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Establishing ethical practices and eliminating the “gray”
OCTOBER 2001, VOL 74, NO 4 EDITORIAL
Establishing ethical practices and eliminating the ”gray“
w
hen early pioneers formed communities based on groups of people living in one place, the different cultures of the groups implied how members would get along with others and survive. Spiritual beliefs supported unwritten codes of ethical behavior, which were accepted and adapted as part of communities’ cultures. Challenges in recent history, however, have caused community boundaries to expand, which requires accepting and adapting behaviors to meet the needs of a larger community, Issues such as patients’ rights, stem cell research, and expanding commerce continue to tax our ability to mandate, expect, or, in some circumstances, even distinguish ethical and unethical conduct. Perioperative nurses have a low tolerance for “gray” areas of practice, and when ethical boundaries are in question, the lines of separation may become unclear. Ambiguity is uncomfortable, and it can make us question right from wrong or good from bad. When parameters are identified, expectations of behavior and practice are known and understood. Walking the thin line between doing no harm and managing difficult situations test our ethical standards and create situations in which there often are no black and white answers. More frequently, ethical boundaries are scrutinized and analyzed in all areas of health care, particularly with the increasing
attention to medical errors. THE PERIOPERATIM COMMUNITY In the perioperative community, nurses, surgical technologists, physicians, and other staff members learn codes of behavior. Rules or standards that govern the conduct of members of the perioperative community are appreciated because they distinguish ethical practices and serve as guidelines for ethical behavior and decision making. When conduct exceeds established boundaries, our intuition is to seek an established norm with the intent of protecting the patient. When others choose not to practice within the boundaries, dissension and even errors can result. In the perioperative community, people’s beliefs and values may differ. At times, people might not even realize these differences. At other times, they may work so hard to overcome the differences that their ethical behaviors interfere with achieving expected outcomes. Consider the ongoing analyses that occur in perioperative lounges throughout the country. Situations described and questions about the behaviors of and choices made by others often evolve from perceptions and interpretations of behaviors that cannot be corrected by a rule or standard. Ethical behaviors take on different meanings because of the setting or the uniqueness of people and their inability to separate themselves from their culture, 456 AORN JOURNAL
religion, philosophy, morality, values, and beliefs. The following examples raise concern BRENDA S. regarding ethiGREGORY DAWES cal behavior. A new learner who values his or her position in perioperative services and believes in the information he or she was taught in class observes a preceptor breaking technique. A circulating nurse observes a surgeon incorrectly using equipment that could result in misdiagnosis of the patient’s condition. A scrub person who also is a friend of the surgeon begins assisting during procedures by performing tasks outside his or her scope of practice. A nurse observes a surgeon display what he or she considers inappropriate behavior with a patient’s family member. Ideally, we should respond to these situations based on evidence, research, or logic, and we should fulfill our responsibility as patient advocates. The reality, however, is that personal characteristics can result in compromise that may or may not seem appropriate at the time. The question is whether compromise is worth erosion of trust, adverse outcomes, or other negative consequences.
OCTOBER 200 1, VOL 74, NO 4
Physical proximity, relationship dynamics, and the responsibility of caring for patients often adds to the complexity of making ethical decisions. As heightened awareness about health care errors opens doors for discussion and problem solving, the entire perioperative team should be involved and responsible. Immediate responses to health care errors that are oriented toward patient care provide stimulus for positive results. Preventive measures that eliminate dilemmas and unethical decision making require that people come together as a team and put aside egos that interfere with ethical actions.
address patient care and safety concerns.’ These documents support ethical decision making in perioperative practice and can eliminate confbsion and dissension among professionals. According to the Comprehensive Accreditation Manual for Hospitals, patients must be informed about outcomes of care, including unanticipated outcomes or whether they are harmed by care provided. These standards are intended to encourage health care administrators to create a culture of safety in which errors are discussed and studied openly. The Code of Ethics f o r Nurses is a statement of ethical obligations and duties of each person who enters the nursing RESOURCES A VAlLABLE Newly released documents are profession, and it expresses nursing’s commitment to society. available to guide practices that Goals, values, and obligations fall in g a y areas. The Joint are identified to provide an ideal Commission on Accreditation of and norm of the profession. This Healthcare Organizations’ document includes statements Comprehensive Accreditation that provide a framework for Manualfor Hospitals and the nurses to use in ethical analysis American Nurses Association’s and decision making. Code of Ethics for Nurses NOTES 1. ComprehensiveAccreditation Manual for Hospitals: i’le Ojicial Handbook-Update I Februaiy 2001 (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organization 2000); Draft 10a Code of Ethicsfor Nurses (Washington, DC:
MAKING THE BEST DECISION Values, beliefs, and human responses can interfere with making the best decision. Situations in perioperative settings can result in nurses becoming middle men. We need to identify personal behaviors that interfere with ethical decision making. As nurses exit the profession because of ethically related distress, ramifications for individual nurses and the profession require attention.2Supportive environments, commitment to discussing ethical dilemmas, and open communicationamong all team members can help nurses resolve issues and improve their accountability in difficult situations. Penoperative nurses have choices. The choice to provide the safest care at organizational,professional, and personal levels is supported by numerous resources. Although patient care will never be black and white, it is our choice to eliminate gray areas in an effort to do no harm. BRENDA S. GREGORY DAWES RN, MSN, CNOR
EDITOR
American Nurses Association, June/July 2001). 2. ML Raines, “Ethical decision making in nurses. Relationships among moral reasoning, coping style, and ethics stress,” JONA 5 Healthcare Law, Efhicsand Regulation 2 (March 2001) 29-41.
