Ethical Issues in Nursing Range

Ethical issues in nursing range across a wide variety of subjects. In recent years, the ethical use of technology has been moving higher and higher on the list of priorities when it comes to ethical practices in the health care environment. Nurses have many new responsibilities due to modern technology and this in turn has created a variety of new ethical issues. These issues include error prevention, training, confidentiality and honesty. This paper discusses each of these ethical concerns one by one, including studies, the effects on practice, and recommendations. This is followed by a conclusion that summarizes the main points of the paper.

Ethical Issues Influencing the Advanced Practice Nurse's (APN's)

Use of Modern Technology

Introduction

Technology is becoming a more prominent part of the APN's job description in the 21st century (Ellis & Hartley, 2004). With this new technology comes new ethical responsibilities. Five of the main ethical issues influencing the advanced nursing practice role in regard to technology are: 1) technological error prevention; 2) responsibilities regarding access to confidential information; 3) responsibility to train new staff members on the system; 4) to ensure complete honesty in all reports; and 5) to maintain commitment through the organization through effective leadership. Each of these issues is discussed in greater length below.

Technological Error Prevention

In order to ensure accurate use of technology, nurses need to make sure that they are alert and aware. Working too many hours on not enough sleep can cloud the mind and make errors more likely to occur. Even worse, alcohol or drug use, even during off hours, can affect the nurse's ability to avoid technological errors. Also influencing the likelihood of errors is a lack of full understanding of the technology. Nurses should never attempt to 'wing it' when they are not sure how to use certain types of technology. They need to be fully trained and have plenty of practice before actually using the technology.

For patients, the impact of being overtired or under trained can literally be a matter of life and death. According Thompson (2003), "Preventable medical errors are the eighth most common cause of death in the United States, killing between 44,000 and 98,000 each year" (p. 349). Clearly this is not an issue that can be ignored or taken lightly. Nurses today are overworked in large part due to the national nursing shortage, which in turn, contributes to the likelihood of mistakes (Thomas & Davies, 2005). There are not enough nurses to train them adequately on the new technology Thomas & Davies, 2005), they are tired from working double shifts to make up for low staffs (Leiter, Harvie & Frizell, 1998), and the stress of the situation may even lead some nurses to substance abuse (Hillhouse & Adler, 1997). Accordingly, in order to properly address the issue of technological errors, the nursing shortage problem must be tackled first.

Washington State's House Bill 3123 was passed almost unanimously (93:1) by the House of Representatives on February 15, 2008, for the purpose of addressing the issue of safe staffing for nurses, in light of the labor shortage plaguing the healthcare industry. The key sponsor was the House Committee on Appropriations, with the original sponsors being Representatives Morrell, Cody, Roberts, Green, and Ormsby. The bill was referred to the Committee on Health Care & Wellness in January of 2008 and was passed approximately one month later.

HB 3123, also called the Safe Nurse Staffing bill, is primarily concerned with the establishment of a strategy to encourage evidence-based nurse staffing in hospitals. The bill requires hospitals to establish committees designed to formulate strategies for nurse staffing that will take into account evidence-based research and best practices. It also establishes that a collaborative effort must be made between nurses and hospital administrators to devise this safe staffing strategy. In other words, nurses on staff at the hospital are required to be a major part of the planning and implementation process related to the staffing strategy.

This collaborative committee is charged with developing, managing and evaluating a safe staffing plan that takes into account every shift that the nurses work, and every area in which they work. The goal is to formulate a strategy that will reduce the burnout and errors associated with overworked nurses in understaffed hospitals. By using the committee to divide the nursing staff equally among shifts and units in terms of skill levels and specialties, there will be less of a chance of lesser qualified or burned out nurses becoming a threat to the quality of patient care.

The Washington State Nurses Association (WSNA) provided free tool kits and training sessions to help hospitals form their committees and take action in devising and implementing the safe staffing plans. There were many specifications that the committees needed to meet in order to satisfy the requirements of the bill. These included the specification that at least 50% must be made up of Registered Nurses currently on staff and providing direct care to patients. The other half (or so) of committee members would need to be made up of hospital administrators/managers. The staff nurses were required to be compensated for their time working on the committee, and the meetings had to take place during regular working hours.

The roles and functions of the committee were spelled out quite clearly. They were to devise a plan that not only fit within the national standards and recommendations on nurse staffing, but that also specified the staffing schedules for each unit and shift, based on the skills and education/certification levels of the nurses. Skill levels were to be determined based on quality indicators collected by the hospital during assessment periods. The bill also required that the staffing plan would be reviewed semi-annually with the appropriate revisions being made based on changes in staffing, circumstance and legislation.

Registered Nurse Chris Barton testified in favor of the bill, citing research that found that 86% of medical errors could be prevented by adequate nurse staffing. She also discussed how adequate nurse staffing could benefit the hospitals financially because errors made by inadequate nursing staffs cost over 17 billion dollars. In addition, inadequate staffing contributes to the nursing shortage because nurses who are overworked or unhappy in their positions are likely to leave the hospital or the nursing profession altogether. Add to that the cost of losing human lives, and Barton makes a compelling case for the passage of HB 3123.

