Four component model of ethical decision making

Rest and Narvaez (1994) identified four integrated abilities that determine moral behavior by health professionals. These conditions or components offer guidelines that allow for more than application of bioethical principles and include the virtue ethics and interpersonal qualities that can assist in resolving ethical conflicts.

The first condition is ethical sensitivity, or the ability to see things from the perspective of others. Rather than focusing on one's own views, a person with greater ethical sensitivity can interpret a situation from other points of view and show sensitivity to the feelings and reactions of others. Dubler (2011) defines a bioethics mediator as one who recognizes that there are always multiple options for the plan of care, rather than advocating for only their own perception of the best plan. On a clinical level, an advanced practice nurse who is ethically sensitive seeks information and listens carefully. Cameron (2004) identifies ethical listening as paying full attention in order to hear an ethical problem in what someone says. This active ethical listening involves being compassionate, establishing rapport, using open-ended statements, and encouraging the person to examine the conflict on a deeper level. Ethical listening requires the professional to avoid lecturing, giving advice, or correcting comments so that the person feels free to talk openly and move closer to a resolution. Advanced practice nurses who use ethical listening skills become skilled at uncovering underlying ethical conflicts that require resolution. Peirce and Smith (2008) state that DNP APRNs must demonstrate ethical sensitivity and knowledge of research ethics, clinical ethics, business ethics, and laws that influence practice.

The second component of the four-component model is moral judgment. Moral judgment requires knowledge of concepts, codes of conduct, and ethical principles, and helps to identify the guidelines that support a decision. APRNs should be familiar not only with the ANA's Code of Ethics (ANA, 2001) and ethical theories and principles, but also the research that helps guide clinical decisions. Dubler (2011) identifies that if health professionals are to assist patients in decision making, they must develop mediator skills, learn to remain neutral, listen to the patient, and identify conflicts and decisional barriers. APRNs should practice teaching skills that allow them to present the potential risks and benefits of treatments using evidence-based findings in a neutral manner.

The third component of Rest's model is moral motivation, that is, the difference between knowing the right thing to do and making it a priority. Moral motivation has to do with the importance given to competing choices. Deficiencies in moral motivation occur when personal values compete with concerns for doing what is right. An NP who decides to spend less time with each patient so that she can get a bonus for having the highest number of patients billed per month may be overlooking important clinical needs at the patients' expense (Ulrich et al., 2006). This behavior demonstrates a deficiency in moral motivation. A nursing administrator who decides to staff short so that her department will exceed budget goals (giving her an administrative bonus) has a problem with moral motivation.

The fourth component of Rest's model is moral character. This component requires APRNs to persist and have courage in implementing their skills. Bebeau (2002) writes, "A practitioner may be ethically sensitive, may make good ethical judgments, and place a high priority on professional values; but if the practitioner wilts under pressure, is easily distracted or discouraged, or is weak willed, then moral failure occurs" (p. 287). Nurses in advanced practice roles should identify how they would carry out a specific moral action in the clinical setting. Clinical situations will expose them to a variety of problems that may require ethical action. For example, when a nurse manager identifies clinically incompetent or negligent performance of a staff nurse but decides not to report it because the staff nurse is not under her direct report, that manager is missing an important ingredient in ethically sound advanced practice.

SUMMARY: ETHICAL DECISION MAKING

Two ethical decision-making frameworks have been discussed as guides for APRNs. Although nurses may be most familiar with the bioethical principles, the principle-oriented frameworks are not as well equipped to address the many everyday ethical issues in health care that are not about life-and-death decisions. These day-to-day decisions may be best served by Rest's four-component model that identified the need to ensure heightened ethical sensitivity and ethical implementation.

APRNs are entering an ever more complex world of practice. As they become aware of the role of ethical behavior and choices in their clinical world, they need to consider ethical approaches to the research and business aspects of their practices (Peirce & Smith, 2008). APRNs can work to improve their awareness of ethical clinical issues by active ethical listening. Education about ethical theories and principles should include skilled practice for becoming neutral mediators with clients, to fully understand the patient's view and understanding. In examining their own professional conduct, APRNs can better understand the choices that compete with the ethical decisions they make.

As information technology explodes in this decade, patient privacy and confidentiality become increasingly important. The consideration of ethics in information sharing is essential. APRNs must become astute to the financial accounting and billing practices of clinical practices. APRNs who work in research settings should conduct themselves ethically in the management of research data, privacy, and confidentiality and be aware of the potential for conflict of interest in industry-supported research.