1Nelda Godfrey, PhD, RN, ACNS-BC, FAAN Ethics and Mistake Making in Nursing: A Transformational Ethical Framework for NursesNelda Godfrey, PhD, RN, ACNS-BC, FAAN
2Objectives:Describe the role and process of discipline in nursing regulationApply a patient safety pathway for discussion and evaluation of nursing practice errors and professional conductDescribe current guidelines and programs for evaluating, treating and managing nurses with a substance use disorder (SUD)Learn how to use a transformational ethical approach when assessing practice errors in nursing; andDevelop skills to interpret body language.
4We Live in Innovative Times Two obvious truths in our profession’s future:ChangeA growing complexity of practice(Benner, et al., 2009)
5Professional Nurse, or Nurse Professional? Professional Nurse: validation by examination or institutional verificationNurse Professional: a person who professes to be a member of the discipline and has individual qualities or characteristics that inform and motivate him to make good moral choices.
6Safe Practice— Culture of Safety— Just Culture— Yet humans make mistakes. . .Culture of safety: 7 elements: leadership, teamwork, evidence based care, communication, learning, just and patient centered care. (Theodosios, 2012)
9Case Study ANurse M is caring for Mr. J., a patient in the Neurological Intensive Care Unit, who has been diagnosed with a meningioma and was recently returned to the NICU after resection of the tumor. She knows that the family is anxious to be with Mr. J., and have waited for hours. But, Nurse M decides to finish her nursing tasks with Mr. J. while the family waits. “Besides, I need to get my work done first,” Nurse M. justifies. “There is no rule to say that I should allow the family in right at this moment.”
10Three Areas of Professional Ethics Principle-Based EthicsRules, codes, standardsProfessional EthicsConsequences-based EthicsOutcomesVirtue (ideal)-based EthicsCharacter
12Case Study BNurse K is the next professional nurse to care for Mr. R. Nurse K is taking courses for graduate school and has a family of younger age children for whom she is responsible. She views work as a necessary evil. “Without work, I don’t support my family. Let’s see, here is my list of tasks. May as well start with Mr. R. Hurry, hurry! Here is the care plan. If I work hard to do all the duties then I can be done by 9:30. I can break then and call Michael’s school. I also need to get online and the cable company. Lunch. I may have time to run to the store and back. Laura can probably cover for me.”
14Stairstep Model of Professional Transformation Crigger , N. & Godfrey, N (2011). The Making of Nurse Professionals: A Transformational, Ethical Approach. Sudbury, MA: Jones & Bartlett.
15How could a Transformational, Ethical Approach make a difference in mistake making and professional practice?
16Professional Discipline/Regulation: Peer reviewDue processInterests of the public/person/professionFormalizedTo some extent, an individual rights/privileges are subrogated to the rights/interests of the public or the person that is harmed
18Case Study CNurse S has been assigned to a patient who is unresponsive. The patient, Mr. L., is ventilator dependent and is to receive oral care as part of the hospital policy to reduce the risk of ventilator- dependent pneumonia. Nurse S knows that no one will know the level of care that is given and does a cursory job of oral care to Mr. L. After all, Nurse S rationalizes, he should put his efforts toward patients who can acknowledge and understand that he has done something good for them. Unconscious patients can neither complain or praise.
19Substance Use Disorder: State of the Science Findings from DATOS reported made it clear that treatment effectiveness is realted to patient motivation and problem severity, therapeutic engagement and intensity of services, as well as linkages to community-based social supports (Simpson, 2003).Supported partnerships between providers and policy makers can achieve wider adoptionn of evidence based treatment practices. (Schmidt, 2012)2009.What works: medication and behavioral therapy.(Drug facts: Treatment approaches for drug addiction, 2009.)
21Case Study DEach nurse at Bayview Medical Center must complete mandatory LMS testing/standards annually. Each module is accompanied by an exam, which must be passed at 90%. Each time Nurse R is asked to complete these modules, she skips the prep modules and takes the test over and over, marking the option she selects on another piece of paper, and by the process of elimination, gets to 90% after several tries—without ever reading the accompanying module.You know that Nurse R has done her ‘mandatories’ this way for several years now. You just heard yesterday that she was boasting of her ‘method’ to others.
22What we know: Substance Use Disorder: Complex Drug specific Substance abuse and substance dependenceComplexDrug specificEfficacy is a central theme
24Case Study ENurse P consistently fails to complete compliance requirements on time, including immunization and routine employment followup (TB Skin test, etc). The unit educator is frustrated about the amount of time it takes to follow up with one employee. Recently, Nurse P was part of a QI peer review assessment for clinical handoff (from one shift to another). In this project, all nurses receive feedback about their handoffs, and are asked to make changes and improvements in how communication is done from one shift to another.
25Using the STOP Model to Make Better Decisions S is for standards and reminds you to consider the nurse practice act, nursing standards of practice, ethical codes, and institutional policies to make the best decision.T is for thorough and reminds you to consider the context of your decision, including relevant history, unspoken rules, personalities, and other elements in addition to the facts.O is for outcomes and reminds you to consider whether your decision is in the best interest of the patient and shows respect for all concerned parties and society.P is for personal values and ideals and reminds you to make sure your decision is consistent with your character and personal values.*********If a nurse is still unable to decide after completing the STOP model, he or she should consult other resources, such as the hospital ethics committee.
26Assessment techniques and considerations in mistake-making situations
27Assessment and considerations Body Language—what do we know?Analysis:Old mental modelsOutcome orientation?Balance between protecting the public--and human kindness and considerationSelf-criticism vs. self reassurancePerfectionism
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29References (con’t)Schmidt, L.A., Rieckmann, T., Abraham, A. , Molfenter, T., Capoccia, V., Roman, P., Gustafson, D.H., & McCarty, D. (2012). Advancing recovery: Implementing evidence-based treatment for substance abuse Vdisorders at the system level. Journal of the Study of Alcohol and Drugs, 73 (3),Shepherd, L. (2011). Creating a foundation for a just culture workplace. Nursing, 41 (8),Simpson, D. (2003). Special section: 5 year follow up treatment outcomes studies from DATOS. Journal of Substance Abuse Treatment, 25 (3),Sorra, J., Nieva, V., Fastman, B., Kaplan, H., Schreiber, G. & King, M. (2008). Staff attitudes about event reporting and patient safety culture in hospital transfusion services. Transfusion, 48,Stavrianopoulos, T. (2012). The development of patient safety culture. Health Science Journal, 6 (2),Sullivan, KM, Such, S., Monk, H., Chup, J. (2012). Personalized performance feedback reduces narcotic prescription errors in NICU. British Medical Journal of Quality and Safety, Oct 4, [abstract].Tidwell, S. (2002). Processing complaints and disciplining nurses: An overview of the investigative process b the Kansas State Board of Nursing. Kansas Nurse, 77 (1).Vogelsmeier, A. & Scott-Cawiezell, J. (2007). A just culture: The role of nursing leadership. Journal of Nursing Care and Quality, 22 (3),Woodgett, J. (06 September 2012). We must be open about our mistakes. Nature. Doi: /489007a.