Ethics are essential in nursing to help nurses navigate through dilemmas and focus on patients’ positive outcomes. The medical field is complex with challenging decisions that compete with self, organizational, and patient interests. Nurses are patient advocates and must balance ethics and values to satisfy patient needs. Ethics helps nurses to always keep patients’ goals before theirs and provide the best care possible. The ethics place nurses under pressure to avoid harm and maltreatment and promote patients’ good.
The paper provides a nursing ethical dilemma to explore the role and benefits of nursing ethics. The case falls under the situation of sacrificing innocent people and blaming others to get the job done. A senior nurse sacrificed a junior to carry the responsibility of an error with blames to have the staff correct the issue. The paper starts with a case description with a focus on matters arising. Next is a section that relates the case with provision 5 of the American Nurse Association [ANA] Code of Ethics for Nurses on integrity. The paper also analyses two ethical principles from the case and a model of providing the most negligible impact.
Two nurses were working on a night shift in an elderly patients’ ward. Most of the patients in the ward had comorbidities, with the majority having mobility issues. While one of the nurses was experienced in the work and facility, the other one was new in practice and junior in the shift. The staffing and pairing of the two aimed to help the younger at work gain experience and become competent. On this day, a call bell rang when the new nurse was attending another patient opposite the nursing room in the ward. On the other hand, the experienced nurse was on a non-urgent friendly call. Despite the hospital policy that nurses on duty should attend such bells within a maximum of two minutes, none of the two checked the patient. However, both nurses could see each other through the transparent windows, and the new staff knew that the other one was free to attend to any urgent need. Negligence on the nurse’s duty led to the patient’s fall as she struggled to get out of the bed for a short call.
The patient got a dislocation of one leg, causing a lot of pain, leading to shouting throughout the ward. There was a need for urgent care on the patient since she was prone to high blood pressure, which could have worsened with persistent pain. The shouting attracted the two to the patient, but instead of helping, an argument broke. None of them wanted to take responsibility for the results of the delayed response to the bell. The nurse, on an unofficial phone call, blamed the new one that she had neglected her duty. She argued that she was training the new nurse to go beyond allocated tasks in sacrifice for patients. “Just because I was free in the staff room does not mean I hand to attend the patient. I was teaching you the art of helping other staff for the benefit of patients,” the experienced nurse claimed. The nurse further stated that the new one should take responsibility and attend to the patient, including reporting it to the nurse head. However, the argument continued without caring about the patient’s extended pain and shouting.
Ethical Situation: Issues
None of the nurses wanted to attend to the patient to avoid punishment from the hospital management for negligence. Taking care of the patient would mean that the nurse was responsible for the fall. However, the experienced staff was on the wrong since she was the free one to respond to the call bell and knew that the other nurse was on another duty. The situation was a dilemma to the old experienced nurse. In one of the options, the nurse could have accepted the failure to answer the call bell. The consequences would have been a punishment from the administration and nursing association but save the patient and protect the junior nurse. Another option was to blame the junior nurse for the fall since the hospital trusted and believed her due to experience. The impact would have been avoided punishment, harm on the patient through persistent pain, and the new nurse following a reprimand from the management.
Relation of the Situation with the Code of Ethics for Nurses
Description of the Integrity Code of Ethics
The situation relates to provision 5 of the American Nurse Association ([ANA], 2014, p. 32) Code of Ethics for Nurses. According to the provision: “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth” (ANA, 2014, 32)
The nurse violates the code of integrity in the profession. Integrity is a self-duty to maintain individual character throughout the profession and in any circumstances. Nurses are supposed to remain consistent in their values, such as honesty and fairness and ethics in decision-making unless such violations support a nurse’s moral integrity (ANA, 2014). Such compromise can also occur where there are no risks to the wellbeing and dignity of others. The code guides nurses in decision-making following the threats to integrity surrounding their complex working environment (Sastrawan et al., 2019). Such threats can be opportunities to lie to other staff, patients, and their families to avoid the duty to care. Mutual respect between nurses and patients and the management supports moral integrity (Sastrawan et al., 2019). The trust and confidence of patients and other staff depend on nurses’ proper practice. Such a relationship leads to nursing success, especially in patient care, through avoided negligence, delays, and other issues.
