{"id":119,"date":"2021-08-24T19:37:24","date_gmt":"2021-08-24T19:37:24","guid":{"rendered":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/6-3-ethical-dilemmas\/"},"modified":"2025-02-18T18:43:02","modified_gmt":"2025-02-18T18:43:02","slug":"6-3-ethical-dilemmas","status":"publish","type":"chapter","link":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/6-3-ethical-dilemmas\/","title":{"raw":"6.3 Ethical Dilemmas","rendered":"6.3 Ethical Dilemmas"},"content":{"raw":"Nurses frequently find themselves involved in conflicts during client care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An <strong>[pb_glossary id=\"427\"]ethical dilemma[\/pb_glossary]<\/strong> results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.\n\nAn ethical dilemma can involve conflicting client\u2019s values, nurse values, health care provider\u2019s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.\n\nTable 6.3a. Examples of Ethical Issues Involving Nurses\n<div align=\"left\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<th class=\"shaded\" scope=\"col\"><strong>Workplace<\/strong><\/th>\n<th class=\"shaded\" scope=\"col\"><strong>Organizational Processes<\/strong><\/th>\n<th class=\"shaded\" scope=\"col\"><strong>Client Care<\/strong><\/th>\n<\/tr>\n<tr>\n<td>\n<ul>\n \t<li style=\"font-weight: 400\">High client acuity<\/li>\n \t<li style=\"font-weight: 400\">Inadequate staffing<\/li>\n \t<li style=\"font-weight: 400\">Overuse of agency staff<\/li>\n \t<li style=\"font-weight: 400\">Improper use of assistive personnel<\/li>\n \t<li style=\"font-weight: 400\">Practicing beyond one\u2019s scope of practice<\/li>\n \t<li style=\"font-weight: 400\">Floating to other units without appropriate orientation<\/li>\n \t<li style=\"font-weight: 400\">Horizontal violence\/workplace bullying<\/li>\n \t<li style=\"font-weight: 400\">Impaired coworkers<\/li>\n \t<li style=\"font-weight: 400\">Violation of client privacy on social media<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n \t<li style=\"font-weight: 400\">Paperwork and administrative task requirements<\/li>\n \t<li style=\"font-weight: 400\">Substituting outpatient for inpatient care<\/li>\n \t<li style=\"font-weight: 400\">Spending limits on care based on reimbursement codes for medical conditions<\/li>\n \t<li style=\"font-weight: 400\">Discharging clients too soon and expecting family members to provide care<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n \t<li>Reproduction Issues\n<ul>\n \t<li style=\"font-weight: 400\">Abortion<\/li>\n \t<li style=\"font-weight: 400\">Birth control methods<\/li>\n \t<li style=\"font-weight: 400\">Sterilization<\/li>\n \t<li style=\"font-weight: 400\">Alternative conception<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n \t<li>End-of-Life Issues\n<ul>\n \t<li style=\"font-weight: 400\">Physician-assisted suicide<\/li>\n \t<li style=\"font-weight: 400\">Withdrawal of food\/fluids<\/li>\n \t<li style=\"font-weight: 400\">Withdrawal of life support<\/li>\n \t<li style=\"font-weight: 400\">DNR\/DNI<\/li>\n \t<li>Full code despite a persistent vegetative state<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n \t<li>Genetics\n<ul>\n \t<li style=\"font-weight: 400\">Screening<\/li>\n \t<li style=\"font-weight: 400\">Stem cell research<\/li>\n \t<li style=\"font-weight: 400\">Cloning<\/li>\n<\/ul>\n<\/li>\n \t<li>Organ transplantation<\/li>\n \t<li>Client refusal of medications or treatments<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"textbox shaded \">\n<p class=\"arrow\">Read more about <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/\" target=\"_blank\" rel=\"noopener\">Ethics Topics and Articles<\/a> on the ANA website.<\/p>\n\n<\/div>\nAccording to the American Nurses Association (ANA), a nurse\u2019s ethical competence depends on several factors<sup>[footnote]American Nurses Association. (2021).<em> Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup>:\n<ul>\n \t<li style=\"font-weight: 400\">Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making<\/li>\n \t<li style=\"font-weight: 400\">An awareness of ethical obligations as mandated in the <em>Code of Ethics for Nurses With Interpretive Statements<\/em><sup>[footnote]American Nurses Association. (2015). <em>Code of ethics for nurses with interpretive statements.<\/em> American Nurses Association. <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/code-of-ethics-for-nurses\/coe-view-only\" target=\"_blank\" rel=\"noopener\">https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/code-of-ethics-for-nurses\/coe-view-only<\/a>\/[\/footnote]<\/sup><\/li>\n \t<li style=\"font-weight: 400\">Knowledge of ethical principles and their application to ethical decision-making<\/li>\n \t<li style=\"font-weight: 400\">Motivation and skills to implement an ethical decision<\/li>\n<\/ul>\nNurses and nursing students must have <strong>[pb_glossary id=\"428\"]moral courage[\/pb_glossary]<\/strong> to address the conflicts involved in ethical dilemmas with \u201cthe willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.\u201d<sup>[footnote]American Nurses Association (ANA). <em>Ethics topics and articles.