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Archive for the ‘professionalism’ Category

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.

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From PBS: Next Health Care Mandate: Flu Shots for Medical Workers?

Brandon Hostler’s arm is usually among the first extended for the annual flu shot at Ruby Memorial Hospital in Morgantown, W.Va. He is, after all, a registered nurse — he knows it can do some good.

But if that shot ever becomes mandatory, he will balk.

“I wouldn’t quit or switch jobs,” he said. “But we are health care professionals. We know the risks and the benefits, and to force us to do something like that and not have a say in it, I think it would be offensive and unwanted.”

This story nicely points out two different facets of one of the most important values in the world of healthcare, namely autonomy.

Why is autonomy important? On one hand, it is important for its own sake. We simply value the ability to choose for ourselves. On the other hand, we value autonomy because we generally believe that when people choose for themselves, they will choose better than when others choose for them. Both of those facets of autonomy appear in the story above. Some nurses are hesitant about the flu shot because they’re uncertain about whether the risks are worth the benefits; others think the benefits are there, but still want the freedom, for its own sake, to say “no thanks.”

But there are also limits on autonomy. And in particular, membership in a profession brings a whole bunch of such limits. The benefits of professionalism involve a kind of quid pro quo — society asks things in return. The hard question, of course, is whether any particular limit on autonomy — such as mandatory flu shots — is or should be part of that bargain.

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A recent book review in the Chronicle of Higher Education highlights the most recent work of neuroscientist, philosopher and author Patricia Churchland, who offers some interesting views on modern day morality, in her new book Braintrust: What Neuroscience Tells Us About Morality(Princeton University Press)

Here’s an excerpt from the Chronicle review of Churchland’s book: Rule Breaker: When it comes to morality, the philosopher Patricia Churchland refuses to stand on principle

Hers is a bottom-up, biological story, but, in her telling, it also has implications for ethical theory. Morality turns out to be not a quest for overarching principles but rather a process and practice not very different from negotiating our way through day-to-day social life. Brain scans, she points out, show little to no difference between how the brain works when solving social problems and how it works when solving ethical dilemmas.

Churchland thinks the search for what she invariably calls "exceptionless rules" has deformed modern moral philosophy. "There have been a lot of interesting attempts, and interesting insights, but the target is like perpetual youth or a perpetual-motion machine. You're not going to find an exceptionless rule," she says. "What seems more likely is that there is a basic platform that people share and that things shape themselves based on that platform, and based on ecology, and on certain needs and certain traditions."

The upshot of that approach? "Sometimes there isn't an answer in the moral domain, and sometimes we have to agree to disagree, and come together and arrive at a good solution about what we will live with.”

The point I found most interesting, reading the review, was that Churchland feels that the emphasis on finding "exceptionless" moral rules is futile. According to her, we should place more emphasis on how we can agree to disagree rather than consistently search to find "exceptionless rules" to apply in difficult moral dilemmas.

She makes a good point and one that many of us should consider. Think of the many times we are faced with moral dilemmas in the context of nursing. Often the most effort goes into attempts to make others see situations from our perspective, and to agree with us. Frequently we hear statements like, "This should never happen" or "We should not allow this in any case" when our colleagues, patients and families are discussing difficult moral issues, like end-of-life care or allocation of scarce resources. These kinds of expressive statements, such as "I believe X is wrong" (instead of “X”, substitute any contentious bioethics concept such as: abortion, euthanasia, harm reduction), reflect a kind of "exceptionless" stance. When we approach difficult moral dilemmas with this kind of a stance, we typically are, in fact, looking for others to agree with us and align with our values to justify an "exceptionless rule" of sorts. However, it's clear that this is almost impossible in diverse societies and groups in which a broad range of values exist.

We accept diversity in many kinds of everyday health care situations and out of that acceptance arises our role of advocate and facilitator. For example, a patient may not wish to take a prescribed sleep aid, may refuse physiotherapy or may wish to delay a procedure. As nurses, we advocate for the choices and wishes of our patients and we try to facilitate their decision-making. We often allow patients to make choices that we perhaps would not make ourselves or that we would not support if we were the only decision-makers. This is part of respecting the autonomy of others and is a straightforward value in nursing and health care. However, when dealing with more difficult or challenging dilemmas, we tend to turn first to our own values and beliefs instead of first trying to consider the different values of others. This isn’t unusual and is a response many have when faced with morally challenging situations: we turn to our own consistently-held values and beliefs in a search for an anchoring answer. In other words, in simple day-to-day health care situations, we often quite easily accept that patients will make choices that reflect different values and beliefs than ours and in turn, we respect those diverse decisions. In more serious or morally challenging situations, however, we may find ourselves turning instead to our own values and beliefs to determine what the “right” option should be.

Churchland notes that trying to find answers to difficult moral problems is just like trying to find our way through less challenging, day-to-day social problems. As she notes, brain scans show very similar activity when sorting out everyday problems or working through serious and difficult moral dilemmas. For many of us, it is perfectly acceptable to “agree to disagree” on the food a patient may eat, the time for a procedure to be done, scheduling therapy or taking a sleeping aid. However, when faced with a patient who is, for example, seeking euthanasia or an abortion for a reason with which we may not agree, many nurses find it disturbing, upsetting and often distressing to care for patients whose values and beliefs, in this context, may be much different than their own. Churchland would likely say that trying to seek alignment of values, in difficult cases like this is neither satisfying or possible and that we should not focus so much attention on trying to do so.

