NR 395 Week 5 Ethical Frameworks Case Analysis Example

Ethical Framework Analysis: One Sitter, Two Patients at 2300, Run Through Four Theories That Do Not Agree

Student Name

College of Nursing, Chamberlain University

NR 395: Ethics, Integrity, and Professional Nursing Trends

Instructor Name

Month Day, Year

Ethical Framework Analysis: One Sitter, Two Patients at 2300, Run Through Four Theories That Do Not Agree

The Case

At 2300 on a medical unit, the charge nurse has one patient safety attendant, called a sitter, available for the night shift, and two patients who meet the unit's criteria for one. The details are composite.

Room 8: Mr. S., 24, admitted this afternoon after an intentional overdose of acetaminophen, medically treated and awaiting psychiatric evaluation in the morning. He is calm, polite, and says he is "fine now." Policy requires constant observation for any patient admitted after a suicide attempt until a psychiatric evaluation is complete.

Room 14: Mrs. B., 88, with pneumonia and delirium, has pulled out two IV lines since 1800 and has swung her legs over the rails three separate times. Her daughter, who sat with her all evening, has just gone home to sleep. Staff have used a bed alarm and moved her near the station. The alternative, if she is not watched, is likely to be restraints, which the unit tries hard to avoid.

No second sitter is available tonight. The nurse must recommend to the charge nurse where the sitter goes, and what is done for the other patient. The case is held here and not re-described below; each framework is applied to it in turn, and each ends with a verdict.

Utilitarian Pass

A utilitarian approach asks which choice produces the most good and least harm across everyone affected. Its first task is to estimate the harms in each room. For Mr. S., the harm the sitter prevents is a second suicide attempt in hospital: rare, but catastrophic and irreversible. For Mrs. B., the harms are more likely but less severe: a fall with a possible fracture, lost IV access, or restraints with their own risks of injury, agitation and worsening delirium. A utilitarian must also count the effect on the unit: a nurse who spends the night responding to Mrs. B.'s alarms has less time for four other patients.

Weighing probability against severity, a utilitarian could reasonably conclude that Mrs. B. faces more expected harm tonight, because her risk is high and near-certain to materialize in some form, while Mr. S.'s risk is low but severe. Verdict: the sitter goes to Mrs. B., and Mr. S. is placed in a room near the station with the door open, checks every 15 minutes, and his belongings searched.

Deontological Pass

A duty-based approach asks what obligations the nurse has, regardless of the balance of outcomes. The nurse has a duty not to allow foreseeable serious harm where it can be prevented, and a duty to follow a policy that exists precisely because staff are poor at judging who is at risk of suicide. Mr. S.'s calm is not evidence of safety; patients who have decided on a plan can appear settled. The unit's rule of constant observation after an attempt is a duty the nurse has already accepted, not an estimate to be re-run each night.

A deontologist would also say that restraints for Mrs. B., if needed, are a harm that must be justified to her and her daughter, but not a breach of the same order as abandoning a required safety measure. Verdict: the sitter goes to Mr. S., as policy requires, and every alternative to restraint is tried for Mrs. B., with restraints as a last, documented measure.

Care Ethics Pass

An ethics of care attends to relationships, vulnerability and the particular person, rather than to rules or totals. It notices things the other two frameworks skip. Mrs. B.'s daughter left because she was exhausted, trusting the unit to keep her mother safe. Mrs. B. is frightened; her pulling and climbing are the actions of a person who does not know where she is. Mr. S. is young, alone, and has just survived something he intended to end his life; being watched all night by a stranger may feel to him like being treated as a danger, not as a person in pain.

Care ethics does not settle the sitter by itself, but it points toward calling Mrs. B.'s daughter to ask whether she, or another family member, could return for part of the night, and toward the nurse spending time talking with Mr. S. rather than only observing him. Verdict: the sitter stays with Mr. S., because his vulnerability tonight is the more hidden one, and the nurse asks the family to help with Mrs. B., framing it as an invitation, not an obligation.

Principlism Pass

Principlism weighs four commitments against each other: the patient's self-determination, doing good, avoiding harm, and fairness. Gillon (1994) argued that these four, together with attention to their scope, meaning to whom each obligation is owed, can organize most clinical ethical problems. Here, justice is the principle doing the most work, because the question is how to allocate a scarce resource fairly between two people. Nonmaleficence applies to both: leaving Mrs. B. unwatched risks harm; so does leaving Mr. S. unwatched. Autonomy is limited for both tonight, one by delirium and one by the circumstances of his admission. Justice asks for a rule that would be defensible if applied to any two patients, and the most defensible rule is to protect first against the harm that is irreversible. Verdict: the sitter goes to Mr. S., and Mrs. B. receives the next best protection available, including a request to the house supervisor for a float staff member for part of the night.

Where the Frameworks Split, and a Choice

The four frameworks split three to one. Utilitarianism favors Mrs. B., because her harm is more probable. The other three favor Mr. S.: deontology because of the duty expressed in policy, care ethics because of his hidden vulnerability, principlism because justice gives priority to irreversible harm. The split is itself informative. It shows that the utilitarian verdict depends on an estimate, the probability of harm in each room, that the nurse is least equipped to make at 2300, and that the policy was written because such estimates about suicide are unreliable.

My recommendation is that the sitter goes to Mr. S. Its weakness is plain: Mrs. B. is more likely to be harmed tonight, and if she falls, the decision will look wrong in the morning. That weakness is why the recommendation comes with three actions for her: calling her daughter, requesting a float, and moving her into the room closest to the station with the door open and a bed alarm. Improving the ethical climate of the workplace is part of the nurse's charge under the sixth provision of the nursing code (American Nurses Association [ANA], 2025), and the last action is to report in the morning that the unit had two patients who needed a sitter and one sitter, so that the next night is not decided the same way.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. BMJ, 309(6948), 184-188. https://doi.org/10.1136/bmj.309.6948.184