NURS6053 Chamberlian Organizational Policies and Practices in Health Paper Competing needs arise within any organization as employees seek to meet their targets and leaders seek to meet company goals. As a leader, successful management of these goals requires establishing priorities and allocating resources accordingly.
Within a healthcare setting, the needs of the workforce, resources, and patients are often in conflict. Mandatory overtime, implementation of staffing ratios, use of unlicensed assisting personnel, and employer reductions of education benefits are examples of practices that might lead to conflicting needs in practice.
Leaders can contribute to both the problem and the solution through policies, action, and inaction. In this Assignment, you will further develop the white paper you began work on in Module 1 by addressing competing needs within your organization.
Review the national healthcare issue/stressor you examined in your Assignment for Module 1, and review the analysis of the healthcare issue/stressor you selected.
Identify and review two evidence-based scholarly resources that focus on proposed policies/practices to apply to your selected healthcare issue/stressor.
Reflect on the feedback you received from your colleagues on your Discussion post regarding competing needs.
The Assignment (4-5 pages):
Developing Organizational Policies and Practices
Add a section to the paper you submitted in Module 1. The new section should address the following:
Identify and describe at least two competing needs impacting your selected healthcare issue/stressor.
Describe a relevant policy or practice in your organization that may influence your selected healthcare issue/stressor.
Critique the policy for ethical considerations, and explain the policys strengths and challenges in promoting ethics.
Recommend one or more policy or practice changes designed to balance the competing needs of resources, workers, and patients, while addressing any ethical shortcomings of the existing policies. Be specific and provide examples.
Cite evidence that informs the healthcare issue/stressor and/or the policies, and provide two scholarly resources in support of your policy or practice recommendations. Ethical Awareness: What It Is and Why It Matters
Aimee Milliken, PhD, RN
Given the complexity of contemporary healthcare environments, it is vital that nurses are able to
recognize and address ethical issues as they arise. Though dilemmas and challenging situations create
the most obvious, dramatic risks to patients, routine nursing actions have implications for patients as
well. Ethical awareness involves recognizing the ethical implications of all nursing actions. Developing
ethical awareness is one way to empower nurses to act as moral agents in order to provide patients with
safe and ethical care. The aim of this article is to provide an overview of the concept of ethical
awareness and the role it plays in patient care. Background information is provided; three everyday
scenarios highlight the importance of ethical awareness in everyday nursing practice; followed by
additional discussion; and strategies for heightening ethical awareness are suggested.
Citation: Milliken, A., (January 31, 2018) “Ethical Awareness: What It Is and Why It Matters” OJIN: The
Online Journal of Issues in Nursing Vol. 23, No. 1, Manuscript 1.
Key Words: ethical awareness, nursing ethics, ethical sensitivity, moral sensitivity, critical care
Ethical awareness involves recognizing the ethical implications of all nursing actions, and is the first step
in moral action.Given the complexity of contemporary healthcare environments, it is vital that nurses
are able to recognize and address ethical issues as they arise. Ethical awareness involves recognizing the
ethical implications of all nursing actions, and is the first step in moral action ( Milliken & Grace, 2015).
This means that nurses must first recognize the potential ethical repercussions of their actions in order
to effectively resolve problems and address patient needs. The aim of this article is to provide an
overview of ethical awareness and its important role in ethical nursing care. Three everyday scenarios
highlight the importance of ethical awareness in everyday nursing practice. Finally, strategies for
heightening ethical awareness in the clinical setting are suggested.
…nurses do not often recognize daily activities… as having ethical implications.Many scholars have
addressed the ethical nature of nursing practice (Austin, 2007; Erlen, 1997; Milliken & Grace,
2015; Truog et al., 2015; Ulrich et al., 2010). Though nursing ethics education often focuses on dilemmas
and challenging situations (Truog et al., 2015; Zizzo, Bell, & Racine, 2016), ethical awareness involves
recognizing that every nursing action has the potential to impact the patient, even routine daily actions
(Grace & Milliken, 2016; Milliken, 2016; Milliken, 2017a; Milliken & Grace, 2015). Recent work suggests
that this awareness may be lacking, and that nurses do not often recognize daily activities (e.g., taking
vital signs, administering medications, or starting an intravenous line) as having ethical implications
(Krautscheid, 2015; Milliken, 2017a; Truog et al., 2015). This trend is problematic, and may put patients
at risk for harm.
