Interpersonal

Competence Competence Competence
- APN education - Education - Active listening
- Special Knowledge & skills - Holistic perspective - Empathy
- License & certification - Clinical exp.& - Communication
-Experience decision making skills

The coaching competency of an APN

Expert Coaching and Guidance: Selected Issues

• Opportunities and initiative that are worthy

of APNs’
– Helping patients manage chronic illness
– Health literacy
– Telehealth and coaching
– Coaching “difficult” patients
 II-Consultation: a
Core
Competency of APNs
Vu Van Dau, RN, PhD
• Consultation is an important aspect of
advanced practice nursing.
• Consultation is part of every APN’s
practice.
• The complexities of today’s health care
setting require that all APNs offer and
receive consultation.
 What are the value of
consultation?
• Increasing practice knowledge and skill
• Improving the quality, depth, and
comprehensiveness of nursing for patients and
families.
• Promote collegiality and team work and
collaborative relationships
• Fostering professional development
• Offers APNs the opportunity to influence health-
care outcome beyond the direct patient care.
 Defining Consultation
• Consultation is an interaction between two
professionals in which the consultant is
recognized as having specialized
expertise (Caplan, 1970; Caplan &
Caplan, 1993).
• The consultee requests the assistance of
that expert in handling a problem that he
or she recognizes as falling within the
expertise of the consultant.
• Goals of consultation
– To enhance patient care and/or improve skills
and confidence of consultee
• Focus
– Consultant may or may not see patient
directly
– Degree of focus on consultee’s skill is
negotiated with consultee
• Responsibility for clinical outcomes
– Remains with consultee, who is free to accept
or reject the advice of consultant
 Distinguishing Consultation from
Co-management, Collaboration, and
Referral
• Co-management takes place
between professionals who consider
themselves part of the same
interdisciplinary team.
• Referral often results in the APN
relinquishing responsibility for care (or
aspects of care), temporarily or
permanently.
• Collaboration is a specific advanced
practice nursing competency.
 Distinguishing Consultation from
Clinical and Administrative Supervision

• Clinical supervision:
• Administrative • Relationship
Supervision • Interaction
• Supervisor & • Goal
Supervisee
• Consultant &
Consultee
 Four Types of Consultation
• Client-centered case consultation:
– The goal is assisting the consultee to develop an
effective plan of care for a patient who has a
particularly difficulty or complex problem.
• Consultee-centered case consultation:
– Focused directly on the consultee’s problem in
handling the situation.
– The goal is to assist the consultee to overcome the
deficits involved (e.g, lack of knowledge, skill,
confidence, or objectivity).
• Program-centered administrative
consultation:
– Focuses on the planning and administration of clinical
services.
• Consultee-centered administrative
consultation:
– Focuses on the consultee’s (or group of consultees’)
difficulties as they interfere with the organization’s
objectives.
 The Nature of Advanced Practice
Nursing Consultation
• APN-APN Consultation
– A primary care nurse practitioner (NP) caring
for an adolescent patient was concerned about
high risk sexual practices her patient reported.
– The NP felt the need foe additional expertise to
facilitate caring for this patient.
– The NP sought the consultation of a psychiatric
NP colleague with clinical and research
expertise in the area of adolescent health care.
• APN-Physician Consultation
– Physician in primary care often consult APNs
regarding issues as assisting patients in
making lifestyle change or in coping with the
effects of chronic illness.
– Etc.
• APN-Staff Nurse Consultation
– E.g., CNS has been consulted to assess the
suicidal risk and make recommendations for
the treatment of the patient.
 Principles of Consultation
• The problem is always identified by the
consultee.
• The relationship between the consultant and
the consultee is nonhierarchical and
collaborative.
• The professional responsibility for the patient
remains with the consultee.
• The consultee is free to accept or reject the
ideas and recommendations of the
consultant.
(Caplan, 1970; Caplan, & Caplan, 1993)
Principles Cont’
• The consultant always considers
contextual factors when responding to the
request for consultation.
• The consultant does not prescribe but
makes recommendations.
• The consultation should be documented.
 Caplan’s Consultation Model
• The consultation is recognized as having
specialized expertise.
• The consultee requests the assistance of
that expert in handling of a work-related
difficulty that he or she recognizes as
falling within the expertise of the
consultant.
Documentation and Legal
Considerations
• Documentation of the
consultation in the patient’s
record is appropriate and
important.
• Consultants should document all
consultations in their own
records.
• APNs should be cognizant of
legal issues in all areas of ANP,
including consultation.
• Reimbursement.
Thank You
III-Research Skills: A
Core Competency for
APNs
Vu Van Dau, RN, PhD
Outline of Discussion

