Over the past decade, the nursing discipline has quickly evolved, leading to an observable gain in the autonomy of everyday practice. In Québec, Canada, the emergence of an advanced practice curriculum began merely 15 years ago (D'Amour, Tremblay, & Proulx, 2009). Newly graduated nurses in advanced practice are still struggling to find their place, to optimize their relationships with general practitioners, and to clarify their professional identity. At the same time, they are distancing themselves from the technical role historically attributed to their profession. This situation contributes to the recognition of their moral agency, as well as their professional integrity and accountability (LaSala, 2009). However, the establishment of an advanced practice field raises serious questions about nurse practitioners' ability to deliberate and make ethically sensible decisions in an interdisciplinary context.
Given that ethical training in nursing education is often perceived by students as abstract and disconnected from reality, educators must find ways to demonstrate the ethical component involved in clinical judgment. Hence, the challenge is not to teach advanced practice nurses to know which abstract principles should be applied in a given situation; it is to lead them to be able to strengthen their moral and professional integrity, avoid moral distress, justify difficult ethical decisions, and collaborate with other health professionals. Strictly speaking, it is believed that the principles approach, namely the one proposed by Beauchamp and Childress (2013), cannot alone achieve such goal because of the specific clinical, yet political, context in which advanced practice nurses evolve (D'Amour et al., 2009). A principles-based approach to ethical training that is insensible to power relationships exerted in the medical system has many practical consequences. The authors suggest that it can weaken the ethical decision process by devaluating their clinical judgement and create either artificial consensus or dilemmas. Inspired by their teaching experience, the current authors created an ethical training program that responds to critics of a principles-based approach and is better adjusted to advanced nursing practice.
Inspired by symbolic interactionism theory, the pedagogical process follows three core objectives: building moral integrity, closing the gap between ethical deliberation and clinical judgement, and fostering interprofessional collaboration in ethically sensitive situations. The authors do not suggest a method that differs from case studies or narrative ethics, as it is believed that they are effective ways to teach clinical ethics. What the authors suggest is a structure to work on cases that reflect the pedagogical objectives. To construct this advanced practice ethical training program, the authors used an analytical process inspired by the preexisting ethical frameworks of the College of Nurses of Ontario (2009), the Markkula Center for Applied Ethics (Santa Clara University, 2009), and the Haute École Robert Schuman (2013). Starting with these frameworks, six procedural steps that students must follow when discussing complex ethical problems were identified (Table).
A Six-Step Ethical Decision-Making Framework for Advanced Nursing Practice
Step 1: Building Moral Integrity
Moral distress is a widespread feeling and topic commonly discussed in nursing. It is defined by Corley, Elswick, Gorman, and Clor (2001) as “the painful psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it because of…obstacles” (p. 250) and is an outcome associated with the capacity of nurses to protect their moral integrity (Laabs, 2007). We now have a broad knowledge of its direct and indirect effects on nurses (Burston & Tuckett, 2013). Proposed solutions to moral distress often refer to structural changes in the health care setting (Wallis, 2015), and acquisition of ethical and communication skills through education is known to be a central element to prevent it (Burston & Tuckett, 2013). However, whether it is associated with an internal incoherence between a moral judgement and a specific action, little less is known about how nurses can acquire the ability to develop their moral integrity. The point is not to discard moral distress as a key concept in nursing ethics, but rather to analyze it from an internal perspective and recognize its pedagogical value. If moral distress is a reaction to the endangerment of moral integrity, as suggested by Laabs (2007), then nurse educators must ask themselves how to contribute to the constitution of such integrity in the educational setting. As Benjamin and Curtis (2010) and Beauchamp and Childress (2013) suggested, Rawls' reflective equilibrium can be a useful tool to achieve this.
As described by Rawls (1999), the reflective equilibrium is a state of coherence among one's specific judgements, principles, and conceptual considerations for a given situation. It is also an analytic method aiming to achieve internal coherence between those three elements, allowing for a justification or modification of one's moral framework by constant adjustment thought deliberation. In addition, it can be an effective tool to counter opinions influenced by a priori appreciations of a situation, or to protect oneself from emotional responses (Barilan & Brusa, 2011). Hence, the practice of reflective equilibrium can be transposed from virtue ethics to a more pragmatic and interactional pedagogical curriculum to contribute to the development of ethical sensitivity and moral integrity.
