University of Virginia School of Nursing Fall, GNUR 540 Ethics, Nursing and the Larger Health Care Arena

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1 University of Virginia School of Nursing Fall, Course Credit: 3 GNUR 540 Ethics, Nursing and the Larger Health Care Arena Course Professor: Pre-requisites: Technology: Ann B. Hamric, PhD, RN, FAAN, Associate Professor Phone: ; Office: Room 5007, McLeod Hall abh4f@virginia.edu None Students should have access to word processing and . We will communicate via Toolkit s feature, so you should either use your Virginia.edu account for , or have your forwarded from your Virginia address to your preferred personal address. Location and Time: McLeod Hall Room 1003 Fridays, 9 11:50 am Course Description: This seminar course is designed to enhance the student s ability to: describe and analyze ethical concepts foundational to nursing practice; utilize a variety of ethical decisionmaking frameworks to analyze ethical dilemmas in practice; and, play a leadership role in promoting ethical health care delivery. This course emphasizes the unique ethical perspective of nursing in the complex heath care arena. Students will be challenged to examine individual and professional values, as well as critically analyze diverse perspectives on various ethical issues. Course Objectives: 1. Compare the historical development of nursing ethics with the current state of nursing ethics. 2. Evaluate theories of bioethics using an identified set of criteria. 3. Apply selected ethical decision-making frameworks in patient care situations that require moral judgment and/or action. 4. Compare personal and professional values and examine their effect on the nurse s ethical decisions. 5. Define leadership opportunities for the CNL to contribute to and maintain an ethical health care environment.

2 Course Outline: 2 Week Topic Assignments Unit I: Introduction to Nursing Ethics #1 Overview; Bioethics, Nursing Ethics, Legal Issues; Critical Thinking & 1/20 Analysis; Why does ethics matter? What does it mean to be an Ethical Nurse? #2 Historical Foundations vs Contemporary Perspectives of Nursing Ethics; 1/27 Clarifying our Values in Nursing; Codes of Ethics; Loyalty, Advocacy, Accountability Unit II: Ethical Theories and Concepts #3 Overview of Bioethics Theory: Virtue, Deontology, Utilitarianism, 2/3 Natural Law; Classic Bioethics: Autonomy #4: 2/10 Classic Bioethics: Beneficence and Justice Decide on Case for Paper #5: 2/17 Alternative Bioethical Theories: Care, Feminist Theory #6 Alternative Ethical Approaches: Casuistry, Narrative; 2/24 Ethical Decision-Making Frameworks and Models Unit III: Ethical Issues in the Real World of Nursing Practice #7 Intra- and Inter-Professional Dilemmas: Among Nurses, in the Nurse- 3/3 Physician Relationship; with other Healthcare Team Members; the Concept of Power in Ethical Practice [3/10 Spring Break] #8 Caring for Difficult Patients/Difficult Situations 3/17 Ethical Analysis Paper Due #9 Working in an Institutional Context I: Clinical Leadership in 3/24 Empowering Nurses to be Moral Agents; Preventive Ethics; Barriers & Facilitators to Building Ethical Environments Debate #1 #10 Working in an Institutional Context II: Managed Care; Cost 3/31 Containment; Organizational Ethics Debate #2 #11 Ethics Committees; Finding and Using Institutional Resources 4/7 Debate #3 Unit IV: Widening the Frame: Ethical Issues in Public Health; Social Justice #12: 4/14 Ethical Issues in the US Health Care System Debate #4 #13: 4/21 Ethical Issues and the Global Community Debate #5 #14 Leadership Roles in Clinical Ethics and Beyond; 4/28 Course Conclusion and Evaluation Final Exam Due?

