Ethics: Creating a Culture of Ethical Watchfulness

Anita’s husband was recently hospitalized for an acute intestinal obstruction that needed to be corrected through surgery. Around the same time, her friend Pat took her 87-year old father to the emergency room of another hospital, as he had suddenly become ill with low blood pressure, dizziness, and confusion. In each of these situations Anita and Pat, both of whom were nurses, were impressed with the knowledge, expertise, caring, and advocacy of some of the nurses they encountered during their family members’ extensive hospital stay. One nurse appropriately interpreted signs of internal bleeding when three physicians failed to recognize the pattern of symptoms. Another nurse ignored protocol and called the attending physician for an urgent problem when first- and second-year residents did not answer her calls. Another nurse initiated a dialogue with the physician to implement recommended measures to prevent central line-associated bloodstream infection (CLABSI).

The situations above illustrate the power that individual nurses have to keep their patients safe. Recommendations for nurses to play an increasingly important role in health care were laid out in the 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, which was the culmination of two years of work by the Robert Wood Johnson Foundation Committee on the Initiative on the Future of Nursing. Four key recommendations:

1. Nurses should practice to the fullest extent of their education and training;
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;
3. Nurses should be full partners with physicians and other health care professionals in redesigning health in the United States; and
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure (Institute of Medicine, 2010, p. 4).

In less than two years since the publication of the IOM report, nursing administrators, educators, researchers, and clinicians have discussed ways to implement the report’s recommendations for nurses to take an instrumental role in improving United States (U.S.) healthcare. Much of the discussion has focused on the need for higher levels of education and training, interdisciplinary practice, and improved data collection and information infrastructure. There has been less emphasis on the recommendation that nurses should use their present education and training to practice to the full extent of their license. The IOM report identified many barriers to meeting this goal. However, in order to ensure ethical practice, it is critical to focus not on what nurses cannot do, but what they can do.

Stevenson (2010) stated that it is timely to envision the notion of watchfulness and the teaching stances of monitoring, role modeling, and mentoring as a springboard for rethinking expertise and articulating nurses’ scope of practice. She noted the difficulties of nurses being called upon to practice to the full extent of their license in today’s complex health care environments, which include institutional and health care policy changes, high patient acuity, and sophisticated advances in technology, while continuing to demonstrate a focused and intuitive watchfulness. The stresses on front-line nurses in the acute care setting are incredible. Yet should not every patient expect to be cared for in a culture of safety, no matter what the barriers? Certainly ethical practice demands this.

Benner, Hooper-Kyriakidis, and Stannard (2011) have referred to the “fragility of practice,” as well as the “trustworthy watchfulness” that is needed for safe and effective patient care (p. 406). How can nurses ensure practices of watchfulness amidst today’s fragile practice? Intelligent and assertive actions of nurses were noted in the scenarios at the beginning of this column, but there is more to the story. During the hospitalizations of their family members, both Anita and Pat encountered situations where nurses exhibited a startling lack of competence and initiative. One nurse seemed mystified when an external catheter would not stay on the patient. She did not know how to apply an external catheter; however, she did not ask for assistance, and in fact was angry when Pat offered to help. As a result the patient was incontinent in his bed. When Anita noticed that the tape was loose on her husband’s nasogastric tube and asked to have it re-taped, the nurse said that she wasn’t allowed to do this. The tube fell out the next day and needed to be reinserted. Another nurse took the patient’s blood pressure and recorded it as 200/110. When Anita, shocked at the high blood pressure, asked when it would be checked again, the nurse said it was not due to be checked again for another four hours. Because Anita objected to the long lapse before rechecking, the nurse agreed to recheck the blood pressure in an hour.

These incidents are only a few of the frustrating and frightening problems that Anita and Pat encountered during their family members’ hospitalizations. As a result, they felt that they needed to be the “trustworthy watchers” for their loved ones. Across the country, along with stories of incredible caring and competence of nurses, we hear stories of lack of caring and competence. As reflected in the IOM (2010) report, it is important to look at the barriers to the expansion of our nursing practice; yet ethically, it is also critical to find ways in our fragile practice to do what we are already empowered to do. In the situations just described, it is not merely the application of the catheter, the taping of the tube, or the taking of the blood pressure that were the problems, but also the lack of clinical reasoning that the nurses needed to make sense of their practice.

As noted above, Stephenson (2010) suggested that watchfulness in front-line nurses is characterized by teaching stances of monitoring, role modeling, and mentoring. Although her research focused on the concept of watchfulness as it impacted the nurse/student relationship, these concepts seem equally applicable to the nurse/patient relationship. Following are four key findings from Stevenson’s study:

1. Nurses are bombarded with organizational changes at unit and system levels that negatively impact their abilities to provide their desired quality of patient care;
2. A unit culture strongly influences how nurses are able to sustain themselves in practice and remain passionate about nursing as a profession;
3. Inter-professional collegiality and collaboration saves time while optimizing shared clinical decision making, and fosters respect and comfort for the contributions of all team members; and
4. Nurses are caught in the middle of many competing demands as they balance numerous responsibilities amidst significant inconsistencies between practice and academia (Stevenson, 2010, p. 255-256)

These findings provide guidance in integrating watchfulness into practice.

The teaching stances of monitoring, role modeling, and mentoring are fluid; they extend along a continuum of nursing expertise and engagement to provide safe and ethical patient care (Stephenson, 2010). Front-line nurses need to watchfully monitor patient changes, but also benefit from the expertise and engagement of their colleagues. They need to role model ethical, safe, and effective care for both new and experienced nurse colleagues. Finally, they need to mentor new nurses who may be struggling to bridge the gap between academia and clinical practice.

The 2010 IOM report has focused the spotlight on the nursing profession and its potential for playing an important role in improving U.S. healthcare. It also points out system problems that lead nurses to spend less time caring for patients and more time documenting, interacting with technology, or dealing with poorly designed systems. Unlike the last major, broad-based study of nursing published by the IOM in 1983, the 2010 recommendations are not as dependent on federal aid and external support (Fairman & Okoye, 2011). Fortunately, we already have many examples of programs where nurses make an important difference through monitoring, role modeling, and mentoring practices. Skin care programs, pain management initiatives, and diabetes management mentor programs are a few examples of how nurses can push through barriers that threaten the ethical practice of caring and competence (AHRQ, 2009; Bernhofer, 2011; Modic & Sorrell, 2012). In the current health care environment, nursing is well positioned to use the Institute of Medicine report as a blueprint for creating a culture of ethical watchfulness.

Author

Jeanne Merkle Sorrell, PhD, RN, FAAN
Email: jsorrell@gmu.edu

Dr. Sorrell is Senior Nurse Researcher in the Department of Nursing Research and Innovation at the Cleveland Clinic, Cleveland, OH, and Professor Emerita, George Mason University, Fairfax, VA. She earned a BSN from the University of Michigan, a MSN from the University of Wisconsin, and a PhD from George Mason University. Her scholarly interests focus on philosophical inquiry, writing across the curriculum, qualitative research, and ethical considerations for patients with chronic illness.