• Research expectations of APNs

• The core APN research competency
Research expectations of
APNs
 The Need for APNs to be
Research-Competent
• Research skills are a core competency for APNs and are
central to an APN’s ability to fulfill his or her current and
future roles.
• The role of the APN is vital to any research endeavors
being organized within a health care setting because of
clinical and leadership expertise.
• The ability to translate knowledge and evidence into
practice and to role model research competencies is
crucial, and APNs are key to this activity, given their
knowledge of the patient population, peer health care
providers, and the organization.
 The Need (Cont’)

• International , National, and Local

Initiatives and Trends:
– Magnet hospital
– Quality and Safety Initiatives
– Information Technology and Telehealth
– Evidence-Based Practice
 Evidence-Based Practice
(Def.)
• “…the conscientious, explicit, and
judicious use of current best evidence in
making decisions about the care of
individual patients”. (Sackett, Rosenberg,
Gray, Haynes, & Richardson, 1996)
• “the integration of the best research
evidence with clinical expertise and patient
values to facilitate clinical decision
making.” (Sackett, Strauss, Richardson
Rosenberg, & Haynes, 2000)
Source: Sackett, D.L., Strauss, S.E., Richardson, W.S., Rosenberg, W.M.C., &
Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach
 The History
• In 1972, A.L. Cochrane, a British
epidemiologist, criticized the health
profession for not knowing the outcomes
of medical treatment.
• In the 1980s, the term evidence-based
medicine was being used at McMaster
University Medical School in Canada.
• These events led to the establishment of
the Cochrane Collaboration.
 The Evolution of EB Health
Care
Do things cheaper
(Efficiency)
Doing things Right

Doing the
right things
right

Doing things better Doing the right things

(Quality Imprv.) (Increasing
effectiveness)
 Role of Evidence in Clinical
Decision Making

Research Evidence develop Implement

findings synthesis clinical clinical Policy

Patients values, Clinical decision Patients

wishes and circumstances
expectations
Evidence-based practice is “doing
the right thing in the right way for
the right patient at the right time”
“As a clinician, by
2019, would you
want your former
students to care
for you using
evidence that
taught them in
2009?”
 EBP should be characterized
by the use of best practices
derived from rigorous research
science, combined with , and
balanced by, individual, patience
and client perspectives, and the
expertise of clinician (Enkin and
Jadad, 1988;Vakil, 2001).
APN Research Competency
and Levels
 Competency I

Interpretation and use of research and other

evidence in clinical decision making

• Fundamental Level • Expanded Level

– Incorporate EBP – Implement EBP
process into process beyond
individual practice. own practice- at
– Assist colleagues to unit, department,
incorporate EBP and/or organization
process into their level.
individual practice.
 The Evidence-Based Practice
Process
Step 1 Asking a clinical question
Step 2 Searching the literature for
relevant research
Step 3 Critically appraising what have
been found. If change is warranted by the
clinician skills, resource availability, and
patient preferences, then the following
stages also take place:
Step 4 Implementing the change in
practice
 Competency II
Evaluation of Practice

• Fundamental Level • Expanded Level

– Identify benchmarks – Design and
appropriate for own implement a process
practice advanced practice
– Design and nursing beyond the
implement a process scope of individual
to evaluate aspect of practice (group of
individual’s APNs, units,
advanced practice. program, clinic,
 Competency II:
Evaluation of Practice
• Component of the • Key Activities
Process
– Identify key aspects of • E.g., list major desired goals
practice of practice on the
organization
– Ensuring collection of • E.g., identify and establish
reliable and valid data data collection tools as
needed
– Determining if practice
changes are necessary • E.g., make recommendation
based on evaluation for change practice based
on the data.
 Competency III
Participation in Collaborative Research

• Fundamental Level • Expanded Level

– Function as a clinical – Function as an
expert/consultant in investigator or co-
a collaborative investigator in
knowledge- knowledge-
generating research generating research
project. project.
 Competency III:
Participation in Collaborative
Research
• Phase of the research • Selected activities
Thank you
Q&A
 IV-The APN Leadership
Competency: Clinical,
Professional, and System
Leadership
Vu Van Dau, RN, PhD,
 Outline of Discussion
• The need for APN leadership
• Definitions of Leadership
• Leadership Domains of APNs
• Defining Characteristics of the APN
Leadership Competency
 The need for APN leadership
• Health Care System Transformation
– Six quality aims: safety, effectiveness, patient-
centeredness, timelines efficacy, and equity
(Institute of Medicine, IOM)
• Redesign of Heath Professional
Education
– Interdisciplinary competencies
• Five competencies that all health professionals must
possess:
– Provide patient-centered care, work interdisciplinary
teams, employ EBP, apply quality improvement
principles, and utilize informatics
– APN competencies
 Definitions of Leadership