Relationship of the Situation with Integrity Ethic
The experienced nurse also violates integrity through a lack of fairness to the colleague. The nurse is taking advantage of her seniority and experience to shift the blame on a junior. Fairness supports organizational objectives through established relationships (Pozgar, 2014). Nurses have a responsibility for fairness in their work to ensure proper patient care. An appropriate relationship of working among nurses allows teamwork to support patient care through collaborative intelligence. In this case, the nurse is not fair to the colleague leading to adverse effects on the patient as they argue. Fairness to accept failure would have led to immediate action leading to fewer injuries. Negligence in attending to the patient first also implies integrity violation.
Integrity in nursing extends to adhering to other ethical codes and practices (ANA, 2014). Nurses have a duty to safe practices to minimize client injuries (Pozgar, 2014). The argument between the two nurses was negligence on safe practice since the patient was suffering. Prolonged pain on a high blood pressure patient risks higher levels. Additionally, the ward’s shouting was causing fear in other patients, which affects their health and satisfaction in care. A proper practice would have been serving the affected client and later settle the issue of responsibility. In this case, the nurses were selfish to prioritize their interests at the expense of the duty to care.
Another indication of violated integrity is the failure to accept the mistake. Nurses are responsible for taking mistakes as an ethical practice following nursing’s complex nature (Pozgar, 2014). However, the experienced nurse assumes the ethical practice to shift the blame of mistake in practice to another staff. Failure to accept the mistake blocks proper practice in this case by leading to an argument that delays patient care. Accepting errors is essential to allow immediate nursing actions and identification of faults in deciding on the solution.
One of the arising ethical principles in the case is beneficence. According to the code, nurses should embrace good actions towards patients (Pozgar, 2014). Compassion, charity, and kindness support nurse’s actions that maximize’ patients’ good. The actions can be good in that they prevent, mitigate, or remove harm on patients. In this case, nurses have to care about improving patient’s health through good actions (Motloba, 2019). Beneficence aims at maximizing good on patients to the level possible on the side of healthcare providers. The idea is to prioritize patients’ interests as much as possible through selfless practices.
Beneficence arises in the case following the patient’s need for attention and nurses’ options on interests. Selfishness does not allow a nurse to go beyond practice in actions that can maximize patient good. In this case, the patient had an urgent need to attend to the consequences of the fall. The two nurses had opportunities to maximize the patient’s good by calling a physician or taking the patient to the urgent care room. Regardless of the issue, either of the nurses could have shelved self-interest to attend to the patient. Serving the patient first and later handle the blame game would have reduced patients’ pain and save the rest from fear. However, the two nurses neglected the chance to fight for their names from the negligence case arising.
Beneficence also arises following the patients’ need for help to get out of the bed. The experienced nurse had more opportunities to do good for the patient. She assumed her role in answering the call bell, a chance that could have provided maximum good to the patient. Another opportunity was to accept the responsibility for the failure of urgent care for the client. Taking the blame could have led to immediate action on the affected client. The goal of sacrificing an innocent person in the case overtook a good action of ensuring patient safety and adverse effects. Selfishness, such as the experienced nurse to protect the job and practice, is against beneficence due to competing chances.
Another ethical principle that might arise in the case is nonmaleficence. Nonmaleficence is a risk-benefit doctrine that requires practitioners to avoid harm to patients (Motloba, 2019). Through the principle, nurses are supposed to analyze a situation and behave in ways that minimize damage. Minimizing ham can be either through an action or absence of action. The principle also falls on nurses’ duty to care, in this case, patient protection (Pozgar, 2014). Nurses are responsible for patients’ health while in the facility to ensure that it does not worsen. Such opportunities include assessing a patient’s effect of medication, including allergic reactions.