3 Criteria for Evaluation 3 Course Requirements: Case analysis Paper: 30% Debate Presentation: 35% Final take-home exam: 35% Case Analysis Paper [Due 3/17]: Students will write a 5-6 page paper analyzing a specific case representing an ethical dilemma or moral distress. The instructor will review the case in advance, which should draw upon the student s clinical experience. The steps of ethical analysis discussed in class will be used, with conclusions about ethically appropriate action developed based upon the analysis. Any references used should be cited, using APA format. Debate [Scheduled the last 6 weeks of class]: Students will be divided into five debate groups. Each group will present a 50-minute debate on an issue of their choosing, illuminating all sides of the issue. The last 10 minutes should be reserved for class voting and discussion. Students may develop their own debate topics, with faculty approval. Each debate group should identify a minimum of 3 references to give to the class to read one week in advance of their debate. Potential Debate Topics: Are we ethically required to provide care to patients who refuse, in spite of our best efforts, to take responsibility for their health? Are we ethically obligated to provide care for illegal aliens who need major surgery? Should nurses assist patients who request aid in dying? Are nurses ethically obligated to provide life-prolonging care to terminally ill patients whose families request continued aggressive therapy? Should parents be able to refuse life-saving treatment for their children on the basis of their religious beliefs? Should the nursing profession take political action to adopt a single payor insurance system to cover all citizens? Do richer countries have an obligation to help poorer countries to ensure the health of their citizens? Are we ethically obligated to provide treatment (such as chemotherapy) to an elderly patient who may have a small chance of remission, but whose quality of life may be harmed? Final Exam [Due last week of class or during exam period we will discuss] This take-home examination will consist of a series of short-answer essay questions covering the major themes of the course. You will be given a choice of three questions to answer. These essay questions will contribute to your CNL portfolio. Grading Policy: This course follows the standard grading scale for the SON. Please refer to the GRADUATE student manual for the complete policy on the grading scale and unsatisfactory grades; note that a grade below B- is not passing in the Graduate Program. One-half letter grade will be deducted for each week an assignment is late.

4 4 Privacy: Faculty and students who utilize patient information as part of any educational experience must follow patient privacy and confidentiality guidelines outlined in the School of Nursing Handbook policy on research and clinical data. The Honor Pledge The University of Virginia has one of the oldest Honor Systems in the country. Integrity and honor and the Community of Trust are integral to our work together. I expect to see all of your work signed with the Honor Pledge, and more importantly, I expect that your signature signifies that you uphold the meaning of the Pledge. Individual assignments will not be accepted unless they are pledged. Required Texts: American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, DC: Author. Beauchamp, T.L., & Childress, J.F. (2001). Principles of Biomedical Ethics. 5 th Edition. New York: Oxford University Press. READINGS: Class #1: Overview Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates. Journal of Nursing Administration, 35(3), Reverby, S. (1999). Rethinking the Tuskegee syphilis study: nurse Rivers, silence and the meaning of treatment. Nursing History Review, 7, Lombardo, P. (2005). Law and ethics: an ongoing conversation. In Fletcher s Introduction to Clinical Ethics, 3 rd Edition, pp Class #2: Historical Foundations and Codes of Ethics Chafey, K., Rhea, M., Shannon, A.M., & Spencer, S. (1998). Characterizations of advocacy by practicing nurses. Journal of Professional Nursing, 14(1), Fowler, M. (1997). Nursing s ethics. In Davis, A.J., Aroskar, M.A., Liaschenko, J., & Drought, T.S., Eds. Ethical dilemmas and nursing practice, 4 th Ed. Stamford, CT: Appleton & Lange, pp Pellegrino, E.D. (1993). The metamorphosis of medical ethics. JAMA, 269, American Nurses Association. (2001). Code of Ethics for Nurses With Interpretive Statements. Washington, DC: Author.

