Ethics and Mistake Making in Nursing:

A Transformational Ethical Framework for Nurses

Nelda Godfrey, PhD, RN, ACNS-BC, FAAN

Objectives:• Describe the role and process of discipline in nursing regulation

• Apply a patient safety pathway for discussion and evaluation of nursing practice errors and professional conduct

• Describe current guidelines and programs for evaluating, treating and managing nurses with a substance use disorder (SUD)

• Learn how to use a transformational ethical approach when assessing practice errors in nursing; and

• Develop skills to interpret body language.

We Live in Innovative Times•Two obvious truths in our profession’s

future: ▫Change▫A growing complexity of practice

◦ (Benner, et al., 2009)

Professional Nurse, or Nurse Professional?

•Professional Nurse: validation by examination or institutional verification

•Nurse Professional: a person who professes to be a member of the discipline and has individual qualities or characteristics that inform and motivate him to make good moral choices.

Safe Practice—Culture of Safety—Just Culture—

Yet humans make mistakes. . .

A Quick Primer on Discipline Within a Profession

Case Study A•Nurse M is caring for Mr. J., a patient in the

Neurological Intensive Care Unit, who has been diagnosed with a meningioma and was recently returned to the NICU after resection of the tumor. She knows that the family is anxious to be with Mr. J., and have waited for hours. But, Nurse M decides to finish her nursing tasks with Mr. J. while the family waits. “Besides, I need to get my work done first,” Nurse M. justifies. “There is no rule to say that I should allow the family in right at this moment.”

Three Areas of Professional Ethics

Professional Ethics

Consequences-based Ethics

Outcomes

Principle-Based EthicsRules, codes,

standards

Virtue (ideal)-based Ethics

Character

Case Study B•Nurse K is the next professional nurse to care for Mr.

R. Nurse K is taking courses for graduate school and has a family of younger age children for whom she is responsible. She views work as a necessary evil. “Without work, I don’t support my family. Let’s see, here is my list of tasks. May as well start with Mr. R. Hurry, hurry! Here is the care plan. If I work hard to do all the duties then I can be done by 9:30. I can break then and call Michael’s school. I also need to get online and email the cable company. Lunch. I may have time to run to the store and back. Laura can probably cover for me.”

Stairstep Model of Professional Transformation

Crigger , N. & Godfrey, N (2011). The Making of Nurse Professionals: A Transformational, Ethical Approach. Sudbury, MA: Jones & Bartlett.

How could a Transformational, Ethical Approach make a difference in mistake making and professional practice?

Professional Discipline/Regulation: •Peer review•Due process• Interests of the public/person/profession•Formalized•To some extent, an individual

rights/privileges are subrogated to the rights/interests of the public or the person that is harmed

Case Study C•Nurse S has been assigned to a patient who is

unresponsive. The patient, Mr. L., is ventilator dependent and is to receive oral care as part of the hospital policy to reduce the risk of ventilator-dependent pneumonia. Nurse S knows that no one will know the level of care that is given and does a cursory job of oral care to Mr. L. After all, Nurse S rationalizes, he should put his efforts toward patients who can acknowledge and understand that he has done something good for them. Unconscious patients can neither complain or praise.

Substance Use Disorder: State of the Science 

Case Study D• Each nurse at Bayview Medical Center must complete

mandatory LMS testing/standards annually. Each module is accompanied by an exam, which must be passed at 90%. Each time Nurse R is asked to complete these modules, she skips the prep modules and takes the test over and over, marking the option she selects on another piece of paper, and by the process of elimination, gets to 90% after several tries—without ever reading the accompanying module.

• You know that Nurse R has done her ‘mandatories’ this way for several years now. You just heard yesterday that she was boasting of her ‘method’ to others.

What we know:•Substance Use Disorder:▫Substance abuse and substance

dependence

•Complex

•Drug specific

•Efficacy is a central theme

Case Study E•Nurse P consistently fails to complete compliance

requirements on time, including immunization and routine employment followup (TB Skin test, etc). The unit educator is frustrated about the amount of time it takes to follow up with one employee. Recently, Nurse P was part of a QI peer review assessment for clinical handoff (from one shift to another). In this project, all nurses receive feedback about their handoffs, and are asked to make changes and improvements in how communication is done from one shift to another.

Using the STOP Model to Make Better Decisions

S is for standards and reminds you to consider the nurse practice act, nursing standards of practice, ethical codes, and institutional policies to make the best decision.

T is for thorough and reminds you to consider the context of your decision, including relevant history, unspoken rules, personalities, and other elements in addition to the facts.

O is for outcomes and reminds you to consider whether your decision is in the best interest of the patient and shows respect for all concerned parties and society.

P is for personal values and ideals and reminds you to make sure your decision is consistent with your character and personal values.

*********If a nurse is still unable to decide after completing the STOP model, he or she should consult other resources, such as the hospital ethics committee.

Assessment techniques and considerations in mistake-making situations

Assessment and considerations•Assessment:▫Body Language—what do we know?

•Analysis:▫Old mental models▫Outcome orientation?▫Balance between protecting the public--and

human kindness and consideration▫Self-criticism vs. self reassurance▫Perfectionism

References• Bashaw, E. & Lounsbury, K. (2012). Forging a new culture: Blending magnet principles with Just Culture. Nursing

Management, October 2012.• Buerhaus, P., DesRoches, C., Donelan, K. & Hess, R. (2009). Still making progress to improve the hospital work

environment? Results from the 2008 National Survey of Registered Nurses. Nursing Economics, 27 (5), 289-301.• Cigularov, K.P., Chen, P.Y., & Stallones, L. (2009). Error communication in young farm workers: Its relationship to safety

climate and safety locus of control. Work and Stress, 23 (4), 297-312.• Crigger, N.& Godfrey, N. (2011). The making of nurse professionals: A transformational, ethical approach. Sudbury, MA:

Jones & Bartlett.• Crigger, N.J. & Meek, V.L. (2007). Toward a theory of self-reconciliation following mistakes in nursing practice. Journal of

Nursing Scholarship, 39 (2), 177-183.• Drenkard, K. (2011). Magnet momentum: Creating a culture of safety. Nurse Leader, 9 (40), 26-31, 46.• Gilbert, P., Clarke, M., Hempel, S., Miles, JNV. & Irons, C. (2004). Criticizing and reassuring oneself: an exploration of

forms, styles and reasons in female students. British Journal of Clinical Psychology, 43, 31-50.• Godfrey, N. & Crigger, N. (2012). Ethics and professional conduct: Striving for a professional ideal. Journal of

Professional Regulation, 3, 910, 32-7. •  Haerkens, M., Jenkins, D., & Van der Hoeven, J. (2012). Crew resource management in the ICU: The need for culture

change. Annals of Intensive Care, 2, 39. • Hawkins, C., Watt, HMG, & Sinclair, KE. (2006). Psychometric properties of the Frost Multidimensional Perfectionism

Scale with Australian adolescent girls: clarification of multidimensionality and perfectionist typology. Educational and Psychological Measurement, 66 (6), 1001-22.

• Johnstone, M. (2005). Processes for disciplining nurses for unprofessional conduct of a serious nature: a critique. Journal of Advanced Nursing, 50 (4), 363-371.

• Leroy, H., Dierynck, B., Anseel, F., Simons, T. Halbesleben, JR, MCCaughey, D. Savage, GT, Sels, L. (2012). Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: A team-level study. Journal of Applied Psychology, 97 (6), 1273-81.

• Meade, D.M. (1999). Mixed messages: Interpreting body language. Emergency Medical Services, Sept 28 (9), 59-62; 73.

• National Institute on Drug Abuse. (2009). Drug Facts: Treatment approaches for drug addiction. www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction. Retrieved 1-5-13

References (con’t)• Schmidt, L.A., Rieckmann, T., Abraham, A. , Molfenter, T., Capoccia, V., Roman, P., Gustafson, D.H., &

McCarty, D. (2012). Advancing recovery: Implementing evidence-based treatment for substance abuse Vdisorders at the system level. Journal of the Study of Alcohol and Drugs, 73 (3), 413-22.

• Shepherd, L. (2011). Creating a foundation for a just culture workplace. Nursing, 41 (8), 46-48.• Simpson, D. (2003). Special section: 5 year follow up treatment outcomes studies from DATOS.

Journal of Substance Abuse Treatment, 25 (3), 123-186.• Sorra, J., Nieva, V., Fastman, B., Kaplan, H., Schreiber, G. & King, M. (2008). Staff attitudes about

event reporting and patient safety culture in hospital transfusion services. Transfusion, 48, 1934-1942.

• Stavrianopoulos, T. (2012). The development of patient safety culture. Health Science Journal, 6 (2), 201-211.

• Sullivan, KM, Such, S., Monk, H., Chup, J. (2012). Personalized performance feedback reduces narcotic prescription errors in NICU. British Medical Journal of Quality and Safety, Oct 4, 2012. [abstract].

• Tidwell, S. (2002). Processing complaints and disciplining nurses: An overview of the investigative process b the Kansas State Board of Nursing. Kansas Nurse, 77 (1).

• Vogelsmeier, A. & Scott-Cawiezell, J. (2007). A just culture: The role of nursing leadership. Journal of Nursing Care and Quality, 22 (3), 210-212.

• Woodgett, J. (06 September 2012). We must be open about our mistakes. Nature. Doi: 10.1038/489007a.