The bill passed almost unanimously, primarily because there are very few logical objections to the bill. In general, the beneficiaries of the bill are the patients, the nurses and the hospitals. The only perceived drawback to the bill is that hospitals will have to pay nurses to attend the committee meetings which takes them off the floor and gives them less time to attend directly to patients.

Confidential Information

The increasing use of electronic health records (EHRs) over the past decade or so has brought up numerous ethical concerns regarding the confidentiality of patient data. EHR systems, which allow patient records to be accessed by authorized medical personnel anywhere and at any time, are designed to provide a variety of benefits. According to Charette (2006) "The benefits claimed for EHRs are that by being able to quickly and accurately access a person's entire health history, deaths due to medical errors (estimated to be 100,000 a year in the U.S. alone) will be drastically cut, billions of dollars in medical costs will be saved annually, and patient care will be significantly improved."

Clearly, these are very important advantages. However, there are concerns regarding what these authorized medical personnel, including nurses, will do with that information. Granted, nurses have always had access to patient charts and could use the information in them for unethical purposes. However the advancement of technology has broadened the scope of the amount and type of information nurses have access to, which in turn, widens the field of possible breaches of ethics. Therefore nurses need to be trained as to what types of ethical breaches can occur from this new technology, and how to avoid them. In fact, training in numerous areas of technology is critical for ethical conduct.

Training Responsibilities

Medical technology, including patient record software, can be difficult to learn without the proper training. The result of improper training is a major compromise of the well being of the patients. Expecting nurses to dive in to new technology with only a limited understanding of how the technology works is both unethical and dangerous. New nurses coming out of college are likely to have had more training in technology than older nurses, but there is no way to teach them everything they need to know inside the classroom. Nurses need proper on-the-job training on the technologies specifically used by the facility in which the work.

Unfortunately, this is not usually what is happening. A study conducted by health IT provider CDW Healthcare reports that of the nurses interviewed, "one-quarter indicated they had received no IT training on the job over the last year, while another 56% said they had gotten only between one and eight hours of IT training" (Lawrence, 2006, p. 1). This is a problem that needs to be addressed by adding more training to the budget. The problem is, most hospitals' budgets are already spread too thin. Therefore, hospital administrators need to work harder to find sources to help fund their activities.

Complete Honesty

Nurses have more power and responsibility than ever before to ensure that they are making honest reports about their patients. They may be in a rush to get home and not feel like entering all of the proper data into the computer. Or, they may take shortcuts in the use of other technologies. It is a nurse's ethical responsibility, however, to ensure honesty in all that she does. This includes 'blowing the whistle' when she sees that other nurses are not being honest or are misusing technology.

This can be extremely difficult, however, considering that nurses often suffer negative repercussions for 'whistleblowing'. A study conducted by McDonald (2000) found that for the 95 nurses they interviewed "Results indicated that there were severe professional reprisals if the nurse reported misconduct, but there were few professional consequences if the nurse remained silent. Official reprisals included demotion (4%), reprimand (11%), and referral to a psychiatrist (9%). Whistleblowers also reported that they received professional reprisals in the form of threats (16%), rejection by peers (14%), pressure to resign (7%), and being treated as a traitor (14%). Ten per cent reported that they felt their career had been halted." Therefore, it is not surprising that many nurses would rather keep their mouths shut than report misconduct. This is something that needs to be changed in a written policy that encourages full disclosure and punishes silence.

Job Satisfaction and Leadership Practices

Many studies have associated job satisfaction with salary and benefits (e.g. Rutherford et al., 2009; Sabharwal & Corley, 2009) . However, nursing and other caring professions do not generally operate on this principle. For example, Mayfield and Mayfield (2006) report on a study of full time nurses for whom the communications styles of their leaders were more of a motivating factor in job satisfaction and organizational commitment than salary and benefits. Watson (2009) found similar results from her survey of 359 medical imaging staff members. The results indicated that supervisors with a transformational leadership style, and who offer contingent rewards were the most highly motivating factors and the most likely to prevent turnover.

According to Kudo et al. (2006) trouble sleeping, often attributed to nursing shortages, poor scheduling practices and unsympathetic supervisors, is also a factor that affects job satisfaction and the likelihood of turnover. Kudo et al. (2006) conducted a study in which 293 full-time registered nurses, licensed practical nurses, and assistant nurses were given a survey designed to determine why they would consider leaving their jobs, if they were going to make such a decision. Using a multiple linear regression analysis as their data analysis method, the researchers were able to conclude that "Turnover intention may be reduced by the enhancement of trust in the organization, giving appropriate advice to young nurses and registered nurses, and developing measures for addressing sleep disorders" (p. 128).

The extent to which nurses are held accountable by their supervisors also enters into the picture of job satisfaction and organizational commitment. Sorensen et al. (2009) conducted a descriptive correlational study of 299 RNs working in rural settings in the Midwest. Using the Specht and Ramler Accountability Index-Individual Referent and the McCloskey-Mueller Satisfaction Scale (MMSS) the researchers were able to find a significant correlation between accountability and job satisfaction.