<\/em> <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/<\/a>[\/footnote] <\/sup>See Figure 6.7<sup>[footnote]\u201cMoral courage.png\u201d by Meredith Pomietlo for <a href=\"https:\/\/www.cvtc.edu\/\" target=\"_blank\" rel=\"noopener\">Chippewa Valley Technical College<\/a>\u00a0is licensed under\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY 4.0<\/a>\u00a0[\/footnote]<\/sup> for an illustration of nurses\u2019 moral courage.\n\n[caption id=\"attachment_118\" align=\"aligncenter\" width=\"184\"]<img class=\"wp-image-118 \" title=\"\u201cMoral courage.png\u201d by Meredith Pomietlo for Chippewa Valley Technical College\u00a0is licensed under\u00a0CC BY 4.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-224x300.png\" alt=\"Image of a shield shaped icon with the caduceus symbol between letters R and N\" width=\"184\" height=\"247\"> Figure 6.12 Moral Courage[\/caption]\n\nNurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup> Nurses may experience <strong>[pb_glossary id=\"429\"]moral conflict[\/pb_glossary]<\/strong> when they are uncertain about what values or principles should be applied to an ethical issue that arises during client care. Moral conflict can progress to <strong>[pb_glossary id=\"430\"]moral distress[\/pb_glossary]<\/strong> when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel <strong>[pb_glossary id=\"431\"]moral outrage[\/pb_glossary]<\/strong> when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA <em>Nursing Code of Ethics.<\/em>\n\nMoral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. <strong>[pb_glossary id=\"520\"]Moral injury[\/pb_glossary]<\/strong> refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.<sup>[footnote]Norman, S. &amp; Maguen, S. (n.d.). <em>Moral injury.<\/em> PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. <a href=\"https:\/\/www.ptsd.va.gov\/professional\/treat\/cooccurring\/moral_injury.asp\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ptsd.va.gov\/professional\/treat\/cooccurring\/moral_injury.asp<\/a>[\/footnote]<\/sup> Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.<sup>[footnote]Dean, W., Jacobs, B., &amp; Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. <em>Annals of Emergency Medicine, 76<\/em>(4), 385\u2013386. <a href=\"https:\/\/doi.org\/10.1016\/j.annemergmed.2020.05.023\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.annemergmed.2020.05.023<\/a>[\/footnote]<\/sup>\n<div class=\"textbox shaded\">\n<p class=\"arrow\">Read more about self-care strategies to address feelings of burnout in the \"<a href=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/12-1-introduction\/\" target=\"_blank\" rel=\"noopener\">Burnout and Self-Care<\/a>\" chapter.<\/p>\n\n<\/div>\n<h2>Frameworks for Solving Ethical Dilemmas<\/h2>\nSystematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup> When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.\n<h3>Nursing Process Model<\/h3>\nThe nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup>\n\nTable 6.3b. Using the Nursing Process in Ethical Situations<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup>\n<div align=\"left\">\n<table class=\"grid\" style=\"height: 798px\">\n<tbody>\n<tr style=\"height: 48px\">\n<th class=\"shaded\" style=\"height: 48px;width: 238px\" scope=\"col\"><strong>Nursing Process Stage<\/strong><\/th>\n<th class=\"shaded\" style=\"height: 48px;width: 893px;padding-left: 40px\" scope=\"col\"><strong>Considerations<\/strong><\/th>\n<\/tr>\n<tr style=\"height: 175px\">\n<th style=\"height: 175px;width: 238px\" scope=\"row\"><strong>Assessment\/<\/strong><strong>Data Collection<\/strong><\/th>\n<td style=\"height: 175px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">What is the issue?<\/li>\n \t<li style=\"font-weight: 400\">Who is involved?<\/li>\n \t<li style=\"font-weight: 400\">What are the facts (health status, pain, treatment)?<\/li>\n \t<li style=\"font-weight: 400\">What are the stakeholder (client, family, health care team, community) concerns?<\/li>\n \t<li style=\"font-weight: 400\">What ethics resources exist (such as an organization\u2019s ethics committee)?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<th style=\"height: 125px;width: 238px\" scope=\"row\"><strong>Assessment\/<\/strong><strong>Analysis<\/strong><\/th>\n<td style=\"height: 125px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Analyze the facts and stakeholder values using ethical principles, ethical theories, the ANA <em>Nursing Code of Ethics<\/em>, or another ethical framework model.<\/li>\n \t<li style=\"font-weight: 400\">Document the ethics resources consulted.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 100px\">\n<th style=\"height: 100px;width: 238px\" scope=\"row\"><strong>Diagnosis<\/strong><\/th>\n<td style=\"height: 100px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Determine the care context and issues, including areas of agreement and conflict.<\/li>\n \t<li style=\"font-weight: 400\">Consider the entire context, including the client, family, health care team, and institutional circumstances.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Outcome Identification<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Establish a goal based on client autonomy.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Planning<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Identify a range of options, realizing there may only be \u201cbest available\u201d options when possibilities are limited.