Archive for the ‘ethical issues’ Category


The Blame Game

April 7, 2014

By Jacob Molyneux, senior editor

TheBlameGameIllustrationThe Reflections essay in the April issue of AJN is called “The Blame Game.” It’s by a nurse who finds herself visiting a family member in the hospital during her shift break at the same hospital. In her distress, she gets little relief or reassurance from the harshly judgmental nurse she encounters.

The vividly told episode raises the question: can the act of casting judgment on another person diminish our ability to see these people as complete human beings, whatever their failings? And also this question: what is the proper attitude of nurses toward their patients?

Please give it a read and see what you think. Is this nurse’s attitude an exception, or more common than it should be, as the author suggests? Here’s a brief quote from near the end:

There seems to be a dangerous epidemic of clinicians blaming patients for their health issues. As a nursing student, I saw more and more of this attitude. The health care profession seems to have evolved a culture of accusation and attack against patients, a group we should be empowering and protecting.

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The Not Good Nurse – Some Dark Holiday Reading

January 2, 2014

By Shawn Kennedy, AJN editor-in-chief

GoodNurseHaving some down time over the holidays can be a good chance to catch up on some reading. Because so much of my work entails reading manuscripts submitted to AJN about nursing practice and research, I look for my leisure reading to be something not connected to nursing.

Well, the book I recently read—a quick, engaging read—was about nursing, sort of. The book was Charles Graeber’s The Good Nurse: A True Story of Medicine, Madness and Murder, the story of nurse-turned-serial-killer Charles Cullen. While I find the title to be a bit sensationalist, the book is not. There’s no real answer as to why Cullen did what he did—Cullen apparently had a miserable childhood, was often a target of bullies, had failed marriages and made many suicide attempts to gain sympathy or attention. Graeber doesn’t really seek to answer the why of what Cullen did but instead focuses on his behavior and relationships.

The chilling aspect of the story is how easy it was for Cullen to get away with his killing through the use of essential technology relied on by nurses for the care of hospital patients. The medication and computer systems that he manipulated to cover his tracks also eventually allowed an intrepid nurse colleague to help police prove their case—only a nurse knowledgeable about the day-to-day use of the systems could uncover the wayward patterns.

But the real issue that comes through is how hospitals, fearing litigation, would simply dismiss Cullen when other nurses voiced concerns about his practice, allowing him to find work elsewhere and become someone else’s problem. That’s something I think many nurses might relate to—I certainly can. I worked with a couple of nurses early in my career who, when we reported to the administration that there were consistent errors in the narcotic count or missing medications when they were working, were given a chance to resign or be fired. Neither was ever reported to the board of nursing. Read the rest of this entry ?


Top 15 American Journal of Nursing Blog Posts in 2013

December 20, 2013
Blogging - What Jolly Fun/Mike Licht,, via Flickr Creative Commons

Blogging – What Jolly Fun/Mike Licht,, via Flickr Creative Commons

In keeping with journalistic custom, here’s an end-of-year list of the most popular 15 blog posts on Off the Charts in 2013. Some were new posts this year. Some were from previous years but are still as relevant as ever. We’d like to think not everything that appears on this blog is ephemeral. Thank you to all our excellent writers and thoughtful readers. Cheers!—Jacob Molyneux, senior editor/blog editor

 1. “The Heart of a Nurse”
“As nurses, we are drawn to the field for many different reasons. What is exciting and fulfilling to some is stressful and boring to others. Our ability to show compassion is perhaps our best nursing skill, better than our proficiency with machines, computers, and even procedures. It may not be what we do so much as how we do it.”

2. “A Report from the ANA Safe Staffing Conference”
“Nurses continue to beg to be taken out of the ‘room and board’ costs and to be seen as an asset. But instead, they are often seen as a major expense that can be reduced for the sake of the bottom line. If this impasse is to be brokered, it will demand new thinking and new communication.”

3. “Should We Get Rid of 12-Hour Nursing Shifts, Despite Their Popularity?”
“So the question remains: should nurses’ convenience trump patient safety and satisfaction, and our own health?”

