E
Bogossian, F., & Kellett, S. (2010). Barriers to electronic portfolio access in the clinical set- ting. Nurse Education Today, 30(8), 768–772.
Garrett, B. M., & Jackson, C. (2006). A mobile clinical e-Portfolio for nursing and medi- cal students, using wireless personal digital assistants (PDAs). Nurse Education Today, 26(8), 647–654.
Garrett, B. M., MacPhee, M., & Jackson, C.
(2013). Of an ePortfolio for the assessment of clinical competence in a baccalaureate nursing program. Nurse Education Today, 33(10), 1207–1213.
Green, J., Wyllie, A., & Jackson, D. (2013).
Electronic portfolios in nursing education:
A review of the literature. Nurse Education in Practice, 14(1), 4–8.
Hill, T. L. (2012). The portfolio as a summa- tive assessment for the nursing student.
Teaching and Learning in Nursing, 7(4), 140–145.
Jonassen, D. (1991). Evaluating constructiv- ist learning. Educational Technology, 36(9), 28–33.
Jones, J. M., Sackett, K., Erdley, W. S., & Blyth, J. B. (2007). ePortfolios in nursing educa- tion: Not your mother’s resume. Annual Review of Nursing Education, 5, 245–258.
Oermann, M. H. (2002). Developing a profes- sional portfolio in nursing. Orthopaedic Nursing, 21(2), 73–78.
Pincombe, J., McKellar, l., Weise, M., Grinter, E., & Beresford, G. (2010). ePortfolio in midwifery practice: “The way of the future.” Women and Birth, 23(3), 94–102.
Yanhua, C., & Watson, R. (2011). A review of clinical competence assessment in nurs- ing. Nurse Education Today, 31(8), 832–836.
Janice M. Jones
E
THICALD
ECISIONM
AKINGDEFINITION
Ethics is a systematic approach to under- standing, analyzing, and distinguishing evaluating the ethics of a situation, personal
beliefs and values, and self-evaluating one’s personal strengths and challenges.
The ePortfolio is not without its limita- tions. Jones, Sackett, Erdley, and Blyth (2007) cite the amount of time spent by faculty to review ePortfolios and students’ complaints of the labor intensiveness of completing the ePortfolio as barriers to its use. These senti- ments were echoed by Bogossian and Kellett (2010) when implementing the ePortfolio within the framework of an actual clini- cal setting. Support from faculty was also cited as a limitation by Jones et al. (2007).
Garrett and Jackson (2006) proposed the use of a mobile clinical ePortfolio that would be directly linked to the student’s personal digi- tal assistant (PDA). This would decrease the time for documentation of competencies.
It is important to note that the ePortfolio should be differentiated from the paper port- folio. The ePortfolio needs to be portable in order to facilitate sharing of its contents with prospective employers, graduate admissions committees, faculty, and accreditation bod- ies. As a most cumbersome process in paper format, the ePortfolio serves an important purpose for students as well as practicing nursing professionals.
RECOMMENDATIONS
The underpinnings of the ePortfolio, such as refl ective practice, can help nurses grow both professionally and personally through- out their career. Although the ePortfolio can enhance the self-refl ective and critical-think- ing process, there are little empirical data to support the effectiveness of the ePortfolio for summative assessments, clinical compe- tence, and its use in refl ective practice for undergraduate students, new graduates, and advanced practice nurses. The ePortfolio may also need to be incorporated into different pedagogical approaches in nursing practice in both academic and clinical settings.
Benner, P. (1984). From novice to expert:
Excellence and power in clinical. Menlo Park, CA: Addison-Wesley.
