Keywords: ethics, infectious, infectious diseases
Rear Admiral Couig (2006), in the Overview and Summary for the Issue in OJIN titled Infectious Diseases: Challenges and Solutions, highlights the ethical obligation nurses have to keep current about infections and their prevention and treatment. She suggests that reading the latest issue of OJIN is one way to help meet our ethical obligations to stay informed. In continuing that theme of ethical obligations, we ask you to consider further the ways in everyday practice where ethical thought and action are required in relation to infectious diseases. Not every break in infection control leads to a major outbreak of disease, a loss of life or limb, an illness for a nurse, or an increased hospital stay, but enough do to cause actual or potential harm to patients, ourselves, the places we work and society. Thus, in this column we will examine the relationship between the trust given to nurses by the public and common themes related to infection control in order to ‘encourage ethical thoughtfulness’ and proactive ethical action.
In several countries, nursing has been repeatedly found to be one of the most trusted professions (Harris Poll, 2006; RCN, 2002) and trust is the key to infection control. The public trusts us with the following duties: 1) to not work when sick, 2) to protect ourselves and patients from disease, 3) to monitor and speak about infections and practice, and 4) to provide care even if it means self-risk from infection. As nurses we have an ethical obligation to meet that trust and the subsequent duties to the public whether we are providing direct care or teaching or overseeing nursing practice.
It seems "easy" to think only of the preceding four duties as lying with nurses in direct care. If it were, however, the duties would still be hard to meet given work shortages, variations in resources among countries and settings, work policies, variations in practice, penalties for whistle-blowing and the cost (financial and emotional) that some of these practices entail. These challenges to ethical practice are where the crux of our ethical dilemmas often lies. We may feel distress in meeting our duties because of competing issues. In this column we will address each of the four duties and offer an example of a challenge from one area of nursing practice. We ask you to reflect ethically on each duty and ask what would you do.
Not Working When Sick
Who has not gone to work feeling under the weather or become ill at work and stuck it out as there was no one to cover patient care, teach a class or attend a required meeting? There lies the challenges; most will admit to working while sick because of obligations, fear of retribution or simply because we would not get paid if we did not go to work. Let’s look at an example from education. As a faculty member, you wake up ill and debate what to do. If you do not go to clinical, there is no coverage for you, and 10 undergraduate students will miss a full day of clinical. What are the ethical issues and what would you do? Can you morally justify your decision? How does the educator’s decision impact you as the staff nurse or as the administrator of the health care facility or the nursing program?
Protecting Patients and Self from Disease
Hand washing is a basic principle that we know is the first and often most important single factor in preventing infection. Let’s look at hand washing from an administrative position. You are the nursing administrator for patient care services at a health care facility and the RN vacancy rate is 20%. Much of your energies are used in dealing with this problem. You have just read the Guideline for Hand Hygiene in Health-Care Settings (Boyce & Pittet, 2002) in the Morbidity and Mortality Weekly Report, and recognize that you do not have a process in place for monitoring "performance indicators" related to hand washing as recommended by the CDC. You know that understaffing is an important factor in disease outbreaks (Stone, Clarke, Cimiotti, Correa-de-Araujo, 2004). What are the ethical issues and what would you do? Can you morally justify your decision? How does the administrator’s decision impact you as the staff nurse or as the educator?
Monitoring and Speaking About Practices
Nurses have a long history of being advocates for patients. From writing books or letters about infection control (as first exemplified by Florence Nightingale) to discreetly correcting someone in an OR about an observed break in sterile technique, advocacy has taken many forms. Let’s examine speaking out from a clinician’s perspective. You work part-time in a 150 bed nursing home. A memo is circulated about a new policy that will be implemented that states each year all residents and their families must be given information about the flu vaccination and that the vaccination must be offered as conditions of participation in Medicare and Medicaid (Federal Registrar, 2005). But it does not make sense to you that the employees do not get free flu vaccinations. You show the Director of Nursing (DON) a report titled Influenza Vaccination of Health-Care Personnel (Pearson, Bridges, & Harper, 2006) that recommends providing the flu vaccine at no cost and at work to employees. The DON is new and refuses to mention the report to the administrator. What are the ethical issues and what would you do? Can you morally justify your decision? How does the nurse’s decision impact you as the administrator or as the educator who has students in the setting?
Providing Care and Self-risk
Who has not had anxiety or fear that caring for patients puts you and/or your family at risk for disease? The most recent and most public example is exposure to severe acute respiratory syndrome (SARS) and its impact on healthcare workers (Murphy, 2006; Stone, Clarke, Cimiotti, & Correa-de-Araujo, 2004). However, in day-to-day care there are many potential episodes to exposure that are ignored or taken for granted. Let’s examine a situation in a hospital. You are serving as a preceptor for a senior student nurse. The student asks to take care of a patient with an infectious disease, but the cause of the disease is not known and there is worry that it is SARS. There is no hospital policy on this matter. You are worried about his or her safety in providing care and express that to the student. The student says, "How will I know how to take care of patients like this when I am done with my education if I do not have the chance to do so while in school?" What are the ethical issues and what would you do? Can you morally justify your decision? How does the preceptor’s decision impact you as the administrator or as the educator?
Increasingly attention has focused on infectious disease and its implications for the safety of the public and the safety of workers. We believe that as attention is focused on the dangers and issues that relate to infection control that we each should examine the everyday ethical implications of providing care for patients and communities in relation to preventing and treating infections. Thus we have framed the discussion of ethical issues in terms of duties that arise from the public’s trust of nurses. Some brief examples of situations have been posed and subsequent to each situation we ask, "What are the ethical issues and what would you do?" based on your ethical values and your view as a clinician, educator or administrator. We invite you to begin personal reflection and open dialogue with colleagues in order to be proactive and protect the trust given to us by the public on everyday ethical issues related to infection control.
Ruth Ludwick, PhD, RN.C, CNS
Mary Cipriano Silva, PhD, RN, FAAN
Article published November 6, 2006