Transition to Professional Practice

Introduction to The Ethical Dilemma Faced in Nursing

Misconduct amongst healthcare professionals is a grave situation wherein the patients are exposed to increased risk or are harmed (Maurits, 2016). This can imperil the patient’s wellbeing and health as well as reduce the quality and standard of healthcare services as a team. As per the ICN Code of Ethics for Nurses (2012), nurses work towards an ethical environment of the organisation and challenge any unethical practices. This means that the nurses need to report any breach in the ethical practice observed by them irrespective of who is found to be engaging in them. The aim of this article is to reflect, using the Gibbs reflective cycle, upon the incident wherein I noticed that the enrolled nurse was not following hand hygiene protocol and the ethical dilemma I faced while deciding to report it to the registered nurse.

Description of The Event

Whilst on placement, working in the general ward as a student nurse, I was on the duty of providing hygiene care to the patients. I was giving a wash to the patient when I noticed the enrolled nurse, who was on the duty of medication administration, was not maintaining hand hygiene protocol while switching between the patients. The ward was full and it was a busy day. The entire nursing team had been working since morning without breaks as there was a shortage of the staff and there were many patients to be taken care of. I noticed a breach of hand hygiene protocol by her and after weighing out the options, I decided to report it to the Registered Nurse. The Registered Nurse immediately called for a meeting and explained to us about how essential it is to adhere to the hand hygiene protocol. She reminded us how at least half of the hospital-acquired infections are preventable and our negligence can put the patients at an increased risk (NSQHS, 2017). After the meeting, the registered nurse spoke to the enrolled nurse in private.

Feelings of The Ethical Dilemma Faced in Nursing

As we were overburdened with work maybe the enrolled nurse did not remember to be careful and maintain hand hygiene. Though, I agree with all the things the Registered Nurse said, that under no circumstances can hand hygiene be skipped as it is essential for the health and safety of the patient. However, I felt bad that I reported against the enrolled nurse and her mistake got highlighted only because of me. She seemed to be sad when I tried talking to her, however, she did not know that I was the one who had reported the incident. Watching her get scolded at and look sad, I started to contemplate my decision.

Though I feel had I not reported the incident she might have continued to do the same mistake and I felt I was only doing my duty by reporting the misconduct. As per the Nursing and Midwifery Board of Australia (2018) “the nurses should document and report concerns if they believe the practice environment is compromising the health and safety of people receiving care”. After the incident, I could also not stop thinking about how understaffing can lead to excess work which can then lead to errors in performing our duties. This experience also made me feel that we as a team need to incorporate measures to increase hand hygiene compliance.

Evaluation of The Ethical Dilemma Faced in Nursing

“If a physician, nurse, or other healthcare workers decide to do nothing to stop a colleague’s or management’s harmful conduct, he or she may be contravening a basic professional commitment to promote and protect patients’ health and welfare” (Mansbach et al, 2014). I noticed the enrolled nurse not following hand hygiene protocol and it came across to me as a major code of misconduct. I acted as per my instinct at the moment and summoned the courage to report it to the registered nurse.

The enrolled nurse failed to abide by the NSQHS (2017) according to which, hand hygiene is an essential approach to fight hospital-associated infections. Most common complication faced by the patients admitted in the hospitals is hospital-associated infections. The principal measure for prevention of healthcare-associated infections has been recognised to be the maintenance of hand hygiene (Ataiyero, Dyson & Graham, 2018). Often due to increased workload, negligence, casual attitude towards infection control or lack of knowledge, one tends to not comply with hand hygiene protocol.

Hence, I could understand and relate this with what the Registered Nurse was trying to explain, that we should be stern with hand hygiene protocol in order to break the chain of infection. As an accountable healthcare professional, we must have the knowledge and skills for effective and safe practice even when working without direct supervision as per the NMBA (2018).

Analysis of The Ethical Dilemma Faced in Nursing

According to the ICN Code of Ethics for Nurses (2012), the nurse should take appropriate action to protect individuals, families and communities when their health is jeopardized by a co-worker or any other person. It was the enrolled nurse’s duty to ensure hand hygiene protocol compliance and by not doing so she exposed so many patients to an increased risk of hospital-associated infection.

A study conducted by Maurits et al. (2016), shows that 42% of nursing staff suspected or noticed professional misconduct by another nurse or healthcare provider. This implies that there occur incidents across various healthcare settings wherein the misconduct catches the attention of the co-workers however it is reported or not reported based on different factors. The two prevalent factors that determine the reporting of misconduct are the educational qualification of the person who notices the misconduct by the co-worker and whether the misconduct was due to the incompetence or impairment of the co-worker.

