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Lucia D. Wocial, PhD, RN, CCNS, Clarian Health Nurse Ethicist

Lucia serves as a resource for the entire three-hospital main campus of Clarian. She holds a PhD in nursing, with a concentration in ethics, and has been involved in nursing for 23 years.

“I wanted to connect with people. Originally I wanted to be a nurse midwife, but my first job was in a neonatal unit and I have never looked back. I love working with people and doing work that really matters.”

When she’s not working with Clarian nurses, Lucia enjoys playing tennis with her husband, wine tasting events, and spending time with her adolescent children when they will let her.

You can read more about where Lucia works at Clarian's ACallToChange.org website: Find Registered Nurse Jobs in Indiana

The Truth About the Trust Line

Saturday, January 9, 2010 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

Here is a troubling story I heard recently:

"My supervisor was asking questions. Apparently there had been a call to the Trust Line and she was 'investigating.' She said they heard the tape and even though the caller did not identify themselves, they were pretty sure they knew who it was."

Hearing this story, I could imagine how a rational person might lose confidence in the Trust Line, or the organization. It may be easier to believe a story told by someone you know than believe a printed flier posted on a bulletin board. The individual who told me this story believed what she thought her supervisor said. The story itself cannot be true.

No one at Clarian EVER hears the tapes from the Trust Line.

An organization OUTSIDE Clarian manages the Trust Line.

Calls are investigated and who does the investigation depends on the nature of the call.

Any attempt to identify a caller to the trust line, or any action meant to punish a caller who reports concerns would be viewed as retribution and would result in disciplinary action.

People develop relationships with individuals not organizations, so trust in an organization begins with trust in the individuals we encounter every day in our work life. If I believed my supervisor was trying to figure out who the caller was, I might feel pretty vulnerable and might have trouble believing in the faceless organization.

I feel a bit awkward having my picture run every time I write a blog entry here or write an article for our internal newsletter. I have come to appreciate however that having a "face of ethics" can be a benefit to individuals in the organization. I have the privilege to have regular face-to-face contact with key leaders in this organization. I respect them and know them to be leaders with integrity. For me, the Trust Line is not some poster on a wall. I see the faces and know the people who stand behind it.

It is troubling to me to think that this story may have undermined trust in the organization and kept people from coming forward, not just to report concerns, but to report behavior that cannot be tolerated in our organization. Don’t let myths like this one feed fear of retribution. Call the Trust Line when you have concerns. Call again if you feel someone is trying to punish you for expressing your concerns.

Lucia D. Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Registered Nursing Opportunities Indiana.

Who Says Silence is Golden?

Wednesday, December 16, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

Recent research shows that silence may actually kill. Fewer than one in 10 people who work in health care say something when they observe concerning behavior, even when the behavior may lead to serious consequences for patients.

Nurses have dual loyalties and sometimes conflicting obligations that make them vulnerable to losing their moral compass in certain circumstances. When people accept the role and responsibility of being a nurse, they accept an obligation to do good for others. When nurses have knowledge of a potential harm to a patient and fail to report it, they contribute to the harm.

When I hear people grapple with the decision whether to report something, their difficulty is often rooted in concerns about personal relationships. They think highly of another person. Maybe they believe there was no malicious intent in the harmful behavior. Maybe they don’t want to get yelled at, or they don’t have confidence anything will be done.

Saying nothing makes the problem personal. Speaking up is the professional way to deal with it. How do you decide when to speak up?

Is the situation serious, and has it created or might it lead to serious harm?
Do you have all the essential information?
Will speaking up serve a useful purpose?

Silence has a hidden cost. It is golden only when actions speak louder than words. Speak up when you see a problem. Do it for your patients; they deserve protection. Do it for your colleagues; they don’t want to cause harm. Do it for yourself; follow your true moral compass.

Lucia D. Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Jobs for Registered Nurses.

Policy and Ethics in Brief: Privileged to Visit

Sunday, November 22, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

It was not that long ago that Clarian endorsed an open visitor policy. As an organization we recognized how family presence contributed to the well-being of our patients. I often hear nurses express concerns about the fairness of the visitation policy. Patients aren’t prisoners, so who are we to tell them who can and cannot visit?

We value family centered care, but that does not mean families may do anything they want. The Clarian policy on visitation provides a lot of latitude to customize visitor guidelines to meet the needs of the patients on individual nursing units.

The flexibility may lead to questions of fairness. One way to decide if the guidelines are applied fairly to different patients is to ask “are we meeting the needs of the patient?” If the visitor is meeting a patient need, aren’t we obliged to meet that need? Most would say yes. So when is it ethical to deny a patient something they need?

Sometimes our duty to protect patients from harm means we have to give up something that might be beneficial. This can happen under normal circumstances when a family becomes disruptive or when visitors pose a potential risk, as is true now with the H1N1 virus.

The policy on visitation places the responsibility and the authority to determine what is in a patient’s best interest squarely on the nursing staff. Not all nurses are alike however, so again, how do we make sure the implementation of the policy is fair?

When nurses decide to make an exception to the visitation policy, they must communicate the reasons not just with patients and families, but with other members of the team. When exceptions are made the criteria used must be transparent for all to see so that a reassessment can occur as the situation warrants.

Consider what is relevant, the need being met, the benefit to be gained and the harm to be avoided. Fair can mean different. When fair is different, we have an obligation to be transparent about the criteria we use to enforce a policy differently.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit RN Job Opportunities Indiana.

Moral Distress Survey Says...

Friday, October 30, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

The results are in from a June survey about moral distress... but before “the big reveal,” it’s important to highlight a few key points.

Moral distress occurs when you believe you know the correct thing to do, but something or someone restricts your ability to pursue the right course of action. It doesn’t mean you have weak morals or that you are acting unethically. It is about a sense that you are not fulfilling your moral obligations, your core values are violated and your moral integrity is at risk because your “ethical” actions are restrained.

Moral distress can affect nurses’ physical and emotional well-being, as well as have an impact on their professional practice. When nurses are affected, patient care also may be affected by nurses distancing themselves from patients, resulting in patients receiving less attentive physical care. Moral distress also contributes to nurse turnover.

More than 1,000 nurses responded to the June survey, allowing us to evaluate a new tool for moral distress called the Moral Distress Thermometer (MDT). The MDT works a lot like a pain rating scale. It’s easy to understand and takes less time to complete than a 38-item survey that until now has been the standard tool for detecting moral distress in nurses. While the MDT is sensitive to detect moral distress in nurses, it cannot identify what may be causing the distress; that data has yet to be analyzed.

Clarian nurses surveyed in June were more likely to have a Bachelor’s degree or beyond, to be certified, and to work in critical care areas. Overall, the moral distress of respondents was 3 on a 1-10 scale. Perhaps the most significant finding of the project was that nurses who answered “yes” to the question “have you considered quitting a job because of moral distress?” scored higher on the MDT. In fact, 30 of our survey respondents had scores high enough that we can say they may be at risk for leaving their current job because of moral distress.

Here’s your challenge: We know through other research and our own experience with Unit-Based Ethics Conversations that having the opportunity to discuss ethically challenging situations is helpful. If you think your moral distress score is high, talk to someone.

Vicky Lachman put it this way, “The space between knowing and acting is bridged by moral courage.” Moral courage is the willingness to take a risk to protect your core values. What are you waiting for?

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Registered Nurse Career Job Search.

What is a Magnet Exemplar? One Example of Nursing Excellence.

Wednesday, September 16, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

When Clarian Health received its initial Magnet designation in 2004, ethics was identified as an opportunity for improvement. In 2009, Clarian earned Magnet re-designation at Methodist, IU, and Riley hospitals. In the re-designation process, the Magnet appraisers cited ethics resources as exemplary sources of evidence, first for the force Quality of Care and second for the force Consultation and Resources, and identified the program in ethics as a “national model.”

At the upcoming October National Magnet Conference in Louisville, Kentucky, Maureen Hancock, clinical director at Riley for pediatric special care and former Fairbanks Center Ethics Fellow, and I will do a presentation highlighting part of our Unit Based Ethics Conversations (UBEC) program.

The mission of UBEC is to create an environment with morally open space where participants feel free to express concerns, give and receive feedback, and reflect on their experiences. The goals of the program are to increase participants’ abilities and confidence in dealing with ethically-challenging situations. The focus is on helping those in attendance reflect on their experiences and develop skills to manage the distress they feel when facing ethically-challenging situations in clinical practice.

