AACN News—February 2005—Opinions

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Vol. 22, No. 2, JANUARY 2005


By Kathy McCauley, RN, PhD, BC, FAAN, FAHA
President, AACN

You must never be fearful about what you are doing when it is right.
—Rosa Parks

What a fulfilling year I am having as AACN president, and how much I’m learning! Especially about the tension between “doing things right” and “doing the right thing.”
Traveling around the country, I am inspired by stories of passionate nurses seeking to live their contribution. I admire these nurses for their relentless resilience and drive to do things right. Many succeed in meeting, even exceeding, patients’ and families’ expectations. Others are stymied by the unabated onslaught of obstacles and challenges.

But what about doing the right thing? That is where the indispensability of nurses shines. And where nurses often collide with brick walls. We all know the feeling—tight gut, racing pulse, shortness of breath, powerlessness, confusion, anger, frustration, sadness.

Our Ethic of Care
Ethics: A set of principles of right conduct. Doing the right thing.

AACN’s mission, vision and values are rooted in an ethic of care that acknowledges how individuals, systems and society are inseparable. Compassion, collaboration, accountability and trust are essential to our ethic. It obligates respect for each person’s uniqueness and worth, promoting good while preventing or removing harm, and faithfulness to the demands of our relationship with others by advocating on their behalf when necessary.

Nurses usually excel at ethically driven clinical practice. No wonder the public repeatedly identifies us as the profession most trusted to act honestly and ethically. When patients’ or families’ rights are threatened, we speak up. When they do not receive care based on the best available evidence, we contribute knowledge. These are obvious ethical violations that generally have a clear, if sometimes difficult, course of action.

Ethical Violations We Overlook
What about the ethical violations we seem to overlook? These usually involve flawed systems and the environments where we do our work. Unspoken and unresolved, they demoralize us, kill our spirit and even make us want to leave nursing. Here are some all-too-familiar examples:

• A nurse chooses to not call a physician known to be verbally abusive. Instead, she uses her best judgment and administers a fatal dose of the wrong drug.
• A department makes decisions in isolation, leading to tension, frustration and a higher risk of errors by everyone its work affects.
• A nurse is placed in a leadership position without adequate preparation and support for his role.
• Contentious relationships heighten between nurses and administrators when managers are required to stretch their responsibilities without preparation and coaching.

Ideally, our work environment should support us to do the right thing. Systems should not be insurmountable barriers. They should open the way.

Surprisingly, the violations we overlook have equally clear—and sometimes difficult—courses of action. The courses are clear because, as David Thomas at Omaha’s Ethics of Choice Training Program asserts, “It is unethical to accept—without working to correct—organizational practices that harm the ability of the organization to accomplish its purpose.”

Whether to address these damaging practices is not in question. It is our obligation. The question is how to best do so in each situation. As one individual wisely observed, there are no wrong ways to do the right thing.

How to Do the Right Thing
When nurses at the bedside don’t address these situations or participate in setting up systems, faulty and sometimes dangerous systems will be adopted. Where can we turn for help? We can invite true collaboration from managers and expert colleagues who recognize their shared obligation—quality improvement specialists, advanced practice nurses, administrators, physicians, pharmacists. In other words, anyone who is part of what’s broken. There are excellent tools that can also support and guide us.

“Nurses have an ethical obligation to preserve their professional integrity while ensuring a patient’s safety and best interest .… Nurses are frequently put in situations of conflict arising from competing loyalties in the workplace .… Nurses strive to resolve such conflicts in ways that ensure patient safety, guard the patient’s best interests and preserve the professional integrity of the nurse.” You’ll find these and other forceful statements in the Code of Ethics for Nurses, developed by the American Nurses Association and adopted by AACN as the nonnegotiable ethical standard for the profession. (Copies are available at www.nursingworld.org.)
4 A’s to Rise Above Moral Distress is AACN’s guide to analyze just these kinds of problems. It is available at www.aacn.org. Processes like failure mode effects analysis and human factors analysis can help us find root causes where safety is at risk. Innovative approaches like Clarian Health Partners’ Safe Passage Program can develop unit-based patient safety experts to help fix it.

Why not request a consultation from our hospital’s expert Ethics Committee? Environmental issues that inhibit professional care and harm patients and families are ethically incorrect, requiring the same scrutiny as a decision to discontinue life support.

A Bold New Tool
Our newest tool is a bold and forceful document destined to have national impact. Faced with overwhelming evidence that unhealthy work environments jeopardize patient safety and block nurses’ best efforts to do the right thing, the association has released the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. The standards are available at www.aacn.org/hwe.

The standards uniquely identify systemic behaviors that are often discounted, despite growing evidence that they contribute to creating unsafe conditions and obstruct the ability of individuals and organizations to achieve excellence. Six essential standards for establishing and sustaining healthy work environments point the way. The standards and accompanying critical elements address skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition and authentic leadership.

AACN is especially grateful and proud of past President Connie Barden, who led an authoritative standards development and review team of more than 50 national experts in nursing and organizational development. The team’s generosity of intellect, experience and critical review has produced a landmark document to guide healthcare.

The new standards complement the widely used AACN practice standards. Implement them in tandem as a living, breathing force that supports ethical, effective and rewarding nursing practice.

Forging Our New Reputation
A recent Time magazine article described a national figure’s “dedication to an inner code of ethics—and his demand for others to follow it.” “I don’t know what the standard is he’s upholding, but when someone is acting outside of it, he will do whatever he feels is necessary to bring them into line,” says a colleague.

Imagine if every nurse enjoyed this reputation for principled passion. We already know the standards to uphold. Now it’s our time to live our contribution and do the right thing. Then write and tell me what you’re doing and how. (kathy.mccauley@aacn.org)

Our lives begin to end the day we become silent about things that matter.
—Martin Luther King Jr.
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