Nursing goals encompass the the protection, promotion, and restoration of health and well-being; the
prevention of illness and injury; and the alleviation of suffering, in the care of individuals, families,
groups, communities, and populations (American Nurses Association [ANA], 2015, p. vii). For a nursing
action to be considered ethical, it should be aimed at promoting the goals of nursing in conjunction
with the patients wishes. Using the language of ethics, the goals of nursing can be broadly categorized
into actions aimed at promoting the four major ethical principles. These principles are autonomy (the
right to self-determination); beneficence (promotion of good); maleficence (avoidance/minimization of
harm); and justice (fairness/equal distribution of benefits and burdens) ( ANA, 2015; Beauchamp &
Awareness ideally leads the nurse to take action to practice in the most ethically acceptable way.If an
action is in conflict with a nursing goal or one of these principles, or if it ignores a patients preferences,
the nurse risks acting unethically. Ethical awareness involves recognizing the risk that nursing actions
could fail to adhere to the goals of nursing, thereby violating an ethical principle. Awareness ideally
leads the nurse to take action to practice in the most ethically acceptable way (Milliken, 2016; Milliken,
2017a; Milliken & Grace, 2015).
Research has suggested that nurses often feel unprepared to manage ethical challenges they face in
practice (Austin, 2016; Rodney, 2017; Woods, 2005), resulting in possible moral distress and burnout.
Ensuring that nurses have the tools to manage difficult situations is one way to mitigate this concern
(Jurchak et al., 2017). Ethical awareness is important for nurses to develop as part of the larger skill set
of ethical competence (Grace & Milliken, 2016; Kulju, Stolt, Suhonen, & Leino-Kilpi, 2016; Lechasseur,
Legault, & Caux, 2016). The following everyday scenarios highlight the importance of ethical awareness,
and focus on the role it plays in day-to-day nursing care. In the interest of confidentiality, these cases
are not actual occurrences, but constructed scenarios that represent common challenges.
Ethical Awareness: Everyday Scenarios
Even everyday clinical situations require careful consideration of ethical risk.Even everyday clinical
situations require careful consideration of ethical risk. Though the risk may seem low at the outset, the
following scenarios highlight the way that even routine situations can have profound ethical implications
for patients. While there are many ways to conduct an ethical analysis, the focus here will be on the four
primary ethical principles foundational to nursing practice (defined above) and how they relate to th e
scenarios. For the purpose of illustration and discussion, these scenarios assume nurses who could
benefit from a higher level of ethical awareness, to include potential everyday challenges, as opposed to
higher profile cases more commonly discussed in the literature (e.g., initiation of feedings/ventilation).
Mr. M is an 85-year-old man admitted to the neurological intensive care unit (ICU) after developing a
subdural hematoma due to a recent fall. Mrs. M (his wife) asks to spend the night in her husbands room,
as she is concerned he may become distressed if she leaves. The rules in the ICU prohibit family members
from staying overnight, unless the patient is actively dying. Citing this rule, John, the ICU nurse, sends
Mrs. M home. Overnight, Mr. M becomes acutely agitated, requiring wrist restraints and repeated doses
of intravenous sedatives.
This case suggests several possible ethical concerns. First, it appears as though John, the nurse, has
acted based on routine. In this sense, we may be concerned that John has not fully considered Mr. Ms
possible unique interests in this case. This relates to Johns ethical obligation to promote Mr. Ms
autonomy, and involves considering the question: what would be best for Mr. M, given his clinical
situation and what we know about his goals and values? A second ethics-related concern has to do with
Johns obligation to promote good (beneficence) and to prevent harm (non-maleficence). The harm, in
this case, would be Mr. Ms increase in agitation and the possible need for restraints and sedation.
Ethical awareness would have helped John to recognize the range of potential ethical implications of his
decisions as they relate to the possible concerns. Ethical awareness would have helped John to
recognize the range of potential ethical implications of his decisions as they relate to the
aforementioned concerns. In other words, ethical awareness would enable John to have a more holistic
view of Mr. Ms predicament and may allow him to develop a plan of care more in line with this view. In
a patient such as Mr. M, with a neurological injury, minimizing the need for sedation and restraints is
preferable, both ethically and clinically, as any change in neurologic status may be cause for concern.
In viewing the situation with this lens, John may have decided to let Mrs. M stay, despite the unit
routine, thus promoting Mr. Ms autonomy. This decision also aligns with Johns obligations related to
beneficence and non-maleficence. Allowing Mrs. M to stay on the unit may minimize the risk of
agitation if her presence helped soothe her husband. This action may have successfully prevented use of
more restrictive measures (i.e., restraints and sedation), thereby promoting a better outcome
(beneficence) and mitigating potential harm.
Mr. L is a 50-year-old man admitted for gastrointestinal (GI) bleeding. After a couple of days his
hematocrit is still low and his physician tells him that he is not ready to be discharged today. Mr. L
becomes angry and tells the team he wants to leave against medical advice (AMA). His nurse, Susan, and
his physician outline the risks of leaving, including the risk of rebleeding, but he insists and leaves the
hospital. That night, Mr. L ends up back in the Emergency Room with profuse GI bleeding.
…the providers obligation to promote the patients best interests may outweigh the patients desire to
act autonomously.While leaving AMA is often viewed as a patient right based on the principle of
autonomy, it is also necessary to consider whether the patient is putting himself at undue risk for harm.
When the risks of a situation outweigh the possible benefits, the providers obligation to promote the
patients best interests may outweigh the patients desire to act autonomously ( Grace, 2014). Thus, the
ethics worry in this case relates to the potential conflict between Susans ethical obligation to promote
good (beneficence) and Mr. Ls right to autonomy.
To promote Mr. Ls ability to act autonomously in the future, it is necessary to minimize the potential
harm to which he exposes himself in the present. To promote Mr. Ls ability to act autonomously in the
future, it is necessary to minimize the potential harm to which he exposes himself in the present. Ethical
awareness would help Susan recognize this responsibility. To address this obligation, Susan could try to
talk through the situation in greater depth with Mr. L in an effort to uncover the reasoning behind his
desire to leave. There may be additional factors of which Susan is unaware that are contributing to Mr.
Ls anger. If these reasons are explicated, perhaps they can arrive at a compromise to appease Mr. L,
while keeping him medically safe.
Additionally, Mr. Ls clinical picture includes a low hematocrit. This factor may be negatively impacting
his decision-making abilities. Susan may wonder whether Mr. L is truly making an autonomous decision,
which would require that he fully understands and is able to use reason to determine the potential long term outcomes of leaving the hospital. Susan could further explore these concerns to ensure that Mr. Ls
decision to leave is actually fully informed. Should she reach an impasse, she may consider seeking
additional resources to keep Mr. L safe, including involving psychiatry and possibly an ethics consult.
Emily is a new nurse on a medical-surgical unit. She has a busy assignment, and is behind on
documentation. She has her patients vital signs on a piece of paper in her pocket but has not written
them in the chart. However she is happy to see her hypertensive patient, Mrs. O, is now normotensive.
The medical team rounds on Mrs. O without Emily, and sees that the most recent blood pressure (BP)
documented in the chart is still elevated. They order an increase in Mrs. Os antihypertensive
medications, not realizing her BP is has now normalized (since Emily has not yet charted it). In an effort
to help Emily catch up, a nurse colleague gives Mrs. O the new dose of medication. An hour later Mrs. O
becomes diaphoretic and dizzy. When Emily rushes in to re-check her blood pressure, she is hypotensive.
Because Emily was behind, the plan of care was changed based on old data, putting Mrs. O in a
dangerous situation. Though Emily had good intentions, her patient was given an improper dose of
medication. Using ethics-language, Emily was unable to provide beneficent (good) care, and her patient
suffered a potential harm. Nurses often fall behind during the course of a shift; this is a reality of
practice. However, this scenario demonstrates that even something as simple and routine as charting
vital signs has potential ethical implications. Falling behind, and being unable to perform necessary
duties, can result in potential harm.
An additional ethics worry is that Emily was so busy that she missed rounds with the medical team. This
means Emily did not have the ability to fully update the team about Mrs. Os progress and to raise any
potential concerns or considerations for the plan of care. This represents a lost opportunity to advocate
for her patient. Advocacy is an important component of the duty to promote autonomy, particularly
when patients are in a position where they cannot make their own needs or wishes known, or when
patients may not have all the necessary information to make informed decisions.
… [Emily] has an ethical obligation address the situation that is leading to her busyness. Ethical
awareness would have helped Emily recognize that, based on her duty to promote good (beneficence),
to advocate for her patient (autonomy), and to prevent harm (non-maleficence), she has an ethical
obligation address the situation that is leading to her busyness. The inability to meet her patients needs
may result in possible harm, as Mrs. O experienced. This is not only a clinical problem or a possible bad
outcome; this is fundamentally ethical in nature. This recognition may help Emily feel more confident in
asking for help. Ethical awareness also may prompt Emily to evaluate the root cause of this issue, so that
she (and possibly others) could avoid similar circumstances in the future.
…increasing nurses ethical awareness to include the implications of everyday decisions is important to
maximize safe, ethical patient care.These three scenarios highlight the importance of recognizing that
even routine and seemingly mundane nursing actions can have major implications for patients. As
noted, nurses have professional goals and related ethical obligations that should guide nursing practice.
