The ability to influence patient care outcomes depends on a variety of forces, each of which the nurse must consider in order to influence care outcomes in an ethically appropriate manner. The introductory articles in the topic, “The Power to Influence Patient Care,” have already defined and described power. This Ethics Column will focus on the forces each individual nurse will want to consider in obtaining the power needed to practice in an ethical manner. These forces include nursing knowledge and skills, an understanding of ethical principles and models, good relationships with patients and the health care team, and the communication skills to nurture these relationships.
Ethically speaking, ‘what should be done’ in an individual, patient-care situation is at the heart of many practice dilemmas nurses face on a regular basis. Consider, for example, the nurse who has received a discharge order for a homeless patient hospitalized for pneumonia. The nurse knows the patient needs further care that will not likely be delivered ‘at home.’ The nurse also knows the bottom financial line is that the patient has ‘used up’ the days allotted for the medical condition and discharge is imminent. This example illustrates the dilemma related to the ethical issue of the distribution of scant resources that occurs frequently within health care arenas. The ethical principle of justice guides the fair and equal treatment of all people; yet, the nurse wrestles with the consequences of limited organizational and societal financial resources.
A nurse’s knowledge and skill are important forces that can contribute to the power to influence patient care in an ethical manner. This power comes from the health care team’s dependence on the nurse’s knowledge and expert skill. There is no substitute for the respect that is earned by a nurse who gives consistent, excellent, holistic care. The reputation for excellence in practice is power! The nurse who diligently reads current professional literature, and shares evidence-based research with colleagues so as to enhance their nursing knowledge and skills, strengthens practice and influences the actions of others, thus improving patient care. This is the power one nurse can have for the good of all - the power of one!
To influence patient care from an ethical perspective, a nurse also needs an understanding of ethical principles and models. Knowledge of ethical principles, such as autonomy and beneficence, arms the nurse with power to be a major player in the decision-making process regarding patient care. A nurse who understands ethical principles, and can use this understanding to influence the health care team to apply these principles, has successfully used power by influencing the action and behaviors of others.
Using ethical principles to arrive at a solution should be done in an atmosphere of caring, respect, openness, and honesty. This process should be based on a sound ethical, decision-making model, using the best evidence-based-practice guidelines available. Chally and Loriz (1998) and also Koloroutis and Thorstenson (1999) have noted the importance of nurse managers assuming the responsibility of integrating an ethical framework (model) for decision making into the nursing practice of their assigned areas. Facilitating discussions of health care dilemmas among staff nurses and other team members is an excellent way to promote an organizational climate where ethical principles are used in a systematic manner. Encouraging nurses to engage in hospital ethics committee meetings, which provide structure for addressing ethical dilemmas, promotes professional growth of individual nurses as the multidisciplinary voices on these committees share perspectives for addressing the dilemma at hand.
Ethical decision making is a process that can be refined and used in addressing any ethical dilemma. Adhering to principles of autonomy and beneficence are foundational to the ethical decision-making process. Respecting a patients’ autonomy means the patient has the right to make choices regarding care and treatment, regardless of medical opinions and other recommendations. A competent patient of sound mind has the right and should be allowed to make personal decisions regarding health care, including the refusal of treatment. The American Nurses Association (ANA) Code of Ethics includes a directive guiding the nurse to promote and advocate for the rights of the patient, an activity which should be at the heart of all decision making (ANA, 2001). The nurse, as patient advocate, plays an important role in communicating and supporting the wishes of the patient, even when doing so may be against the opinions of the family and physician.
The ability to influence patient care outcomes also depends on the power a nurse has in relationships with physicians and other team members. A nurse gains power through establishing positive, collegial, working relationships with physicians, other nurses, and all the members of the health care team. Productive relationships increase a nurse’s power to base care decisions on ethical principles.
Finally, communication skills are essential to establish and maintain effective working relationships with health care colleagues. These skills require acquisition of ‘tools,’ such as conflict management, team-building, and effective communication skills to use in discussing ethical issues. The power of each nurse comes as s/he commits to the organization and unit by serving as an exemplary role model, innovator, critical thinker, and communicator for the health care team. Owning one’s power translates to conscious, deliberate, and participative decision making regarding ethical dilemmas.
I encourage you to examine your current level of power, the extent you are using this power to provide care based on ethical principles, and to develop a systematic plan to develop and strengthen these important forces for influencing your patient’s care through sound decisions by the health care team. You may be the essential link in advocating for your patient and assuring your health care team practices according to the highest of ethical standards.
Article published November 26, 2007