Running Head: ETHICAL ISSUES OF PRACTICE

Ethical Issues of Practice

Rebecca Sopelak
April 16, 2015

ETHICAL ISSUES OF PRACTICE

2
Introduction

For many years, pain has become the focus of patient care. It has recently been deemed
the fifth vital sign because of its importance in the care of patients. In a study done by the
American Pain Society (2005), they found that the best recommendation to improve patient
outcomes is the prompt recognition and treatment of pain (para. conclusion). Many hospitals
have put protocols in place to help improve the promptness of the treatment of pain. At Augusta
Health, under their interventions, there is a spot for pain assessment. The pain assessments are
required every two hours. This is the same situation at Sentara Rockingham Memorial. Some
think that this may be excessive, but the policies are in place for a reason. A study of acute pain
management by Pamela Macintyre and Stephan Schug (2015) states that the reason for
guidelines is to try and improve quality of clinical decision making, improve quality of care,
and minimize potential harm (p.9) for the patients. As we can see the policies that the hospital
puts in place for pain management is to improve the care for patients. It may seem excessive, but
it is in the best right of the patient. However, I have seen situations where the nurse did think
that the policy was excessive. The situation that I have been involved in goes as follows.
Background
During a labor and delivery rotation in the Birthing Suite at Augusta Health, I was
following a nurse who was caring for a woman in labor. Throughout the process she was
explaining to myself and another student about the labor process, fetal monitoring strips, and the
steps that the nurse needs to take while caring for this woman. While talking with her, she
mentioned to us that she does not like to ask patients their pain level during the required every
two hours on the charting system. Rather, she likes to ask them about their pain when she sees
that the women expresses signs of pain. When we asked her about this, she explained that this

ETHICAL ISSUES OF PRACTICE

was because of a research article that she recently found that stated the more we ask patients
about their pain, the more they are going to think about it. This could cause someone who had
been functioning on the pain or someone who didnt have pain to come up with a number
whether they are in pain or not. These scales are then the basis on which medications to use and
are causing an overuse of pain relievers and narcotics.
As she continued to explain the reasoning, it created a moral dilemma inside me. The
nurse makes a valid point about rating pain and the relation with the overuse of pain medications,
but you dont want to have a patient sit around all day in pain and never have it addressed.
Method
To look at this situation, I will be using the James Madison University 8 Key Questions.
The eight key questions are laid out in The Eight Key Questions Handbook (2013) set out by the
Madison Collaborative. These questions are based off the eight key ideals [fairness, outcomes,
responsibilities, character, liberty, empathy, authority, and rights] (p. 10) that ethical reasons are
centered around. From these ideals, we base the questions that we pose to help deliberate moral
dilemmas and moral distress. These questions in turn help us to come up with a decision on what
is best to do in a given ethical situation. Used together, all eight of these questions can help you
take a more in-depth look at the ethical situation as a whole, break it down into smaller pieces,
and help to decide what the best possible next step should be.
Findings
Fairness: By this nurse not asking the patient her pain until she shows signs of it or
expresses her pain, is that treating her like the other patients on the floor? No it is not. If
protocol calls for asking the patient every two hours how her pain is, that is what needs to be
done. If the protocol is neglected, the patient is being treated like all other patients on the floor.

ETHICAL ISSUES OF PRACTICE

Outcomes: What are the short and long-term consequences of refraining from asking
about pain? Short-term, it can be prolonging the womans pain. Long-term it can make her miss
her window of opportunity for adequate pain treatment. With women in labor, there is a window
of opportunity for receiving an epidural. If the nurse waits to long to ask the patient about her
pain and potential desire for an epidural, you can miss that window of time.
Liberty and Right: This can also prevent the women from having the liberty to choose
her care. Patients have the right to have a say in their care. This is the whole basis of patientcentered care. If the patient wanted an epidural, which is her right to request, and the nurse
neglects to ask about her pain in a timely manner, the epidural could potentially miss the window
of opportunity, thus not be able to be administered. We then violate that womans right to direct
her care. By blocking that right, we are taking away patient autonomy and neglecting out
responsibility as a nurse caring for this patient.
Responsibility and Authority: The nurse has a responsibility to keep the patient safe
and healthy. They have a responsibility to follow the hospital protocols. If the nurse doesnt
agree with the protocol, she can think about the American Nurses Association Code of Ethics
(2015) that helps guide nursing practice. Provision 2 states that the nurses primary
commitment is to the patient (p. v), Provision 3 addresses advocating for and protecting
patients rights, health and safety (p. v), and Provision 4 talks about the nurse having authority
and responsibility to provide optimal care in all settings (p.v).
Empathy: By following this guide, nurses promote the health of their patients, which in
turn helps them to better understand the patient. This understanding helps to empathize with the
patient. This empathy is how we put ourselves in the patients shoes. You personally would not

ETHICAL ISSUES OF PRACTICE

want to be sitting in pain for an extended period of time because no one had the decency to ask
you about how you were feeling, so it shouldnt be done to this patient either.
Character: This situation as a whole can diminish the woman and nurses character. If
the woman had her birth plan set as a way to help her become who she wanted to be, she will
want it to be followed. By not allowing her to follow her birth plan, that could prevent her from
becoming her ideal self and diminish her character. For the nurse, if she gets in trouble for not
asking about pain, that can diminish her character if she gets in trouble for that. Getting in
trouble for ignoring her policies is not promoting her best self, thus diminishing her character.
Conclusion
In retrospect, this situation couldve been taken care of be further pushing for this nurse to follow
her patients protocol. Her reasoning behind the frequency of the pain scale linking to an
overuse of medications is valid, but the protocol is there for a reason. By looking at the eight
key questions, it helps prove why the protocols should be followed to increase patient centered
care and improve patient outcomes. No one wants to be in excessive amounts of pain and not be
asked about it. Not everyone shows his or her pain either. The protocol in the hospital is set for
this reason. It is to promote the health and healing of the patients in the most comfortable way
possible. By neglecting to ask the patient about their pain, the nurse is not following her
responsibility of promoting the patients health to the best that she can. If we were to go back in
time, I would make sure to point this out to the nurse. I would encourage her to look more into
the reason why the protocol is there. I understand her use of evidence-based practice is what she
was going for, but by going against the hospital protocol to do so was not in the best interest for
her nursing practice or in best interest of the patients care.

ETHICAL ISSUES OF PRACTICE

References
American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements.
Retrieved from:
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNur
ses/Code-of-Ethics-For-Nurses.html
Gordon, D. B., Dahl, J. L., Miaskowski, C., McCarberg, B., Todd, K. H., Paice, J. A., Carr, D.
B. (2005). American Pain Society Recommendations for Improving the Quality of Acute
and Cancer Pain Management. Arch Intern Med 165(14), 1574-1580.
doi:10.1001/archinte.165.14.1574.
Macintyre, P. E. & Schug, S. A., (2015) Acute Pain Management: A Practical Guide, Fourth
Edition. Boca Raton, FL: Taylor and Francis Group LLC. Retrieved from:
https://books.google.com/books?
hl=en&lr=&id=uzDcBQAAQBAJ&oi=fnd&pg=PP1&dq=pain+management+protocols
&ots=YtPNXKqZ7f&sig=7ChHAjr50x0E0KYVGBsdjRTuO24#v=onepage&q=pain
%20management%20protocols&f=false
The Madison Collaborative. (2013). The Eight Key Questions Handbook. The Madison
Collaborative Ethical Reasoning in Action, 1. Retrieved from:
https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf