POSADAS, KRISTINA GRACE NCI MWF 6:30-7:30

SUMMARY

Annie R., being the chief nurse in the critical care unit of

Albany Medical Hospital, is faced with the dilemma of dealing

with a university professor she was committed to meet regarding

the delegation of student nurses and at the same time, attend to

a patient emergency in her unit. In this regard, three possible

solutions were seen and evaluated as to their adherence to

institutional policies and patient rights, and effects on

professional relationships. First, is for Annie to ask the

professor to wait for the patient crisis to be settled. Second,

is for her to delegate another staff member to assist the

university professor. And third, is for Annie to log on to the

system for the professor. Considering the pros and cons each

solution may bring, and taking into account that patient rights

must precede over any other factor, it is recommended that the

second option be adopted by Annie. Giving due consideration for

a long-term solution that will finally address the problem is

also highly suggested.

PROBLEM

Annie R. is the chief nurse in the critical care unit of Albany

Hospital. She had arranged a meeting at 3 p.m. between her and a

university professor of the Albany Medical College to review and

discuss potential patient assignments for a group of student

nurses the following day. Just as the university professor

arrives, an emergency situation came up regarding a dehiscent

post-operative patient in her unit requiring her immediate

attention.

Annie has to do attend to multiple tasks all at the same time.

First, she has to deliver effective and efficient healthcare to

the patient in crisis (as this is her primary duty as a nurse

and conversely, it is the right of the patient to receive the

best possible care). Second, she must maintain the

confidentiality of the medical records of other patients since

it is again her responsibility to secure such documents and to

assure that her patients’ right to privacy and confidentiality

are safeguarded. Third, she must attend to the commitment she

made with the professor regarding patient assignments.

The main predicament here is how Annie can perform three tasks

without necessarily compromising any right or relationship or

violating any policies, and that each of the requirements of the

persons involved will be satisfactorily satisfied.

SOLUTIONS

1. Annie may ask the professor to wait until the patient

crisis is solved.

> In doing so would guarantee that there won’t be any

policy violations, that she will be able to attend to the

patient crisis, and that other patients’ right to privacy

of their medical records will be safeguarded. However, this

may bring about the possibility of jeopardizing collegial

relationships, especially so that she herself gave a

commitment to meet with the university professor and

discuss matters with him in person.

2. Annie may delegate another staff member to assist the

university professor.

> Given such a scenario, no policy violations will be

committed, the patient crisis will be dealt with, and the

student assignments will be completed. However, it is a

must to consider that the staff nurses may be preoccupied

with their own tasks; and if fortunately they are not, the

problem may be that they are not that well-versed or

familiar with the cases of the different patients to whom

she will delegate the student nurses. In this case what

will be put on the line would be the learning of the

student nurses, for the staff member may not give an

 “expert” advice as to who should handle each patient.

Another thing is that, the delegated nurse may fail to

provide accurate patient history and current health status,

as well as certain nursing considerations when caring for a

specific patient.

3. Annie may log on to the system for the professor.

> What will be most striking in this situation is that

the professor himself may take over the delegation of his

students as he was already given the privilege to access

the patients’ medical records. However, this will seem to

worsen the situation, most especially for Annie, as there

will be a clear violation of patient rights, as well as a

negligent act on her part as it is her duty as a nurse to

protect such confidential matters. And although it is given

that the professor bears the same interest as Annie, it is

still no assurance that the professor will not abuse such

privilege.
RECOMMENDATIONS

Given the analysis for each possible solution presented above,

it is therefore recommended for Annie to delegate another staff

member to be of assistance to the university professor. This is

so because it will maintain computer system integrity (which is

lacking in Solution No. 3) and protect professional ties (as

what is deficient in Solution No. 1) while recognizing the

patients’ rights to privacy and confidentiality in medical

records and to receive the best possible care from the

healthcare provider assigned to him/her. However, as already

indicated in the alternative analyses, delegation may not be an

ideal solution since the staff nurse whose assignment is to

assist the professor may not possess the same extensive

information about all of the patients as the chief nurse. It is

however the best immediate solution to the dilemma and certainly

safer than compromising computer system integrity and patient

rights.

Furthermore, an immediate solution may not be enough to cater to

such recurrent issues. Long-term options must also be presented

and evaluated regarding the maintenance and security of computer

systems. Questions on who should be given access to, how to keep

track of information obtained and entered to the system, and

through what device or mechanism should the access be granted

are but some of the key points to ponder on.

SUMMARY

Jean W. is a labor and delivery room nurse in a community

hospital catering to both private and clinic patients. The

patient assigned to her was due for an elective cesarean

delivery. Her patient insisted that she be kept awake; however,

an incompetent anesthesiologist attends to her and fails to give

the patient an epidural anesthesia. The obstetrician then orders

for the patient be put to sleep instead, and let the delivery

push through as scheduled. Jean is now in the crisis of

upholding the patient’s desire to stay awake without

compromising her duty as an assistant to the physician. Three

possible solutions were seen and evaluated as to whether or not

such actions will recognize the patient’s rights, let the nurse

perform her duty, lessen tension between the nurse and the

doctor, and finally permanently address the problem. First, Jean

can say nothing to the obstetrician and help with the delivery.