In a pedagogical setting, it is possible to construct different cases on specific topics and ask subgroups to analyze them by following a step-by-step decisional approach (Table). Taking the thematic of “autonomy and consent” and cases studies on consent-to-care as examples, multiple cases are submitted to students, such as the consent to pediatric care by parents, the refusal of life-sustaining care by an adult, the consent and refusal of psychiatric care, and substituted consent in critical care. The activity starts, in step 1, with questions asking students individually about their initial reaction on the cases submitted: What are the personal, professional, and societal values that are mobilized by the situation? Based on their clinical experience, what is their ethical appreciation of the situation? The students then express themselves and it is therefore possible to initiate a dialectic interaction within the group by asking probing questions to explore whether their judgment is justified by a coherence with their personal rules, principles. and theoretical knowledge. This process is conducted to act as a structure that is transversal to the deliberative process proposed below, which asks students to constantly adjust their moral framework as they work on their cases.
Steps 2 to 4: From Clinical to Ethical Judgement
Authors, such as Cousineau and Payot (2014), discussed the issues surrounding the professionalization of clinical ethics over the past decades and the risks inherent to this process. One of them is to exclude clinicians from any ethical deliberation and to let ethical committees, or experts in ethics, have a preeminent impact on medical decisions. It must agreed that ethical committees or experts have a specific knowledge of those matters and that their involvement can be insightful, but the internal logic followed through this approach reflects the preoccupation of these authors; their aim is to depict the ethical substance of the clinical judgement as an essential component of advanced practice. Whether steps two through four appear to reflect a classical approach in case study analysis, the overall pedagogical intention, therefore, is to underline the necessity of analyzing factual elements, including the service user's opinion, peripheral systems, and scientific evidence, and to interpret them in the light of normative referents, whether legal or ethical. By bringing together in a specific sequence contextual, legal, and ethical analysis of a situation, it is believed that this process can strengthen the link between clinical and ethical judgements. The authors also suggest that it encourages students to acknowledge their moral accountability when facing an ethical challenge and to find creative solutions to solve complex clinical situations rather than imposing a dualistic decision making process.
For example, when this approach is applied to case studies of consent to care, it requires a broad knowledge of the service users' personal situations, values, and choices, their family dynamic, and the sociocultural system surrounding them. Those elements are of specific importance when considering surrogate decision making. For example, cases of consent and refusal of psychiatric care not only ask for an identification of legal referents but also encourage students to develop critical thinking about the notions of stigmatization, marginalization, vulnerability, and, on the ethical conceptions of autonomy, whether rational or relational. It should also be considered that whether there is any doubt about the capacity to consent to care, a significant body of scientific literature and sociolegal referents can help to clarify the evaluation process of such capacity (Appelbaum, 2007). Not only can this information be useful in the decision making process, but it can also shed light on interventions that should be considered and documented before going further in the analysis of the situation.
Steps 5 and 6: Fostering Interprofessional Collaboration
Referring to the first step described above, the authors suggest that the development of moral integrity is an important stage toward an ethical training for advanced practice. Yet, another objective suggested to fight moral distress is to foster interprofessional collaboration through an ethical training program that is sensible to power relationships and provides tools to facilitate healthy and efficient interactions between nurses and other health professionals. By expanding the deliberative competencies of advanced practice nurses, it is now demonstrated how discourse ethics, integrated in the fifth and sixth steps, can help them understand potential contextual bias brought on by power relationships during the deliberation process. The authors believe discourse ethics can also be specifically useful to question the notion of consensual decision and, secondly, to avoid a priori dilemmas,
The first element that should be considered is the deliberative procedure in itself. The authors suggest that advanced practice nurses' ethical sensibility should be complemented by a procedural competency related to the decision making process. Hence, it is sufficient to say that there is not unanimity in the decisional outcome if there is no procedure that guarantees everyone's right to deliberation, reflection, and expression. For example, it is possible that service users and families involved in the decision making process remain silent as they feel intimidated by the expertise around the table. Some professionals can also hesitate to participate in the discussion because of shyness or fear or because the discussion space is already taken by people generally more comfortable in public speaking situations. In other words, the consensual decision must be justified by procedural safeguards, which can guarantee that everyone's opinion shall be listened to and valued, even if there is disagreement on the option selected. A variety of strategies can be implemented and adapted to the specific parameters of a group. Examples include going around the table to give everyone an opportunity to comment, prioritizing those who usually remain silent to break the potentially monopolistic discussion between a few professionals, and encouraging the right to speak and taking secret votes. If such procedures are in place and respected, a real consensus can emerge and be considered legitimate.