• Transformational leadership
– A process whereby “the purpose of the leader
and the follower become fused , creating
unity, wholeness and collective purpose”
(barker, 1994, p 83).
– Transformational leadership occurs when
people interacts in ways that inspire higher
levels of motivations and morality among
participants.
• Situational leadership
– The interaction between a individual’s
leadership style and the features of the
environment or situation in which he or she
is operating.
– Leadership styles are not fixed and may
based on the environment.
– Situational leadership depends on
particular circumstances which leaders and
followers assuming interchangeable roles
according to environment demands.
 Leadership Domains of APNs

• APNs exercise leadership in four key

domains:
– in clinical practice environment,
– in the nursing profession,
– at the system level,
– and in health policy arena.
• APNs may exercise leadership activities at
local, regional, and/or national levels.
 Clinical Leadership
• Clinical leadership focuses first on the patient
and his or her needs and ensuring that quality
patient care is achieved.
• APN leaders are role model and mentors who
empower patients and colleagues.
• Some clinical leadership skills are part of the
competencies of consultation and collaboration.
• Most common clinical leadership roles:
– Advocate (for patient, family, staff, or
colleague)
– Group leader (team leader, lead patient care
team)
– System leader (administrative leader at a
system level)
 Professional Leadership
• Mentorship, empowerment, and active
participation in organizations are
particularly important within the
professional domain.
• Professional leadership is also
exercised by participation in
professional organizations
– Novice APNs: Membership on a committee
of a local, national, interdisciplinary
organizations.
 System Leadership
• System leadership means leading at organizational or
delivery system level – a skill that requires a
mutlidimensional understanding of systems.
• APNs, whether in a line/supervisory position or not,
should have the authority to provide system leadership
related to delivery of clinical care by virtue of their
clinical credibility and specific APN job responsibilities.
• Entrepreneurial leadership refers to those leaders who
go outside of traditional employment systems to create
new opportunities to exercise their special abilities.
 Health Policy Leadership
• APNs should be aware of and must often
respond to local, state, and national
policymaking efforts likely to affect these laws
and regulations.
• To be a leader at the level of health policy
requires an ability to analyze health care system,
an understanding of the personal qualities that
are associated with effective leadership, and the
skill to use these understandings to act
strategically.
Defining Characteristics of the
APN Leadership Competency
 Defining Core Elements
Characteristics (Knowledge and Skills)
• Mentoring and • Share vision
empowerment • Seeks mentors and
serves as a mentor
• Willing to share
power
• Self-reflection
 Defining Core Elements
Characteristics (Knowledge and Skills)
• Innovation and • Knowledge of models of
change agency leadership and change
• System thinking
• Systems assessment skills
• Flexibility
• Risk taking
• Expect communication
 Defining Core Elements
Characteristics (Knowledge and Skills)
• Activism • Knowledge and
understanding of factors
driving change in the health
care system
• Involvement in policy
arenas, whether local,
regional, national, or global
• Advocacy for patients,
advance practice nurses,
and the nursing profession
• APNs are change specialists who operate
at the boundary between today’s health
care system and tomorrow’s.
• “From the bedside to the White House”
• “many small change contribute to a big
change” (Gladwell, 2000).
V-Collaboration

