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Running head: ETHICAL DILEMMAS RELATED TO INPATIENT FALLS

Ethical Dilemmas Related to Inpatient Falls and Hospital Policy

Lindsay R. Perkins

James Madison University


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ETHICAL DILEMMAS RELATED TO INPATIENT FALLS AND HOSPITAL POLICY
Ethical Dilemmas Related to Inpatient Falls and Hospital Policy

Introduction

One of the largest risks for elderly patients is falls. From deteriorating muscle strength to

side effects of certain medications, the elderly population requires close monitoring to prevent

falls in the hospital. According to an article about preventative nursing care for elderly patients,

“preventable complications negatively impact a patient’s quality of life, extend hospital length of

stay, and utilize resources that are costly and may not be reimbursed” (Cutugno, Hozak,

Fitzsimmons, & Ertogan, 2015). The avoidable aspect of these added expenses have molded

hospital policies to effectively prevent inpatient falls in the hospital. In a study done about the

costs of inpatient falls, the cost of fall-related injuries “resulted in a $9,389 increase in annual

medical expenditures” (Hoffman, Hays, Shapiro, Wallace, & Ettner, 2017). With the absurd rise

in cost of health care, hospitals must develop inpatient fall protocol to help safeguard their

hospital from added costs; however, this protective mechanism can result in ethical situations

that must be dealt with by hospital staff.

Background

At my first semester clinical, I was assigned to work on the skilled nursing floor of the

hospital. I was standing outside of a union of four rooms when I heard a loud crash followed by

distressed screams for help and assistance. My clinical professor happened to be standing next to

me at the time of the incident and told me to enter the room and stay with the patient, but I was

not allowed to touch him. Riddled with confusion as to why I could not touch this patient, I

entered his room. He had fallen off of the toilet in the bathroom while trying to get up and hit his

ear on a chair and his knee on the hard floor. He proceeded to yell, “Why are you just standing
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ETHICAL DILEMMAS RELATED TO INPATIENT FALLS AND HOSPITAL POLICY
there? Help me up off of this floor! Isn’t this your job?” I responded by saying, “My clinical

professor told me to stand next to you to make sure you do not further hurt yourself; however, I

was told not to help you off of the floor.” Making the decision to follow hospital policy rather

than helping the patient, I continued to observe him and calmed him down through conversation

until the appropriate staff members arrived and took over at the scene. Instead of following

policy, I could have chosen to follow through with my job as a nursing student, to help all

patients in need, and help him off of the floor, clean him up, and put him back in his bed.

This scenario presented as an ethical dilemma as I had to make a decision that had two

equally justifiable options. On one hand, I could have abided to hospital policy or I could have

helped the patient and followed through with a nurse’s commitment to help all patients in need.

The first option would be to follow hospital policy; this is a justified action as I am a student and

I should comply with the rules. The second option would also be an acceptable response to this

dilemma, as the response shows that I abide by the responsibility of a future nurse- to help all in

need.

Methods/Findings

I will analyze the situation using the James Madison University Madison Collaborative’s

Eight Key Questions as an established system for making ethical decisions. The Eight Key

Questions incorporate a method for ethical decision making by focusing on eight human values,

which include: fairness, outcomes, responsibilities, character, liberty, empathy, authority, and

rights (The Madison Collaborative, 2013). Since my situation dealt with hospital fall protocol,

the protocol set in place allows for every case of falls to be treated in the same fashion which

would support procedural fairness. Following hospital policy was the fair/just option to carry out.

