Ethical issues at work (nursing)
Moral Courage in Action: Case Studies
Moral Courage with a Dying Patient
Mr. T. is an 82-year-old widower who has been a patient on your unit several times over the past 5 years.
His CHF, COPD, and diabetes have taken a toll on his body. He now needs oxygen 24 hours a day and still has dyspnea and tachycardia at rest. On admission, his ejection fraction is less than 20%, EKG shows a QRS interval of greater than 0.13 seconds, and his functional class is IV on NYHA assessment. He has remained symptomatic despite maximum medical management with a vasodilator and diuretics. He tells you, “This is my last trip; I am glad I have made peace with my family and God. Nurse, I am ready to die.” You ask about an advance directive and he tells you his son knows that he wants no heroics, but they just have never gotten around to filling out the form. When the son arrives, you suggest that he speak with the social worker to complete the advance directive and he agrees reluctantly. You page the physician to discuss DNR status with the son. Unfortunately, Mr. T. experiences cardiac arrest before the discussion occurs and you watch helplessly as members of the Code Blue Team perform resuscitation. Mr. T. is now on a ventilator and the son has dissolved into tears with cries of, “Do not let him die!” What is the action the nurse needs to take? It is the ethical obligation of this nurse to support the self-determination of this patient. This patient had capacity when he voiced “no heroics” and the expectation that his son, as his surrogate decision maker, would honor his expressed wishes. Mr. T. met the criteria for hospice referral prior to hospitalization, but even more so now that he has a history of cardiac arrest (National Hospice Organization, 1996). The attending physician is not discussing the facts of the case with the son and has never brought up the topic of hospice. The Code for Ethics for Nurses (the Code) (American Nurses Association [ANA], 2001, p. 9.) provides the following guidance for the nurse: The nurse supports the patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in decision-making process. The nurse knows the son will need help in letting go of his father and asks if he would like her to call his sister and pastor. The nurse also musters the courage to start a conversation with the physician and discovers that Mr. T. has been his patient for 20 years. Though both physician and son initially are defensive, the nurse’s assertiveness and perseverance get results. Mr. T. is removed from the ventilator 24 hours later. He dies peacefully in the presence of his family and physician.
Moral Courage to Confront Bullying
Melissa started on the unit as a new graduate 5weeks ago. She is still in orientation and has a good relationship with her preceptor. The preceptor has been assigned consistently to Melissa for most of the last 4 weeks, but due to family emergency has not been available in the last week. Melissa has been told that she will be precepted by a different nurse for the remainder of her orientation. The new preceptor has not been welcoming, supportive, or focused on the educational goals of the orientation. In fact, this new preceptor has voiced to all who will listen her feelings about the incompetence of new BSN graduates. The crisis occurs when Melissa fails to recognize a patient’s confusion as a result of an adverse medication effect. The preceptor berates Melissa in the nurses’ station, makes sarcastic comments in shift report about “inability of university-educated nurses to recognize the basics,” and informs the nurse manager “that new graduates are a danger to patients.” Melissa tells you that she thinks she should resign and that maybe her previous preceptor was too easy on her. You know her preceptor is an excellent clinician and experienced teacher. What is your advice to Melissa?
The ethical obligation to support colleagues is outlined in a section of the Code (ANA, 2001, p. 9) below: The principle of respect for persons extends to all individuals with whom the nurse interacts. The nurse maintains compassionate and caring relationships with colleagues and others with a commitment to the fair treatment of individuals....The standard of conduct precludes...any form of harassment or threatening behavior, or disregard for the effect of one’s behavior on others. Although workplace verbal abuse has many sources, it is most stressful when a co-worker is the perpetrator (Center for American Nurses, 2007). The nurse who is bullying in this situation is using the power imbalance of being a senior nurse. The victim of bullying is emotionally affected, resulting in an inability to use normal problem solving as a coping strategy. Unless something is done, Melissa’s self-confidence and psychological well-being will be eroded. By discussing this abuse with you, she is less isolated, but your assistance also needs to include how to approach the perpetrator. To support her acting courageously, the guidance to Melissa should include the following:
1. Prepare what she will say the next time she is criticized by the preceptor.
2. Include in the statement that the behavior is unacceptable and harmful: “When you criticize me in front of people, I feel degraded because your comments are not meant to help me constructively be a better nurse. I would like you to focus your feedback on how I can change behaviors to be a great nurse.”
3. If the confrontation does not work, then she must go to the manager. Role playing with her a few times also would be supportive. What is important is that the nurse speak up; otherwise the abuse will continue.