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COVID-19 CASE STUDY
You are a newly graduated registered nurse working in a remote rural hospital
called Little Town Memorial Hospital (LTMH) in the northern region of British Columbia
(BC). LTMH has limited capabilities in handling any sort of crisis. For example, the
hospital only has four Intensive Care (ICU) Beds and only two Respirators. It is the
middle of the COVID-19 pandemic and all hospitals in BC, including LTMH, are
functioning at 145% occupancy, and this is expected to climb. Every additional space in
the hospital, including the cafeteria, is currently housing clients. To make matters worse
many of the nurses, doctors and other health professionals (HPCS) who are employed
by LTMH are off ill, so there is a shortage of skilled personnel to deliver patient care.
Health care supplies are also dwindling. The supply of Oxygen is becoming scarce.
The emergency stockpile of PPEs turns out to be expired.
Your local administrators know as much as you do about the situation, as
information systems begin to break down. You are receiving the message from your
local administrators that expired level one masks are effective against the spread of
COVID-19, and that droplet precautions are sufficient to protect you and your patients.
On the other hand, you have seen on social media that major news outlets are reporting
on studies that suggest that the spread of COVID-19 could occur through airborne
transmission. You graduated three years ago, and so no longer have access to
academic databases to check for yourself.
One of eight patients you are assigned to care for on day shift is Ms. Satura.
She is a 78-year-old patient who suffers from chronic obstructive pulmonary disease
(COPD) and has tested positive for COVID-19. Ms. Satura is mentally alert and does
not demonstrate any cognitive impairments. You have been looking after Ms. Satura for
three shifts now and you are aware that she has a tremendous will to live. For instance,
she is determined to get well so she can return home to be with her beloved wife and to
resume her much enjoyed hobby of playing the piano. She is of Japanese descent and
through conversation you learn that she was born in a Japanese internment camp
during World War 2. There is a historical record of Ms. Satura being treated in a
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psychiatric institution in the 1970’s for “homosexual tendencies.” Ms. Satura is still quite
ill. She has a temperature of 39.0 degrees C, her respirations are labored at 3840/minute and O2 Saturations are 80 % on room air but improve to 86 – 88 % when she
receives Oxygen at 5 liters/minute by mask.
It is noon and your Nurse Manager calls you into her office to inform you that a
decision was just made by the Great North Health Authority to only provide life-saving
treatment measures to patients that have the most likelihood to live longest upon
survival. You are informed that Ms. Satura does not qualify as one of those patients
and that effective immediately only palliative measures will be offered to her. Oxygen is
to be removed and she will be discharged back home into the care of her frail, elderly
75 year-old wife who also suffers from COPD but has tested negative for COVID-19.
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THE MOSAIC MODEL FOR ETHICAL DECISIONS (as adapted from Stephany, 2012)
Part 1: Identifying what Matters to Clients & Others
a) Briefly state the ethical problem.
b) Have the client tell their story.
c) Identify other players and their views/values.
Part 2: Determine the Key Ethical and/or Legal Issues
a) Identify if there is an ethical dilemmas or moral distress.
b) Is there a law that mandates how the health team should proceed? If yes, obtain
legal advice and follow it.
Part 3: Make Use of Other Sources of Knowledge
a) Draw upon the following for guidance in decision-making:
MAYERHOFF’S MULTIFACETED ASPECTS OF CARE
Knowledge & care, Alternating rhythms of care, Demonstrating patience, Being honest & trustworthy,
Showing humility, Having hope & Maintaining courage
PERLMAN’S INVENTORY OF CARING TRAITS
Warmth, Acceptance, Caring-concern, Genuineness & Empathy
STEPHANY’S COMPONENTS OF THE MOSAIC OF CARE
Compassion, Generosity & care, Unconditional positive regard & Presencing
SOUND MORAL PRINCIPLES
Integrity, Veracity, Fidelity, Respect for self-worth, Beneficence, Non-Maleficence, Autonomy & Advocacy
CNA CODE OF ETHICS VALUES
Providing Safe, Compassionate, Competent and Ethical Care
Promoting Health and Well-Being
Promoting and Respecting Informed Decision-Making
Honouring Dignity
Maintaining Privacy and Confidentiality
Promoting Justice
Being Accountable
b) Consider any additional knowledge as deemed appropriate. Identify how some
of these notions apply to each side of the dilemma or to an issue involving moral
distress.
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Part 4: Consider Possible Courses of Action as well as the Benefits & Risks
a) List the benefits versus risks of any course of action.
b) Reflect on the ethical action.
Part 5: Additional Considerations
a) Consider situations that may arise and create problems for any family
member and/or healthcare professional who are involved such as: moral
distress, moral agency violations, moral residue, moral disengagement &
moral outrage.
b) Who requires help with dealing with what transpired?
c) Take into account societal issues that may be relevant.
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Questions:
Please read all the questions before beginning your answer.
1. Analyze this case using all five parts of the Mosaic Model for Ethical Decision-Making.
2. When analyzing part 3 of the Mosaic Model, please ensure that you consider:
a. What fiduciary relationships exist in this case study, and how does this impact your
considerations?
b. To whom are nurses accountable, and how does this play out in this scenario?
c. What role does advocacy normally play in nursing, and how does it play out here?
d. What are the issues of technological utility that must be considered in this scenario?
3. When analyzing part 4, section C of the Mosaic Model, please ensure you consider:
a. What issues are raised by the client’s race and gender.
Notes on format:
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Answer in essay format.
Use the APA 6 style guide to format your essay, including appropriate citations and referencing.
Abstract and key words are not required.
Maximum length is 5 pages, excluding title page, references, and optional appendixes.