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<th style=\"height: 125px;width: 238px\" scope=\"row\"><strong>Implementation<\/strong><\/th>\n<td style=\"height: 125px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Ensure the option chosen is right, suitable, and appropriate. Be aware that not all options are appropriate in all contexts.<\/li>\n \t<li style=\"font-weight: 400\">Implement the plan in collaboration with the client, family, and other stakeholders.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Evaluation<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n \t<li style=\"font-weight: 400\">Evaluate what happened and what can be learned after every ethical dilemma.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>Four-Quadrant Approach<\/h3>\nThe four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup> See Table 6.3c for sample questions used during the four-quadrant approach.\n\nTable 6.3c. Four-Quadrant Approach<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote]<\/sup>\n<div align=\"left\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<td><strong>Health Care Indications <\/strong>\n\n<strong>(Beneficence and Nonmaleficence)<\/strong>\n<ul>\n \t<li style=\"font-weight: 400\">What is the diagnosis\/prognosis?<\/li>\n \t<li style=\"font-weight: 400\">What are the goals of treatment\/care?<\/li>\n \t<li style=\"font-weight: 400\">What is the likelihood of success of treatment?<\/li>\n \t<li style=\"font-weight: 400\">Will the proposed treatment plan benefit the client and avoid harm?<\/li>\n<\/ul>\n<\/td>\n<td><strong>Individual and Family Preferences<\/strong>\n\n<strong>(Respect for Autonomy)<\/strong>\n<ul>\n \t<li style=\"font-weight: 400\">What are the client\u2019s preferences?<\/li>\n \t<li style=\"font-weight: 400\">Does the client understand their condition?<\/li>\n \t<li style=\"font-weight: 400\">Has the client provided informed consent, and do they understand the risks and benefits of the proposed treatment?<\/li>\n \t<li style=\"font-weight: 400\">Is the client competent and capacitated to make decisions? If not, are there advance directives in place?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><strong>Quality of Life<\/strong>\n\n<strong>(Beneficence, Nonmaleficence, and Respect for Autonomy)<\/strong>\n<ul>\n \t<li style=\"font-weight: 400\">What is the probability of the client\u2019s return to normal life with or without treatment?<\/li>\n \t<li style=\"font-weight: 400\">Would the person experience any physical, mental, or social deficits even if the treatment succeeds?<\/li>\n \t<li style=\"font-weight: 400\">Do the health care providers have any biases that might prejudice their evaluation of the client\u2019s quality of life?<\/li>\n \t<li style=\"font-weight: 400\">Has forgoing treatment been discussed?<\/li>\n \t<li style=\"font-weight: 400\">Are there plans for comfort and\/or palliative care?<\/li>\n<\/ul>\n<\/td>\n<td><strong>Contextual Features<\/strong>\n\n<strong>(Justice and Fairness)<\/strong>\n<ul>\n \t<li style=\"font-weight: 400\">Are there family or provider issues, such as implicit bias, that might influence treatment decisions?<\/li>\n \t<li style=\"font-weight: 400\">Are there religious, financial, social, racial, or legal issues that might affect treatment decisions?<\/li>\n \t<li style=\"font-weight: 400\">Are there issues related to allocation of resources that might affect treatment?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>MORAL Model<\/h3>\nThe MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.<sup>[footnote]American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association.[\/footnote],[footnote]Crisham, P. (1985). Moral: How can I do what is right? <em>Nursing Management, 16<\/em>(3), 44. <a href=\"https:\/\/journals.lww.com\/nursingmanagement\/citation\/1985\/03000\/moral__how_can_i_do_what_s_right_.6.aspx\" target=\"_blank\" rel=\"noopener\">https:\/\/journals.lww.com\/nursingmanagement\/citation\/1985\/03000\/moral__how_can_i_do_what_s_right_.6.aspx<\/a>[\/footnote]<\/sup>\n\nTable 6.3d. MORAL Model\n<div align=\"left\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>M: Massage the dilemma<\/strong><\/th>\n<td style=\"width: 865px\">Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>O: Outline options<\/strong><\/th>\n<td style=\"width: 865px\">Generate several effective alternatives to reach the goal.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>R: Review criteria and resolve<\/strong><\/th>\n<td style=\"width: 865px\">Identify moral criteria and select the course of action.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>A: Affirm position and act<\/strong><\/th>\n<td style=\"width: 865px\">Implement action based on knowledge from the previous steps (M-O-R).<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>L: Look back<\/strong><\/th>\n<td style=\"width: 865px\">Evaluate each step and the decision made.