458 AORN JOURNAL
Establishing ethical practices and eliminating the ”gray“
w
hen early pioneers formed communities based on groups of people living in one place, the different cultures of the groups implied how members would get along with others and survive. Spiritual beliefs supported unwritten codes of ethical behavior, which were accepted and adapted as part of communities’ cultures. Challenges in recent history, however, have caused community boundaries to expand, which requires accepting and adapting behaviors to meet the needs of a larger community, Issues such as patients’ rights, stem cell research, and expanding commerce continue to tax our ability to mandate, expect, or, in some circumstances, even distinguish ethical and unethical conduct. Perioperative nurses have a low tolerance for “gray” areas of practice, and when ethical boundaries are in question, the lines of separation may become unclear. Ambiguity is uncomfortable, and it can make us question right from wrong or good from bad. When parameters are identified, expectations of behavior and practice are known and understood. Walking the thin line between doing no harm and managing difficult situations test our ethical standards and create situations in which there often are no black and white answers. More frequently, ethical boundaries are scrutinized and analyzed in all areas of health care, particularly with the increasing
attention to medical errors. THE PERIOPERATIM COMMUNITY In the perioperative community, nurses, surgical technologists, physicians, and other staff members learn codes of behavior. Rules or standards that govern the conduct of members of the perioperative community are appreciated because they distinguish ethical practices and serve as guidelines for ethical behavior and decision making. When conduct exceeds established boundaries, our intuition is to seek an established norm with the intent of protecting the patient. When others choose not to practice within the boundaries, dissension and even errors can result. In the perioperative community, people’s beliefs and values may differ. At times, people might not even realize these differences. At other times, they may work so hard to overcome the differences that their ethical behaviors interfere with achieving expected outcomes. Consider the ongoing analyses that occur in perioperative lounges throughout the country. Situations described and questions about the behaviors of and choices made by others often evolve from perceptions and interpretations of behaviors that cannot be corrected by a rule or standard. Ethical behaviors take on different meanings because of the setting or the uniqueness of people and their inability to separate themselves from their culture, 456 AORN JOURNAL
religion, philosophy, morality, values, and beliefs. The following examples raise concern BRENDA S. regarding ethiGREGORY DAWES cal behavior. A new learner who values his or her position in perioperative services and believes in the information he or she was taught in class observes a preceptor breaking technique. A circulating nurse observes a surgeon incorrectly using equipment that could result in misdiagnosis of the patient’s condition. A scrub person who also is a friend of the surgeon begins assisting during procedures by performing tasks outside his or her scope of practice. A nurse observes a surgeon display what he or she considers inappropriate behavior with a patient’s family member. Ideally, we should respond to these situations based on evidence, research, or logic, and we should fulfill our responsibility as patient advocates. The reality, however, is that personal characteristics can result in compromise that may or may not seem appropriate at the time. The question is whether compromise is worth erosion of trust, adverse outcomes, or other negative consequences.
OCTOBER 200 1, VOL 74, NO 4
Physical proximity, relationship dynamics, and the responsibility of caring for patients often adds to the complexity of making ethical decisions. As heightened awareness about health care errors opens doors for discussion and problem solving, the entire perioperative team should be involved and responsible. Immediate responses to health care errors that are oriented toward patient care provide stimulus for positive results. Preventive measures that eliminate dilemmas and unethical decision making require that people come together as a team and put aside egos that interfere with ethical actions.
address patient care and safety concerns.’ These documents support ethical decision making in perioperative practice and can eliminate confbsion and dissension among professionals. According to the Comprehensive Accreditation Manual for Hospitals, patients must be informed about outcomes of care, including unanticipated outcomes or whether they are harmed by care provided. These standards are intended to encourage health care administrators to create a culture of safety in which errors are discussed and studied openly. The Code of Ethics f o r Nurses is a statement of ethical obligations and duties of each person who enters the nursing RESOURCES A VAlLABLE Newly released documents are profession, and it expresses nursing’s commitment to society. available to guide practices that Goals, values, and obligations fall in g a y areas. The Joint are identified to provide an ideal Commission on Accreditation of and norm of the profession. This Healthcare Organizations’ document includes statements Comprehensive Accreditation that provide a framework for Manualfor Hospitals and the nurses to use in ethical analysis American Nurses Association’s and decision making. Code of Ethics for Nurses NOTES 1. ComprehensiveAccreditation Manual for Hospitals: i’le Ojicial Handbook-Update I Februaiy 2001 (Oakbrook Terrace, 111: Joint Commission on Accreditation of Healthcare Organization 2000); Draft 10a Code of Ethicsfor Nurses (Washington, DC:
MAKING THE BEST DECISION Values, beliefs, and human responses can interfere with making the best decision. Situations in perioperative settings can result in nurses becoming middle men. We need to identify personal behaviors that interfere with ethical decision making. As nurses exit the profession because of ethically related distress, ramifications for individual nurses and the profession require attention.2Supportive environments, commitment to discussing ethical dilemmas, and open communicationamong all team members can help nurses resolve issues and improve their accountability in difficult situations. Penoperative nurses have choices. The choice to provide the safest care at organizational,professional, and personal levels is supported by numerous resources. Although patient care will never be black and white, it is our choice to eliminate gray areas in an effort to do no harm. BRENDA S. GREGORY DAWES RN, MSN, CNOR
EDITOR
American Nurses Association, June/July 2001). 2. ML Raines, “Ethical decision making in nurses. Relationships among moral reasoning, coping style, and ethics stress,” JONA 5 Healthcare Law, Efhicsand Regulation 2 (March 2001) 29-41.
458 AORN JOURNAL