If asked by the patient later why she needed to be put to sleep,

she can simply opt to refer her to the obstetrician. Second,

Jean can remind the obstetrician that the patient was adamant

about wanting to be awake and suggest that a different

anesthesiologist be called in. And third, Jean can say nothing

and assist with the delivery, but resolve to talking to the

obstetrician after the delivery. Analyzing the three, the last

option is much recommended since it will not hamper the

completion of the procedure and that it will provide a long-term

action on the problem. Furthermore, issues of marginalization

and competence of healthcare providers were evident in the

situation and must then be subjected to supplementary studies.

PROBLEM

Jean W. is a labor and delivery room nurse in a small community

hospital that serves both private and clinic patients. Jean has

always felt that certain members of the obstetrics-gynecology

medical staff have treated these two groups of clients

differently. On this particular morning, Jean is caring for a

woman who is scheduled for an elective cesarean delivery. The

woman (who is a clinic patient) has made it very clear that she

wants to be awake for the delivery and has requested epidural or

spinal anesthesia. Jean is dismayed when the anesthesiologist

enters the delivery room because the anesthesiologist’s success

rate with epidural anesthesia is very poor. The anesthesiologist

unsuccessfully attempts to perform an epidural block. After

waiting for 20 minutes for results, the obstetrician is growing

impatient and instructs the anesthesiologist to put the patient

to sleep. Jean feels the rights of this patient are being

violated but is unsure of what her response should be.

Let us take a closer look at the situation.

• The patient is in stable medical condition (elective

cesarean delivery, not an emergency) and has made it very

clear that she wishes to be awake for the delivery. The

patient is not a private paying patient of the

obstetrician.

• The anesthesiologist has a poor success record with

epidural anesthesia.

• The obstetrician seems to want to complete the delivery

quickly. In the past, he has seemed to give more weight to

following wishes of private patients as opposed to clinic

patients. He is the head of the obstetrics-gynecology

department; he believes nurses should obey physician’s

orders unquestioningly.

• Nurses have in the past expressed dissatisfaction with the

different levels of care being provided to private and

clinic patients, but no one to date has formally addressed

the concern.

Given the situation Jean has the following roles to fulfill:

• Promote and protect the patient’s interests

• Follow physician’s orders

• Perform her duty as the physician’s assistant in executing

the procedure
 • Suggest a course of action to permanently address the

problem

SOLUTIONS

1. Jean can say nothing to the obstetrician and help with the

delivery. If asked by the patient later why she needed to

be put to sleep, she can simply opt to refer her to the

obstetrician.

 In this course of action, Jean is able to fulfill her

obligation to the physician and to the hospital. The

delivery was carried out in record time and the

obstetrician is happy. However, the patient’s wishes

are disregarded and the probability of the problem’s

recurrence is still present.

2. Jean can remind the obstetrician that the patient was

adamant about wanting to be awake and suggest that a

different anesthesiologist be called in.

 If the obstetrician agrees, the patient may get her

wish and everyone is satisfied.

  If the obstetrician refuses and insists the patient be

put to sleep, the nurse can also decline participating

in the procedure. With this act, the problem may

worsen since it would seem that Jean has abandoned her

patient and harm may ensue, or that it would look as

if she does not trust the competence of the physician

in handling such situations, or worse, that it would

appear as though she is the inept one. Thus,

jeopardizing the patient’s welfare, professional ties,

and her stature as a nurse.

3. Jean can say nothing and assist with the delivery,

believing it would be the wisest course of action for the

time being, but resolve to talking to the obstetrician

after the delivery.

 The procedure was executed with the physician’s

satisfaction; however, the patient’s wish was still

not fulfilled. Another problem is that there is no

guarantee that speaking to the obstetrician will solve

the problem and the need for Jean to move through the

proper administrative channels may arise, leading to a

50:50 chance of either being heard or sacked in the

process.
RECOMMENDATIONS

Having weighed the three possible solutions presented above, it

is highly suggested that Jean opt for the third solution. In

this scenario, Jean will be able to meet her goals of performing

her duty to be of assistance to the physician and to execute the

procedure without further delays (as Solution No. 2 suggests).

Although the burden of not being able to fulfill the patient’s

wish will always be evident, for Jean to actually confront the

physician and possibly call for proper administrative action

(than do nothing as implied by Solution No. 1) , is enough

reparation for such failure.

The problem still presents more pressing issues than a mere

nurse-doctor conflict. It also touches several areas such as (1)

marginalization, especially when it comes to a person’s

financial capabilities, and (2) the competence of health care

providers. Faced with such, it is greatly advised to study the

predisposing factors regarding such deeds and possibly address

(or significantly minimize) such crises.