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Compromised Patient Care

Julietta Verish

James Madison University

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Introduction

Throughout my two semesters of clinical experience, I have witnessed and observed

wonderful care exhibited by the nursing staff at the local healthcare facilities, but there are some

examples I do not wish to follow. Most of the poor examples I have witnessed was in the clinical

settings of long term care facilities. Events and outcomes in long term care facilities are more

likely to reflect the culture of an institution rather than an individual’s character (Pickering,

Nurenberg & Schiamberg 2017). If the culture of an institution allows for more incidences of

compromised care, patients will not be receiving the best care possible. “Ethical issues are

unavoidable in healthcare and can result in opportunities for improving work and care

conditions; however, they are also associated with detrimental outcomes including staff burnout

and moral distress” (Preshaw, Brazil, McLaughlin & Frolic, 2016). Witnessing a patient be

pardoned of the care they deserve can motivate a nurse to improve, or cause them so much moral

distress they leave the facility or change professions.

Background

In one of my clinical experiences, fellow students and I witnessed a situation that made

each of us feel uncomfortable and powerless. One morning after reviewing the patient’s chart,

two nursing students were assisting a heavier patient ambulate to the bathroom. At this point, a

registered nurse on staff intervened and told the nursing students they should not be ambulating

this patient and she should be only using the bedside commode. Apparently, the nurse had

recently injured herself attempting ambulate this patient on her own. Based on this, she came to

the conclusion the student nurses should not be ambulating the patient due to the patient’s size

and how difficult she assumed the task would be.

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The nursing students had explained that they had reviewed the patient’s chart which now

stated to ambulate her to the bathroom instead of transferring her to the bedside commode. Since

this intervention was now included in the patient’s chart, it was considered an improvement in

her condition. The nurse finally stated the nursing students could help her walk to the bathroom,

but the nurse was not going to help them or take any part. The nurse explained and said she did

not feel like putting in the energy to help ambulate this patient or risk injuring herself again.

The students felt very uncomfortable and awkward after being confronted by the nurse.

The nursing students decided to tell the other students in the group along with our clinical

instructor. Our clinical instructor then approached the nurse and explained the students were only

following what was ordered in the patient’s chart. The nurse understood, but was still adamant

about not helping the students with this task. This order by the physician was intended to

improve the overall status of the patient and the patient had the right to receive the assistance she

and all other patients deserve.

An alternative response could have been articulating to the nurse that we understood she

was in fear of injuring herself further, but there are safe ways and resources available to assist in

ambulating a patient of larger size, especially when it is in the best interest of the patient. “Moral

distress occurs when one knows the ethically correct action to take but feel powerless to take that

action” (Epstein & Delgado 2010). This situation caused the nursing students moral distress

because they knew the right action to take; to ambulate the patient, but felt powerless to take the

action because someone of authority, the registered nurse instructed them not to.

Methods/Findings

James Madison University’s Madison Collaborative program has posed eight key

questions in order to assist in proper ethical decision making. These eight key questions highlight
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vital human values which are believed to be common cross culturally (The Madison

collaborative: Ethical reasoning in action). In regards to the first of the eight key questions,

fairness applies to both the patient and the nurse. Although the nurse was hesitant to assist and

allow the nursing students to assist the patient, it was because she was concerned about her own

safety and the safety of the nursing students. The nurse holds the responsibility to provide

optimal care for their patients, but also owe that to themselves. The outcomes for this patient

depended on which actions the nursing students were going to take, ambulating or just

transferring to the commode. The physician added this to the patient’s chart because the

physician believed the patient was ready and capable of doing so. Ambulating this patient would

improve her long term outcomes if ambulated safely.

According to the Provision 4 of the ANA code of ethics, the nurse holds the

responsibility to promote health and provide optimal care for all of their patients (American

Nurses Association 2015). As nursing students, we hold that same responsibility even when no

one is watching. The character of the nurse and the nursing students were both taken into

consideration in this situation. The action of the nursing students best reflected the role which all

nurses, including myself should desire to take part in. The patient in this situation did not have

much liberty or personal freedom in which type of care they would be receiving. She was an

elderly woman who spoke very few words and just followed what the nurses wanted to do.

Although she could have attempted to verbalize which type of care she preferred, she did not.

The nursing students showed empathy towards the patient, where they understood it

would be difficult for her to get to bathroom, but it was in her best interest. Whereas the nurse

did not show empathy towards the patient and only acted in her own best interests. If this patient

was my family member, I would hope that the nurses used everything in their power to make
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sure my family received the best care. The nurse in this situation had authority over the nursing

students, but the chart which stated the physician’s orders and the ANA Code of Ethics held

authority over the nurses and the quality of care they are trusted to provide. This proved to be a

difficult situation because there was not a physician present at this time to implement their

authority in person. The patient had the right to receive the best care possible even when it

proves to be difficult for those providing the care.

Conclusion

Years of being in the nursing profession can ultimately diminish someone’s passion and

drive to provide the best nursing care one can, especially if the institution entertains a culture

which allows it. In this situation, the clinical instructor was notified and then confronted the

nurse caring for this patient. If this were to happen again, the same or similar course of action

should be taken place by the nursing students. The clinical instructor should be notified in order

to reduce tension between the nursing students and the registered nurse and promote peace

within the learning environment and work place. Situations involving moral distress experienced

by nursing students should be reported to a person of authority in order to reduce burnout and

changes in career paths. In regards to patient care, student nurses should report any situation

which makes them feel uncomfortable because no patient should have their health compromised

regardless of the culture of institution or type of institution patient care takes place in.
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References

American Nurses Association. (2015) Code of ethics for nurses with interpretive statements.

ANA. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-

for-Nurses.html

Epstein, E.G., & Delgado, S. (2010). Understanding and addressing moral distress. Online

Journal of Issues in Nursing, 15(3). doi: 10.3912/OJIN.Vol15No03Man01

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in action.

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

Pickering, C. Z., Nurenberg, K., & Schiamberg, L. (2017). Recognizing and responding to the

“Toxic” work environment: worker safety, patient safety, and abuse/neglect in

nursing homes. Qualitative health research, 27(12), 1870-1881.

doi:10.1177/1049732317723889

Preshaw, D., Brazil, K., McLaughlin, D., & Frolic, A. (2016). Ethical issues experienced by

healthcare workers in nursing homes. Nursing Ethics, 23(5), 490-506.

http://dx.doi.org/10.1177/0969733015576357