ENE_20311_PTR_05_Alpha E_119-148_01-12-15.indd 131
ENE_20311_PTR_05_Alpha E_119-148_01-12-15.indd 131 1/10/2015 12:35:00 PM1/10/2015 12:35:00 PM
132 ■ ETHICAL DECISION MAKING
E
the nature of organizational relationships in which situations occur (Hardingham, 2004;
Pavlish, Brown-Saltzman, Jakel, & Rounkle, 2012). Complementary teaching method- ologies like interprofessional ethics rounds, classroom group reports, or use of case stud- ies in problem-solving teams can foster con- sideration of others’ values and conclusions (Garity, 2009; Robichaux, 2012).
SYNOPSIS
Ethical decision making is complex and described using multiple interchangeable terms that make understanding the process even more complicated. For nursing practice, the American Nurses Association Code of Ethics states that ethics is an integral part of the foundation of nursing and one that is not negotiable in any setting (ANA, 2001). For bac- calaureate nursing, the American Association of Colleges of Nurses (AACN, 2008) Essentials include two objectives on ethics. These are encouraging use of an ethical framework and the ethical principles of autonomy and justice in relation to ethical conduct and pre- vention of unethical practices (AACN, 2008).
The AACN Essentials of Masters Education for Advanced Practice Nurses, Essential III, objective 1, presses for ethical decision mak- ing and analysis of common ethical dilem- mas (AACN, 1996). Therefore, nurses receive instruction on bioethical principles in cur- ricula, but research has continuously found nurses to be ill prepared to address ethi- cal dilemmas (Dierckx de Casterle, Izumi, Godfrey, & Denhaerynck, 2008). Laabs (2012) found that advanced practice nurses have a high level of confi dence in their ability to manage clinical ethical problems, but their overall knowledge is low. Comrie (2012) found that junior and senior students did not recognize confl ict as part of patient care because they believed that they did not con- front individual moral issues in daily prac- tice during clinical rotations. Concurrently, new graduates base their clinical actions on individual ethical codes, eventually chang- ing with environmental pressure (Dierckx de Casterle et al., 2008; Ham, 2004).
right and wrong matters (Beauchamp &
Childress, 2013). Ethical decision making is a complex dynamic process where a moral problem is revisited from evolving perspec- tives as one reasons through the dilemma to reach a resolution (Beauchamp & Childress, 2013; Burkhardt & Nathaniel, 2014).
APPLICATION
Moral issues are present in almost every patient interaction. Moral reasoning plays a key role in ethical decision making, as does the person’s cultural background, the orga- nizational environment, practice experience, and knowledge of ethics. Because clinical ethical issues can differ from daily life expe- riences, norms learned during childhood are insuffi cient. Through practice, nurses learn over time how to be sensitive enough to iden- tify and address ethical dilemmas. Inability to pursue the right action due to organiza- tional constraints, when one knows it is the morally correct action to take, leads to moral distress, a negative feeling state (Corley, 2002), which can result in burnout. To hone ethical decision-making skills, nurses are encouraged to use refl ection to analyze their feelings and diffi cult situations they encoun- ter. Ethical sensitivity develops as one gains the personal capacity to assess responses and feelings of others and the ability to deal with the ethical confl ict (Park, Kjervik, Crandell,
& Oermann, 2012).
Numerous models facilitate making ethical decisions, most of which promote a step-by-step analysis of the moral problem.
Burkhardt and Nathaniel’s (2014) model pro- vides a framework similar to the nursing pro- cess that enables nurses to make decisions while requiring ongoing evaluation and assimilation of information. Steps include problem identifi cation, information gather- ing to clarify issues, exploration of strate- gies, strategy implementation, and outcome evaluation. Use of such models promotes a systematic method to critically analyze and refl ect on the ethical dilemma, but they do not take into account the ethical climate or
ETHICAL DECISION MAKING ■ 133
E
baccalaureate education for professional nurs- ing practice. New York, NY: Author.
American Nurses Association. (2001). ANA code of ethics. Retrieved from http://www .nursingworld.org/codeofethics
Beauchamp, T., & Childress, J. (2013). Principles of biomedical ethics. New York, NY: Oxford University Press.
Burkhardt, M., & Nathaniel, A. (2014).
Ethics and issues in contemporary nursing.
Stamford, CT: Cengage.
Comrie, R. (2012). An analysis of undergrad- uate and graduate student nurses’ moral sensitivity. Nursing Ethics, 19, 116–127.
Corley, M. C. (2002). Nurse moral distress:
A proposed theory and research agenda.
Nursing Ethics, 9, 636–650.
Dierckx de Casterle, B., Izumi, S., Godfrey, N., & Denhaerynck, K. (2008). Nurses’
responses to ethical dilemmas in nurs- ing practice: Meta-analysis. Journal of Advanced Nursing, 63, 540–549.
Garity, J. (2009). Fostering nursing stu- dents’ use of ethical theory and decision making models: Teaching strategies.
Learning in Health and Social Care, 8, 114–122.
Ham, K. (2004). Principled thinking: A com- parison of nursing students and expe- rienced nurses. Journal of Continuing Education in Nursing, 35, 66–73.
Hardingham, L. (2004). Integrity and moral residue: Nurses as participants in a moral community. Nursing Philosophy, 5, 127–134.
Laabs, C. (2012). Confi dence and knowledge regarding ethics among advanced prac- tice nurses. Nursing Education Perspectives, 33, 10–14.
Park, M., Kjervik D., Crandell J., & Oermann, M. H. (2012). The relationship of ethics education to moral sensitivity and moral reasoning skills of nursing students.
Nursing Ethics, 19, 568–580.
Pavlish, C., Brown-Saltzman, K., Jakel, P., & Rounkle, A. M. (2012). Nurses’
responses to ethical challenges in oncol- ogy practice: An ethnographic study.
Clinical Journal of Oncology Nursing, 16(6), 592–600.
Most entry-level nursing programs oper- ate in an institutionalized environment. A lone ethics course is provided because the primary focus of baccalaureate education is to instill knowledge and technical compe- tency for students to become generalists and pass the NCLEX. Faculty freely choose how to implement ethical principles in classes, often not having time to develop the student’s moral reasoning skills. No guidelines proffer faculty qualifi cations to teach ethics in com- parison to other program requirements.
RECOMMENDATIONS
The ability to make an ethical decision devel- ops over time. A college course on ethics may not suffi ce to prepare nurses to meet the growing ethical challenges they expe- rience at the bedside and in the workplace.
Continuous education of health care person- nel, to include faculty, on bioethical principles and ethical decision-making skills in relation to the nurse–patient relationship must occur throughout nursing curricula and as one’s career progresses. Special attention to the transition period from graduation to clinical practice, as in a nurse residency, may address moral reasoning lapses. Faculty must also be accomplished in the study of ethics as well as experienced in ethical decision making before being selected to teach an ethics class.
The need for scholarly inquiry on moral reasoning and ethical decision making in multiple areas is vast. Interprofessional team dynamics and identifi cation of forces infl uencing critical review of patient dilem- mas within these teams require study. High- fi delity simulation exercises could be used to discover types of moral issues that may arise during patient care experiences and how eth- ical decisions are reached among health care personnel.
American Association of Colleges of Nurses (AACN). (1996). The essentials of masters education for advanced practice nurses. New York, NY: Author.
American Association of Colleges of Nurses (AACN). (2008). The essentials of
ENE_20311_PTR_05_Alpha E_119-148_01-12-15.indd 133
ENE_20311_PTR_05_Alpha E_119-148_01-12-15.indd 133 1/10/2015 12:35:00 PM1/10/2015 12:35:00 PM
134 ■ ETHICS
E
of conduct (International Council of Nursing [ICN], 2012) established a social contract and guideline for ethical practice. Ethics is taught in a variety of formats to undergraduate and graduate nursing students. In the under- graduate study, the focus is often defi ning the terms, discussing values clarifi cation as a novice nurse, and providing examples of clinical application for future reference.
In graduate nursing courses, much of the work may be case based and additional top- ics include leadership and organizational