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>PLUS Ethical Decision-Making Model<\/h3>\nThe PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:\n<ul>\n \t<li style=\"font-weight: 400\"><strong>P:<\/strong> Policies, procedures, and guidelines of an organization<\/li>\n \t<li style=\"font-weight: 400\"><strong>L:<\/strong> Laws and regulations<\/li>\n \t<li style=\"font-weight: 400\"><strong>U:<\/strong> Universal values and principles of an organization<\/li>\n \t<li style=\"font-weight: 400\"><strong>S:<\/strong> Self-identification of what is good, right, fair, and equitable<sup>[footnote]Ethics &amp; Compliance Initiative. (2021). <em>The PLUS Ethical Decision Making Model<\/em>. <a href=\"https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/<\/a>[\/footnote]<\/sup><\/li>\n<\/ul>\nThe seven steps of the PLUS Ethical Decision-Making model are as follows<sup>[footnote]Ethics &amp; Compliance Initiative. (2021). <em>The PLUS Ethical Decision Making Model<\/em>. <a href=\"https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/<\/a>[\/footnote]<\/sup>:\n<ul>\n \t<li style=\"font-weight: 400\">Define the problem using PLUS filters<\/li>\n \t<li style=\"font-weight: 400\">Seek relevant assistance, guidance, and support<\/li>\n \t<li style=\"font-weight: 400\">Identify available alternatives<\/li>\n \t<li style=\"font-weight: 400\">Evaluate the alternatives using PLUS to identify their impact<\/li>\n \t<li style=\"font-weight: 400\">Make the decision<\/li>\n \t<li style=\"font-weight: 400\">Implement the decision<\/li>\n \t<li style=\"font-weight: 400\">Evaluate the decision using PLUS filters<\/li>\n<\/ul>","rendered":"<p>Nurses frequently find themselves involved in conflicts during client care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_427\">ethical dilemma<\/a><\/strong> results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.<\/p>\n<p>An ethical dilemma can involve conflicting client\u2019s values, nurse values, health care provider\u2019s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.<\/p>\n<p>Table 6.3a. Examples of Ethical Issues Involving Nurses<\/p>\n<div style=\"text-align: left;\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<th class=\"shaded\" scope=\"col\"><strong>Workplace<\/strong><\/th>\n<th class=\"shaded\" scope=\"col\"><strong>Organizational Processes<\/strong><\/th>\n<th class=\"shaded\" scope=\"col\"><strong>Client Care<\/strong><\/th>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li style=\"font-weight: 400\">High client acuity<\/li>\n<li style=\"font-weight: 400\">Inadequate staffing<\/li>\n<li style=\"font-weight: 400\">Overuse of agency staff<\/li>\n<li style=\"font-weight: 400\">Improper use of assistive personnel<\/li>\n<li style=\"font-weight: 400\">Practicing beyond one\u2019s scope of practice<\/li>\n<li style=\"font-weight: 400\">Floating to other units without appropriate orientation<\/li>\n<li style=\"font-weight: 400\">Horizontal violence\/workplace bullying<\/li>\n<li style=\"font-weight: 400\">Impaired coworkers<\/li>\n<li style=\"font-weight: 400\">Violation of client privacy on social media<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li style=\"font-weight: 400\">Paperwork and administrative task requirements<\/li>\n<li style=\"font-weight: 400\">Substituting outpatient for inpatient care<\/li>\n<li style=\"font-weight: 400\">Spending limits on care based on reimbursement codes for medical conditions<\/li>\n<li style=\"font-weight: 400\">Discharging clients too soon and expecting family members to provide care<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li>Reproduction Issues\n<ul>\n<li style=\"font-weight: 400\">Abortion<\/li>\n<li style=\"font-weight: 400\">Birth control methods<\/li>\n<li style=\"font-weight: 400\">Sterilization<\/li>\n<li style=\"font-weight: 400\">Alternative conception<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>End-of-Life Issues\n<ul>\n<li style=\"font-weight: 400\">Physician-assisted suicide<\/li>\n<li style=\"font-weight: 400\">Withdrawal of food\/fluids<\/li>\n<li style=\"font-weight: 400\">Withdrawal of life support<\/li>\n<li style=\"font-weight: 400\">DNR\/DNI<\/li>\n<li>Full code despite a persistent vegetative state<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Genetics\n<ul>\n<li style=\"font-weight: 400\">Screening<\/li>\n<li style=\"font-weight: 400\">Stem cell research<\/li>\n<li style=\"font-weight: 400\">Cloning<\/li>\n<\/ul>\n<\/li>\n<li>Organ transplantation<\/li>\n<li>Client refusal of medications or treatments<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div class=\"textbox shaded\">\n<p class=\"arrow\">Read more about <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/\" target=\"_blank\" rel=\"noopener\">Ethics Topics and Articles<\/a> on the ANA website.<\/p>\n<\/div>\n<p>According to the American Nurses Association (ANA), a nurse\u2019s ethical competence depends on several factors<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-1\" href=\"#footnote-119-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><\/sup>:<\/p>\n<ul>\n<li style=\"font-weight: 400\">Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making<\/li>\n<li style=\"font-weight: 400\">An awareness of ethical obligations as mandated in the <em>Code of Ethics for Nurses With Interpretive Statements<\/em><sup><a class=\"footnote\" title=\"American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/code-of-ethics-for-nurses\/coe-view-only\/\" id=\"return-footnote-119-2\" href=\"#footnote-119-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/sup><\/li>\n<li style=\"font-weight: 400\">Knowledge of ethical principles and their application to ethical decision-making<\/li>\n<li style=\"font-weight: 400\">Motivation and skills to implement an ethical decision<\/li>\n<\/ul>\n<p>Nurses and nursing students must have <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_428\">moral courage<\/a><\/strong> to address the conflicts involved in ethical dilemmas with \u201cthe willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.\u201d<sup><a class=\"footnote\" title=\"American Nurses Association (ANA). Ethics topics and articles. https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/\" id=\"return-footnote-119-3\" href=\"#footnote-119-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a> <\/sup>See Figure 6.7<sup><a class=\"footnote\" title=\"\u201cMoral courage.png\u201d by Meredith Pomietlo for Chippewa Valley Technical College\u00a0is licensed under\u00a0CC BY 4.0\u00a0\" id=\"return-footnote-119-4\" href=\"#footnote-119-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/sup> for an illustration of nurses\u2019 moral courage.<\/p>\n<figure id=\"attachment_118\" aria-describedby=\"caption-attachment-118\" style=\"width: 184px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-118\" title=\"\u201cMoral courage.png\u201d by Meredith Pomietlo for Chippewa Valley Technical College\u00a0is licensed under\u00a0CC BY 4.0\" src=\"https:\/\/pressbooks.ccconline.org\/accphysicalgeology\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-224x300.png\" alt=\"Image of a shield shaped icon with the caduceus symbol between letters R and N\" width=\"184\" height=\"247\" srcset=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-224x300.png 224w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-763x1024.png 763w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-768x1030.png 768w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-1145x1536.png 1145w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-1527x2048.png 1527w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-65x87.png 65w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-225x302.png 225w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage-350x469.png 350w, https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-content\/uploads\/sites\/225\/2021\/08\/Moral-Courage.png 1676w\" sizes=\"auto, (max-width: 184px) 100vw, 184px\" \/><figcaption id=\"caption-attachment-118\" class=\"wp-caption-text\">Figure 6.12 Moral Courage<\/figcaption><\/figure>\n<p>Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-5\" href=\"#footnote-119-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><\/sup> Nurses may experience <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_429\">moral conflict<\/a><\/strong> when they are uncertain about what values or principles should be applied to an ethical issue that arises during client care. Moral conflict can progress to <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_430\">moral distress<\/a><\/strong> when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_431\">moral outrage<\/a><\/strong> when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA <em>Nursing Code of Ethics.<\/em><\/p>\n<p>Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. <strong><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_119_520\">Moral injury<\/a><\/strong> refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.<sup><a class=\"footnote\" title=\"Norman, S. &amp; Maguen, S. (n.d.). Moral injury. PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. https:\/\/www.ptsd.va.gov\/professional\/treat\/cooccurring\/moral_injury.asp\" id=\"return-footnote-119-6\" href=\"#footnote-119-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/sup> Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.<sup><a class=\"footnote\" title=\"Dean, W., Jacobs, B., &amp; Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. Annals of Emergency Medicine, 76(4), 385\u2013386. https:\/\/doi.org\/10.1016\/j.annemergmed.2020.05.023\" id=\"return-footnote-119-7\" href=\"#footnote-119-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/sup><\/p>\n<div class=\"textbox shaded\">\n<p class=\"arrow\">Read more about self-care strategies to address feelings of burnout in the &#8220;<a href=\"https:\/\/pressbooks.ccconline.org\/accnursing2030\/chapter\/12-1-introduction\/\" target=\"_blank\" rel=\"noopener\">Burnout and Self-Care<\/a>&#8221; chapter.<\/p>\n<\/div>\n<h2>Frameworks for Solving Ethical Dilemmas<\/h2>\n<p>Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-8\" href=\"#footnote-119-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><\/sup> When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.<\/p>\n<h3>Nursing Process Model<\/h3>\n<p>The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-9\" href=\"#footnote-119-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a><\/sup><\/p>\n<p>Table 6.3b. Using the Nursing Process in Ethical Situations<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-10\" href=\"#footnote-119-10\" aria-label=\"Footnote 10\"><sup class=\"footnote\">[10]<\/sup><\/a><\/sup><\/p>\n<div style=\"text-align: left;\">\n<table class=\"grid\" style=\"height: 798px\">\n<tbody>\n<tr style=\"height: 48px\">\n<th class=\"shaded\" style=\"height: 48px;width: 238px\" scope=\"col\"><strong>Nursing Process Stage<\/strong><\/th>\n<th class=\"shaded\" style=\"height: 48px;width: 893px;padding-left: 40px\" scope=\"col\"><strong>Considerations<\/strong><\/th>\n<\/tr>\n<tr style=\"height: 175px\">\n<th style=\"height: 175px;width: 238px\" scope=\"row\"><strong>Assessment\/<\/strong><strong>Data Collection<\/strong><\/th>\n<td style=\"height: 175px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">What is the issue?