In reference to outcomes, I am split between the two options. By choosing to wait for the
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ETHICAL DILEMMAS RELATED TO INPATIENT FALLS AND HOSPITAL POLICY
appropriate staff to help the patient, the short-term outcome is that the patient will be in pain and

agony until personnel arrives and the long-term outcome would be that the patient could sustain

worsening injuries. The short-term outcome for the hospital would be that the staff could

appropriately document the fall and the long-term outcome would be that the institution would

save money and cover themselves for any potential law suits. On the other hand, violating policy

and assisting the patient immediately would produce a short-term outcome of the patient being in

less pain and a long term outcome of hospital lawsuits and/or potentially losing access to be a

student in their hospital. When considering responsibilities, my duty as a nursing student is to

help those in need and be an available resource to all patients; whereas, my responsibility as a

visitor to this hospital is to abide by their policies and procedures. The option that I chose in the

situation ultimately reflects my character; I strive to be a person of integrity, and I believe that

the option I chose reflects that I abide by the rules and I “do the right thing” even when no one

else is watching. The principle of liberty affects my situation as the patient expressed his desire

to get up from the floor, but he could not do so due to his physical limitations. Upholding his

personal autonomy would be contingent upon helping him off of the floor. If I were to display

empathy, by caring deeply about the person involved, I would help him off the floor immediately

as that would soothe his anxiety and pain. My legitimate authority, the hospital, expects me to

abide by their policies. By choosing to wait for the appropriate personnel to arrive, I followed

their inpatient fall protocol. As an institution, the hospital as a legal right to develop policy and

has a right to expect that all employees follow the protocols. However, the patient also as a right

to the best quality of care available, and leaving him on the floor would not be giving him the

care that he rightfully deserves.


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ETHICAL DILEMMAS RELATED TO INPATIENT FALLS AND HOSPITAL POLICY
The American Nurses Association (ANA) is a reputable authority of nursing ethics and

has authored a Code of Ethics list that encompasses nine provisions that a nurse should follow.

Provision four states, “The nurse has authority, accountability and responsibility for nursing

practice; makes decisions; and takes action consistent with the obligation to promote health and

provide optimum care” (American Nurses Association, 2015). In reference to my ethical

dilemma, this provision makes me realize that I choose to take actions that will provide the

highest quality of care for my patient. Reviewing this provision would help guide my decision to

help the patient off of the floor, regardless of hospital policy.

Conclusion

Throughout my experience, I have learned that even as a student I am obligated to make

ethical decisions that, once made, will mold my method of nursing practice. From this situation, I

have learned that patient care and hospital policy can be at separate ends of the spectrum;

although, those two aspects should be intertwined. The Eight Key Questions is a helpful tool in

trying to navigate through complex, ethical scenarios and I believe others should utilize this

process. In retrospect, I would have made the same decision. I have no authority in that hospital

as I am not an employee. In addition, I am a firm believer in upholding actions that bolster my

character; since integrity is very important in my life, I feel like I made the appropriate decision.

If the circumstances changed and I was an employee and/or the patient sustained life-threatening

injuries from the fall, I may act differently. Calming the patient down with therapeutic

conversation was an appropriate action to deescalate the situation, while following protocol. For

future instances, I will continue to follow protocol outlined in my job description and I believe

that increasing elderly patient monitoring would decrease the amount of ethical decisions needed

to be made regarding this topic.


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ETHICAL DILEMMAS RELATED TO INPATIENT FALLS AND HOSPITAL POLICY
References

American Nurses Association. (2015). Code of ethics with interpretative statements. [PDF File].

Silver Spring, MD. Retrieved March 21, 2018 from

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNur

ses/Code-of- Ethics-For-Nurses.html

Cutugno, C., Hozak, M., Fitzsimmons, D. L., & Ertogan, H. (2015). Documentation of

Preventive Nursing Measures in the Elderly Trauma Patient: Potential Financial Impact

And the Health Record. Nursing Economic$, 33(4), 219-226.

Hoffman, G. J., Hays, R. D., Shapiro, M. F., Wallace, S. P., & Ettner, S. L. (2017). The Costs of

Fall-Related Injuries among Older Adults: Annual Per-Faller, Service Component, and

Patient Out-of-Pocket Costs. Health Services Research, 52(5), 1794-1816.

doi:10.1111/1475-6773.12554

The Madison Collaborative. (2013). The Eight Key Questions Handbook. [PDF File]. Retrieved

from https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf