护理伦理决策的挑战 | AORN Journal

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The profession of nursing is rife with decisions that can be difficult and challenging. Nurses have a responsibility to patients, health care team members, and our profession to ensure ethical decisions are upheld in the organization and in practice. Our moral and ethical value systems are frequently challenged. As a result, nurses often struggle with making correct decisions.

Nurses’ unspoken pledge to duty is an integrated and fundamental part of nursing practice that holds nurses accountable for the well-being of patients and their families, ensuring interventions are appropriate to optimize care. Another essential principle that underlies nursing practice is respect for the intrinsic dignity, value, and rights of all individuals.1 Nurses are hardwired and committed to providing optimal care to their patients while respecting the rights and decisions of individuals; however, sometimes care requirements can interfere with what we believe are the correct decisions. Thus, it is essential for nurses to understand and demonstrate competency in providing ethical care. According to AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses With Interpretive Statements, “Ethical practice is … a critical aspect of nursing care, and the development of ethical competency is paramount for present and future nursing practice.”2(p2)

ETHICAL DILEMMAS

At times in nursing, our personal morals cannot determine the course of action and can conflict with decisions. In such situations, called ethical dilemmas,

the nurse is expected to choose between different options. The nurse is conflicted because each of the opposing choices is ethically supported while at the same time each of the opposing choices is also considered ethically problematic.3(p1517)

Nurses find themselves confronted with ethical dilemmas daily that may occur during patient care or other workplace activities; many of these can be categorized as world-imposed dilemmas or moral uncertainties.

World-imposed ethical dilemmas are when decisions are being determined by an outside force and there is no option to make an independent decision. In such instances, the nurse is bound to follow outside instruction based on the current situation. Nurses are faced with decisions that may be forced upon them because of policies, administrative decisions, or management direction. For example, the current nursing shortage has led to inadequate staffing that has affected care decisions. In my organization and many others, the coronavirus disease 2019 (COVID-19) pandemic affected how we staffed perioperative areas, such as the postanesthesia care unit, with less-than-optimal nurse-to-patient ratios. Nurses felt overworked and questioned whether care was being compromised, but they submitted to the staffing model even though it conflicted with what they believed optimal care should be. In addition, there was a rush to fast-track personnel into specialty areas without adequate training because of staffing needs. Nurses were sometimes deployed to specialty areas without having the skills and competencies needed to care for the specific patient population.

Moral uncertainty can be thought of as what a virtuous person would do, or what is right to do, despite individuals’ own personal beliefs about the situation. The conclusion does not guarantee that they are correct. Many times, an individual can become morally biased because of vested interests, peer influence, culture, religion, upbringing, or influence from the status quo.4 Nurses often find themselves doubting their own beliefs and decisions. Moral uncertainty impacted health care during the pandemic. For example, as part of providing appropriate care, nurses try to ensure that patients and their families have adequate emotional support. However, the COVID-19 pandemic limited the ability for families to be with their loved ones; at times, patients died without their loved ones by their side. My last place of employment realized the importance of family member presence during the end-of-life stage and implemented a practice called “No One Dies Alone” so loved ones could be with their family member during their passing.

Moral uncertainty also can arise in situations in which patients refuse care or certain care approaches. For example—as nurses, although we know the various treatments for breast cancer, there are patients who do not want to proceed with radical treatment. A nurse could become judgmental and assume this is what the patient should do for themselves and their family. However, nurses should not impose their own views on patients.5

Cultural Considerations

The focus on cultural competency is how the caregiver responds to the value systems of our diverse population. The multigenerational workforce of today can influence the quality of care and staff member interaction. Generational differences among employees can be beneficial to an organization because diversity nurtures inventiveness and a differentiated approach to problem-solving. When nurses do not understand cultural competency, the results can affect our care and create ethical dilemmas. An individual’s value systems—whether the individuals are nurses or patients—can influence the decisions we make. The importance of not generalizing individuals and instead attempting to understand, relate to, and appreciate the behaviors of members from all generations is instrumental in understanding generational differences and maintaining effective and satisfying relationships at work.6 It is critical for us to acquaint ourselves with the patient’s culture to fully understand their behavior within the cultural context.7

CONCLUSION

Perioperative nursing presents its own unique challenges, and there have been unprecedented levels of transformation over the last decade that have affected our ethical decisions regarding patient care. Nurses are among the most critical stakeholders in all of this change. Together, we must develop opportunities while collaboratively promoting processes that involve team members as part of the decision-making process. It is important that nurses comprehend the impact of the ethical decisions we make; although ethical decisions may not always be clear, they should always be made with the patient’s best interests in mind.

全文翻译（仅供参考）

护理行业充满了困难和具有挑战性的决定。护士有责任对患者、医疗团队成员和我们的职业负责，以确保在组织和实践中维护道德决策。我们的道德和伦理价值体系经常受到挑战。因此，护士经常难以做出正确的决定。

护士不言而喻的责任承诺是护理实践的一个基本组成部分，它要求护士对患者及其家人的福祉负责，确保干预措施适合优化护理。护理实践的另一个基本原则是尊重所有人的内在尊严、价值和权利。1护士性格坚强，致力于为患者提供最佳护理，同时尊重个人的权利和决定；但是，有时护理要求会干扰我们认为正确的决定。因此，护士必须了解和展示提供道德护理的能力。根据AORN 对 ANA 的围手术期说明带有解释性声明的护士道德规范，“道德实践是……护理的一个关键方面，道德能力的发展对于当前和未来的护理实践至关重要。” 2 (p2)

道德困境

有时在护理中，我们的个人道德不能决定行动方针，并且可能与决定发生冲突。在这种情况下，被称为道德困境，

护士应该在不同的选项之间做出选择。护士是矛盾的，因为每个相反的选择都在道德上得到支持，同时每个相反的选择也被认为在道德上存在问题。3 (p1517)

护士发现自己每天都面临着在病人护理或其他工作场所活动中可能发生的道德困境；其中许多可以归类为世界强加的困境或道德不确定性。

世界强加的道德困境是当决策由外部力量决定并且没有选择做出独立决定时。在这种情况下，护士必须根据当前情况遵循外部指示。由于政策、行政决定或管理方向，护士面临着可能被迫做出的决定。例如，当前的护理短缺导致人员配备不足，从而影响了护理决策。在我的组织和许多其他组织中，2019 年冠状病毒病 (COVID-19) 大流行影响了我们为围手术期区域配备人员的方式，例如麻醉后护理室，护士与患者的比例不太理想。护士们感到劳累过度，并质疑护理是否受到损害，但他们接受了人员配置模型，即使它与他们认为的最佳护理相冲突。此外，由于人员需求，急于将人员快速进入专业领域而没有经过充分培训。护士有时被派往专业领域，但没有照顾特定患者群体所需的技能和能力。

道德不确定性可以被认为是一个有道德的人会做什么，或者做什么是正确的，尽管个人对这种情况有自己的个人信念。结论并不能保证它们是正确的。很多时候，由于既得利益、同伴影响、文化、宗教、教养或现状的影响，个人可能会在道德上产生偏见。4护士经常发现自己怀疑自己的信念和决定。在大流行期间，道德不确定性影响了医疗保健。例如，作为提供适当护理的一部分，护士试图确保患者及其家人获得足够的情感支持。然而，COVID-19 大流行限制了家庭与亲人在一起的能力；有时，患者在没有亲人陪伴的情况下死亡。我上一个工作的地方意识到在临终阶段家人陪伴的重要性，并实施了一项名为“没有人孤独死”的做法，以便亲人在他们过世时可以与家人在一起。

在患者拒绝护理或某些护理方法的情况下，也会出现道德不确定性。例如——作为护士，虽然我们知道乳腺癌的各种治疗方法，但有些患者不想进行根治性治疗。护士可能会变得有判断力，并认为这是患者应该为自己和家人做的事情。但是，护士不应将自己的观点强加给患者。5

文化考量

对文化能力的关注是看护者如何回应我们不同人群的价值体系。今天的多代劳动力可以影响护理质量和员工互动。员工之间的代际差异可能对组织有益，因为多样性可以培养创造力和解决问题的差异化方法。当护士不了解文化能力时，结果可能会影响我们的护理并造成道德困境。一个人的价值体系——无论是护士还是病人——都会影响我们做出的决定。不概括个人的重要性，而是试图理解、相关、6我们必须熟悉患者的文化，以充分了解他们在文化背景下的行为。7

结论

围手术期护理提出了自己独特的挑战，在过去十年中发生了前所未有的转变，影响了我们关于患者护理的伦理决策。护士是所有这些变化中最关键的利益相关者之一。我们必须共同开发机会，同时协作推动将团队成员作为决策过程一部分的流程。护士理解我们做出的道德决定的影响是很重要的；尽管道德决定可能并不总是明确的，但应始终以患者的最大利益为出发点。