The review in the Chronicle is a thorough one, highlighting a number of other key points in Churchland’s work. I haven’t read the book yet so it’s difficult to comment too much on her views, as noted by the reviewer, without reading about them firsthand, so I will read the book and, hopefully, will review it here as well.

The point that struck me was that we don’t really think enough (or at all!) about how we approach moral dilemmas. In nursing, these kinds of dilemmas arise often unexpectedly or quickly and must be dealt with in the moment. We expend a majority of our emotional and working energy trying to sort through a few incredibly challenging problems but often don’t take the time to reflect upon “how we did” and whether we were simply seeking an “exceptionless rule”, i.e. seeking the alignment of others with our own values rather than trying to find a more middle-of-the-road moral ground that everyone can live with. In terms of expending our energy, doing so to understand just a little better the way we’re wired as well as the way we react to and process these kinds of difficult moral dilemmas makes good sense.

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Unionization by health professionals is a touchy subject. And when it’s not, it ought to be.

See this story by James Warren for the New York Times: Finally, Nurses Are Set to Vote on Unionizing

The American Federation of State, County and Municipal Employees is still at it and will finally get a representation election next Wednesday and Thursday among about 270 registered nurses at one of the group’s locations, Our Lady of the Resurrection Medical Center.

It’s a drawn-out, nearly decade-long tussle fit for the times. The union has met resistance and filed 50 complaints about unfair labor practices with the National Labor Relations Board. The company voluntarily settled 18 of the 50 complaints brought against its various properties before any federal hearing….

Interestingly, Warren’s article makes absolutely no mention of the fact that nurses are not just regular employees, that they are health professionals. Nurses are licensed professionals with a code of ethics and an avowed commitment to the public good. That makes them pretty different from municipal employees or auto workers. That’s not to say that they shouldn’t unionize. But it does raise concerns about nurses joining unions that are not exclusively unions of nurses. Unionization has a purpose, and unions have their goals. But the goals of a union can quite easily conflict with the goals to which a health professional swears upon joining the profession.

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Bullying, or even subtler forms of interpersonal conflict, can be common in any kind of workplace. But it’s particularly corrosive, and dangerous, in healthcare settings, where effective teamwork really can make the difference between life and death.

See this editorial by Theresa Brown, for the NY Times: Physician, Heel Thyself

…while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

Of course, as Brown recognizes, the issue is much more complex than simply ‘MD vs RN.’

…because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

But even this puts too much emphasis on the behaviour of doctors; I strongly suspect that nurses (and other professionals) are perfectly capable of bullying (or “eating their own young”) even without MDs setting a negative example. The bullying that goes on within nursing (and among different parts of the nursing profession, broadly understood, including between RNs, NPs, LPNs, etc.) is just as important as the bulling that goes on between MDs and RNs.

The hardest questions I’ve ever been asked by med students and nursing students have to do with bullying, and with the difficulties inherent in being at the bottom of their respective professional hierarchies. Students understandably find it difficult — and a source of moral distress — to be not only subject to bullying, but to sometimes be involved in courses of action that they see as unethical and yet powerless to do anything about it. It’s hard to know what to tell them, because sometimes there really is very little they can do. But one thing they can do, I tell them, is to consider, starting right now, how they think they should treat those beneath them in the hierarchy, once they inevitably move up it, and how they are going to make sure they don’t fall into those all-too-common toxic behaviours.

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In most stories about conscience clauses and nurses, the nurse involved is the one appealing to conscience-clause legislation to justify non-participation in some medical procedure.

But that’s not always the case.

See this story, from CNBC: Idaho board: No action in Walgreens complaint

The Idaho Board of Pharmacy says it has no basis to start proceedings against Walgreen Co. in a complaint that alleged one of the drug store chain’s pharmacists in Nampa improperly refused to fill a prescription.

A nurse practitioner from Planned Parenthood of the Great Northwest contended the pharmacist abused the state’s 2010 conscience law in November after balking at filling a prescription for a drug that helps control bleeding after childbirth or abortions….

This I think is a little-discussed aspect of “conscience clauses” or “conscience laws”: they can be a focal point for disagreement between members of different professions. Also, while conscience clauses may sometimes help nurses avoid participation in procedures that go against deeply-held values, in other cases such clauses are going to frustrate nurses’ attempts to help patients obtain the services of other health professionals.

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Here’s a headline worth shouting from the rooftops: Nurses Top Honesty and Ethics List for 11th Year

Nurses continue to outrank other professions in Gallup’s annual Honesty and Ethics survey. Eighty-one percent of Americans say nurses have “very high” or “high” honesty and ethical standards, a significantly greater percentage than for the next-highest-rated professions, military officers and pharmacists….

Interestingly, the high numbers (and top ranking) for nurses is essentially unchanged over the last several years. Why do nurses consistently rank so highly? The folks at Gallup speculate as follows:

The consistently most positively rated professions, including nurses and pharmacists, have generally been able to avoid widespread scandals and, as such, Americans continue to hold them in the highest regard.

What do you think?

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