Posts Tagged nursing ethics
Posted by jeanhill in Good Nursing Practice is Practising with the Heart and Mind, Nursing Discussion, Random Thoughts on Wednesday 04 July 2012
A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could. I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.
I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby. Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.
I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby. I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before. Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.
The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious, are not the same.
It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them. Come back with a subpoena, we tell them. They try anyway.
Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.
So what do we do about it? Approximately nothing. We might document the injuries, in case there are legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?
But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?
It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.
Posted by torontoemerg in Battered Nurse Syndrome, Before I Start Throwing Things, I'd Better Write This Down, When the Health Care Corporation Speaks on Monday 14 May 2012
More on the Texas hospital, Citizens Medical Center, which banned fat people from being hired. Citizens Medical Center, you might remember, made it policy to exclude new hires with a body mass index >35, and explicitly stated employees appearance should “fit with a representational image or specific mental projection of the job of a healthcare professional . . . free from distraction” for patients. Medscape has a video (sorry, couldn’t figure out how to embed) from a medical ethicist named Art Caplan with another point of view. Partial transcript:
Look, I’m all for trying to set a good example and I think there are plenty of businesses where being thin and being in shape really do matter. I guess if you run a modeling agency it is very important. But I’m not convinced, really, that putting in weight restrictions is the best idea in terms of sending out the right message or a necessary message to patients. Patients, I think, can work with their doctors to try to overcome common problems. Doctors see all kinds of patients with all kinds of habits and all kinds of lifestyles. I think patients can deal with seeing all kinds of healthcare workers with all kinds of habits and all kinds of lifestyles. If they want a thin one, they should be able to pick one, but I don’t think the hospital necessarily should have to say that only the thin ones can work here. [Emphasis mine.]
Really? That last bit sounds needlessly, well, stupid. Does he really think patients should be allowed to choose their health care providers on the basis of their appearance? ”Let’s see. . . ” one can imagine patients musing, “that nurse is too fat. Tht nurse is too old. That nurse is too. . . dark. That nurse is too male. That nurse is too Muslim. That nurse is too gay.” And so on. Apart from fostering bigotry and discrimination, and demeaning and devaluing staff, in practical terms, you’d soon run out of nurses. I mean, not every nurse looks is thin, white, young and female.
One more thing. I understand there is a role for hospital policies regulating appearance: hygiene, facial hair, tattoos, uniforms and jewellery are usually targeted. Fair enough. I also understand the need for an ethicist to weigh (so to speak) both sides of the issue, but isn’t there some point where, after all is said and done, you have to say evaluating people of the basis of their body characteristics in general is just wrong? I don’t think that medical ethicist Art Caplan exactly said it was wrong. Making a value judgement, that employers treating nurses and physicians as human beings with inherent dignity and worth, is important. It might even be a good place to start.
[UPDATE] Also, too, these thoughts from a writer named Susan Pape at Policymic.com:
When I am in need of hospital care, I want the staff to be the best, hardest working, most talented, most caring available. I do not care if they are overweight. Employing health care providers on the basis of their competence is a matter of life or death …to me.
Obesity is not a choice, and it is not immoral.
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind on Sunday 08 April 2012
One thing you may or may not know about me, dear readers, is that I’m a retired Catholic. Like many other people, I left because what some Catholics would call “below-the-belt” issues, but also because the (ongoing) sexual abuse scandals, the treatment of women, and the utter hatred and contempt shown to our gay and lesbian brothers and sisters by the Church hierarchy. I guess I simultaneously rejected the Catholic Church’s authority to be the final arbiter of my conscience on these issues, and any denied actual belief that the Church’s position on these any of these issues was tenable. Or humane. Or Christian.
But still, I won’t pretend my nursing practice hasn’t been deeply influenced and illuminated by Catholic ethics. Here’s one way they are. Call it my personal theoretical basis for practice. The Works of Mercy:
For me, anyway, the works of mercy are a pretty good touchstone for what’s good and valuable in nursing practice: there isn’t one of them that doesn’t touch some aspect of nursing. Inevitably, your mileage may vary. And of course, many Christians reject them outright.
Posted by torontoemerg in Before I Start Throwing Things, I'd Better Write This Down, Good Nursing Practice is Practising with the Heart and Mind, Life in the Emergency Department on Monday 02 April 2012
I found this story how a homeless woman died very disturbing:
Anna Brown wasn’t leaving the emergency room quietly.
She yelled from a wheelchair at St. Mary’s Health Center security personnel and Richmond Heights police officers that her legs hurt so badly she couldn’t stand.
She had already been to two other hospitals that week in September, complaining of leg pain after spraining her ankle.
This time, she refused to leave.
A police officer arrested Brown for trespassing. He wheeled her out in handcuffs after a doctor said she was healthy enough to be locked up.
She told officers she couldn’t get out of the police car, so they dragged her by her arms into the station. They left her lying on the concrete floor of a jail cell, moaning and struggling to breathe. Just 15 minutes later, a jail worker found her cold to the touch.
Officers suspected Brown was using drugs. Autopsy results showed she had no drugs in her system.
Six months later, family members still wonder how Brown’s sprained ankle led to her death in police custody, and whether anyone — including themselves — is to blame.
There seems to be no simple answer.
Actually there is a very simple answer. At some point in her care, a nurse or physician decided Anna Brown deserved to die. I don’t mean literally a health care professional wrote Anna Brown’s chart, “This patient deserves to die.” But someone decided — a nurse, a physician, or maybe it was a collective, Emergency Department judgment — that because Anna Brown was homeless, because she was black, because she was poor, because she had made multiple visits, because she was still in pain, because she advocated for herself by making a fuss, because she possibly had (undiagnosed) mental health issues, she was not entitled to proper care.
She was labelled. She was drug-seeking. She was crazy. She was a frequent flyer. And that killed her as surely as if a nurse had bolused potassium chloride.
I will tell you why I think this is true. Because Anna Brown had made repeated visits, and no one took her seriously. Because she told staff about her increasing pain, and no one believed her. Because she was unable to walk, and no one thought to ask why. All of these are enormous waving red flags for any emergency department health care professional, and neither physician nor nurse did anything about them. That’s the thing about labels: they contain their own little subjective judgements about patient care, and obscure the obvious.
If Anna Brown had been a middle-class white woman with a nice home, a job and a car, I am willing to bet — no, I know the outcome would have been different — or at least, she would not have died, gasping for air, from a pulmonary embolism on a cold jailhouse floor. There certainly would not have been any of this Kafkaesque horror of being in obvious distress with a deep vein thrombosis, about to throw a clot, and being utterly unable to get help at the very place where you might expect it.
I will let the public in on a little secret. We all do it. Each and every one of us. I don’t exclude myself. We all label patients. It is deeply embedded in the culture of health care to the point where it is an accepted practice. We all call patients drug seeking and crazy and frequent flyers and failures-to-die and failures-to-cope. We laugh at them. Hell, there are whole blogs and books devoted to the art of ridiculing patients we have already labelled. (Though when you think about it, there is nothing quite as charming as making fun of human beings who are powerless, is there?) Has any one ever thought labelling patients might cloud and impair clinical judgment? Or that it dehumanizes patients and is just plain wrong?
But the way Brown died was not the result of a few bad choices. It was the result of a myriad of institutional violences: white supremacy, the broken health care system, police brutality and the prison industrial complex, the racism and classism of the child welfare system, ableism and its intersection with racism, dehumanization and criminalization of (suspected) drug users, and the lack of housing as a human right, among others. Anna Brown did not die with the dignity we afford to human beings, but with the contempt we reserve for garbage. And a woman’s humanity is not just forgotten and cast aside with no systemic reason.
Don’t think I have much to add.
[UPDATE: A long time reader suggests instead of the word label, I should use "profile," as in "racially profiling." Once upon a time I might have thought the word unnecessarily inflammatory --- but now I am not so sure.]
[UPDATE II: Small corrections to syntax. Hobbit not cooperating.]
- Surveilling the Death of Anna Brown (bagnewsnotes.com)
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Life in the Emergency Department on Tuesday 06 March 2012
MY EMERGENCY DEPARTMENT COLLEAGUES are a youngish group as a whole, compared to me, that is, and most of them have school-aged children. A subset of this group of have traded shifts so they’re substantially working a straight night shift line,* in order to attend to family obligations. Almost all of these, I think, are coming in exhausted. I’m not talking I-missed-an-hour-because-little-Tiffany-woke-me-up, but exhausted. Bagged. Corpses-are-livelier tired. Black circles under the eyes. Uncommunicative to the point of being catatonic. Most work a 12-hour night, go home, get the kids off to school, catch a couple of hours between tending to the ones still at home, cook lunch and dinner, clean house, what-have-you, and still come in for another night.
These nurses scare me a little. We all know about the health effects of working shift, and consistently getting fragmented sleep while on a two or three day run of nights probably isn’t the best for personal wellness. Studies of have linked shift work and poor sleeping patterns to higher levels of cancer and metabolic syndrome. But more importantly, what about the patients? On balance, nurses aren’t doing their patients any favours by coming in sleep-deprived. One study suggests cognitive and psychomotor impairment correlates with sleep loss. Seventeen hours of wakefulness is the equivalent of having one or two drinks. After 24 hours, the alcohol equivalent goes up to two or three drinks.To put it bluntly, who would think of going to work having a few drinks? But we do, clutching our Tim Horton’s coffee like a talisman. But then there’s also this: there’s good evidence sleep deprivation contributes to medication errors. For nurses who had poor/ interrupted sleep
the odds of reporting any accident or error were twice as high for rotators [i.e. day/night] as for day/evening nurses. Rotators had 2.5 times the odds of reporting near-miss accidents. After adjustment the effect of rotating on medication errors was reduced from 2.2 to 1.8.
Considering we work in a profession that depends on judgement, clarity of thought, decision-making, organization, information gathering and processing, and critical thinking in general, you might think we would be more concerned with the consequences of sleep deprivation. But we aren’t — we seemed to be trapped in a professional culture which tells us to suck it up, while demanding perfection at the same time — and neither, it seems, are our employers.
One last thought: I have to wonder, where are the spouses in all of this? I get that it is probably far easier for most nurses to arrange their schedules around their spouses as far as child care is concerned. But I think it also speaks volumes about the perceived value of nursing that the professional issues surrounding sleep deprivation — and nursing in general — are ranked rather lower than the spouses’ ability to juggle their schedules. We maybe haven’t come as far as we think.
*In unionized Ontario hospitals, which is to say, the vast majority of hospitals in the province, nurses must be assigned 50% shift.