5 Optional: Robb, I.H. (1900/1926). Nursing ethics: for hospital and private use. Cleveland, OH: E.C. Koeckert, Publisher, pp Class #3: Overview of Bioethics Theory; Autonomy Munson, R. (2000). Intervention and reflection: basic issues in medical ethics, 6 th Edition. US:Wadsworth, Introduction, pp Drane, J.F. (1994). Character and the moral life: a virtue approach to biomedical ethics. In DuBose, E.R., Hamel, R., & O Connell, L.J., Eds. A matter of principles? Ferment in U.S. bioethics, pp Valley Forge, PA: Trinity Press International. Beauchamp & Childress, Chapter 3 Class #4: Beneficence and Justice B&C, Chapters 4, pp ; 5, pp ; 6, pp , Toulmin, S. (1981). The tyranny of principles. Hastings Center Report, 11, Class #5: Care and Feminist Theory Carse, A.L. (1991). The voice of care : Implications for bioethical education. Journal of medicine and philosophy, 16, Gilligan, C. (1987). Moral orientation and moral development. In E.F. Kittay & D.T. Meyers, Eds. Women and moral theory. Savage, MD: Rowman & Littlefield, pp Wolf, S.M. (1996). Introduction: gender and feminism in bioethics. In S.M. Wolf, Ed. Feminism & bioethics: beyond reproduction, pp Beauchamp & Childress: Chapter 8, pp Class #6: Casuistry, Narrative, Ethical Decision-Making Frameworks Arras, J.D. (1997). Nice story, but so what? Narrative and justification in ethics. In Nelson, H.L., Ed. Stories and their limits: Narrative approaches to bioethics, pp Chambers, T. (1996). Dax redacted; the economies of truth in bioethics. Journal of medicine and philosophy, 21, Beauchamp & Childress: Chapter 9, pp Toulmin, S. (1994). Casuistry and clinical ethics. In DeBose, E.R., Hamel, R. & O Connell, L.J., Eds. A matter of principles? Ferment in U.S. bioethics, pp Valley Forge, PA: Trinity Press International. Jonsen, A.R. (1990). Case analysis in clinical ethics. Journal of clinical ethics, 1(1), Rubin, S.B. (**). Beyond the authoritative voice: casting a wide net in ethics consultation. In R. Charon & M. Montello, Eds. Stories matter: the role of narrative in medical ethics. New York: Routledge, pp

6 Chally, P.S. & Loriz, L. (1998). Ethics in the trenches: decision making in practice. AJN, 98(6), Spencer, E.M. (2005). A case method for consideration of moral problems. In Fletcher s Introduction to Clinical Ethics, 3 rd Edition, pp Hagerstown, MD: University Publishing Group. Class #7: Intra- and Inter-Professional Dilemmas Asch, D.A., Shea, J.A., Jedrziewski, M.K., & Bosk, C.L. (1997). The limits of suffering: critical care nurses views of hospital care at the end of life. Social Science Medicine, 45, Viens, D.C. (1994). Moral dilemmas experienced by nurse practitioners. Nurse Practitioner Forum, 5, Optional: Ceci, C. (2004). Nursing, knowledge and power: A case analysis. Social Science and Medicine, 59, Peter, Lunardi & Macfarlane (2004). Nursing resistance as ethical action: literature review. Journal of Advanced Nursing, 46, Hamric, A.B. (2001). Reflections on being in the middle. Nursing Outlook, 48, Hamric, AB. (2000a). Moral distress in everyday ethics. Nursing Outlook, 48, Stein, L.I., Watts, D.T., & Howell, T. (1990). The doctor-nurse game revisited. New England Journal of Medicine, 322, Class #8: Caring for Difficult Patients/Difficult Situations Liaschenko, J. (1994). Making a bridge: the moral work with patients we do not like. Journal of palliative care, 10(3), Levine, D.Z. (1999). What is our duty to a hateful patient? Differing approaches to a disruptive dialysis patient. American journal of kidney diseases, 34, Resnick, D.B. (2005). The patient s duty to adhere to prescribed treatment: An ethical analysis. Journal of Medicine and Philosophy, 30, Kelley, M. (2005). Limits on patient responsibility. Journal of Medicine and Philosophy, 30, Class #9: Working in an Institutional Context I: Clinical Leadership; Barriers & Facilitators to Building Ethical Environments Forrow, L., Arnold, R.M., & Parker, L.S. (1993). Preventive ethics: expanding the horizons of clinical ethics. Journal of Clinical Ethics, 4, Chambliss, D.E. (1996). Beyond caring: hospitals, nurses and the social organization of ethics. Chicago, IL: University of Chicago Press, pp. 1-11, Chapter 4,