In 2009, we conducted a formal evaluation of the UBEC program. Nurses who work on units that have hosted UBECs for more than six months were asked to participate. Nearly ten percent of survey respondents said they had attended a UBEC. When asked, 86 percent of attendees stated the UBEC helped them to address ethical issues they faced in their clinical practice, and 67 percent stated they felt better-able to manage ethically challenging situations after attending UBECs. Overall, 93 percent would recommend the program to a colleague. All our evidence suggests this is a valuable program that helps nurses deal with ethically-challenging situations.

Our Magnet re-designation puts us in the top two percent of hospitals nationwide. Nurses from other hospitals look to Clarian for ways to improve their practice. Sharing our experience with UBECs at the Magnet conference is one way for Clarian to lead by example and provide a benchmark of quality for others to strive toward.

The availability of UBECs is one way Clarian is working to be proactive in helping nurses deal with ethical issues in clinical practice. If you would like more information about UBECs, please contact me by replying to this blog.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Registered Nurse Career Job Search.

You can also search for available Nursing Jobs at Clarian Health by Nurse Specialty.

R-E-S-P-E-C-T: Get It By Practicing Ethical Fitness

Wednesday, August 19, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

When you have the title “Nurse Ethicist” on your name badge, people tend to tell you stories about ethical challenges. A common theme in the stories is some injustice or perception of unfairness, either seen or experienced by the story teller. When people feel they are facing ethically challenging situations, emotions typically run high and a person’s ethical fitness is put to the test.

Think of ethical fitness as a skill like BLS, ACLS, PALS, or NRP. It needs to be practiced, so it becomes automatic when a critical situation arises. Effective communication is the essential skill needed to demonstrate ethical fitness. Effective communication depends heavily on constructive working relationships with all members of the team. It does not help matters that it is at these moments that strained relationships become more so.

A harsh tone of voice, an impatient request or a thoughtless comment can compromise even a normally well functioning team. These actions may be taken as personal attacks by some, even though the perpetrator may be completely unaware. It amounts to a kind of disrespect or failure to meet expectations, which if left uncorrected can violate trust and eventually compromise the care we provide to our patients. It is a choice to tolerate less than optimal working relationships with colleagues.

Take the time to determine if what you see, hear, and feel is accurate. What have you done lately to clarify expectations and clear the air with colleagues? Pause for just one minute and ask yourself if you believe the people around you are people of good conscience. What do you expect them to do to show you they respect you and will do the “right” thing? If they are not meeting your expectations, do they know it (have you told them?) Now ask yourself how they would answer these questions about you.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Jobs for Registered Nurses.

You can also Search for Available Nursing Jobs at Clarian Health by Nurse Specialty

Trust is More Than a Policy

Wednesday, July 29, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

What does it say about an organization that has a mechanism (and a policy) for reporting compliance-related concerns, better known as the Trust Line?

Clarian is an organization that knows it is not perfect, but it wants to provide employees with resources that help it stay true to the values that are at the core of its foundation.

Trust is the belief in and reliance on the moral character of another. The Trust Line is a tool that employees can use to hold each other accountable to do the right thing.

While Clarian asks us to trust people in positions of power and report any concerns (speak truth to power), that trust comes with risks, namely vulnerability.

As employees, we may feel we are the vulnerable ones. But consider this: One individual who persists in behavior that is unbecoming a Clarian employee ruins it for all of us. Turning a blind eye to this type of behavior violates the trust Clarian has put in each of us to demonstrate our moral character and help maintain Clarian’s core values.

Transparency is essential for ethical practice, open discussion of difficult issues and the establishment of a culture of mutual respect and trust. When open discourse is not possible, people in positions of power must do what they can to minimize the risks inherent in speaking truth to power. That is what the Trust Line is all about.

Doing the right thing is not always easy. Sometimes even the best of us slips up, intentionally or accidentally. Contrary to popular myth, Big Brother is not watching and waiting for a chance to either cover up these circumstances or use them as an easy way to thin the herd.

Trust is based on mutual respect. The leaders at Clarian rely on each of us to maintain fidelity to moral norms, to internalize Clarian’s values and, when necessary, defend them.

Policies can’t change things. That is up to us. Are you up to the task? And what does your organization do to enhance trust and transparency?

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To be a registered nurse at Clarian, visit Registered Nurse Career Job Search.

You can also Search for Available Nursing Jobs at Clarian Health by Nurse Specialty

Privacy is a Matter of Trust

Tuesday, May 19, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

In a world where cell phones have cameras and millions of people participate in social networking activities like Facebook, Twitter and MySpace, it is easy to forget what information is private. People receiving care in hospitals are at their most vulnerable. Because we as health care workers have access to sensitive information, we are held to a high standard when it comes to patient privacy.

Patients trust that what they tell us will stay with us unless they give us permission to share the information, or the information is shared for the safety and well-being of the patient. This duty was much easier when each patient had only one copy of a paper record. Today electronic records make it possible to forget the boundaries of privacy and inappropriately share confidential information; these days, such a breach can mean that anyone with access to the World Wide Web is looking.

Protecting private health information has become very complex, which is why there is a federal HIPAA Privacy and Security Rule. Clarian Health also has HIPAA policies and procedures to guide employee behavior. The HIPAA rules create national standards designed to protect personal health information. The rules set limitations on the use and disclosure of health records and establish safeguards to protect the privacy of health information. For the average health care provider like Clarian, the Privacy Rule requires activities such as:

Adopting and implementing privacy procedures
Training employees so that they understand the privacy procedures
Designating an individual to be responsible for overseeing privacy procedures
Properly securing patient health information

Health care providers have a strong tradition of safeguarding private health information. That tradition is based on trust.

The hospital system I work for has an abundance of resources to help nurses navigate the nuances of the HIPAA rules including a new Web page with links to policies, training modules and people who can help us uphold the trust of our patients when it comes to protected health information.

What does your employer do to help you understand HIPAA?

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To apply for a nursing position at Clarian, visit Registered Nurse Jobs Indianapolis.

Registered Nurses Show Respect By Telling The Truth

Saturday, May 2, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

This is your first time to care for Ms. X. You hear in report that Ms. X’s family does not want her to know she has a terminal condition. This should raise in your mind a number of questions: Why does the family know the diagnosis before the patient? Is Ms. X capable of understanding what her diagnosis means? Can she make decisions for herself? Honoring the family’s request for secrecy means that you, the nurse, may not speak honestly with Ms. X, even if she asks you a direct question.

When we look to ethics for answers we are trying to determine the right action to take. Values tell us why we do what we do. At Clarian, respect is a core value. We show respect by telling the truth. Honesty is the foundation for a trusting relationship with patients and their families. Respecting patients means we support their right to participate in all decisions about their care, unless there are legitimate, compelling reasons to hide the truth.

The nurse caring for Ms. X must uncover the nature of the family’s request: Is the request based on a cultural tradition? Has Ms. X told her doctor she wants her family to make decisions for her? If the information in report is accurate and the physicians and others taking care of Ms. X endorse withholding information from her, there must be documented evidence of the plan and the process followed to arrive at it.

There are circumstances when not offering the truth to a patient is how we respect them, but the evidence for the ethics of this action must be clear to all who care for Ms X. The Clarian core value of respect suggests we could not ask our employees to be dishonest with a patient if asked a direct question, no matter what a family member believes is best for the patient.

It is one thing not to disclose information, based on knowing a patient. It is quite another to lie.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join the Registered Nurses at Clarian, visit Registered Nursing Position Indiana

A Registered Nurse Needs Reassurance, Too

Sunday, April 26, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

Not long ago I was contacted by a nurse manager regarding one of her nurses, Q. It seems Q had been the nurse caring for a patient who was dying and she was experiencing some distress. Shortly after Q administered the prescribed dose of narcotic for the patient, the patient stopped breathing. Q worried that she had somehow hastened the patient’s death. I met with Q, and we talked about what had happened.

As Q told her story, it was clear she had used appropriate indicators in her assessment that the patient was suffering. The dose she administered was well within normal prescribed doses. She administered it in the routine fashion.

As we talked I did my best to reassure Q that the timing of the patient’s last breath was simply a coincidence. By the end of our discussion, Q was clear in her mind:

Her intent was to alleviate pain.
Alleviating pain and suffering at death is a good thing.
While narcotics may cause respiratory suppression, the need to alleviate the pain is more compelling than the potential for respiratory suppression.
She did not intend to alleviate the suffering by causing respiratory depression.

In her heart however, Q still believed it would violate her ethics to participate directly in the care of dying patients.

Clarian has a policy that supports employees who feel they are unable to participate in certain treatments or types of patient care due to their cultural values, ethics or religious beliefs. Does your facility have a policy like this?

There are limits to an employee’s refusal to participate in certain types of care. As in Q’s case, however, if the employee approaches their manager and discusses their concerns in a professional respectful way, there is a clear process to follow to ensure that Clarian’s patients receive safe care, and, whenever possible, our employee’s personal ethics are supported.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join the Registered Nurses at Clarian, visit Registered Nurse Job Opportunities

If a Registered Nurse Believes a Physician is Incompetent, What Should You Do?

Wednesday, April 22, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

What do I do if I think a physician is not competent? This question was posed to me recently, and I think the suggestions outlined here are worth repeating.

Most people could probably give the “correct” answer – report it – but that answer is both reactionary and premature.

What behaviors suggest a physician is not competent? Two examples were given: “The pharmacy said we haven’t done that for years” when the nurse called to clarify an unusual order; and “We always have to call the resident to get the orders fixed.” So on the face of it, this is more than a one-time event, and there is potentially a pattern.

First and foremost, focus on the patients who are in the physician’s care. If there is an immediate patient safety issue, any nurse caring for a patient should be aware of the workplace policy for resolving clinical concerns. In a hospital, policies apply to all who give care.

The purpose of a policy is to ensure that concerns about patient care are resolved quickly and accurately by the most appropriate staff. At Clarian Health, the policy includes both a nursing and medicine chain of authority. After discussing this policy with Dr. Richard Graffis, Chief Medical Officer for Clarian, he reinforced, “No one is exempt from this policy” – not the resident, attending staff physician or chief medical officer.

The most frequent reason cited by staff for not reporting concerns has to do with the perceived power of the physician involved. Known as an authority gradient, the power is either related to the status of the physician or fear that the physician will somehow punish the nurse. In either case, the code of conduct for medical staff also has no exceptions and provides a mechanism for giving physicians feedback.

Talk over your concerns with your charge nurse, shift coordinator or nurse manager. Do it in a respectful, professional manner (not in the lounge over lunch). Put your concerns in writing, and send them to your supervisor, who should be obligated to send the concerns forward for evaluation by the medical staff committee. If the concerns continue with new examples, continue to put them in writing.

Nurses are not in a position to evaluate the competence of physicians, any more than physicians are in a position to evaluate nurses. However, each is responsible for providing feedback to those who are in a position to evaluate competence.

Focus on the patient. If this were your loved one, what do you hope the nurse would do?

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join the Clarian nursing team, visit Registered Nurse Career Job Search

Nurses Finding the “Right” Words

Tuesday, April 7, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

Nurses often describe their role as the translator for complex medical terms that patients and families can understand. Patients bleed (not hemorrhage) and stop making urine (not anuric).

Yet nurses may not be as skilled at translating their concerns about an ethically challenging situation because they are unfamiliar with the language of ethics. The question I hear most often related to this topic is “Can patients demand everything?”

Sadly, there is no simple answer to this question, but it is important to look at it using words that convey some understanding of the ethical issue at stake. Patients are entitled to exercise their autonomy, meaning they have a right to determine which medical treatments they consent to and which they do not.

Consent depends on knowing all the risks, benefits, burdens and alternatives to the treatments. There is often a tension between a patient’s autonomy and paternalism from members of the health care team.

Paternalism refers to actions or attitudes that suggest someone knows better than the patient what is best for the patient. The overriding ethical principle behind paternalism is beneficence, or the desire to benefit and promote the welfare of other people.

When the question “Can they demand everything?” is asked, the underlying concern is whether the patient has enough information to truly consent to the treatment or if “everything” is a “good” thing.

Nurses have a duty to address both concerns.

First, nurses can ask patients to explain what they understand about the proposed treatment/procedure. Any gaps in understanding should be brought to the attention of the attending physician.

Second, nurses can help the patient define the “good” that will come from the procedure by reviewing the patient’s goals (restoration of health, return to independent living or better quality of life, for example). Agreeing on the goals of treatment is essential to respecting a patient’s autonomy and avoiding premature judgments about what you may think is best for a patient.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join the Registered Nurses at Clarian, visit RN Job Opportunities Indiana

Nursing and Informed Consent: Authority Without Responsibility?

Saturday, March 28, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

Nursing and Informed Consent: Authority Without Responsibility?

A signed Informed Consent form represents more than a patient’s autonomous choice to undergo a treatment or procedure. It is all about patient safety.

Patient consent is a medical staff policy, and nurses are not always present for the discussion about risks, benefits and alternatives. So what is the role of the nurse in this important process? Think TEAMWORK.

At Clarian, there are patient care policies – Procedural Time Out (Universal Protocol) and Perioperative Patient Safety Verification – that give any health care provider, but especially nurses, the authority to “pause” the team before any treatment or procedure begins.

Nurses are responsible for confirming or verifying that the consent form is signed. This is more than checking to see if a signature is present on the line. I frequently hear nurses express concern that a patient doesn’t really understand what they are consenting to. When nurses feel this way, for any reason, they owe it to the patient to clarify their goals regarding their treatment choice.

Being part of a team means the nurse should take it one step farther: “Can you tell me in your own words what procedure you are going to have? Did you have the opportunity to have all your questions answered? What goal do you hope to achieve by having this procedure done?”

If the patient’s responses are inconsistent with your understanding of the risks, benefits and alternatives to the procedure, it is your responsibility to notify the attending physician and express your concerns. Document your concerns and your actions.

No one wants to delay a procedure or treatment for a documentation detail. However, that detail is evidence that we have respected the patient’s rights by properly obtaining their informed consent.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join a team of Registered Nurses that respects patient rights, visit Nursing Jobs Indianapolis

Registered Nurses Display Moral Courage When They Stand Up for Patients and the Profession of Nursing

Friday, March 20, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

A nurse recently told me a story. I am honored that she trusted me enough to tell me. She is a nurse with moral courage who is willing to do the ethically “right” thing, even though it is not easy. With her permission, I get to retell the story here and hope that you will find courage to do the right thing, even when it is difficult. The identities have been disguised to protect the privacy of the individuals in the story.

N typically gets along with most of her colleagues. However, she does not get along with A, one of the other nurses. N believes that A is not engaged in her work, socializing more with her peers than caring for patients. When the two work together, the atmosphere is tense, but the two nurses are able to maintain a professional working relationship.

N accidentally discovered A falsifying a document in a patient’s record. She immediately brought it to the attention of her charge nurse who assured N it would be handled appropriately. After the incident, N naturally had a heightened sense of alertness to A’s interactions with patients. Much to her dismay, a similar incident happened within a few weeks of the first. This time N made sure her nurse manager knew.

Shortly after this, N’s nurse manager mistakenly attributed the report to the known interpersonal difficulties between the two nurses. N knows that other members of the team have concerns about A, but feels like she is the only one sharing concerns. N feels unsupported and disheartened that her motives have been questioned and that the behavior she witnessed from A has been tolerated, particularly when the behavior had direct consequences for patients.

N took time off to consider what to do. After returning to work, she took a chance and told her story to her nurse manager’s supervisor. She felt listened to and believes something will happen, even though she can’t know if the individual is in corrective action because that is private information.

N knows it’s important to continue doing the right thing, even when she doesn’t feel the support of others. N says she will give A the benefit of the doubt, but continue to report behaviors inconsistent with expectations for nurses.

N’s actions exemplify moral courage. She is standing up for patients and professional nursing. I am proud N is a nurse colleague.

One nurse with moral courage is not enough. I hope others follow her lead and report situations like this whenever they happen – even if the report is met with skepticism or doubt. Doing what is right, especially when it is unclear if your actions make a difference, makes the action all that more courageous.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To show your courage at Clarian, visit Jobs for Registered Nurses

Deconstructing DNR for Registered Nurses with Questions

Monday, March 16, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

The majority of our training as registered nurses is geared toward promoting health and caring for people when they are sick with the hope of restoring their health. When it is clear to a patient that they have a condition that will certainly limit their life expectancy, they may choose to forgo resuscitation, which requires a “Do Not Resuscitate” (DNR) order to be placed in their chart.

It may be confusing when a patient comes to the hospital to receive an aggressive life-prolonging therapy such as chemotherapy when they have a DNR order on their chart. How is this possible?

At Clarian Health, a policy for “Withholding or withdrawal of life-prolonging procedures” provides clarification of this point. Other hospitals have similar policies, I'm sure.

DNR is a very specific order that requests withholding of any one or a combination of treatments in the event of a cardiac or respiratory arrest. A cardiac arrest occurs when there is an absence of a palpable pulse. A respiratory arrest occurs when there is no spontaneous breathing or there is agonal breathing. The treatments considered “resuscitation” include endotracheal intubation and initiation of ventilatory support, chest compressions, electrical countershock, external cardiac pacing and bolus administration of inotroes, vasopressors or antiarhythmics.

A DNR only limits the provision of cardiopulmonary resuscitation (CPR). A DNR order does not limit or restrict the use of any other medical treatment, diagnostic test or intervention. In fact, we are obliged to provide the clinically appropriate standard of care to all patients, regardless of their code status.

Resuscitation is one type of treatment that patients may choose to forgo. Patients, their families and physicians also may choose to forgo other treatments, such as dialysis, blood transfusions or an organ transplant, but these limitations are not automatic when a patient chooses to forgo CPR.

Clarian policy defines circumstances when it may be appropriate to consider withdrawing or withholding certain treatments for patients. However, until a physician’s order is written that defines the patient/family preference and consent to limit treatments, nurses must assume that patients want and should receive all treatments.

What does your hospital's policy say?

Nurses who feel a patient meets the criteria for consideration of withdrawal or withholding treatments as defined in policy should discuss their assessment with other members of the health care team and, when appropriate, the patient and/or patient’s family.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

To join the Registered Nurses at Clarian, visit Registered Nurse Career Job Search.

RNs Have Promises to Keep When Patients Want to Leave Against Medical Advice

Monday, March 9, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

When patients come to the hospital, we enter into a fiduciary relationship with them. Essentially we promise to take care of them. We make recommendations and offer skilled interventions. We are motivated to do good for the patient (beneficence).

Implied in our promise is that we will avoid harm to the patient (non-maleficence). For the most part patients accept our help and follow the plan of care. So what should we do when a patient wants to leave against medical advice?

One of the great myths about leaving AMA is that a patient’s insurance company will not cover their current or future hospitalizations if they leave. This is not true. Insurance companies routinely have no way of knowing the circumstances surrounding a patient’s discharge.

To suggest this to a patient has the potential to damage the trusting relationship with the patient. It may send the message that you are more concerned about the hospital getting paid than you are about the health and well being of the patient.

Patients leaving AMA may not be denied prescriptions for discharge medications. Refusing to provide a prescription for a needed medication may constitute abandonment.

Nurses must follow established hospital procedures when a patient expresses a desire to leave before a physician is ready to officially discharge them.

Competent adult patients have the right to refuse treatment. What about our promise to help them? How far should we go in trying to convince a patient to stay in the hospital if we feel they are putting themselves at risk by leaving AMA?

We should inform them of the medical consequences of their choice. We can cajole them with gentle appeals and benevolent persuasion. However we must never coerce them with threats of financial hardship or medical abandonment.

Our fiduciary relationship with the patient is a mutual agreement. While it is certainly distressing to nurses when a patient rejects our care despite our best efforts and chooses to leave AMA, in the end, it is the patient’s decision.

Lucia Wocial, PhD, RN
Clarian Health Nurse Ethicist

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Nurses Face Great Challenges

Thursday, February 19, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

I recently received a note from a nurse who was saddened by feeling she was unable to facilitate a good death for a patient. Her challenge lay in being a stranger to the patient and family. While she did not “know” the patient, she intuitively knew the patient was actively dying. The patient was not in distress so the physicians were focused on other patients who were in immediate need of attention.

So if a nurse believes a patient is dying, but she is a stranger to the family, what “should” she do? No one wants to cause the family harm by suggesting a patient is dying when they are not, and certainly nurses don’t want to say or do anything that is contradictory to what a physician has told a family. However, we have an obligation to dying patients as much as to those whose lives can be saved by our expert interventions. When a nurse’s clinical judgment suggests a patient is dying, that is a time to speak up to physicians and families.

Acknowledge the difficult conversation, the desire to do no harm, then take a deep breath and express your concern. Perhaps your concern is that the patient will die and family will not be present; maybe you fear upsetting the family needlessly because the patient is not dying.

Take a risk – first with the physicians. If their attention is divided due to other patients’ needs, ask permission to gently assess the family’s acceptance of their loved one’s situation. Ask about their preferences and values if their loved one should die – not the same as the DNR talk. Having this conversation helps lay the groundwork for the DNR talk.

I wonder if people rate nurses as most trusted (see recent Gallup poll results on the Internet) because they have to believe they are trustworthy, given how vulnerable people are when they are in our care?

Earn the trust of patients and families by caring enough to have a difficult conversation at a crucial time. Don’t be afraid to ask about values and preferences surrounding death. The only way to facilitate a good death for a patient is to explore with the patient or family their preferences for end-of-life care.

Lucia Wocial

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Harassment on the Job While Nursing at Clarian

Sunday, February 8, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

A nurse recently asked me about her rights at work. She said: “What am I supposed to do if a patient touches me inappropriately?”

On the face of it, this seems like a simple question. But when several nurses asked me the same question about the same patient, it led me to believe that nurses often spend so much time protecting the rights of patients that they (nurses) forget that they also have rights.

According to the ANA Bill of Rights for Nurses, “Nurses have the right to a work environment that is safe for themselves and for their patients,” among other things. View the ANA’s stance on the issue at www.nursingworld.org. The Bill of Rights sets forth expectations for the workplace environment. Any behavior that is considered offensive or fails to respect the rights of others is a form of harassment.

Experience shows that a number of considerations sometimes prevent nurses from addressing harassment from patients: fear that no one will believe the report; concern that what the patient did was not intentional; and even embarrassment or failure to recognize that this type of behavior will not be tolerated.

Clarian has a zero-tolerance policy for harassment from patients or co-workers, and a policy exists to define the expectations when someone experiences this type of behavior.

The short answer to the original question is: Immediately report any harassing behaviors to your supervisor and/or an employee relations consultant. Any nurse reporting such behavior should expect a timely confidential investigation and an action plan to resolve the situation.

At the very least, the nurse reporting the behavior should expect a person in authority to speak with the offending individual AND expect to hear the outcome of the investigation, including what plans are in place to protect you in the future.

In most cases, having an individual in authority speak to the patient effectively resolves the behavior. If you do not report the behavior, no one can help you and it likely will continue – if not with you, then with others.

Lucia Wocial

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Take a "Time Out" to Remain an Ethical Nurse

Tuesday, February 3, 2009 by Lucia D. Wocial, PhD, RN, CCNS, Clarian Nurse Ethicist

In my role as a nurse ethicist, I recently had a conversation with a staff nurse who asked me a simple question: “Is it an ethical issue if one of my co-workers is dissing a patient?” By “dissing” she meant her colleague was making disrespectful comments about the patients in her care.

Everyone needs an opportunity to vent, even complain sometimes. So when does it cross a line and become an ethical issue?

The answer is in the standards of professional practice, defined in the ANA Code of Ethics, which serves as the foundation for nursing practice at Clarian Health. Within the fundamental values of the code are provisions for practicing with compassion and respect for the inherent dignity of individuals.

Complaining about patients violates this fundamental value when the complaints become the rule instead of the exception; when the complaints drift outside the privacy of a locker room or staff lounge, when they are spoken within ear shot of a patient or a family member and, in rare cases, when they reflect a true disdain for a particular patient or “type” of patient. This type of behavior is not consistent with a healthy working environment.

The code is not just about our duty to patients. As nurses, we have a duty to ourselves, to preserve our integrity and seek continued growth in our practice. Complaining to the point of habit suggests it’s time to evaluate our need to rejuvenate.

It takes energy and endurance to maintain ethical practice in the face of computer problems, ringing phones, family demands, ill calls and all the other pressures that would even tax a saint. Oddly enough, people whose complaining has become a habit may not realize what they are doing.

If you have a colleague who has slipped into this behavior, offer them support by way of feedback and suggest “a time out,” something as simple as covering their assignment for a short break, or encouraging them to utilize the sanctuary of healing space.

Lucia Wocial