Running head: BRIDGE TO PRACTICE: ETHICS 1

Bridge to Practice: Ethics in the Healthcare Setting

Abilene Schiefer

James Madison University

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Bridge to Practice: Ethics in the Healthcare Setting

Healthcare-associated infections are a huge problem in the United States. An article from

the New England Journal of Medicine reported that in 2011, roughly 721,000 inpatients acquired

a healthcare-associated infection (Magill et al., 2014). The spread of pathogens in hospital

settings has proven to be difficult to control, however implementing the evidence-based practice

of isolation precautions has been used to combat this issue. The Joint Commission states that

personal protective equipment consisting of an isolation gown and gloves should be worn when

"clothing will have direct contact with the patient or potentially contaminated environmental

surfaces or equipment in close proximity to the patient" (2017). With droplet isolation

precautions, a face mask should also be worn. The CDC has described the importance of

educating healthcare workers and hospital visitors about the principles and practices used for

preventing transmission of infectious agents, which includes training anyone who has an

opportunity for contact with patients or medical equipment (2007). All of these guidelines and

recommendations point to increased education and adherence to the precautions as a contributing

factor to reducing healthcare-associated infections.

Background

During one of my clinicals, I had a patient who was on contact and droplet isolation

precautions because she had the flu. I was taught the importance of strictly adhering to these

precautions. I wore the proper PPE every time I went in her room. I was told that the patient’s

daughter would be coming in soon to visit. My patient was an older woman with dementia, and

her daughter was her primary caretaker. The daughter also happened to be a retired nurse, who

had worked at the same hospital that we were in. When the daughter arrived, I was slightly taken

aback when she did not put on any of the isolation garb. I wasn’t sure what to say. I knew that
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she was educated about the importance of isolation precautions because she had worked as a

nurse. I brought it up with my clinical instructor, who happened to know the daughter personally,

and she said that the nurses had talked to the daughter about it, but she still refused to adhere to

the guidelines, so the nurses just let her be. I decided to not pursue the situation further.

This situation caused me slight moral distress, because I knew that the woman should be

following the precautions, and that she was risking spreading her mother’s infection to others. I

feel like her age, experience as a nurse, and the fact that she had an overall aggressive demeanor

held me back from saying something. I chose not to act, but I had plenty of opportunities to

speak up, and I could have at least asked her why she chose not to wear the PPE.

Methods and Findings

To further analyze the situation in clinical, I used the JMU 8 Key Questions, which is an

established system formed by the Madison Collaborative to help make ethical decisions (2017).

The questions provide a flexible open framework to be used as prompts at the point of decision-

making. These questions highlight important values that are to be considered.

One question I must ask myself is how can I act equitably and balance legitimate

interests? I have to consider the interests of the daughter, as well as the staff and visitors on the

unit, as well as myself. It is not fair to put everyone at risk of acquiring the flu because the

daughter did not want to wear the isolation garb. By her not following precautions, she could

easily spread her mother’s germs throughout the entire unit and the hospital, which is not fair to

everyone who is exposed. It is not really unfair or unreasonable to require her to wear the gown,

mask, and gloves. She might be slightly uncomfortable, but it is not an unfair request of her.

Another thing to consider is, what action achieves the best outcomes for me and all

others? The best outcome would be achieved by convincing the daughter to wear the isolation
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garb. It would significantly reduce the spread of infection. She might become uncomfortable, but

the health and safety of everyone (including herself) outweighs her desire for comfort.

I must also ask, what duties or obligations apply in this situation? I have the

responsibility to protect my patient’s from harm when I can. The daughter’s actions are putting

my patient’s at harm, so I have a responsibility to try and put a stop to it.

I also have to think about what action best reflects who I am and the person I want to

become. The ideal person I want to be would not be too intimidated to say something to the

daughter. I would provide education and it would be in the best interest of everyone involved.

When making my decision, I must remember that people have freedom. The daughter has

the freedom to choose what she wants to wear. I can’t force her to consent to wear the garb.

Whoever is supervising the unit could ask her to leave, if they deemed it to be a big enough

problem, but no one can make her follow the precautions. She has the autonomy to choose

whether or not to follow the precautions, whether or not it is in the best interest of anyone else.

Another aspect to think about is empathy. I can empathize with the daughter, because

she’s probably having a very hard time right now, with her mother’s health condition. It is a

stressful time for her, and I imagine she doesn’t like the idea of having to wear all the garb when

she’s in her mother’s room all day, because it can feel restrictive. However, I also have to

empathize with the other patients on the unit. They and their families are probably going

through similar situations, and if the daughter isn’t following precautions, they are at risk for

catching her flu. So while I understand why the daughter may feel the way she does, I have to

look at the bigger picture and think of everyone who is at risk from her actions.

I also have to determine everyone’s rights in this matter. The patients have a right to

safety. Patients expect to go to the hospital to get better, not to acquire an infection from
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someone else. The daughter has a right to visit her mother, however asking her to wear the garb

doesn’t infringe on those rights.

A big issue I must face is thinking about what legitimate authorities expect of me. My

clinical instructor expects me to be aware of the precautions and follow them, but did not expect

me to address the situation with the daughter, who was also an authority figure due to her

experience as a nurse. The other nurses did not expect me to handle the situation either, because

they had already discussed the decision with her and decided to just let it go.

The highest authority I have to consider is the American Nurses Association code of

ethics. Provision 3.5 Protection of the Patient Health and Safety by Acting on Questionable

Practice states that nurses must be alert to and take action in all instances of “incompetent,

unethical, illegal, or impaired practice or actions that place the rights or best interest of the

patient in jeopardy” (2015, p.12). Refusing to wear proper PPE is not illegal, but it could be

considered impaired or incompetent, so it is my duty to either address the daughter, or bring it up

with someone who has the authority to ask the mother to leave if she does not comply.

Conclusion

All of the questions point to saying something to the daughter. Even though my clinical

instructor said that the nurse’s had talked to her about it, I could have done more. I could have

asked her to explain to me her reasoning for refusing to follow the precautions. If I couldn’t

convince her, at least I could have educated her further and really explained to her the

implications of what she was doing. In the future, I’m sure I will face many more family

members who don’t know about isolation precautions, or just don’t want to follow them. When

that happens I want to be able to effectively educate them on the importance of it, because even

though it may be uncomfortable to address, it is the right thing to do.

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References

American Nurses Association (2015). Code of ethics for nurses, 12. Retrieved from

http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html]

Centers for Disease Control and Prevention (2007). 2007 Guideline for isolation

precautions: preventing transmission of infectious agents in healthcare, 66-73. Retrieved

from https://www.cdc.gov/hicpac/2007IP/2007ip_part2.html

James Madison University: The Madison Collaborative (2017). The eight key questions.

Retrieved from https://www.jmu.edu/mc/8-key-questions.shtml

Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A., Fridkin,

S. K. (2014). Multistate point-prevalence survey of health care–associated infections,

370, 1198-208. Retrieved from

http://www.nejm.org/doi/full/10.1056/NEJMoa1306801#t=articleResults

The Joint Comission (2017). Infection prevention and control (hospital and hospital

clinics / hospitals). Retrieved from

https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?Standa

rdsFAQId=1203&StandardsFAQChapterId=69&ProgramId=0&ChapterId=0&IsF

eatured=False&IsNew=False&Keyword=&print=y