<\/li>\n<li style=\"font-weight: 400\">Who is involved?<\/li>\n<li style=\"font-weight: 400\">What are the facts (health status, pain, treatment)?<\/li>\n<li style=\"font-weight: 400\">What are the stakeholder (client, family, health care team, community) concerns?<\/li>\n<li style=\"font-weight: 400\">What ethics resources exist (such as an organization\u2019s ethics committee)?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<th style=\"height: 125px;width: 238px\" scope=\"row\"><strong>Assessment\/<\/strong><strong>Analysis<\/strong><\/th>\n<td style=\"height: 125px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Analyze the facts and stakeholder values using ethical principles, ethical theories, the ANA <em>Nursing Code of Ethics<\/em>, or another ethical framework model.<\/li>\n<li style=\"font-weight: 400\">Document the ethics resources consulted.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 100px\">\n<th style=\"height: 100px;width: 238px\" scope=\"row\"><strong>Diagnosis<\/strong><\/th>\n<td style=\"height: 100px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Determine the care context and issues, including areas of agreement and conflict.<\/li>\n<li style=\"font-weight: 400\">Consider the entire context, including the client, family, health care team, and institutional circumstances.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Outcome Identification<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Establish a goal based on client autonomy.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Planning<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Identify a range of options, realizing there may only be \u201cbest available\u201d options when possibilities are limited.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<th style=\"height: 125px;width: 238px\" scope=\"row\"><strong>Implementation<\/strong><\/th>\n<td style=\"height: 125px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Ensure the option chosen is right, suitable, and appropriate. Be aware that not all options are appropriate in all contexts.<\/li>\n<li style=\"font-weight: 400\">Implement the plan in collaboration with the client, family, and other stakeholders.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 75px\">\n<th style=\"height: 75px;width: 238px\" scope=\"row\"><strong>Evaluation<\/strong><\/th>\n<td style=\"height: 75px;width: 893px\">\n<ul>\n<li style=\"font-weight: 400\">Evaluate what happened and what can be learned after every ethical dilemma.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>Four-Quadrant Approach<\/h3>\n<p>The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-11\" href=\"#footnote-119-11\" aria-label=\"Footnote 11\"><sup class=\"footnote\">[11]<\/sup><\/a><\/sup> See Table 6.3c for sample questions used during the four-quadrant approach.<\/p>\n<p>Table 6.3c. Four-Quadrant Approach<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-12\" href=\"#footnote-119-12\" aria-label=\"Footnote 12\"><sup class=\"footnote\">[12]<\/sup><\/a><\/sup><\/p>\n<div style=\"text-align: left;\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<td><strong>Health Care Indications <\/strong><\/p>\n<p><strong>(Beneficence and Nonmaleficence)<\/strong><\/p>\n<ul>\n<li style=\"font-weight: 400\">What is the diagnosis\/prognosis?<\/li>\n<li style=\"font-weight: 400\">What are the goals of treatment\/care?<\/li>\n<li style=\"font-weight: 400\">What is the likelihood of success of treatment?<\/li>\n<li style=\"font-weight: 400\">Will the proposed treatment plan benefit the client and avoid harm?<\/li>\n<\/ul>\n<\/td>\n<td><strong>Individual and Family Preferences<\/strong><\/p>\n<p><strong>(Respect for Autonomy)<\/strong><\/p>\n<ul>\n<li style=\"font-weight: 400\">What are the client\u2019s preferences?<\/li>\n<li style=\"font-weight: 400\">Does the client understand their condition?<\/li>\n<li style=\"font-weight: 400\">Has the client provided informed consent, and do they understand the risks and benefits of the proposed treatment?<\/li>\n<li style=\"font-weight: 400\">Is the client competent and capacitated to make decisions? If not, are there advance directives in place?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr>\n<td><strong>Quality of Life<\/strong><\/p>\n<p><strong>(Beneficence, Nonmaleficence, and Respect for Autonomy)<\/strong><\/p>\n<ul>\n<li style=\"font-weight: 400\">What is the probability of the client\u2019s return to normal life with or without treatment?<\/li>\n<li style=\"font-weight: 400\">Would the person experience any physical, mental, or social deficits even if the treatment succeeds?<\/li>\n<li style=\"font-weight: 400\">Do the health care providers have any biases that might prejudice their evaluation of the client\u2019s quality of life?<\/li>\n<li style=\"font-weight: 400\">Has forgoing treatment been discussed?<\/li>\n<li style=\"font-weight: 400\">Are there plans for comfort and\/or palliative care?<\/li>\n<\/ul>\n<\/td>\n<td><strong>Contextual Features<\/strong><\/p>\n<p><strong>(Justice and Fairness)<\/strong><\/p>\n<ul>\n<li style=\"font-weight: 400\">Are there family or provider issues, such as implicit bias, that might influence treatment decisions?<\/li>\n<li style=\"font-weight: 400\">Are there religious, financial, social, racial, or legal issues that might affect treatment decisions?