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Here’s another in the Globe & Mail’s series on understanding the healthcare system. This one’s a short video, called: How do hospitals decide who gets a bed?. The voiceover is by a “patient flow specialist,” an RN whose

A couple of quotes from the video:

“It’s constant juggling. We’re constantly playing with missing pieces of a puzzle, we’re trying to make the best to make it work and make everyone get the care that they need…”

“What we’re often doing is speaking to the charge nurses, speaking to the staff physicians, speaking to the fellows, to say if I only do get one bed, who’s the best to move out at this time? You want to take the best patient, the most stable patient — that way you don’t get anyone bouncing back.”

“A patient flow specialist is a registered nurse who basically triages patients from all areas of the hospital, and brings them according to the skillset of the floor, according to patient need…”

The video also touches on the challenges in getting patients and their families to understand hospital prioritization practices when it comes to beds:

“I think it’s very hard for people to understand, when they themselves or their loved one is sick, to understand that there are other needs outside. It’s very hard to accept that when the immediate person at that time requires help and care.”

Finally, the video also touches on the big picture, and the fact that hospital beds are (or should be) just one option among a range of options including various forms of home- and community care.

Ethics of Triage

The Globe & Mail recently ran an interesting piece called “Nurse, who should see the doctor first?”, which challenged readers to prioritize 4 hypothetical visitors to an ER. The question: who should be seen first by a doctor, and why?

The 4 patients (described in greater detail in the article) were…

A man complaining of chest pains and shortness of breath following a long airplane flight.
A young woman with a painful sprained ankle.
A middle-aged man with a headache, blurred vision and an inability to use his right arm.
A senior man who’d shot himself in the hand with a nail gun.

The follow-up piece, featuring the wisdom of an experienced ER nurse, is here: “What would a nurse do?”

Here’s the order recommended:

#1 The middle-aged man with a headache, blurred vision and an inability to use his right arm.
#2 The man complaining of chest pains and shortness of breath following a long airplane flight.
#3 The young woman with a painful sprained ankle.
#4 The senior who’d shot himself in the hand with a nail gun.

It would be easy — and useful — to add details to each patient’s story to make this into a good exercise for an ethics class.

Questions for disucussion:

    Should it matter if one of the patients is homeless?
    Should it matter if one of the patients is a “whiner”?
    Should it matter if one of the patients is a verbally abusive?
    Should it matter if the nail gun injury is the man’s “own ‘fault”?
    Should it matter if one of the patients is a local celebrity?
    Should it matter if the girl with the sprained ankle is the daughter of a major donor to the hospital?
    Should it matter if the patient is a “frequent flyer” (i.e., someone who visits the ER quite often, perhaps seeking attention)?

This is a great example of the close interconnection between nursing skills and ethical decision making.

What’s the connection between manners and ethics?

A recent piece in Time discusses worries about rudeness on the part of physicians: It’s Not You, Doctors Are Just Rude. The piece discusses “a new study from Johns Hopkins University showing that young doctors in their first year out of medical school are unlikely to take the time to introduce themselves to hospitalized patients, or to sit and have an eye-to-eye conversation with patients.”

The point of posting this here is not to promote doctor-bashing. All professions can be susceptible to problems of rudeness; there are rude nurses just as surely as there are rude doctors.

Several years ago, I wrote a short commentary on the topic, for the Newsletter of the College of Physicians and Surgeons of Saskatchewan, called Manners and Ethics: Is it Wrong to be Rude? The key point in that article is that the link between manners and ethics is respect. Manners are a sign of respect, and respect is a fundamental element of ethical behaviour. Individual instances of rudeness might not amount to something unethical, but a pattern of rudeness signals a worrisome level of disrespect that is both unproductive and unprofessional.

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p.s. this is of course closely related to the problem of bullying, which is a significant one in some nursing contexts.

We at the Nursing Ethics Blog are big fans of critical thinking. In fact, we’re working on a new textbook (under contract to Oxford University Press) on critical thinking for nurses.

