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Marcia Bosek DNSc, RN Hollie Shaner-McRae DNP, RN, FAAN JONA's Healthcare Law, Ethics, and Regulation October/December 2010 Volume 12 Number 4 Pages 101 - 105 The importance of healthcare professionals performing hand hygiene consistently was first demonstrated by Ignaz Semmelweis1 in the 1840s. After concluding that puerperal fever was contagious, he directed that all medical students wash their hands with chlorinated lime prior to examining patients. Despite minimizing the rate of maternal death from 12% to 1%, Dr Semmelweis' hand-washing practices encountered opposition from various hospital and medical leaders.1 One hundred sixty years later, incidences of failure to protect patients from harm simply by performing hand hygiene continue.2 Ethical Case While informally meeting with staff nurses in a nursing station, Molly, a midlevel nurse leader, was distracted by an event taking place across the unit hallway. Molly could not help but notice that an attending physician and medical student had just entered a patient room requiring contact isolation precautions neglecting to don personal protective equipment (PPE) or perform hand hygiene. In addition, the attending physician was sipping on a cup of coffee as the duo entered the patient's room, engaged in conversation with the patient and family, viewed the various monitor displays and exited the room on to their next destination again without performing hand hygiene. Excusing herself from her meeting, Molly walked over to the attending physician and after introducing herself, including name and institutional title, commented, "Excuse me, but I noticed that you missed an opportunity to perform hand hygiene. The patient's room you just came from is an isolation room, and there are signs instructing all who enter to follow contact precautions, which would include donning PPE and performing hand hygiene before and after entering the room." The physician appeared somewhat surprised by the conversation and leaned forward honing in on Molly's employee ID badge and inquired "[horizontal ellipsis]and who are you, again?" Molly reintroduced herself, but neither the physician nor the medical student reciprocated. The physician then stated, "I didn't touch anything in the room, so those rules do not apply to me." Molly responded, "It is not about you. It's about the patient. What would you have done if the patient reached out to shake your hand to thank you for the wonderful care you are providing for him? How would you have responded? When you go into patient isolation rooms without PPE, it leaves you unprepared to respond fully to whatever the situation may require." The physician paused, as if he was really listening to the words. Next, he looked Molly in the eye, pointed toward Molly with his index finger, and made an oral clucking sound, followed by the words "Good point." He turned and walked away, without further comment, and entered another patient's room without performing hand hygiene. The bewildered medical student, taking in every nuance of this encounter remained silent and followed the attending physician into the next patient's room, also without performing hand hygiene. Once the duo had disappeared into the patient's room, a group of staff nurses in the nursing station, who unbeknown to Molly had been observing the encounter, offered up a small round of applause while exclaiming, "Way to go! Wish we could do that!" The nurses' response was disconcerting to Molly because she viewed patient advocacy as the first and foremost role of every nurse. She believed that she was simply fulfilling her obligation to promote safety, an ordinary
act, something every nurse should feel compelled to do as a patient advocate. Upon returning to her office, Molly began to wonder who the physician was and reflected on what her next steps should be because her encounter did not inspire the physician to perform hand hygiene. Using the hospital's online provider directory, Molly identified that the physician held a senior leadership position within the institution as well as the medical school. Concerned about the potential ramifications from her encounter with this physician, Molly felt compelled to disclose the event with the director of nursing (DON). The DON strongly encouraged Molly to file an event report using the hospital's computer event reporting system stating, "This is an opportunity to create a teachable moment for the organization. No healthcare professional should be above the rules when patient safety is concerned." Thanking the DON for her support, Molly knew she could not submit an event report without carefully thinking through the potential professional, personal, and ethical ramifications. Molly took some time to sort out her thoughts related to the facts of the ethical situation she had just experienced. She quickly recognized that she was working on a variety of assumptions and professional beliefs, but was not confident that she could substantiate these assumptions and beliefs. First, Molly verified whether there was, in fact, a national standard related to hand hygiene in the acute healthcare setting. She quickly found that goal 7 of the 2010 Joint Commission National Patient Safety Goals is to "reduce the risk of healthcare-associated infections." Also, the Centers for Disease Control and Prevention3 and the World Health Organization4 have hand-hygiene guidelines that promote hand hygiene as the best practice for preventing healthcareassociated infections. After confirming the hand-hygiene guidelines, Molly wondered, "Surely all practicing physicians in America are aware of the myriad challenges associated with infection prevention and are all too familiar with the national campaigns to reduce hospital-acquired infections. What was that physician thinking?" Molly's next step was to review the organization's hand-hygiene policy. She noted the clarity and specificity with which it was written, including "Applicability: all healthcare providers" and "all healthcare workers caring for patients must perform appropriate hand hygiene." Molly took one more step and consulted with a physician colleague to confirm her assumption that physicians have received education regarding hand-hygiene policies and procedures. As anticipated, she was informed that a requirement of the hospital's initial physician credentialing process as well as the medical staff reappointment process, which occurs every 2 years, includes the successful completion of an online hand-hygiene competency tutorial and assessment. Thus, as an organizational leader and medical school faculty member, this attending physician would be expected to have the knowledge and an obligation to serve as a role model for all healthcare providers and medical students, especially related to an action as basic as hand hygiene. The American Nurses Association's (ANA's) Code of Ethics for Nurses With Interpretive Statement5 states that "The nurse's primary commitment is to the patient" (provision 2) and that the "nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (provision 3). Since her first day in nursing school, Molly had been told and believed that the nurse's role is to advocate for and protect all patients from harm. In fact, Molly's institutional job description stated that she was expected to * provide broad clinical oversight in the development and maintenance of systems that support evidence-based nursing practice across the organization,
Nonmaleficence or do no harm is the primary ethical justification for infection control practices and limiting human liberties. smoking. this nurse leader clearly understood that she was not experiencing moral distress. drinking. and staff from preventable infections. physician. the fact that healthcare professionals are required to wear PPE and engage in hand hygiene is clearly publicized upon entry to the patient's room as well as in the patient's medical record. Because of increased potential of risk of exposure. [Moral courage] puts principles into action. Prior to completing the hospital event report. Does that fact that the physician holds a senior leadership position place him above or outside the institution's usual monitoring and disciplinary policies and procedures? Equity requires that like persons be treated similarly in similar situations. the Occupational Safety & Health Administration11 stipulates that "Eating. are implemented to minimize the spread of infection between patients. The principle of equity would require that the same disciplinary actions be implemented for every hospital employee (regardless of rank or job description) observed to be in noncompliance with isolation precautions despite the person's role. such as the use of PPE and hand hygiene. or even his significant others) if the physician's hands or clothing were to come in contact with the infectious agent. Acting with moral courage when faced with an act of wrongdoing is often not easy. applying cosmetics or lip balm. such as the hospital's initiative to minimize hospital-acquired infections. What is the right thing to do? 2. and * make decisions and take actions in an ethical manner." Thus. which "is the presence of constraints. Molly should review the hospital's event reporting policy and follow the steps accurately. When considering whether to file a hospital event report. and informed participants on the healthcare team. If an institution does. involved. How should the term similar be interpreted in this situation? Because the isolation policy directs that every person entering the room must comply with the identified restrictions and directions. the Joint Commission has a national Speak Up Campaign."6(p331) In fact. and resources as the need to minimize hospital-acquired infections is a national priority. healthcare professionals."8(p235) Additionally. this nurse leader's willingness to seek advice from a colleague as well as an ethicist provides her with the opportunity to identify and analyze the potential personal as well as professional risks that might be associated with completing a hospital event report. Molly's concerns about potential personal and professional harms if she were to complete a hospital event report are realistic and related to the concepts of positional power and equity. and reappointment processes every 2 years. such as freedom of movement or patient privacy by the use of signage. drinking coffee while providing patient care places the healthcare provider at increased risk." Infection control practices. other healthcare professionals. then the hospital must also be willing to terminate the employment of any nurse. when initiating an informal ethics consultation. As she deliberates. Thus. and the public. her sense of integrity will be violated as illustrated by her comment "I would feel like a hypocrite when teaching. in fact. considering them as learning opportunities through performance of root-cause analysis. physicians within this institution are required to pass a handhygiene competency as part of their credentialing. The Centers for Disease Control10 has readily available guides. What action do I need to take to maintain my integrity? Molly clearly recognizes that the physician's actions need to be reported and that. if she fails to follow through. Moral courage is the individual's capacity to overcome fear and stand up for his or her own core values. and visitor is held to the same standard. believe that no person is above the rules. and the organizational systems that review the events. would the physician be able to block a future promotion for Molly or create a negative work environment for Molly or other nurses? Consulting a nurse leader colleague (the DON) was a wise and appropriate action because the DON is able to provide guidance and positional support if Molly chooses to submit a hospital event report.6 While faced with a variety of ethical questions. thus creating a potential internal/personal constraint. What do I need to handle my fear? 3.