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
Principle-Based
Ethics
Rules, codes,
standards
Professional
Ethics
Consequencesbased Ethics
Virtue (ideal)based Ethics
Outcomes
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 ventilatordependent 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 mistakemaking 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
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