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This assignment reinforces the importance of ethical decision-making in nursing. You will apply an ethical decision making model from this week’s readings to an ethical issue.Review “An Integrated Ethical-Decision-Making Model for Nurses” from this week’s Electronic Reserve Readings.Apply the ethical decision-making model in the article to access to care or an ethical issue of your choice.Note: If you have questions about your chosen topic, contact your faculty member to ensure it is appropriate.Follow the steps provided in the model, including the following:State the ethical issue and its relevance for nursing practice.Collect and analyze additional information: What populations does this serve?Who are the key stakeholders?What information is needed to overcome the problem?After looking at additional information, decide whether the initial problem was correctly stated.Develop alternatives and compare them:What alternative programs address the issues?Justify the decision:Explain why this is important, needed, or beneficial for vulnerable populations.Find strategies to implement the plan:What ethical arguments could you use to dissuade someone who disagrees with the program?Format your assignment as one of the following:18- to 20-slide presentation875-word paperCite at least 3 evidence-based, peer-reviewed sources published within the last 5 years to support your position(s).Include an APA-formatted reference list.


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An integrated ethical
decision-making model
for nurses
Nursing Ethics
19(1) 139–159
ª The Author(s) 2012
Reprints and permission:
Eun-Jun Park
Kyungwon University, Korea
The study reviewed 20 currently-available structured ethical decision-making models and developed an
integrated model consisting of six steps with useful questions and tools that help better performance
each step: (1) the identification of an ethical problem; (2) the collection of additional information to
identify the problem and develop solutions; (3) the development of alternatives for analysis and comparison; (4) the selection of the best alternatives and justification; (5) the development of diverse, practical ways to implement ethical decisions and actions; and (6) the evaluation of effects and development
of strategies to prevent a similar occurrence. From a pilot-test of the model, nursing students reported
positive experiences, including being satisfied with having access to a comprehensive review process of
the ethical aspects of decision making and becoming more confident in their decisions. There is a need
for the model to be further tested and refined in both the educational and practical environments.
decision making, ethics, ethical issues, nursing ethics, problem solving
Patients’ safety and well-being are dependent, to a large extent, on professionals’ ethical decisions.1
Regardless of his or her excellence in clinical knowledge and skills, a healthcare professional who has low
or non-existent ethical standards should be considered unfit to practice. For responsible healthcare, professionals have to be competent in ethical decision making.2 An ethical problem is ‘as [an ethical] matter or
issue that is difficult to deal with, solve, or overcome and which stands in need of a solution’ (p.94).3 Ethical
problems in a clinical setting are those we rarely confront in our daily lives, and ethical norms learned from
our parents or schools are not sufficient to resolve clinical ethical issues. There are concerns about professionals’ ethical competency. Health professionals often adopt an inconsistent decision-making process or
reach inconsistent ethical conclusions in attempts to resolve identical ethical problems.1,4,5 Moreover, they
tend to come to decisions of an ethical nature before reviewing all possible alternatives or going through a
systematic and comprehensive decision process.2 It is challenging for clinicians to make ethical decisions.
Health professionals attempt to achieve the best possible and morally-justifiable resolution while prioritizing a patient’s interest.6 Accordingly, the quality of ethical decision making should be evaluated in terms
not only of its conclusion but also the process of decision making. For example, whether all individuals
Corresponding author: Eun-Jun Park, Department of Nursing, Kyungwon University, San65, Bokjeong-Dong, Sujeong-Gu,
Seongnam-Si, Gyeonggi-Do, 461-701, Korea
Email: [email protected]
Nursing Ethics 19(1)
affected by the decision have an opportunity to share their informed decisions or preferences.7 An explicit
and systematic method for ethical decision making is highly likely to improve the quality of such decisions for several reasons.2,8-11 First, ‘a model functions as an intellectual device that simplifies and clarifies the sources of moral perplexity and enables one to arrive at a self-directed choice’ (p.1701).2
Second, it eliminates a possibility of deviated assessment of an ethical problem, for example, not considering all relevant parties and their diverse preferences,12 or reaching conclusions based on his/her
intuition rather than on intellectual rigor.13,14 Third, ‘communication and documentation of an explanation for a course of action’8 and collaboration among stakeholders become easier throughout an ethical
decision-making process when a systematic decision-making model is shared.7 A systematic decisionmaking model helps identify where a gap in understanding an issue or a difference in value systems (disagreements) exist among stakeholders (interdisciplinary team) through transparent communication.1,15,16
Finally, the use of a systematic model of ethical decision making will allow for the accumulation of
information concerning ethical decisions, thus revealing norms.7 Although nurses make ethical decisions
every day, we know little about how similar are our ethical decisions to those of other nurses. If we
collect information on our ethical decisions, codes of ethics can be developed being based on our normative ethics,7 which can be more acceptable and evidence based.
