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Define a critical thinking task that your staff does frequently (Examples: treat high blood sugar, address low blood pressure, pain management, treating fever etc.). Create a concept map or flow chart of the critical thinking process nurses should take to determining the correct intervention. Include how much autonomy a nurse should have to apply personal wisdom to the process. If the critical thinking process was automated list two instances where a nurse may use “wisdom” to override the automated outcome suggested. Note the risks and benefits of using clinical decision making systems.
A critical thinking task that staff on our unit are frequently challenged with is treating low blood glucose levels, which are considered to be a blood glucose level less than 80 mg/dl. The flow chart that follows is what our diabetic educators would like to see being done by nurses to address low blood glucose levels.
Although the flow chart is straight forward and easy to follow, nurses often use nursing wisdom, which is based on their knowledge and experience (McGonigle & Mastrian, 2012). For example, rather than giving orange juice or one tube of glucose gel and rechecking a patient’s blood glucose in 15 minutes, nurses may wait for a breakfast tray to arrive and recheck a patient’s blood glucose after breakfast. Possible risks include a patient not eating his or her breakfast and their blood sugar continuing to drop. Possible benefits are a patient eats his or her breakfast and his or her blood sugar returns to normal. However, there are applications in the computer where a diabetic educator is able to view when a patient had a low blood sugar and it was not rechecked in a timely manner to ensure that the blood glucose returned to normal. Managers are often being talked to by diabetic educators, because nursing staff at times decide to use their own judgment when treating low blood sugars rather than following the hospital protocol and then nurses are forced to explain their decisions. Thus, the importance of documenting and ensuring a patient’s blood glucose has returned to normal, even though the flow chart was not implemented is often emphasized.
Describe an ethical dilemma that could occur in your organization. Apply the ethical decision making model. Using the detailed analysis of alternative actions (Chapter 5, Table 5-1) create a table analyzing potential alternative solutions for your dilemma.
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Description of Dilemma
Nurse precepting a new graduate nurse gets frustrated that she has to leave work late, because the graduate nurse forgets to sign off her medications in the computer. The experienced nurse signs off the medications, because she assumes they were given by the graduate nurse.
Ethical Model for Ethical Decision Making
Examine the ethical dilemma
An experienced nurse thinks it is appropriate to document the administration of medication for a new nurse who often forgets to sign of her medication. The experienced nurse has commitments after work and needs to leave in a timely manner. However, the experienced nurse has a responsibility of ensuring medications are administered correctly, which included proper documentation by the new nurse. As a preceptor, the experienced nurse also has an obligation to ensure the new nurse is educated on hospital policy, which includes documenting medication. She may have solved her problem by documenting the administration of medication for the new nurse, but she violated hospital policy of proper administration of medication.
Thoroughly Comprehend the Possible Alternatives Available
The possible alternatives available include:
(1) If the new nurse was behind, the experienced nurse could have helped with the administration of medication.
(2) The experienced nurse could have educated the new nurse on hospital policy of medication administration. The experienced nurse could have instructed the new nurse that medications should not be administered without verification of the MAR on the computer and should be signed off as they are being administered.
(3) The new nurse could have fewer patients to concentrate on providing care until she demonstrates she could safely care for more than a few patients.
Hypothesize Ethical Arguments
The utilitarian approach can be applied to this example. In this example, there is a violation of hospital policy, which is created to ensure positive patient outcomes and patient safety. The experienced nurse trusted that the new nurse was giving the medications to the patients. However, she did not visualize patient administration, so she could not be positive. Also, the experienced nurse is responsible, while precepting the new nurse to ensure the new nurse is providing care correctly, which includes documenting medications correctly. To ensure the greatest good for the greatest number of people, the experienced nurse needs to make sure the new nurse is documenting medications correctly (McGonigle & Mastrian, 2012). This will ensure the new nurse understands hospital policy and patients are not harmed. Do the nurse’s personal obligations outweigh documenting medications for the new nurse? No, patient safety comes first. The experienced nurse compromised patient safety for her personal needs and did not educate the new nurse on adequate administration of medication, which could result in harming many patients.
Investigate, Compare, and Evaluate the Arguments for Each Alternative
Ethical Decision Making Alternative Actions Analysis Grid
Alternative Good Consequences Bad Consequences Do any rules nullify? Expected Outcome? Potential Benefit > Harm
Help new nurse with administration of medication Patient safety is ensured. The new nurse is not learning how to care for a full load of patients. No Best: Patients are safe and experienced nurse leaves on time.
Worst: Medication administration may take a long time and experienced nurse leaves late Patient safety ensured. New nurse understands the importance of documenting medications as they are administered. Patient safety is the greater benefit.
Educate the new nurse on hospital medication policy Patient safety is ensured. New nurse may feel overwhelmed and unable to properly administer medications on a full load of patients. No Best: New nurse properly administers medications to patients
Worst: New nurse is unable to finish administration of medication on all her assigned patients Patient safety is priority. The benefit is greater than the harm. New nurse is practicing medication administration to her capability.
Give nurse fewer patients New nurse can focus on learning policies and feel comfortable caring for patients New nurse may be on orientation for a longer time and experienced nurse will have patients to take care of in addition to precepting No Best: Patient care safely completed. Worst: New nurse may express concern for having to take fewer patients Patient safety is met, while new nurse builds on learning policies and safe patient care. Positive patient outcome is priority here.
Choose the Alternative You Would Recommend
The best immediate solution is to give the new nurse fewer patients, until she demonstrates she is able to complete patient care safely and adequately on a smaller assignment, while reviewing hospital policies with the new nurse.
Act on Your Chosen Alternative
The experienced nurse gives the new nurse two patients and takes the rest of the assignment. The experienced nurse explains the policy on medication administration and supervises the new nurse in patient care.
Look at the Ethical Dilemma and Examine the Outcomes While Reflecting on the Ethical Decision
Although taking patients away from the new nurse may cause mixed emotions for the new nurse. It is the best immediate solution to the dilemma, because patient safety, which is priority, is being ensured. Rather than the experienced nurse falsely documenting what she feels is being done by the new nurse, looking at the picture as a whole, the new nurse would realize there are missing pieces to the completion of safe patient care.
McGonigle, D., & Mastrian, K. (2012). Nursing Informatics (2 ed.). Burlington, MA: Jones & Bartlett.
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assess evidence for nursing practice (9 ed.). Philadelphia: Lippincott Williams & Wilkins.