<\/li>\n<li style=\"font-weight: 400\">Are there issues related to allocation of resources that might affect treatment?<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>MORAL Model<\/h3>\n<p>The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.<sup><a class=\"footnote\" title=\"American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.\" id=\"return-footnote-119-13\" href=\"#footnote-119-13\" aria-label=\"Footnote 13\"><sup class=\"footnote\">[13]<\/sup><\/a>,<a class=\"footnote\" title=\"Crisham, P. (1985). Moral: How can I do what is right? Nursing Management, 16(3), 44. https:\/\/journals.lww.com\/nursingmanagement\/citation\/1985\/03000\/moral__how_can_i_do_what_s_right_.6.aspx\" id=\"return-footnote-119-14\" href=\"#footnote-119-14\" aria-label=\"Footnote 14\"><sup class=\"footnote\">[14]<\/sup><\/a><\/sup><\/p>\n<p>Table 6.3d. MORAL Model<\/p>\n<div style=\"text-align: left;\">\n<table class=\"grid\">\n<tbody>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>M: Massage the dilemma<\/strong><\/th>\n<td style=\"width: 865px\">Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>O: Outline options<\/strong><\/th>\n<td style=\"width: 865px\">Generate several effective alternatives to reach the goal.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>R: Review criteria and resolve<\/strong><\/th>\n<td style=\"width: 865px\">Identify moral criteria and select the course of action.<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>A: Affirm position and act<\/strong><\/th>\n<td style=\"width: 865px\">Implement action based on knowledge from the previous steps (M-O-R).<\/td>\n<\/tr>\n<tr>\n<th style=\"width: 266px\" scope=\"row\"><strong>L: Look back<\/strong><\/th>\n<td style=\"width: 865px\">Evaluate each step and the decision made.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<h3>PLUS Ethical Decision-Making Model<\/h3>\n<p>The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:<\/p>\n<ul>\n<li style=\"font-weight: 400\"><strong>P:<\/strong> Policies, procedures, and guidelines of an organization<\/li>\n<li style=\"font-weight: 400\"><strong>L:<\/strong> Laws and regulations<\/li>\n<li style=\"font-weight: 400\"><strong>U:<\/strong> Universal values and principles of an organization<\/li>\n<li style=\"font-weight: 400\"><strong>S:<\/strong> Self-identification of what is good, right, fair, and equitable<sup><a class=\"footnote\" title=\"Ethics &amp; Compliance Initiative. (2021). The PLUS Ethical Decision Making Model. https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" id=\"return-footnote-119-15\" href=\"#footnote-119-15\" aria-label=\"Footnote 15\"><sup class=\"footnote\">[15]<\/sup><\/a><\/sup><\/li>\n<\/ul>\n<p>The seven steps of the PLUS Ethical Decision-Making model are as follows<sup><a class=\"footnote\" title=\"Ethics &amp; Compliance Initiative. (2021). The PLUS Ethical Decision Making Model. https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" id=\"return-footnote-119-16\" href=\"#footnote-119-16\" aria-label=\"Footnote 16\"><sup class=\"footnote\">[16]<\/sup><\/a><\/sup>:<\/p>\n<ul>\n<li style=\"font-weight: 400\">Define the problem using PLUS filters<\/li>\n<li style=\"font-weight: 400\">Seek relevant assistance, guidance, and support<\/li>\n<li style=\"font-weight: 400\">Identify available alternatives<\/li>\n<li style=\"font-weight: 400\">Evaluate the alternatives using PLUS to identify their impact<\/li>\n<li style=\"font-weight: 400\">Make the decision<\/li>\n<li style=\"font-weight: 400\">Implement the decision<\/li>\n<li style=\"font-weight: 400\">Evaluate the decision using PLUS filters<\/li>\n<\/ul>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-119-1\">American Nurses Association. (2021).<em> Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-119-2\">American Nurses Association. (2015). <em>Code of ethics for nurses with interpretive statements.<\/em> American Nurses Association. <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/code-of-ethics-for-nurses\/coe-view-only\" target=\"_blank\" rel=\"noopener\">https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/code-of-ethics-for-nurses\/coe-view-only<\/a>\/ <a href=\"#return-footnote-119-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-119-3\">American Nurses Association (ANA). <em>Ethics topics and articles.<\/em> <a href=\"https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.nursingworld.org\/practice-policy\/nursing-excellence\/ethics\/ethics-topics-and-articles\/<\/a> <a href=\"#return-footnote-119-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-119-4\">\u201cMoral courage.png\u201d by Meredith Pomietlo for <a href=\"https:\/\/www.cvtc.edu\/\" target=\"_blank\" rel=\"noopener\">Chippewa Valley Technical College<\/a>\u00a0is licensed under\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY 4.0<\/a>\u00a0 <a href=\"#return-footnote-119-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-119-5\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-119-6\">Norman, S. &amp; Maguen, S. (n.d.). <em>Moral injury.