4. “Scrubs on the Street: Big Concern?”
“She wants people to photograph the ‘offenders’ and send the photos to hospital administrators.”

5. “Issues Raised by Media Coverage of a Nurse Declining to Do CPR”
A wide-ranging post by nurse-ethicist Doug Olsen dealing with institutional policy and advance directives, journalistic ethics, the public’s ignorance about CPR, and the roles of nurses.

6. “E-Cigarettes: Positive Smoking Substitute or a New Problem Replacing the Old”
“Only time will tell if e-cigarettes are safer than cigarettes and a viable option as an aid to quit smoking.”

7. “‘Go Home, Stay, Good Nurse’: Hospital Staffing Practices Suck the Life Out of Nurses”
“This practice isn’t new; we covered it in “The Other Side of Mandatory Overtime” in our April 2008 issue. Still, when I speak with nurses who work under this system, the injustice strikes me anew. Yet nurses seem to think this is the norm. Why is this an acceptable practice?”

8. “Well On His Way: A Nursing Professor’s Humbling Experience”
“He’d been able to see the patient holistically, while I’d focused on ensuring the student could perform tasks.”

9. “Ten Lessons Learned from Florence Nightingale’s Life”
“My husband has called this trip a ‘game changer’ for me, and indeed it has been. I see things differently now, including our health care system and the critical contributions that nurses are making, and need to continue making, to improve care for patients.”

10. “Fecal Impaction and Dementia: Knowing What to Look for Could Save Lives”
“I’ll always be grateful to the nurse who correctly diagnosed my grandmother’s problem before it was too late.” Read the rest of this entry ?


When There’s a Disconnect Between Good Nursing Practice and Reality

December 6, 2013

Recently I spoke with other nurses about our personal experiences with hospitalization and those of family members, and the conversation turned to disappointment with nursing practice and nursing care. In fact, whenever I’ve asked, every colleague has disclosed a similar experience. Some say that they’d never leave a family member alone in a hospital.

We need to acknowledge that there is a disconnect between what we know to be good practice and what is often the reality—even in facilities with Magnet accreditation. There are far too many instances in which nursing practice is substandard.

shawnkennedyThis is a heads-up about Shawn Kennedy’s editorial in this month’s issue of AJN, excerpted above. You should read it. The article, “Straight Talk About Nursing,” is free. There are no easy answers to the issues it raises. That’s all the more reason to discuss them openly.

In AJN, we often focus on examples of best practices and insightful, compassionate, engaged care. And we get that there are many institutional obstacles that undermine nurses in their attempts to provide quality care to patients. But even so, we’d be remiss to pretend we don’t hear about, and sometimes personally experience, care that simply falls short. This is scary, at least to me. Patients depend on nurses in so many ways. So have a look at the article and let us know your thoughts, as a nurse or as a patient.—Jacob Molyneux, senior editor

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Are You Glad Ariel Castro Is Dead?

September 18, 2013

Lorry Schoenly is a correctional nurse blogging at CorrectionalNurse.Net. This guest post is a modification of a recent post on her site. Follow her on Facebook or Twitter.

Ariel Castro's home in Cleveland, OH/Wikimedia Commons

Ariel Castro’s home in Cleveland, OH/Wikimedia Commons

What were your first thoughts when you heard the news of convicted Ohio kidnapper and rapist Ariel Castro’s successful suicide while in protective custody in a state prison reception facility? Based on my Twitter and Facebook timelines, there have been a variety of responses in the public, nursing, and correctional health care communities. Many are glad that society is saved from the cost of caring for such a heinous criminal. Some are critical of the mental health and security oversights that led to this opportunity for self-injury. After all, Castro’s suicide potential score must have been off the chart. Fellow blogger and forensic psychiatrist Annette Hanson (@clinkshrink) provides a thoughtful post with her take on the subject: “Your Patient Died. Who Cares?”

This major news item is a reminder of the personal and professional conflict frequently experienced by those of us who care for criminals, many of whom are pretty unlovely, even monstrous, people. The very definition of professional nursing, however, requires us to consider their well-being and seek their best by preventing illness and injury while alleviating suffering. Are people like Ariel Castro unworthy of our efforts? Many think so. The issue gets to the root of an ethical dilemma in our specialty and can provide insight into the very heart of nursing practice. Read the rest of this entry ?


Chemical Attack Response, Posts for Nursing Students, Ethical Agonies, Blog Carnivals, More

September 6, 2013

By Jacob Molyneux, AJN senior editor

You’re working in the ED of a 300-bed metropolitan hospital one Sunday morning when you receive a radio transmission from a paramedic whose ambulance is en route with a casualty of a suspected nerve gas attack. The paramedic reports that two additional ambulances are also on the way. Nerve gas? You’re stunned. What should you do first?

quinn.anya/via flickr creative common

quinn.anya/via flickr creative commons

That’s the start of our 2002 article (free for a month, until October 5) about chemical attacks and their aftermath. Such an event is not an impossibility here in the U.S. Remember the 1995 attacks in Japan, in which sarin gas was released at several points on the Tokyo subways by members of a radical cult, killing 12 and injuring thousands? And there is now convincing evidence (not to mention horrific photos of the many children killed) that the Syrian government used nerve gas on its own people last week despite widespread prohibitions against its use. In fact, USA Today reported that a number of the nurses and physicians who treated the victims of the gas attack may have subsequently died themselves from exposure to the patients’ clothing and skin.

Our 2002 article describes how nerve gas works on the body, the main types of poison gas that are known to exist, the history of chemical warfare, hospital preparedness, the drugs that are used to counteract the effects of poison gas, how to undertake patient decontamination, and other essential facts providers should be aware of.

Blogging - What Jolly Fun/Mike Licht,, via Flickr Creative Commons

Blogging – What Jolly Fun/Mike Licht,, via Flickr Creative Commons

Since many nursing students recently returned to school for the fall or started their first year, this seems a good time to trot out some greatest hits from our posts by or about nursing students or some aspect of nursing school:

“On Euphemism and Learning to Be Present”

“Notes of a Student Nurse: A Dose of Reality”

“That Acute Attention to Detail Bordering on Wariness”

“Well On His Way: A Nursing Professor’s Humbling Experience”

“‘My Professor Said to Submit My Paper’ (We Hope They Also Told You This)”

“Don’t Cling to Tradition: A Nursing Student’s Call for Realism, Respect”

“One Instructor’s Updated Nightingale Pledge”


“The Priceless Clarity of Inexperience”

Tell us: what can we do to better address the needs of nursing students? What do you want to hear about from veteran nurses?

Remember the aftermath of Hurricane Katrina? There’s an enthusiastic and nuanced review in the New York Times of a new book by journalist Sheri Fink called Five Days at Memorial. It’s about Memorial Medical Center in New Orleans in the days following Hurricane Katrina, when nurses and physicians found themselves on their own in making agonizing decisions about the treatment of a number of critically ill patients. The situation and its legal aftermath, in which several providers were charged with murder, raises complex and important ethical questions with no easy answers. The facts of this awful episode remain both disturbing and riveting, and are certainly worth learning from. Read the rest of this entry ?


Who Will Watch the Watchers? Consider Nurses

July 17, 2013

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

Sometimes my surgical mask feels like a gag/by Julianna Paradisi

Sometimes my surgical mask feels like a gag/by Julianna Paradisi

Does anyone else find it ironic that, while the National Security Agency (NSA) is seeking to extradite and prosecute the contractor who revealed the agency’s alleged widespread spying on ordinary Americans and visitors from other countries, nurses can get fired for far more local breaches of privacy?

When the government gives 500,000 private contractors access to data hoards compiled from the electronic and phone conversations of U.S. citizens, is HIPAA still relevant?

Two years ago, the nurse blogosphere raged over the expulsion of three nursing students for posting the photo of a placenta on Facebook. Today, in light of the NSA’s potentially far-reaching privacy violations, the decidedly insensitive exploits of those students seem a bit less newsworthy.

More famously, the ordeal of Vickilyn Galle and Anne Mitchell, nurses who were fired after they blew the whistle on medical malpractice while exposing a conflict of interest affecting patient safety within the hospital, illustrates the high accountability placed upon nurses to protect patient privacy. Read the rest of this entry ?


When Loved Ones and Patients Don’t Choose Life

July 15, 2013

By Karen Roush, AJN clinical managing editor

Photo by the author

Photo by the author

This isn’t the blog post I started out to write. That was a more personal story about someone close to me, let’s call this person Jess, who died after years of chronic illness worsened by self-neglect—after years of being that person Olsen talks about in this month’s article (free until August 15) on helping patients who don’t help themselves (and in his related blog post from last week).

But as I wrote, I realized that it wasn’t fair, that I was leaving out the complex story behind their persistent unhealthy behaviors, behaviors that eventually led to a lingering, awful death.

And without that background knowledge, it was too easy to be judgmental—as it is sometimes too easy for us as nurses to be judgmental of patients who don’t help themselves, who even seem to be willfully destroying their own health: the obese person who keeps drinking those giant sodas, the smoker who lights up another cigarette. As a nurse it can be very frustrating to care for a patient who ignores health recommendations, to their own detriment. As a family member or friend, it can be heartbreaking and infuriating.

There are limits to what we can do. We cannot force patients to eat well, take necessary medications, quit smoking, modify their alcohol intake, wear their seatbelts . . . the list goes on and on. Yes, we can and should provide patients with the tools they need to choose healthy behaviors: knowledge, access to treatment, realistic options, high quality, evidence-based care. We need to be persistent in our efforts and objective, and we need to show concern for their well-being. We also need to keep the politics—cost to society, impact on health insurance costs—outside the clinic or hospital door and outside the therapeutic relationship between nurse and patient.

Sometimes when I think about Jess I feel angry, but mostly I just feel terribly sad. Happy people choose health; they choose life. Jess chose neither. Why someone would do that is perhaps the most difficult thing for us, nurses or loved ones, to understand.
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Obesity as Disease and the Health Care Culture’s Take on Personal Responsibility and Suffering

July 11, 2013

Doug OlsenBy Doug Olsen, PhD, RN, associate professor, Michigan State University College of Nursing, and AJN contributing editor. Olsen regularly addresses topics related to nursing ethics. His most recent article for AJN was “Helping Patients Who Don’t Help Themselves” (July issue; free until August 15).

Why does the American Medical Association’s recognition of obesity as a disease (AMA, 2013) stir strong feelings? People are just as heavy as before, their health is suffering as much, and the therapies for obesity remain the same. The main difference is that the label may give clinicians a better rationale to seek reimbursement for obesity-related services, which might help increase treatment rates. No one yet knows if the new label will really have an effect on treatment rates; in any case, this is not what people are concerned about.

The issue is what labeling a health problem with a behavioral component as a “disease” implies about personal responsibility—or what people think it means. How does personal responsibility relate to individual suffering?

The relationship between decision making, suffering, and personal responsibility is at the heart of bioethics as it is practiced in the United States. But bioethics didn’t invent our cultural tendency to connect personal responsibility and sympathetic regard for suffering, and our current approach to the issue was developed through 28 centuries of increasing focus on the individual as the center of the moral universe in Western thought.

In the West, we are heavily invested in considering humans as autonomous—beings that act deliberately and are internally self-directed. In bioethics, the principle that clinicians should respect patient autonomy, patients’ deliberate, self-directed decisions, has preeminence over all other principles. Many critique this preeminence as a shortcoming, some deny its truth, and some defend it as right and proper. Patient autonomy can be ethically denied, but only with substantial justification.