Structured models for ethical decision making have been introduced by different authors. To name a
few, Johnstone’s moral decision-making model3 includes stages to assess the situation, to identify moral
problem(s), to set moral goals and plan moral action, to implement moral plans of action, and to evaluate
moral outcomes. According to Davis, Fowler, and Aroskar,17 if a conflict of moral duties or values
exists, we need to go through the following stages: 1) review of the overall situation to identify what
is going on; 2) identification of the significant facts about the patient; 3) identification of the parties
or stakeholders involved in the situation or affected by the decision(s) that is made; 4) identification
of morally relevant legal data; 5) identification of specific conflicts of ethical principles or values; 6)
identification of possible choices, their intent, and probable consequences for the welfare of the patient(s)
as the primary concern; 7) identification of practical constraints and facilitators; 8) make recommendations for action; 9) take action if you are the decision maker and implementor of the decision(s) made;
and 10) review and evaluate the situation after action is taken. In addition, Thompson et al.’s11 DECIDE
model suggests to: 1) Define problems – what is an ethical issue?; 2) Ethical review – what principles
are relevant to case?; 3) Consider options; 4) Investigate – ethical outcomes, costs and benefits; 5)
Decide on action; and 6) Evaluate results. However, it is hard to say what are their strengths or weaknesses and which one is more greatly-accepted by clinicians. Therefore, the current study critically
reviewed structured ethical decision-making models found via a systematic search of literature and suggested an integrated and comprehensive ethical decision-making model by synthesizing strengths of the
different ethical decision-making models and by pilot-testing it. The suggested ethical decision-making
model is meant to be prescriptive so that nurses may directly apply it in practice.
Peer-reviewed journal articles were searched using Medline and CINAHL databases. The following
keywords and the subject headings were entered into the PubMed and CINHAL interface on 30 June
2010: (ethical OR moral) AND ((decision AND making) OR (decision AND model)). Four hundred
and twenty-six articles from Medline and 202 additional articles from CINAHL were retrieved. Their
titles and abstracts were reviewed for potential relevance, and then the selected 78 articles were
reviewed for their full-text. Studies were selected if (1) their authors originally developed an original
ethical decision-making process or model, (2) the ethical decision-making process or model clearly
presented steps for decision, and (3) they were written in English. Studies were excluded mostly
because (1) the authors introduced or applied an ethical decision-making process or model developed
by other people, (2) they described only a theoretical background of ethical decision making without a
decision-making process, or (3) their ethical decision-making process or model were developed for
non-healthcare practitioners or for non-clinical settings, such as business, information technology,
education, or research. A report of an ethical decision-making process for family physicians of
Canada18 was included after reviewing references of the selected articles. Twenty structured ethical
decision-making processes were reviewed systematically.
An integrated ethical decision-making model was developed and modified through a pilot test of its
usability. In two nursing ethics courses, 67 second-year baccalaureate nursing students were asked to
solve four cases of clinical ethical problems through a group discussion involving three or four people
and to submit a report of their decisions. This was a regular classroom activity of a nursing ethics course
taught by the author. To test the developed model, 22 student groups discussed an initial two cases
before learning the model, and, after a brief orientation, a further two cases applying the model. After
the discussion class, the students were invited to participate in this study as a group by submitting their
reflective essay of how the use of the structured model influenced their decision-making process or outcomes. Twenty student groups voluntarily participated without revealing their names, and thus individual
participants were not identifiable so as to protect the students. Accordingly, whether or not they participated in this study, their grades or student-teacher relationships were unaffected.
Reviews of ethical decision-making or problem-solving models
Twenty different ethical decision-making models were classified into two groups and ordered by their
publication year: ‘Nine ethical decision-making processes’ (Table 1) and ‘Eleven ethical problemsolving processes’ (Table 2). An ethical problem-solving process includes an ethical decisionmaking process, which refers mainly to a cognitive process, but goes further by adding implementing
the decision and evaluating its results. However, the authors of the reviewed articles did not clearly
distinguish this difference, and interchangeably used the two terms: ‘ethical problem solving’ and
‘ethical decision making’. Only two studies1,18 out of the 11 (Table 2) explicitly acknowledged the
difference by mentioning it in their article titles. These two terms were differentiated in this study,
as necessary; otherwise the term ‘ethical decision making’ is used to refer to both, and they are analyzed and discussed together. The reviewed 20 studies were published from 1976 to 2010: one in the
1970s, seven in the 1980s, four in the 1990s, and eight in the 2000s. They show that interest in ethical
decision-making process has been ongoing and that new models are being constantly developed even
today. A chronological pattern of change was not found in ethical decision-making or problemsolving models. Among the reviewed 20 models, seven were developed for RNs or nurse practitioners, five for health professionals in general, four for physicians, two for psychologists, one for
social workers, and one for a neonatal intensive care unit.
Theoretical backgrounds and contextual factors. Most authors suggested ethical pluralism applying diverse
ethical theories and perspectives in decision making as one ethical theory or perspective was unlikely
to be a panacea for every ethical problem. Ethical pluralism seems to be natural in modern societies that
are experiencing an increasing diversity of values.3 By adopting various theoretical alternatives, nurses
are more likely to have a comprehensive moral vision.16 Deontology (principle-based approach) and
consequentialist theory (teleology, ends-based approach) were predominantly adopted by the authors
of the models, whereas some models were based on a single ethical theory: consequentialism.7,15,19
Bunting and Webb (1988)23
Haddad (1992)24
8 stages of decision theory
2. Gather information
1. Respond to the sense or
feeling that something is
5 stages
Health professionals, long-term
care givers
Utilitarianism & deontology
Ethical reasoning structure of a
professional (individual value), Psychological factors influencing
decision: bounded rationality,
contextual component (the
projection, mixed motives or
decision maker’s relationship
competing demands
with the client, the health care
Health professionals
Grundstein-Amado (1991)21
1. Problem perception
Identification of the ethical
Identification of the medical
3. What further information do 2. Information processing
you require about either of the Gathering medical-technical
above in order to make a
Seeking other sources of
4. Who are the persons who will
3. Identification of the patient
be affected by the decision?
5. What are the values of the
involved parties?
1. What are the health issues?
2. What are the ethical issues?
Physicians (Perinatologists &
Nurse practitioners
Consequentialism & deontology Consequentialism & nonconsequential ethical theory
Substantive structure: 1) philoso(deontology, codes of ethics,
phy of the physician-patient
the patient’s bill of rights)
relationship, 2) interpretation
of ethical principles, 3) ethical
theories, 4) ultimate sources of
our morality
5 stages of procedural structure 10 stages
Pellegrino (1987)6
1. Establish a data base 1. Establish the Facts
2. Determine what is in the
patient’s best interests
6 stages
Teleology & deontology (rights and
duties of involved
Curtin and Flaherty
Table 1. Nine studies of ethical decision-making processes
Pellegrino (1987)6
7 stages
Decision analysis
DeWolf Bosek
6. Reach resolution
Grundstein-Amado (1991)21
Kaldjian et al. (2005)9
8. What are the alternatives
9. What are the ethical justifications for each alternative?
10. What are the probable outcomes of each alternative?
7 stages
Neonatal intensive care unit
Collaborative decision
(Consequentialism approach)
Individual value system & the core
values of the unit
5. Work with others to determine a course of action
7. The choice
8. Justification
Baumann-Holzle et al. (2005)14
4. Seek a resolution/ determine
3. Identify the ethical problem
Haddad (1992)24
5. Listing the alternatives
6. Listing the consequences
6. What are the conflicts between 4. Identification of the ethical
values or ethical principles?
7. Must a decision be made and, if
so, whose decision is it?
