When Being Good Means Looking Bad: An Ethical Quandary for Nurses

Performance measurement, an increasingly pervasive trend in health care, is credited with significant improvements in the quality of care . . . . Even so, this is little comfort when a nurse faces a situation where an action necessary for meeting a performance measure isn’t what she or he believes is best for a particular patient. For example, falls are often tallied as a performance measure, but frail patients need to be walked; raising the head of the bed to prevent pneumonia is often counted in performance evaluation but may result in less turning of the patient, which may mean more sacral ulcers—which may or may not be tallied as a separate performance measure.

That’s from an article in this month’s AJN by nurse ethicist Doug Olsen. It’s called “When Being Good Means Looking Bad,” and is about potential unintended effects of some well-intentioned performance measures that don’t easily allow for consideration of clinical context. Olsen writes that the nurse may, in certain situations, find herself or himself faced with three highly imperfect options to choose between:

  • Conform care to get the best score on the performance measurement, although that may mean less than the best care for the patient.
  • Use deception, in the form of a work-around or an outright lie, to give the appearance of meeting the measure—while actually doing what one thinks is best. 
  • Give the best care, document accurately—and accept the consequences.

Olsen explains the ethical principles in play, weighs the options, and then offers nurses some succinct advice for finding a way forward. Please have a look and let us know if you’ve ever experienced such a conundrum.—Jacob Molyneux, senior editor

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. ninjanurse October 14, 2011 at 5:31 pm

    I get in trouble more often for following the rules and being slow, than speeding past them. In twenty years I’ve had my garbanzos saved more than a few times by sticking to the rules– but I have probably been less effective and creative as a nurse. Most of my regrets are things not done.
    Maybe not only rules but principles? I have more autonomy in my present job- home care. Combined with the confidence of having experience, I now feel I can defend my actions when they respond to a particular situation rather than one size fits all.
    One thing we need is a system that gives patients fair compensation for malpractice, and nurses fair protection from the uncertainties of our work.

  2. RehabRN October 7, 2011 at 11:25 pm

    Personally, I am tired of seeing the problems, presenting them to management and then hearing, “Oh, everything’s fine.”

    No, it’s not, and some management prefer not to do root cause analysis because it’s too much work for them, too, just as it’s work for me to write stuff up. If they get too many writeups, they risk their own evals, bonuses, etc.

    Just one other reason why I am so happy I’m not a floor nurse full-time anymore. Protecting management from idiocy is not my job, but protecting my patients from it, is.

    I will do that wherever I am. My patients deserve it.

  3. Leah Balderson October 7, 2011 at 8:12 pm

    I agree that this is a sad fact within the nursing community. I am sure that every type of Nursing has it’s own ethical dilemmas that they face on a regular basis. However; I cannot in good conscious ignore the issue as one in which deception can be perceived as the best for the patient. I know that sometimes bringing issues to supervisors, managers and other do not always bring needed changes, if the issue needs to be taken to a higher authority then so be it. I did like the statement of that written by Shawn today that we should be following evidenced based reasearch practices. I do not know why Hospitals and sometimes department heads find it so hard to acknowledge that there is proven nursing practices that are much better for patient care and improved outcomes. I guess change really is hard for some and still we must as nurses continue to educate not only our patients but out administrators as well.

  4. Shawn Kennedy October 7, 2011 at 7:06 pm

    This is an important issue. In my travels out and about, I’ve spoken to many hospital nurses who say they’ve “had it” with all the checklists. They are unanimous in agreeing that it’s necessary to do evidence-based practices, like increasing the head of the bed to prevent pneumonia, etc, but many object to what they see are bureaucratic mandates and extra paperwork. Chart documentation should be enough, they say.

  5. ninjanurse October 7, 2011 at 5:23 pm

    If we pretend something is working when it isn’t, then things won’t change. I worked in a mental health agency that required an incident report every time a pill was found on the floor. One day I saw numerous staff develop temporary blindness and finally picked up the pill myself and threw it away. I was swamped with work and that was all the time I could spare, but thought it better to remove the pill than to pretend I didn’t see it. A well-intentioned rule, but clients dropped pills a lot and we would have spent all our time writing incident reports if we followed it.

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