Nonmaleficence arises in the case through opportunities to harm the patients. The two nurses had ways to reduce damage to patients but did not take a risk-benefit analysis. One of the actions that needed analysis on merits and demerits was the argument. The blame game was a risk to the patient and others in the ward through prolonged pain. Acute pain was a risk of high blood pressure. Regardless of the consequences of accepting the blame through service to the patient, saving a life and damages was more valuable.
The experienced nurse also had actions that needed risk-benefit analysis. The choice between assuming the call bell and dropping the phone call impacted the patient’s life, especially in protecting against falls. Another action was handling the failure to avoid harm to the new nurse’s practice and work alongside the patient’s health. In this case, accepting the mistake could have prevented damage to the new patient and the new nurse.
Mitigating the Impact of the Situation
The above case is a dilemma with negative consequences on either decision. Accepting the fault lessens harm and maximizes good on the patient and the new nurse. However, the decision affects the experienced nurse’s practice and job due to negligence. On the other hand, denying the failure responsibility will save the nurse’s license and job but harm the patient and the other new staff. The nurse can use the American Association of Critical Care Nurses’ [ACCN] 4 A’s framework to reduce impact. The ACCN (n.d) 4As is a framework for making the best decision out of moral distress. Moral distress in healthcare occurs when an individual is aware of the most ethical choice but cannot pick the option. The model guides through a process of self-awareness to affirm the right action and provide the drive to act. The most appropriate ethical practice in healthcare that provides less impact is following the moral code of nursing practice. Such a decision addresses the patient’s interest first to ensure safety and maximum good. The 4 As a model, which includes asking, affirming, assessing, and acting, supports nurses to prioritize patients by taking selfless actions.
Under the first stage asking, the nurse would assess her feelings to create awareness of existing moral distress (ACCN, n.d). ACCN recommends asking a question such as “Am I feeling distressed or showing signs of suffering?” (ACCN, n.d). In the next stage, affirm, the nurse would commit to addressing the distress. The level requires reviewing professional obligations and validating feelings with others. A nurse can quickly skim over the code of ethics back in mind to arouse a sense of responsibility. The third stage is an assessment that involves getting ready to act. Under this stage, a nurse can evaluate the source of pressure, severity, and readiness to take action (ACCN, n.d, 2). Finally, the practitioner acts by preserving the affected ethics, such as integrity, and maintain authenticity. The stage involves further preparation to act, action, and maintaining the culture throughout the situation (ACCN, n.d). A quick scan on the 4As would enable the nurse to develop an ethical environment related to nursing for the situation and take the best action that minimizes harm on the patient and the other staff. In this case, the nurse would have settled on taking the responsibility of failing to answer the call bell, which produces less impact.
The case study reveals the importance of organizational ethics in maintaining goals and objectives. Organizations and professional bodies develop a code of ethics to regulate conduct within the required framework that delivers positive outcomes. The focus of healthcare and nursing associations is to ensure patient safety, proper care, and recovery. In the analyzed case, the nurse had the option of lying to avoid punishment following negligence at work but affect patient health and another staff’s practice. There was also an alternative of talking the truth, get a penalty but save the patient’s health and another staff’s nursing practice. The analysis shows that observing the ANA’s code of ethics on integrity and ethical principles of beneficence and nonmaleficence would have led to better patient outcomes. Nurses can use decision-making models to guide their practice towards the best behaviors. One of the frameworks is the ACCN 4As that helps an individual become sensitive to professional ethics and toe the line.
American Association of Critical Care Nurses’ (n.d). The 4A’s to rise above moral distress.
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Motloba, P. D. (2019). Non-maleficence-a disremembered moral obligation. South African Dental Journal, 74(1), 40-42.
Pozgar, G. D. (2014). Legal and ethical issues for health professionals (4th ed.). Jones & Bartlett Learning.
Sastrawan, S., Newton, J. M., & Malik, G. (2019). Nurses’ integrity and coping strategies: An integrative review. Journal of clinical nursing, 28(5-6), 733-744.