* assume accountability for meeting standards of professional performance [through] contributing to the professional development of peers and colleagues. tools. the policy does not provide for exclusions. For example. either internal (personal) or external (institutional)[horizontal ellipsis] that prevent one from taking actions that one perceives to be morally right. the nurse leader described how her desire to preserve and protect her professional career within the institution and her desire to role model professional and personal integrity for staff nurses and nursing students were potentially at odds. Additionally."7(p131) Lachman7(p132) identified 3 questions that must be addressed when acting with moral courage: 1. Seeking an Ethics Consultation This nurse leader was fortunate to possess a wealth of positive professional experiences that over time have helped her to develop moral courage and a sense of professional power. and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. visitors. or administrator with a similar pattern of behavior. Molly's decision to "sleep on it" allows for reflection and minimizes the potential to act rashly. appointment. She should also verify the presence of any institutional retaliation policy or state retaliation legislation. visitors.8 In this scenario. the physician's freedom to move about the hospital and drink coffee without restrictions is being limited based on the potential of harm to self if he were to be exposed to the infectious agent and/or also potential harm to others (such as patients. it will be important for her to avoid experiencing moral residue (lingering feelings that one has morally compromised himself/herself). In addition. However. For example. How the hospital enforces this policy reflects the institution's organizational ethics. and[horizontal ellipsis] healthcare institutions have a high level of obligation to protect the health of patients. Taking the time to process this encounter and validate her assumptions in a relaxed moment gave Molly the courage and confidence to complete the organizational event report about the situation. if the institution would terminate a member of the housekeeping department after 3 witnessed violations of the isolation procedure. Molly must consider the potential that the physician through official or unofficial means might be able to initiate acts of retaliation toward Molly. hospital employee. .9 urging "patients to take a role in preventing healthcare errors by becoming active. Molly clearly identified several institutional supports. It is the willingness to speak out and do that which is right in the face of forces that would lead a person to act in some other way. "Hospital managers have a heightened responsibility to reduce the burden of adverse consequences attributable to preventable infection. knowing that doing so was absolutely the right next step to do.7 Infection prevention is the root of this ethical situation. the hospital's event reporting system. then the organization would need to be equitable with all disciplinary actions regardless of the employee's rank or title. rather every healthcare professional." The second question related to fear appears to be the key question with which this nurse leader is grappling.
negating any doubts that she harbored about the steps she took or the way she went about addressing this challenging situation. 2009. . Exploring the factors associated with hand hygiene compliance of nurses during routine clinical practice. World Health Organization. In this case. 2010. J Clin Ethics. As an advocate for the patient. Appl Nurs Res. seeking value consistency as well as "practicing what she preached. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. Molly has a professional obligation to report this incident of negligent behavior. Third.int/publications/2009/9789241597906_e ng. http://whqlibdoc."13(p438) Thus. Recommendations for Nurse Managers Future Research Questions Ethical situations related to nurse empowerment and interprofessional dialogue and accountability are prime topics for future research and quality improvement projects.cdc. Korniewicz DM. The overlay of organizational politics. 1. [Context Link] 4. Millar M. validating standards. Molly is correct to act with careful consideration and to garner support from the DON.gov/ncidod/EID/vol7no2/cover. is there a difference between the issues identified anonymously versus known reporters? Summary This case study provides an in-depth look at a scenario that many nurses encounter every day.23(2):86-90. [Context Link] 8. Moral distress. the nurse should also carefully reflect on how his/her action or inaction might impact the nurse personally as well as professionally. 