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Nursing students were not too happy with how they responded to observed ethics violations, ranging from patient privacy violations to infection control issues, according a recent study of nursing students.1 The findings suggest better preparation could be useful.
Also, it is not just nursing students who need more confidence in responding to ethics violations. The same is true of many medical students and residents, according to William Nelson, PhD, MDiv. Some suspect they have observed an ethics violation, but are not completely sure. Other times, they are certain it is a violation, but have no idea how to respond. In either scenario, ethics can be of great help, Nelson offers.
Recently, a resident asked a senior medical student to discuss details on a patient in the middle of a crowded elevator. The student suggested they talk in private to avoid disclosing identifiable patient information in a public area. “The resident was not totally content with the student’s initial response, but later commented that she appreciated the medical student’s professionalism and action to protect confidentiality,” says Nelson, director of the ethics and human values program at Geisel School of Medicine at Dartmouth.
In this case, the student knew full well that it was a breach of patient confidentiality, but was reluctant to confront the resident. “As students, they know that residents are going to be evaluating them at the end of the clerkship, and they don’t want to undermine the relationship,” Nelson notes.
Clinicians may face similar discomfort within an organizational hierarchy, making it difficult to challenge higher-ups. “Providers might be junior, in terms of status, to a senior person who is violating an ethical standard,” Nelson suggests.
Since graduate medical education trainees and senior physicians serve as role models, the effect of ethics violations is compounded. “It not only diminishes the integrity of the individual clinical or administrator,” Nelson says. “It really undermines the professionalism of the profession.”
Clinicians may see all kinds of transgressions, such as colleagues concealing medical errors from patients, failing to give a true informed consent, or performing nonbeneficial tests that help providers financially. “Whatever you can do to help clinicians respond to these types of challenging situations, the better off you and the organization will be,” Nelson says.
According to Nelson, clinicians need what he calls “in-the-moment skills.” This know-how can boost one’s confidence when reacting on the spot to ethics violations. Sometimes, it is necessary to skillfully discuss the situation with the violator right away. In other cases, the right course of action is to discuss the violation (whether real or perceived) with the appropriate person, such as the clerkship director or chief resident. “Just as an impaired provider must be appropriately called out, so must an ethically impaired provider,” Nelson says.
Failure to act on observed ethics violations negatively affects the quality of patient care, Nelson warns. “Healthcare professionals have a duty to patients, the public, and the profession to recognize and address ethical misconduct,” he says.
Ethicists can offer plenty of regular education sessions: on ethics principles, examples of ethics dilemmas, conflict resolution mechanisms, and decision-making, says Andria Bianchi, PhD, a clinician-scientist and bioethicist at University Health Network in Toronto. “Clinicians will hopefully feel confident in providing real-time responses while also knowing that the ethics team can offer additional support,” she offers.
Case-centered ethics rounds effectively prepare clinicians for these situations, says Rosalind Ekman Ladd, PhD, a visiting scholar in philosophy at Brown University. Some violations, such as “forgetting” infection control measures, call for an immediate response. “Role-playing is a useful technique,” Ladd suggests.
A clinician can practice saying things like, “Did you forget to use the hand sanitizer?” or “Using the sanitizer every time is such a pain, isn’t it?” Then, such discussions come more naturally. Suspicion of impairment or medical error call for a different approach. “There should be a consensus about which violations call for immediate response, and which require reporting to someone else,” Ladd explains.
A resident may be mistaken about what he or she thought was a medical error, or mistaken that a clinician is impaired. “If it requires serious disciplinary action, that is better undertaken by the person’s superior,” Ladd says.
Financial Disclosure: Physician Editor Arthur R. Derse, MD, JD, Nurse Planner Susan Solverson, RN, BSN, CMSRN, Editor Jonathan Springston, Editor Jill Drachenberg, Editorial Group Manager Leslie Coplin, Accreditations Manager Amy M. Johnson, MSN, RN, CPN, and Author Stacey Kusterbeck report no consultant, stockholder, speakers’ bureau, research, or other financial relationships with companies having ties to this field of study.