Another current problem often faced with ethical training is the need to justify its pertinence related to ethical dilemmas inherent to medical and nursing practice. However, advanced practice nurses must also learn to differentiate an ethical problem that does not impose a decision between to opposite scenarios from an ethical dilemma that does impose it. To achieve that, they should learn how to reflect about problems in a nonbinary way to find creative solutions and how to detect an a priori dilemma that can bring major bias into discussion. A lack of ethical sensibility could engender blindness to complex ethical problems or situations that do not impose a choice between two mutually exclusive options. In addition, an ethical problem left aside can evolve into an ethical dilemma if nothing is done to prevent it. The authors suggest that the decision making process should be centered on problem solving, rather than exclusively on ethical dilemmas. Another suggestion from D'Amour, Ferrada-Videla, San Martin Rodriguez, and Beaulieu (2005) refers to the necessity of finding a common goal shared by the team, respecting the multiple perspectives of its different members. For example, if a nurse practitioner, a psychiatrist, and a social worker take part in an ethical deliberation related to care refusal and self-starvation of a young physically disabled service user living in a rehabilitation center, it is possible they will have different clinical objectives. Discussing them and finding a shared goal helps instigate a deliberative process respectful of the patient's needs (D'Amour et al., 2005).
Discourse ethics can be integrated transversely from the collaborative analysis of each case to the selection and application of a course of action and to the evaluation of the outcomes (Table). Whether anticipating the evolution of a complex ethical situation is difficult in the pedagogical setting, the authors suggest discussing about the outcomes of the deliberative procedure itself. In doing so, it is consequently possible to question students about their appreciation of the decision making process:
- Was everybody able to speak freely about his or her evaluation of the situation?
- Is the group comfortable with the final decision and how it was achieved?
- Whether dissension exists, how is it justified and how can a team cope with such situations in the clinical setting?
- Which changes in the personal moral framework of each participant can be observed between their initial appreciation of the situation and the final decision?
A last intervention would be to compare the solutions reached for each of the different cases and ask: why are there so many different, yet justified, positions? The pursued objective is to create an interactional space for students, helping them to refine their moral framework and allowing for discussions about complex situations related to a same broad ethical topic.
As Barilan and Brusa (2011) suggested, the aim of ethical deliberation is not to systematically reach a consensus or discover the hidden truth about health, sickness, death, or experience. It is about being able to discuss complex, emotionally tainted subjects related to care in a reflective, nondiscriminatory, and democratic way. Therefore, legitimate consideration must be given to the justification process one ought to go through when arguing about its position. Following Barilan and Brusa (2011), the authors suggest that an emphasis on the development of a moral framework by the practice of reflective equilibrium can foster professional integrity and moral development. The authors believe it can help advanced practice nurses to construct their personal moral framework, to expend it when discussing about different ethically sensible clinical problems, and to justify its coherence to oneself and others when engaging an ethical deliberation. It is also important to develop deliberative competencies that can facilitate discussions, debates, and, maybe, consensus.
The principal challenge in this situation is to construct an ethical training program adapted to advanced nursing practice that contributes to the clarification of the nurse's professional identity and provides a common ground to facilitate discussion with other health professionals, services users, and families. Case studies are certainly a widely adopted and privileged method. Yet, as this brief discussion aimed to show, the authors believe they can be enriched by a pedagogical approach that emphasizes the consolidation of moral integrity and the acquisition of deliberative competencies. The authors believe such method can also prevent the discussion from focusing solely on issues reported as dilemmas, when they are in fact complex problems, which do not impose a binary decision but rather call for a sustained clinical judgement and ethical sensitivity. Although there are rarely any perfect solutions in an ethically sensible situation, a few potentially optimal ones exist that need to be discussed and articulated in creative, clinically, and ethically sound ways. Agreeing on a common definition of the situation and identifying a shared goal through the ethical deliberation process is one way to do so, and establishing clear procedures to discuss the matter respectfully and without self-censorship is another. Through this process, ethical problem solving can become the key to developing self-confidence and establishing satisfying relationships with other members of the team.
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A Six-Step Ethical Decision-Making Framework for Advanced Nursing Practice
|Pedagogical Objectives||Reflexive, Deliberative, and Decisional Process|
|Building moral integrity||1. Development of ethical sensibility and reflexive competence;
Appreciation of the situation and values clarification;
Application of Rawls reflexive equilibrium method.
|From clinical to ethical judgment||2. Factual evaluation of the situation
(The user, its family, its socio cultural context, clinical and scientific guidelines);
3. Construction of the relevant legal framework;
4. Identification of the relevant ethical principles;|
|Fostering interprofessionnal collaboration||5. Development of deliberative competencies;
6. Evaluating the outcomes of the deliberative process
Construction and application of deliberative procedures;
Identification of common goals to reach through discussion;
Collaborative analysis of the situation;
Identification of possible scenarios;
Selection and application of a course of action.