Ethics professor discusses high-fidelity patient simulation exercise with student. Photo courtesy of Linda Koharchik.
I once spent an hour in an ambulatory surgery PACU when interviewing for work at the place. A few minutes into my visit, one of the patients awoke in tears. The PACU RN proceeded to slap the woman across the face. An open-handed, full-face slap. “No crying here!” she snapped.
I was floored, and reported the incident to the clinic’s medical director. This nurse not only assaulted a patient, she did so in full view of a visitor (me). I suspect that if, instead, I had been an instructor from their medical center with students in tow, she would not have behaved differently. And would I have responded differently if students were present? Would I have confronted the nurse while other patients were watching, to make clear to the students that willfully harming a patient can never be tolerated?
Approaches to ethical instruction.
In “Promoting Nursing Students’ Ethical Development in the Clinical Setting” (free until December 13) in the November issue of AJN, Linda Koharchik and colleagues discuss the ways in which we can further students’ understanding of ethical practice—not only in the classroom, but also when we are with them on the clinical units. “These ethical dilemmas,” they write, “present an important opportunity for ethical instruction in the clinical setting.”
Role modeling in clinical instruction.
The authors point out the impact that role modeling by clinical instructors and other experienced nurses can have on students. When we remind a doctor or nurse to don an isolation gown after they’ve neglected to do so, or talk to a nurse (away from the bedside) who inappropriately describes a patient as “drug-seeking” and refuses to administer post-op pain medication, we can model “a morally courageous response to an immoral status quo.” The authors observe:
“One would hope the instructor would stand up for what’s right…but doing so in this situation has the added benefit of providing students with practical ethical instruction.”
But take a moment to read the article, and feel free to let us know your thoughts or experiences.
Ethical issue- I recently had a bilateral mastectomy with a TRAM reconstruction at a major Boston Hospital. The nurse wanted me up and walking after the surgery. As a nurse myself, I knew the drill but I was VERY uncomfortable. The nurse proceeded to tell me that if I didn’t get up, I would up like the others that go home and return in a body bag. She repeated herself multiple times. I laid in bed contemplating my death knowing that I just had extensive abd and chest surgery. Was she right in what she did? I got up. As a healing profession, I think it would have been appropriate to acknowledge “good behavior “ when I started walking. My faith and trust in this facility went down. It felt like I was involved in an abusive relationship. What is the ethical expectation of “making a sick patient walk? Is it ok to threaten death and create fear. Should the nurse have has any positive follow through?
All well and good..but this feel-good article makes the explicit assumption that all clinical faculty are adequately prepared to behave and model ethically because they are nurses with experience in ethical challenges. However, “One would hope the instructor would stand up for what’s right” does exactly nothing to address instructor assessment, training, and preparation for clinicals. As we all know, hope is not a plan. So I must disagree with the authors’ characterization that “This type of instruction requires no formal background in ethics.”
Deans and program directors might be excused for not requiring clinical faculty to have had a series of formal ethics classes, but they get no free pass to send clinical faculty into facilities without a very, very clear set of expectations about ethical practice. The example of the “drug-seeking” patient is instructive, you should pardon the pun; I know clinical faculty who would think nothing of agreeing with the staff nurse’s assessment and passing along the bestowed wisdom of denying adequate pain relief to somebody with a “pill problem.” “And, without substantial background and formal training in the field of ethics, how can clinical instructors succeed?” Indeed.
In my experience, a seminar for faculty with scenarios on these issues in the weeks before clinicals begin would open some eyes– including deans’. These scenarios should involve chronic pain patients (“Drug-seeking”), battered women (“Why doesn’t she just leave him?”), homeless (“Lazy, unemployed, get a job”), and addicted (“Drug-seeking, no willpower, no character”), undocumented people (“They think they deserve as much as real citizens”), ethnic/religious populations (“They don’t value life/feel pain as much as we do anyway”), and people in legal custody (“Criminals don’t deserve better treatment”).
It was not that very long ago that many, many nurses and clinical instructors behaved shamefully towards AIDS patients; some of the things I saw nurses do in those terrible times were not only ethically indefensible, but breathtakingly cruel. There is no reason for me to expect that things have changed that much with a new generation of nurses at work; there’s always a “less deserving” population to dehumanize for something. Let’s think about that, shall we?