Bunting and Webb (1988)23
Social workers
Ethical pluralism including conseTeleology & deontology
quentialism & deontology
Value system or preference of the
decision maker, context of the
environment, individual decision making styles
7 stages
6 stages
1. State the problem plainly
Mattison (2000)13
4. State your decision in concrete
5. Justify the decision
3. Define the ethical issues and
2. Identify and clarify
the ethical
3. Determine the
rights, duties,
authority and
capabilities of the
decision makers
4. Determine possible
causes of action
5. Reconcile facts and
values; hold multiple
values in tension
Curtin and Flaherty
Table 1 (continued)
Kaldjian et al. (2005)9
Baumann-Holzle et al. (2005)14
1. Background information /case
2. Separating practice
considerations and ethical
4. Decision (consensus)
5. Planning the discussion with the
6. Discussion with the parents
1. Description of the child’s
2. Gather and organize data:
medical information, care and
medical facts, medical goals,
social situation
patient’s goals and preferences,
2. Different aspects of evaluation
the infant’s chances of survival
the infant’s chances of dying if
mechanical ventilation and
other critical assistance are
the infant’s actual suffering
the infant’s possibility to live
independently in the future
without developing severe
3. Ask: Is the problem ethical?
3. Identifying value tensions
4. Identifying principles in the code 4. Ask: Is more information or
dialogue needed?
of ethics which bear on the case
3. Developing at least three
5. Identify possible courses of
different scenarios
action (benefit/cost, projected
Mattison (2000)13
6. Identify the best
6. Assessing which priority/obliga- 5. Determine the best course of
action and support it with
tion to meet foremost and jusreference to one for more
tifying the choice of action
sources of ethical value: ethical
7. Resolution
principles, rights, consequences, comparable cases,
professional guidelines,
conscientious practice
7. Evaluate the action
6. Confirm the adequacy of the
7. Evaluation of the decision
choice (justification)
making process
3. Identify possible
4. Assign probabilities
5. Calculate expected
1. Identify desired
2. Assign utilities
DeWolf Bosek
Table 1 (continued)
Consequentialism & deontology
Aroskar (1986)25
Tymchuk (1986)7
6. Implementation
9. Participate actively in resolving the
10. Apply state/federal laws governing
nursing practice
11. Evaluate the resolutive action
4. Determination of which alternative to 8. Choose and act on a resolutive
5. Review procedures
9. Follow the situation until you can see 7. Reviewing the process to learn what 7. Evaluation
needs to be changed in dealing with
the actual results of your decision, and
future ethical situations in patient care
use this information to help making
future decisions
5. Consider as many possible alternative 4. Seeing what help may be gained by
looking at the alternatives from the
decisions as you can
perspective of ethical theories and
6. Consider the longand short-range
consequences of each alternative
5. Making a decision
7. Reach your decision
8. Consider how this decision fits in with
your general philosophy of patient
6. Taking action
11 stages
1. Identify the moral aspects of nursing
RNs & nursing students
Code of ethics, ethical principles
Cassells and Redman (1989)26
2. Gather relevant facts related to a
moral issue
3. Clarify and apply personal values
4. Understand ethical theories and
5. Utilize competent interdisciplinary
6. Propose alternative actions
2. Determination of available
7. Apply nursing code(s) of ethics to
help guide actions
3. Determination of who should decide
which alternative to implement
7 stages
7 stages
1. Distinguishing a predominantly ethical
situation from one, for example, that
is primarily a communication issue
1. Determination of who should
2. Gathering an adequate information
3. State who’s involved in making the
participate in the decision
4. Identify your role (quite possibly, your 3. Identifying the value conflicts
role may not require a decision at all.)
Clinicians in general (The University of
Colorado Medical Center)
9 stages
1. Identify the health problem.
2. Identify the ethical problem.
Murphy and Murphy (1976)19
Table 2. Eleven studies of ethical problem solving processes
1. Identification of ethically relevant
issues and practices
1. Perceive the situation as having ethical 1. Review the situation and identify a)
health problems, b) decision(s)
needed, and c) key individuals
10 stages
Teleology, deontology, existentialism,
synthesis of different ethical theories
Individual influences: level of cognitive
moral development, ethical orientation, demographic profile
Issue specific influences (moral intensity): temporal immediacy, magnitude
of consequence, proximity, concentration of effect, probability of effect,
and social consensus
Significant other influences (family,
friends, coworkers, peers, and/or a
wide variety of extraneous
Situational influences: culture/climate
and p …
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