7 Rodney, P., & Street, A. (2004). The moral climate of nursing practice: inquiry and action. In J.L. Storch, P. Rodney, & R. Starzomski, Eds. Toward a moral horizon: nursing ethics for leadership and practice. Toronto: Pearson Prentice Hall, pp Cooper, R.S., Frank, G.L., Hansen, M.M., Gouty, C.A. (2004). Key ethical issues encountered in healthcare organizations. Journal of Nursing Administration, 34(3), Class #10: Working in an Institutional Context II: Managed Care; Cost Containment; Organizational Ethics Mills, A.E. & Spencer, E.M. (2005). Introduction to organizational ethics. In Fletcher s introduction to clinical ethics, pp Werhane, P.H. (2000). Business ethics, stakeholder theory, and the ethics of healthcare organizations. Cambridge quarterly of healthcare ethics, 9, Fleck, L.M. & Squier, H. (1995). Facing the ethical challenges of managed care. Family practice management, October, Proenca, E.J. (2004). Ethics orientation as a mediator of organizational integrity in health services organizations. Health care management review, 29(1), Class #11: Ethics Committees; Finding and Using Institutional Resources Optional: Walker, M.U. (1993). Keeping moral space open: new images of ethics consulting. Hastings center report, 23(2), Aulisio, M.P., Arnold, R.M., & Youngner, S.J. (2000). Health care ethics consultation: nature, goals, and competencies. Annals of internal medicine, 133(1), McGee, G., Spanogle, J.P., Caplan, A.L., Penny, D. & Asch, D.A. (2002). Successes and failures of hospital ethics committees: A national survey of ethics committee chairs. Cambridge quarterly of healthcare ethics, 11, Class #12: Ethical Issues in the US Healthcare System Beauchamp & Childress, pp Optional: Leape, L.L. & Berwick, D.M. (2005). Five years after To Err is Human: What have we learned? JAMA, 293, Fryer-Edwards, K. (2004). Talking about harmful medical errors with patients. In Tough Talk: Helping Doctors approach difficult conversations. Seattle, WA: University of Washington; an Oncotalk project, pp Emanuel, E.J. (2002). Patient v. population: resolving the ethical dilemmas posed by treating patients as members of populations. In Danis, M., Clancy, C., & Churchill, L.R., Eds. Ethical dimensions of health policy.new York: Oxford University Press, pp

8 Gostin, L.O. (2005). Ethics, the constitution, and the dying process: the case of Theresa Marie Schiavo. JAMA, 293(19), Class #13: Ethical Issues and the Global Community Austin, W. (2004). Global health challenges, human rights, and nursing ethics. In J.L. Storch, P. Rodney, & R. Starzomski, Eds. Toward a moral horizon: nursing ethics for leadership and practice. Toronto: Pearson Prentice Hall, pp Dugger, C.W. (2004, July 12). An exodus of African nurses puts infants and the ill in peril. NY Times. Aiken, L.J., Buchan, J., Sochalski, J., Nichols, B., & Powell, M. (2004). Trends in international nurse migration. Health Affairs, 23 (3), Chaguturu, S., & Vallabhaneni, S. (2005). Aiding and abetting nursing crises at home and abroad. New England Journal of Medicine, 353, Class #14: Leadership Roles in Clinical Ethics and Beyond Holly, C.M., & Lyons, M. (1993). Increasing your decision-making role in ethical situations. Dimensions of Critical Care Nursing, 12, Wocial, L.D. (1996). Achieving collaboration in ethical decision making: strategies for nurses in clinical practice. Dimensions of Critical Care Nursing, 15, Suggested References for Assignments: Davis, A.J., Aroskar, M.A., Liaschenko, J., & Drought, T.S. (1997). Ethical Dilemmas and Nursing Practice. 4 th Edition. Stamford, CT: Appleton & Lange. Fletcher, John C., Spencer, E.M., & Lombardo, P.A., Eds. (2005). Fletcher s Introduction to Clinical Ethics. 3 rd Edition. Hagerstown, MD: University Publishing Group. Fry, S.T., & Veatch, R.M. (2006). Case Studies in Nursing Ethics. 3 rd Edition. Boston: Jones & Bartlett. Quick, Pragmatic Pocket Reference: Schroeter, K., Derse, A., Junkerman, C., & Schiedermayer, D. (2002). Practical ethics for nurses and nursing students. Hagerstown, MD: University Publishing Group.

GEORGE MASON UNIVERSITY College of Nursing and Health Science. NURS 660/PHIL 510 Seminar in the Ethics of Health Care (3)

GEORGE MASON UNIVERSITY College of Nursing and Health Science. NURS 660/PHIL 510 Seminar in the Ethics of Health Care (3) NURS 660/PHIL 510 Seminar in the Ethics of Health Care (3) Fall 1995 section 001 Robinson B, 105 Tuesday, 4:30 pm -7:10 pm MARY SILVA, RN, Ph.D Office: Rob. I, A373 Phone: 993-1909 (0) 425-6136 (H) Fall