Critical thinking is “the systematic evaluation or formulation of beliefs, or statements, by rational standards.”* It involves thinking outside of the box, and a willingness to ask hard questions when the need arises. We’ve blogged a bit about the significance of critical thinking in nursing ethics in particular here and here.

But critical thinking is a tricky concept to apply within the context of nursing. After all, nurses simply cannot question every practice and assumption. Sometimes immediate action is needed, and now is not the time to sit back and ask probing questions. Being part of a self-regulating profession means that RNs need to stick closely to established technical and ethical standards. And most nurses work in more-or-less hierarchical teams and institutional settings that involve a huge number of rules, policies, and procedures that simply must be followed.

What is really required, then, is a critical approach to critical thinking: a responsible nurse needs to systematically about when and where to question established rules. The key, of course, is to develop the attitude and skills of a critical thinker, and to be ready to apply them in appropriate circumstances.

This is just one way of illustrating this general point about ethics: while individual judgment and critical thinking are essential to good ethical reasoning, it needs to be balanced against the collective wisdom that is often embodied in laws, rules, and social conventions.

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*Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 3rd Canadian Edition, Oxford University Press, 2013.

Here’s an interesting story from The Telegraph: Psychiatrists and nurses admit lying to dementia patients.

Truth-telling is one of the ethical pillars of modern healthcare. Telling patients the truth is generally seen as a key part of treating them with respect. Lying to them is a form of manipulation that is usually incompatible with respecting patient autonomy.

Are patients with demential an exception? Certainly it’s hard to make a case for a blanket exception, given the enormous variation in cognitive capacities and emotional states that can fall under the general heading of “dementia.” It may well be that there are a limited number of particular circumstances with particular patients in which lying is justified. But nurses should never be complacent or come to think that lying is part of standard care.

Should healthcare professionals accept gifts from patients? Small gifts? Big ones? How about multi-million dollar gifts?

That’s the topic tackled in this opinion piece by bioethicist Art Caplan: Heiress’ gifts to medical workers raise thorny ethical issues.

The gifts in question in the case Caplan discusses are very large indeed. Most health professionals will never have to give serious consideration to the ethics of accepting a million dollar gift. But thinking through the ethics of a case like this one is a good way to focus discussion on the principles behind the need to maintain boundaries.

Nurse-patient ratios probably aren’t discussed in most nursing ethics classrooms. But it’s clearly an ethical issue. Check out this recent story out of Massachusetts:

Mass. Nurses Association demands mandatory nurse-patient ratios

The trade group representing nurses is pledging to put the “sweat equity” of its 23,000 members behind a push to impose statutory nurse-to-patient ratios, but hospital officials are decrying the proposal as running counter to the trend toward a health care system where providers are reimbursed based on the quality of care they deliver and patient satisfaction.

The Massachusetts Nurses Association on Monday outlined plans to press for passage of a 2014 ballot proposal if the Legislature does not act by the middle of next year to pass nurse staffing legislation, which would apply to acute care hospitals.

The proposal calls for one nurse for every four patients in medical/surgical units….

It’s clearly a complicated issue. Nursing ratios are of course crucial to patient care, in general, but I suspect it is very hard to describe a one-size-fit’s-all solution, which is more or less what regulation would require.

Note also the difficult challenge, here, from the point of view of responsible advocacy. The MNA wants to advocate from the point of view of patient safety, which is entirely appropriate. But any attempt to legislate nursing ratios will of course be perceived by some as an attempt to maintain employment levels for nurses.

Finally, note that this issue raises questions of interdisciplinarity and the role of allied health professionals. In some cases, nurse ratios are being reduced because nurses are being replaced (or supplemented) with other kinds of workers. Sometimes that will be a very bad thing (for patients). Sometimes that will probably be a good thing (for patients). Sorting out which is which is a significant ethical challenge.

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