Archive for the ‘workplace’ Category

As has been widely reported, a recent study indicates that almost half of New Zealand nurses have considered leaving their jobs out of ‘moral distress.’ The high rate of moral distress among nurses is not surprising, given the morally-significant nature of their work. In fact, that’s a feature of clinical work of all kinds. I made this general point in reference to a specific clinical context almost a decade ago, in the Canadian Journal of Psychiatry, in an article called Treatment Resistance in Anorexia Nervosa and the Pervasiveness of Ethics in Clinical Decision making. Here’s a quote that sums up the main point:

But it is useful to remind ourselves that an ethical issue is not something that arises every few weeks in clinical settings, in those regrettable moments of crisis in which clinicians feel the need to seek advice from ethics consultants or committees. Ethical issues of an acute nature may (we hope) be rare, but ethics—the making of value judgements, of weighing our actions against shared standards—is a task inherent to clinical life.

As the New Zealand study illustrates, it’s a point that applies to nursing practice quite generally.

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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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When is unethical behaviour by a nurse not a matter of ‘nursing ethics’?

From the Wisconsin State Journal: “Nurse disciplined for using donor program credit card for personal use”

A registered nurse who used a Neenah hospital’s organ donor program credit card to take cruises and vacations with her husband has been disciplined by the state Board of Nursing.

The board suspended the license of Peggy Grambsch, of Poy Sippi, for six months on Jan. 26. It also ordered Grambsch to take a nursing ethics course and pay $750….

It’s hard to blame the board for requiring that Grambsch take an ethics course. But it’s hardly likely to be the right remedy here. First, the behaviour she engaged in is, as far a I can see, a matter of outright criminality, rather than subtly unethical behaviour. Secondly, to the extent that there are ethical issues here — misappropriation of funds is of course unethical, in addition to being illegal — I suspect such issues are not covered in most nursing ethics courses. If I were on that board, I would have insisted on a business ethics course, especially one with a section on financial integrity and ethics in the workplace.

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Finger pointing is easy. Figuring out what to do about labour relations in healthcare is harder.

See this recent story: Patient Dies During Hospital Labor Dispute

California authorities are investigating the death of a patient at an Oakland hospital that police and hospital and union officials said resulted from a medication error made during a labor dispute between nurses and the health system that runs the hospital.

Police and officials at Alta Bates Summit Medical Center told the local media the woman died after she received an incorrect dose of medication administered by a replacement nurse. At the time, regular staff nurses employed by Sutter Health System were locked out following a one-day strike by 23,000 nurses across the state….

A couple of things differentiate labour disputes in healthcare from labour disputes in, say, the auto industry. One is that in healthcare, the “labourers” tend to be licensed professionals, subject to a code of ethics, etc.

The other difference is that, in healthcare, there’s always a shared focal point for ethical argumentation, namely the patient. Both sides in a healthcare labour dispute have to put some of their most central arguments in terms of patient wellbeing. In the auto industry, by comparison, there’s much less common ground. Sure, both GM and the UAW have an interest in making sure the company stays in business. But beyond that, it’s “us vs. them.” Every dollar gained by the workers is a dollar lost by someone else (managers, shareholders, etc.) In healthcare everyone has to bow to patient interests. You can be as cynical as you want about the other side, but you still know that, in public at least, the arguments they give must give priority to patient wellbeing.

One final note: an ethicist quoted in the story above blames inadequate compensation for troubles like this. I’m skeptical about that. I don’t doubt that wages are an issue. But higher wages wouldn’t necessarily mean fewer labour disputes. You would likely still see the regular cycle of negotiation, strike, contract, period of calm, and then renewed negotiations. And so on. And after all, wages aren’t the key issue in the eyes of nurses, are they? What do you think?

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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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From the Sydney Morning Herald: Nurses fear bedlam in jail hospital

NURSES at the state’s highest security psychiatric prison hospital fear for their safety, and say they are left defenceless against violent patients.

The NSW Nurses Association and the government confirmed a male nurse at Long Bay Forensic Hospital had his skull fractured this year by a patient, and was put in a taxi to get to hospital.

Nurses have also been bitten and punched by patients, many of whom are accused of rape and murder….

This is, obviously, much more than just an issue of ethics. Clearly, it’s an issue of workplace safety and one in which both the needs of the patients and the needs of the nurses are not being met. Acting as a full-time security guard, as the article describes most nurses’ roles, is not conducive to any kind of nurse-patient relationship. The reality is that nurses are, as many say, “on the front line” and with inpatients, in almost every institutional setting, for 24 hours a day. Issues of workplace safety, dangerous or harmful situations, insecure or injurious environments tend to have the greatest impact upon nurses and, logically, upon the perceived and real quality of nursing care. And that is one reason that this becomes not only a workplace or practice issue (a very critical one) but also an ethical issue.

Situations like this but less serious are echoed by nurses in many settings. Overwhelming workloads, unsafe ratios of nurses to patients, staffing based on numbers of beds rather than patient acuity — these kinds of workplace concerns are frequently voiced in cafeterias, nurses’ lounges and classrooms.

Despite this, it’s difficult to get nurses to organize and take action, such as approaching management in order to voice concerns, to note the kinds of serious problems that may be affecting patient care and to suggest change. Further compounding this difficulty, as the article notes, it’s often perceived as very difficult to get management to “pay attention” to the problems, according to many nurses. In this article, one forensic nurse notes that ”The general feeling is that it will probably take a very serious assault for them to bring in security.” Like many situations in clinical practice, the worst-case scenarios tend to attract attention and induce changes in practice or force management to come up with concrete strategies to address problems. This, however, shouldn’t be one of those situations.

The Canadian Nurses Association’s Code of Ethics , revised in 2008, offers a discussion on “quality work environments” and the link to ethical practice of nurses. The inclusion of this section, as I recall, was seen as somewhat controversial when it was introduced for discussion as the revisions were taking place. Quality work environments are, according to the Code, essential for ethical nursing practice, but not enough just on their own. The Code goes on to say that nurses have a responsibility to reflect on the kinds of interactions they have and the resources required to help create and sustain a workplace in which “safe, compassionate, competent and ethical” care can be provided. Reflection is great and highly useful in a variety of contexts, but there is no doubt that this situation calls for, at this point, far less reflection and far more purposeful action. While it may be a health care provider’s (not only nurses!) responsibility to maintain a place and space in which compassionate, competent and ethical care can be delivered, safety of everyone involved needs to come first.

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