Vu Van Dau, RN, PhD,

Definition of Collaboration
• Dictionary:
– “to work together, especially in a joint
intellectual effort”
• Hanson & Spross:
– A dynamic , interpersonal process in which
two or more individuals make a commitment
to each other to interact authentically and
constructively to solve problems and to
learn from each other to accomplish
identified goals, purposes, or outcomes. The
individual recognize and articulate the
shared values that make this commitment
possible.
 Domains of Collaboration in
Advanced Practice Nursing
• APNs execute the collaboration
competency in several domains– between
or among individuals, work groups, and
organizations.
• The collaboration competency is often
executed at the same as other
competencies.
 Domain (Cont’)
• Collaboration with individuals
– Patients, other APNs
– The APN is also executing the direct care.
• Collaboration with teams/groups
– With clinical teams and on department and
institutional committee
– A key function of the collaborative competency is
the facilitation of team work to ensure the delivery
of effective, high-quality care.
 Domain (Cont’)
• Collaboration in the organizational
and policy arenas to individuals and
groups
– The focus of collaboration extends
beyond the delivery of care to
individuals and groups
• Collaboration in global arenas
– Global communication and collaboration
will be the keys to successful living,
working, and economics success over
the next century.
What is Not “Collaboration”
• Parallel communication :
– Providers interact with a patient
separately; they do not talk together
before seeing a patient, nor do they see
the patient together.
– E.g., RN, medical student, attending
physician all ask the patient about his or
her medications.
• Parallel functioning:
– Providers care for patients, addressing
the same clinical problem, but do not
engage in any join or collaborative
planning.
• Information exchange:
– But not a result of joining planning
• Coordination
– Such as charge nurse role.
• Consultation:
– The clinician who is caring for a patients seek
advice regarding a patient concern but retains
primary responsibility for care delivery.
• Co-management:
– Two or more clinicians provide care, and each
professional retains accountability and
responsibility for defined aspects of care.
• Referral:
– The APN directs the patient to a physician or
another practitioner for management of a
particular problem or aspect of the problem is
beyond the APN’s expertise
 Characteristics of Effective
Collaboration
• Common purpose
• Clinical competence and accountability
• Interpersonal competence and effective
communication, including assertiveness
• Humor
• Mutual respect
• Trust
• Valuing and respecting of diverse,
complementary knowledge and skill s
Thank you
VI-Ethical Decision Making : A
Competency of APNs

Vu Van Dau, RN, PhD,

• Change in professional roles,
advanced in medical technology,
availability of information online,
revisions in patient care delivery
system, and heightened economic
constraints have increased the
complexity of ethical issues in the
health care setting.
• Although all nurses are moral agents,
APNs are expected to be leaders in
resolving moral problems, working to
create ethical practice environments,
and promoting social justice in the
larger health care system.
• Ethics… from the Greek word ETHOS
Meaning custom or character

• Rules that govern “right” conduct

• What “ought” to be/the right thing to do
• The “should” of human behavior
• “An ethical or moral dilemma”
occurs when two or more morally
acceptable courses of action are
present and to choose one prevents
selecting another.
 Two type of moral problems in
nursing
• Moral uncertainty
– The nurse experiences unease and
questions the right course of action
• Moral distress
– Nurses believe they know the ethically
appropriate action but feel constrained
from carrying out that action because of
institutional obstacles such as lack of time
or supervisory support, physician power,
institutional policies, or legal constraints.
 Three themes of moral
problems
• Communication problems

• Multidisciplinary involvement
– Issues such as refusal of treatment,
end-of life decision making, cost
containment, confidentiality.
• Multiple commitments
– Balancing commitments to multiple
agents
 Characteristics of Ethical
Dilemmas in Nursing
1. End-of life decision
2. Breaches of patient confidentiality
3. Incompetent, illegal, of unethical practice
of colleagues
4. Pain management
5. Patient autonomy
6. Truth-telling
7. Health care resources
8. Informed consent for procedures
9. Etc…….
 Ethical Principles
• Respect for autonomy
– Respect others’ personal liberty and
individual values, beliefs and choices
• Nonmaleficence
– freedom from harm
• Beneficence
– Do good and prevent or remove harm
• Justice
– fairness and equity
• Veracity
– Tell the truth and not to deceive others
• Confidentiality
– Not to disclose information shared in an
intimate and trusted manner
• Privacy
– Respect limited access to a person
Ethical Decision Making Process
1. Perceptions of the problem
2. Identification of ethical
components
3. Clarification of the persons
involved
4. Exploration of Options
5. Application of ethical
theories/approaches
6. Resolution/Evaluation
(Curtin, 1979)
• APNs play an important role in
decreasing the incidence of both
moral uncertainty and moral
distress among nursing staff
through education, empowerment,
and problem solving.
 Phases of Development of Core
Competency for Ethical Decision Making
• Phase 1:
– Knowledge development—Moral
sensitivity
– Knowledge: Ethical theories,
Ethical issues in specialty,
Professional code,
Professional standards,
Legal precedent,
Moral distress
• Phase 2:
– Knowledge application—Moral action
– Knowledge: Ethical decision
frameworks,
Mediation/facilitation
strategies
• Phase 3:
– Creating an ethical environment
– Knowledge: Preventive ethics,
Awareness of environment
barriers to ethic practice
• Phase 4:
– Promoting social justice within the
health care system
– Knowledge: Concept of justice,
Health policies affecting
specialty population
Thank You