CNA Codes of Ethics
Part I. Nursing Values and Ethical Responsibilities — describes the ethical responsibilities
central to ethical nursing practice articulated through seven primary values and responsibility
statements. These statements are grounded in nurses’ professional relationships with persons
receiving care as well as with students, nursing colleagues and other health-care providers. The
seven primary values are:
A. Providing safe, compassionate, competent and ethical care B. Promoting health and wellbeing C. Promoting and respecting informed decision-making D. Honouring dignity E.
Maintaining privacy and confidentiality F. Promoting justice G. Being accountable
Part II. Ethical Endeavours Related to Broad Societal Issues — describes
activities nurses can undertake to address social inequities. Ethical nursing practice
involves endeavouring to address broad aspects of social justice that are associated
with health and well-being.
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Using the Code in Nursing Practice The seven primary values are related and overlapping. It is
important for all nurses to work toward adhering to the values in the Code at all times for persons
receiving care — regardless of attributes such as age, race, gender, gender identity, gender
expression, sexual orientation, disability, and others — in order to uphold the dignity of all.
Nurses recognize the unique history of — and the impact of the social determinants of health on
— the Indigenous Peoples of Canada. In healthcare practice, values may be in conflict. Such
value conflicts need to be considered carefully in relation to each practice situation. When such
conflicts occur, or when nurses think through an ethical situation, many find it helpful to use an
ethics model for guidance in ethical reflection, questioning and decision-making (see Appendix
A).
While nursing practice involves both legal and ethical dimensions, the law and ethics remain
distinct. Ideally, a system of law would be compatible with the values in the Code. However,
there may be situations in which nurses collaborate with others to change a policy that is
incompatible with ethical practice. When this occurs, the Code can guide and support nurses in
advocating for changes to law, policy or practice. It can be a powerful political instrument for
nurses when they are concerned about being able to practise ethically
Nurses are responsible for the ethics of their practice. Given the complexity of ethical
situations, the Code can only outline nurses’ ethical responsibilities and guide them
in their reflection and decision-making. It cannot ensure ethical practice. For ethical
practice, other elements are necessary, such as a commitment to do good, a sensitivity
and receptiveness to ethical matters, and a willingness to enter into relationships with
persons who have health-care needs and other problems. Practice environments have
a significant influence on nurses’ ability to be successful in upholding the ethics of
their practice. Nurses’ self-reflection and dialogue with other nurses and health-care
providers are essential components of ethical nursing practice.
Advocacy Advocacy refers to the act of supporting or recommending a cause or course of action,
undertaken on behalf of persons or issues. It relates to the need to improve systems and societal
structures to create greater equity and better health for all. Nurses endeavour, individually and
collectively, to advocate for and work toward eliminating social inequities.
Ethical Types of Experiences and Situations When nurses can name the type of ethical concern
they are experiencing, they are better able to discuss it with colleagues and supervisors, take
steps to address it at an early stage, and receive support and guidance in dealing with it.
Identifying an ethical concern can often be a defining moment that allows positive outcomes to
emerge from difficult experiences. In the Code, the terms moral and ethical are used
interchangeably based upon consultation with nurse ethicists and philosophers.3 There are a
number of terms that can assist nurses in identifying and reflecting on their ethical experiences
and discussing them with others:4 ethical (or moral) agent. Someone who has the capacity to
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direct their actions to some ethical end, for example, good outcomes for patients (Storch,
Rodney, & Starzomski, 2013). Exercising that capacity would be ethical (or moral) agency.
ethical (or moral) courage. When nurses stand firm on a point of moral principle or a particular
decision about something in the face of overwhelming fear or threat to themselves. ethical (or
moral) dilemmas. Arise when there are equally compelling reasons for and against two or more
possible courses of action, and where choosing one course of action means that something else is
relinquished or let go. An ethical dilemma is a particular type of ethical problem. ethical (or
moral) disengagement. Can occur when nurses normalize the disregard of their ethical
commitments. A nurse may then become apathetic or disengaged to the point of being unkind,
non-compassionate or even cruel to other health-care providers and persons receiving care.
ethical (or moral) distress. “Arises when nurses are unable to act according to their moral
judgment” (Rodney, 2017, s-7). They feel they know the right thing to do, but system structures
or personal limitations make it nearly impossible to pursue the right course of action (Jameton,
1984; Webster & Baylis, 2000; Rodney, 2017). Moral distress can lead to negative consequences
such as feelings of anger, frustration and guilt, yet it can also be a catalyst for self-reflection,
growth and advocacy (Rodney, 2017).
ethical (or moral) indifference. “Implies a failure to assume the ethical responsibilities of the
profession, leaving one in a passive state that calls into question the moral integrity of the [nurse]
as well as imperiling the obligation to protect the vulnerable patient” (Falcó-Pegueroles, LluchCanut, Roldan-Merino, Goberna-Tricas, & Guardia-Olmos, 2015, p. 604). ethical (or moral)
problem. A situation where there are conflicts between one or more values and uncertainty about
the correct course of action. Ethical problems involve questions about what is right or good to do
at individual, interpersonal, organizational and societal levels. ethical (or moral) residue. What
each of us carries with us from times in our lives when, in the face of morally distressing
situations, we have been seriously compromised. These instances leave lasting and powerful
impressions in our thoughts that persist over time; hence the term moral residue (Webster &
Baylis, 2000). ethical (or moral) resilience. The capacity of an individual to sustain or restore
their integrity in response to moral complexity, confusion, distress or setbacks (Rushton, 2016).
ethical (or moral) violations. Involve actions or failures to act that breach fundamental duties to
the persons receiving care or to colleagues and other healthcare providers. ethical (or moral)
well-being. Congruence between thought and action that results from nurses having the
necessary mechanisms and resources in place to optimally resolve ethical conflicts (FalcóPegueroles et al., 2015).
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