<\/em> PTSD: National Center for PTSD, U.S. Department of Veterans Affairs. <a href=\"https:\/\/www.ptsd.va.gov\/professional\/treat\/cooccurring\/moral_injury.asp\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ptsd.va.gov\/professional\/treat\/cooccurring\/moral_injury.asp<\/a> <a href=\"#return-footnote-119-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-119-7\">Dean, W., Jacobs, B., &amp; Manfredi, R. A. (2020). Moral injury: The invisible epidemic in COVID health care workers. <em>Annals of Emergency Medicine, 76<\/em>(4), 385\u2013386. <a href=\"https:\/\/doi.org\/10.1016\/j.annemergmed.2020.05.023\" target=\"_blank\" rel=\"noopener\">https:\/\/doi.org\/10.1016\/j.annemergmed.2020.05.023<\/a> <a href=\"#return-footnote-119-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-119-8\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-119-9\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><li id=\"footnote-119-10\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-10\" class=\"return-footnote\" aria-label=\"Return to footnote 10\">&crarr;<\/a><\/li><li id=\"footnote-119-11\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-11\" class=\"return-footnote\" aria-label=\"Return to footnote 11\">&crarr;<\/a><\/li><li id=\"footnote-119-12\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-12\" class=\"return-footnote\" aria-label=\"Return to footnote 12\">&crarr;<\/a><\/li><li id=\"footnote-119-13\">American Nurses Association. (2021). <em>Nursing: Scope and standards of practice<\/em> (4th ed.). American Nurses Association. <a href=\"#return-footnote-119-13\" class=\"return-footnote\" aria-label=\"Return to footnote 13\">&crarr;<\/a><\/li><li id=\"footnote-119-14\">Crisham, P. (1985). Moral: How can I do what is right? <em>Nursing Management, 16<\/em>(3), 44. <a href=\"https:\/\/journals.lww.com\/nursingmanagement\/citation\/1985\/03000\/moral__how_can_i_do_what_s_right_.6.aspx\" target=\"_blank\" rel=\"noopener\">https:\/\/journals.lww.com\/nursingmanagement\/citation\/1985\/03000\/moral__how_can_i_do_what_s_right_.6.aspx<\/a> <a href=\"#return-footnote-119-14\" class=\"return-footnote\" aria-label=\"Return to footnote 14\">&crarr;<\/a><\/li><li id=\"footnote-119-15\">Ethics &amp; Compliance Initiative. (2021). <em>The PLUS Ethical Decision Making Model<\/em>. <a href=\"https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/<\/a> <a href=\"#return-footnote-119-15\" class=\"return-footnote\" aria-label=\"Return to footnote 15\">&crarr;<\/a><\/li><li id=\"footnote-119-16\">Ethics &amp; Compliance Initiative. (2021). <em>The PLUS Ethical Decision Making Model<\/em>. <a href=\"https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/\" target=\"_blank\" rel=\"noopener\">https:\/\/www.ethics.org\/resources\/free-toolkit\/decision-making-model\/<\/a> <a href=\"#return-footnote-119-16\" class=\"return-footnote\" aria-label=\"Return to footnote 16\">&crarr;<\/a><\/li><\/ol><\/div><div class=\"glossary\"><span class=\"screen-reader-text\" id=\"definition\">definition<\/span><template id=\"term_119_427\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_427\"><div tabindex=\"-1\"><p>Conflict resulting from competing values that requires a decision to be made from equally desirable or undesirable options.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_119_428\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_428\"><div tabindex=\"-1\"><p>The willingness of an individual to speak out and do what is right in the face of forces that would lead us to act in some other way.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_119_429\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_429\"><div tabindex=\"-1\"><p>Feelings occurring when an individual is uncertain about what values or principles should be applied to an ethical issue.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_119_430\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_430\"><div tabindex=\"-1\"><p>Feelings occurring when correct ethical action is identified but the individual feels constrained by competing values of an organization or other individuals.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_119_431\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_431\"><div tabindex=\"-1\"><p>Feelings occurring when an individual witnesses immoral acts or practices they feel powerless to change.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_119_520\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_119_520\"><div tabindex=\"-1\"><p>Distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><\/div>","protected":false},"author":32,"menu_order":3,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[48],"contributor":[],"license":[],"class_list":["post-119","chapter","type-chapter","status-publish","hentry","chapter-type-numberless"],"part":107,"_links":{"self":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/119","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/users\/32"}],"version-history":[{"count":2,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/119\/revisions"}],"predecessor-version":[{"id":556,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/119\/revisions\/556"}],"part":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/parts\/107"}],"metadata":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapters\/119\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/media?parent=119"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/pressbooks\/v2\/chapter-type?post=119"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/contributor?post=119"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accnursing2030\/wp-json\/wp\/v2\/license?post=119"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}