However, routine practice actions may not always be viewed through this lens. This lack of recognition is
in no way malicious or intentional; it stems from lack of awareness. Consequently, it becomes clear that
increasing nurses ethical awareness to include the implications of everyday decisions is important to
maximize safe, ethical patient care.
An awareness of the ethical components of a situation ideally should prompt nurses to take action
(Milliken, 2016; Milliken & Grace, 2015). The scenarios above demonstrate how heightened ethical
awareness may have helped clarify the way that these nurses thought about the implications of their
decisions. This perspective may have helped them view the scenarios more completely, and be sensitive
the possible range of actions they might have taken (Rest, 1982). In other words, had the nurses in these
cases recognized that their patients were at risk, they may have been more likely to intervene or take
…ethical awareness is an important first step in sustainable, optimal ethical practice.Such a proactive
measure, or intervention, is called moral agency. The nurse recognizes a potential ethical issue, and
acts to resolve it. In addition to willingness and ability to take action, moral agency requires that nurses
embody this perspective in practice, recognizing that as a profession, we have an obligation to act as
agents on behalf of patients (Liaschenko & Peter, 2016; Musto & Rodney, 2016). Embracing ones role as
a moral agent in this way can facilitate resilience, or an individual nurses ability to learn and grow from
challenging clinical situations that may cause distress (Rushton, 2016b). Consequently, ethical
awareness is an important first step in sustainable, optimal ethical practice.
The important role of ethical awareness in patient care suggests that individual nurses, as well as nurse
leaders and healthcare organizations, hold the responsibility to develop this important skill. Strategies to
heighten ethical awareness in the clinical setting have been discussed in depth elsewhere ( Milliken,
2017b). Briefly, these include interventions targeted at the individual, unit, and organizational level. For
example, individual nurses can improve ethical awareness by developing ethical competence, or overall
ethical understanding and skill-set (Kulju et al., 2016; Lechasseur et al., 2016). Participating in ethicsrelated discussions, utilizing available ethics resources (Milliken, 2017b), and becoming familiar with the
ANA Code of Ethics for Nurses with Interpretive Statements (Code of Ethics) are several ways of
developing ethical competence.
The ANA Code of Ethics (2015) establishes the ethical standard for the profession (p. vii) and serves as
the professions non-negotiable ethical standard (p. viii). The nine provisions outline the expectations
to which nurses, as professionals, must adhere. The Code of Ethics emphasizes that the scope of ethical
nursing practice extends far beyond the nurses role in challenging dilemmas. Recent work suggests that
many nurses may be unfamiliar with the Code of Ethics document (Heymans, Arend, & Gastmans,
2007; Milliken, 2017a). Nevertheless, familiarity with this document has been identified as an essential
part of preparation for ethical practice and should serve as a foundational step to develop ethical
awareness (Grace & Milliken, 2016).
At the unit and organizational-level, nurse leaders can create opportunities for individual nurses to
develop moral agency and resilience (Milliken, 2017b). These opportunities may include unit-based
ethics rounds; in-services; formal and informal ethics training; and participation in interprofessional
education (Hamric & Wocial, 2016; Milliken, 2017b; Rushton, 2016b). Nurse leaders can also model and
contribute to shifting values toward an organizational culture that supports ethical awareness and
ethical practice (Hamric & Epstein, 2017; Liaschenko & Peter, 2016). This requires attention to unitspecific issues (e.g., complex patient populations and staffing issues) and creation of platforms for
nurses and other healthcare providers to participate in regular discussions about ethics and ethical
issues (Hamric & Wocial, 2016; Liaschenko & Peter, 2016; Milliken, 2017b).
Interventions such as these can foster individual and collective ethical awareness. Keeping ethics at the
forefront of conversation, in this way, can help to better ensure that patient needs are met. It may also
help nurses facing everyday, yet challenging situations, like those in the case scenarios, to feel more
confident in decision making and in their ability to access ethics-related resources at the moment of
Developing and fostering ethical awareness fundamentally requires recognition that ethics is in
everything that we, as nurses, do.Developing and fostering ethical awareness fundamentally requires
recognition that ethics is in everything that we, as nurses, do (Austin, 2007; Milliken & Grace,
2015; Truog et al., 2015; Ulrich et al., 2010). While dilemmas and challenging situations create the most
obvious, dramatic risks to patients, routine actions have implications for patients as well. Consistent
recognition of the ethical implications of nursing actions will, ideally…
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