But patient autonomy has another implication that’s less often discussed—people are considered responsible for the consequences of autonomously made decisions. Autonomy over health decisions and the concomitant responsibility for health decisions has emotional consequence that take a toll on clinical relationships (Olsen, 1997).

People tend to feel diminished sympathetic regard for the suffering of persons they hold responsible for that suffering—possibly because of the sense that the suffering is deserved. Suppose you tell a friend that John really hurts over his divorce from Mary, and your friend replies, “He treated her poorly and brought it on himself.” Is there any doubt about the friend’s lack of sympathetic regard for John’s suffering, although feelings were never mentioned, only a formulation about responsibility.

For nurses, the tendency to tie sympathetic regard for patient suffering to their personal behavior and choices has two potentially negatives effects on the clinical relationship. On one hand, nurses who blame patients for their pathology may have less caring concern for the patient.(Olsen, 1997) When patients sense this, they can feel marginalized and judged. Read the rest of this entry ?


Fictional Nurses, Intractable Conditions, Nonspecific Symptoms, Frustrating Patients, More

June 27, 2013
COPD smoker

Dept. of Bad Ideas..

By Jacob Molyneux, senior editor

Keeping up with the Web-sters. If you happen to use a Web reader of any sort to collect updates (feeds) from all your favorite nursing blogs and health care news sources in one place—we ran an article on using RSS feeds a while back, “RSS for the Uninitiated,” which will be free for the next month—you may know that Google Reader, long a convenient choice, will soon no longer exist. Here are 10 alternative readers you might want consider as replacements (and if you don’t use a reader already, you might want to try it).

A new kind of nursing blog. Nurse, artist, blogger Julianna Paradisi, who writes a monthly post for this blog, has just launched a new blog that will be narrated by a fictional nurse called Niki. This sounds like a really great idea that could go in a lot of potential directions.

Lyme disease continues to grow as a health threat in leafy environments further and further afield. It’s insidious, can attack the body in multiple ways, and there’s a huge amount of controversy about whether conventional short-term antibiotic treatments actually wipe it out or not. Many argue that it can be chronic, and that it’s often missed by the tests most often used to detect its presence. This article in the New Yorker gives a really good overview of the state of the research and the central questions being debated by patient advocates and researchers. Be warned: it may leave you feeling a bit disheartened about the limits of medical certainty.

DOMA and Obamacare. The Supreme Court’s ruling yesterday that the Defense of Marriage Act (DOMA) is unconstitutional is likely to have repercussions in the always tricky world of health care coverage. Here’s a brief overview of issues of relevance to those who may be obtaining insurance through Obamacare in the near future.

When patients harm themselves. From the June issue of AJN, here’s an ethics article that you might have missed: in “Helping Patients Who Don’t Help Themselves” (free until July 27), nurse ethicist Doug Olsen considers the ethical obligations and challenges nurses face in treating patients who continue self-destructive practices such as smoking with COPD, gobbling junk food when suffering from the consequences of out-of-control type 2 diabetes, and so on. Writes Olsen:

Caring for patients who continue to behave in harmful ways can be personally frustrating and professionally unsatisfying. Nurses have reported feeling powerless and losing empathy when they’re unable to stop patients from continuing an unhealthful lifestyle. Clinicians may also feel less connected to patients they see as responsible for their pathology.

When your child has epilepsy. And in the July issue, now live on our Web site, the Viewpoint essay is by Linda Breneman, whose son developed epilepsy at age three. Breneman’s story serves as the basis for an impassioned call for more research into epilepsy, especially into how we can help the 20% to 30% of those with epilepsy who have the “intractable” kind, those whose seizures are not controlled by medication, diet, drugs, nerve-stimulating implants, or radical brain surgery.

April is the cruelest month? And from the New York Times Well blog, a post looking at new research into possible reasons for the increase in suicide rates in May and June, a question that takes on greater urgency given an overall increase in the suicide rate in recent years, particularly among middle-aged men. While an obvious contributing factor would seem to be the economic pressures felt by Americans, the research considers theories such as increased inflammatory activity at certain times of year.

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