2010. The ANA's Code of Ethics for Nurses With Interpretive Statement. Second. January 28. the reporter is noting a breach in the standard of care that places patients at risk and is made without "malice or consideration of personal gain. 2010. Finally. one must also act to promote a separate good. Molly should keep a written record of the incident as well as any encounters or discussions that transpire as she deliberates and/or after filing a hospital event report.html . Because the physician seems to have made a conscious decision to not follow basic hand-hygiene principles and isolation procedure. and every healthcare provider's primary focus should be on the safety of the patient.pdf . and the ever present realization that "our patients" could be us or one of our loved ones can create both a hesitancy and a compulsion to act. Molly concluded that the physician should be knowledgeable about and aware of his professional obligation to practice hand hygiene routinely. The Joint Commission. Department of Health and Human Services Centers for Disease Control and Prevention. The ethical principle beneficence requires that after preventing harm. Code of Ethics for Nurses With Interpretive Statements. Molly's interaction with the physician illustrates her commitment to beneficence. such as witnessing noncompliance with hand hygiene. What types of issues are reported in hospital event reports? What types of outcomes are associated with the different issues? Are there equity and consistency in outcomes? If anonymous reporting is available. [Context Link] 2. Provision 3. Molly still had some minor remnants of doubt after filing the event report and therefore sought out an informal ethics consult."12(p18) Finally. all nurses should strive to create a culture of no blame and mutual reminding because healthcare is recognized as a team effort. However. [Context Link] 3. her knowledge of the Joint Commission National Patient Safety Goals. [Context Link] 7." Even after going through all the steps outlined above. Facts About Speak UpTMInitiatives. In this scenario. Epstein EG. and the crescendo effect. DC: ANA.15 and her own organization's institutional priority to reduce/prevent hospital-acquired infections gave her the validation she needed to act after recognizing the physician's breach of standards. Recommendation for Nurses When challenging situations emerge. El-Masri M. Emerg Infect Dis [serial on the Internet]. [Context Link] 9.htm . [Context Link] 5. unethical. April 2001 [date cited]." nor should they take on that role. moral residue. she is promoting the image of and power of nursing by role modeling for the staff nurses how to professionally address a clinical issue with another healthcare professional. nurses are patient advocates and peers of other healthcare professionals. as well as seeking the counsel of a nursing director. The ethics consult provided Molly with a professional sounding board.73:232-238. the nurse should remember to involve nursing leaders in the decision-making process and to conscientiously follow the institutional chain of command as well as policy and procedure when reporting the issue. 2001. American Nurses Association. Accessed September 3. What are the ethical and clinical situations that staff nurses experience but do not feel empowered or safe to act upon? 2. 2010.20(4):330-342.cdc. Theoretically. further assessment of the nurse-physician dynamic within this unit is warranted as well as staff education on professional communication and collaboration. For example. and professional obligations. [Context Link] 6. in 2007.5 her job description.gov/handhygiene/Guidelines. Moral courage: a virtue in need of development? Medsurg Nurs. familiarity. completing a hospital event report is an example of internal whistle-blowing since "whistleblowers are people who expose negligence. abuse. Second. Accessed September 3. or danger such as professional misconduct or incompetence that exists in the organization in which they work.5 in ANA's Code of Ethics for Nurses With Interpretive Statement5 (2001) stipulates. illegal. 2009. Ignaz Philipp Semmelweis (1818-65) [about the cover]. the nurse leader is augmenting the medical student's understanding of isolation protocol and professional accountability. Washington. Molly's sense of responsibility was further heightened by her dual role as a practice coordinator and adjunct nursing professor.who. 2009. Molly is to be commended for first approaching the physician directly with her observations. Nurses are not the handhygiene "police. REFERENCES 1. assumptions. 2007. Hand hygiene in healthcare settings: guidelines. the nurse must be alert to and take appropriate action regarding instances of incompetent.For example. First."12(p18) When making a good-faith claim. Colorado enacted legislation "to protect healthcare workers from retaliation for making a good-faith report or disclosure regarding patient safety information or quality of patient care. Do we need an ethical framework for hospital infection control? J Hosp Infect. or impaired practice by any member of the healthcare team or the healthcare system or any actions of others that places the rights or best interests of the patient in jeopardy. http://www. Lachman VD.16(2):131-133. http://www. As a result of this interaction. relationships. Hamric AB. the nurse should consider the element of timeliness when considering how to respond to a challenging situation.
[Context Link] 15.http://www.org/GeneralPublic/Speak+Up/abo ut_speakup.jointcommission. Accessed September 3.gov/ncidod/dhqp/healthDis. Grenny J. Retaliation against healthcare workers prohibited.cdc. [Context Link] 12. Department of Health and Human Services Centers for Disease Control and Prevention. Ray SL.http://www.1030(d) (2)(ix). Klein CA. Bloodborne pathogens standard 1910.htm . McMillan R. Colo Nurse.osha. Healthcare-associated infections. http://www.show_document? p_table=STANDARDS&p_id=10051#1910.108(3):18. 2006.html .pdf . 2010. Accreditation program: hospital national patient safety goals effective July 1. [Context Link] 11. The Joint Commission. Switzer A. 2010. New York: McGraw-Hill. Accessed September 3. Accessed September 3. Whistleblowing and organizational ethics. 2008. [Context Link] 10. [Context Link] 14. Patterson K. [Context Link] .1030%28c %29%281%29 . 2010. Nurs Ethics. 2010.13(4):438-445. [Context Link] 13. Accessed September 3.org/NR/rdonlyres/868C9E07037F-433D-88580D5FAA4322F2/0/July2010NPSGs_Scoring_HAP2. Crucial Conversations: Tools for Talking When Stakes Are High. 2002.jointcommission. http://www. US Department of Labor Occupational Safety & Health Administration. Covey SR. 2010.gov/pls/oshaweb/owadisp.
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