Phases of Core Competency Development

The core competency of ethical decision making for APNs can be organized into four phases. Each phase depends on

Phases of

1. Knowledge Development-Moral Sensitivity

2. Knowledge Application-Moral Action

3. Creating an Ethical Environment

4. Promoting Social Justice Within the Health Care System

of Core

Ethical theories

Ethical issues in specialty

Professional code

Professional standards

Legal precedent

Moral distress

Ethical decision-making frameworks

Mediation and facilitation strategies

Preventive ethics

Awareness of environmental barriers to ethical practice

Concepts of justice

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Health policies affecting a specialty population

the acquisition of the knowledge and skills embedded in the previous level. Thus, the competency of ethical decision making is understood as an evolutionary process in an APN’s development. Phase 1 and beginning exposure to Phase 2 should be explicitly taught in the APN’s gradu- ate education. Phases 3 and 4 evolve as APNs mature in their roles and become comfortable in the practice setting; these phases represent leadership behavior and the full enactment of the ethical decision making competency. Phase 4 relies on competencies required of DNP-prepared APNs; the knowledge and skills needed for Phases 3 and 4 should be incorporated into DNP programs. Although an expectation of the practice doctorate, all APNs should develop their ethical knowledge and sldlls to include elements of all four phases of this competency. The essential elements of each phase are described in Table 13-1.

Phase 1: Knowledge Development The first phase in the ethical decision making competency is developing core knowledge in ethical theories and principles and the ethical issues common to specific patient

for Ethical Decision

Sensitivity to ethical dimensions of clinical practice — — — —- —– — – —

Values clarification

Sensitivity to fidelity conflicts

Gather relevant literature related to problems identified

Evaluate practice setting for congruence with literature

Identify ethical issues in the practice setting and bring to the attention of other team members

Apply ethical decision making models to clinical problems

Use skilled communication regarding ethical issues

Facilitate decision making by using select strategies

Recognize and manage moral distress in self and others

Role model collaborative problem solving

Mentor others to develop ethical practice

Address barriers to ethical practice through system changes

Use preventive ethics to decrease unit-level moral distress

Ability to analyze the policy process

Advocacy, communication, and leadership skills

Involvement in health policy initiatives supporting social justice

populations or clinical settings. This dual knowledge enables the APN student to integrate philosophical concepts with contemporary clinical issues. The emphasis in this initial stage is on learning the language of ethical discourse and achieving cognitive mastery. The APN learns the theories, principles, codes, paradigm cases, and relevant laws that influence ethical decision making. With this knowledge, the APN begins to compare current practices in the clinical setting with the ethical standards desctibed in the literature.

Phase 1 is the beginning of the APN’s personal journey toward developing a distinct and individualized ethical framework. The work of this phase includes developing sensitivity to the moral dimensions of clinical practice (Weaver, 2007). A helpful initial step in building moral sensitivity is understanding one’s values, in which students clarify the personal and professional values that inform their care (Fry & Johnstone, 2008). Engaging in this work uncovers personal values that may have been internalized and not openly acknowledged, and is particularly important in our multicultural world.

Another key aspect of this phase is developing the ability to distinguish a true ethical dilemma from a situation of moral distress or other clinically problematic situation. This requires a general understanding of ethical theories, principles, and standards that help the APN define and discern the essential elements of an ethical dilemma. Novice APNs should be able to recognize a moral problem and seek clarification and illumination of the concern. The APN identifies ethical issues and formulates the concerns about which others are uneasy. This step earns credibility and enables the APN to gain self- confidence by bringing the issue to the awareness and attention of others. If the issue remains a moral concern after clarification, the APN should pursue resolution, seeking additional help if needed.

Formal education in ethical theories and concepts should be included in graduate education programs for APNs. Although some beginning graduate students will have had significant exposure to ethical issues in their undergraduate programs, most have not. A 2008 U.S. survey of nurses and social workers found that only 51% of the nurse respondents had formal ethics education in their undergraduate or graduate education; 23% had no ethics training at all (Grady, Danis, Soeken, et al., 2008). APN students with no ethics education will be at a disadvantage in developing this competency because graduate education builds on the ethical foundation of professional practice.

The current master’s essentials (AACN, 2011) do not address ethics education directly but include compe- tencies in the use of ethical theories and principles. The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) contains explicit ethical content in five of the eight major categories (Box 13-1). Even categories that do not explicitly list necessary ethical content imply it in referring to issues such as improving access to health care, addressing gaps in care, and using conceptual and analytic skills to address links between practice and organizational and policy issues.

Exposure to ethical theories, principles, and concepts allows the APN to develop the language necessary to articulate ethical concerns in an interprofessional environment. It is important, however, that knowledge development extend beyond classroom discussions. Clinical practicum experiences also need to build in discussions of ethical dimensions of practice explicitly rather than assume that these discussions will naturally occur. In one study of the clinical experiences of graduate students from four graduate programs, only 4 of 20 students were identified as having experience with an ethical dilemma and only 2 of 22 preceptors noted any exposure to ethical dilemmas for students (Howard & Steinberg, 2002). The authors concluded that this apparent void in clinical education may have been a function of limited recognition.