The ability to have awareness about an ethical conflict including feelings as well as self-awareness of one’s responsibility in situations which are ethically sensitive is known as moral sensitivity. Nursing students generally show less moral sensitivity in comparison with the registered nurses and are more likely to feel powerless in an ethical conflict that occurs at the workplace (Yeom, Ahn & Kim, 2016). The specific areas where the nursing students face ethical dilemmas include nurse-patient relationship, nursing care and conflicts between peers.

Ethical dilemmas are very common in healthcare especially in the field of nursing (Rainer, Schneider & Lorenz, 2018). Usually, ethical decision-making requires the person to be able to make a choice between either two equally good or poor choices. However, resolving the ethical dilemma remains a complex process and can even lead to moral distress.

The incident also made me realise how perilous our practice could be if hand hygiene is neglected and there exists a need to find out the ways we can increase hand hygiene compliance. Optimal practices to maintain and incorporate hand hygiene continue to be a challenge in most healthcare facilities (Boyce, 2019). On an average, healthcare providers don’t maintain hand hygiene more than half the times they should (CDC, 2020). Clean Hands Count Campaign started by CDC (2020), My 5 Moments for Hand Hygiene by WHO (2020) and National Hand Hygiene Initiative by the Australian government aim to improve the adherence of hand hygiene protocol by the healthcare providers.

Conclusion on The Ethical Dilemma Faced in Nursing

In nursing practice, ethical dilemmas often occur and unveil many challenges. An understanding of the ethical principles, knowledge about the code of ethics for nurses and moral sensitivity are essential to guide the process of decision-making. It can be difficult to make the right choice and decision-making can also lead to stress and moral distress. Also, hand hygiene practices of the healthcare workers are a major concern worldwide. There exist strategies and approaches initiated by WHO, CDC as well as the Australian Government to increase hand hygiene compliance.

After having thought about the incident and evaluating the options I had, I felt I did the right thing by reporting the incident to the Registered Nurse. The Registered Nurse was right that hand hygiene should be followed under all circumstances. This incident also encouraged me to think about how we can improve our hand hygiene compliance even in stressful conditions and abide by the hand hygiene protocol mentioned in NSQHS, 2017.

Plan of Action

As ethical dilemmas are an inevitable part of nursing, I intend to once again read and refer to the ICN Code of Ethics for Nurses (2012), NMBA decision-making framework (2020) and NMBA code of conduct for nurses (2018). I intend to discuss this incident with my teacher so that she can guide me and make me understand if there could have been a better way to deal with this situation. I also plan to be less impulsive the next time I notice any ethical principle not being followed or code of conduct being breached and discuss it with the person involved in the act. I plan to learn how to confront a person involved in the act in the right way and to adopt a friendly and positive approach towards them when doing so.

With the increasing emphasis on hand hygiene compliance, how we manage to maintain high standards of hand hygiene protocol is of considerable importance. As I am on the path of becoming a Registered Nurse, I need to ensure I have excellent hand hygiene compliance and make efforts to reduce the risk of infection for the patients as per the NSQHS, 2017. I will also make it a point to discuss hand hygiene compliance and the new approaches of hand hygiene protocol that I came across with my peers.

References for The Ethical Dilemma Faced in Nursing

Ataiyero, Y., Dyson, J. & Graham, M. (2018). Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. American Journal of Infection Control, (2018), 1-9. doi:10.1016/j.ajic.2018.09.014

Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards (NSQHS). Retrieved from: https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf

Boyce, J. M. (2019). Current issues in hand hygiene. American Journal of Infection Control, 47, A46–A52. doi:10.1016/j.ajic.2019.03.024

Centers for Disease Control and Prevention. (2020). Clean hands count for safe healthcare. Retrieved from: https://www.cdc.gov/patientsafety/features/clean-hands-count.html

International Council of Nurses. (2012). The ICN code of ethics for nurses. Retrieved from: https://www.icn.ch/sites/default/files/inlinefiles/2012_ICN_Codeofethicsfornurses_%20eng.pdf

Mansbach, A., Kushnir, T., Ziedenberg, H. & Bachner, Y. G. (2014). Reporting misconduct of a coworker to protect a patient: A comparison between experienced nurses and nursing students. The Scientific World Journal, 2014, 1–6.

Maurits, E. E. M., de Veer, A. J. E., Groenewegen, P. P. & Francke, A. L. (2016). Dealing with professional misconduct by colleagues in home care: a nationwide survey among nursing staff. BMC Nursing, 15(1), 1-11. doi:10.1186/s12912-016-0182-2 

Nursing and Midwifery Board of Australia. (2018). Code of conduct for nurses. Retrieved from: file:///C:/Users/HP/Downloads/Nusing-and-Midwifery-Board---Code---Advance-copy---Code-of-conduct-for-nurses---Effective-1-March-2018.PDF

Nursing and Midwifery Board of Australia. (2020). Decision-making framework for nursing and midwifery. Retrieved from: file:///C:/Users/HP/Downloads/Nursing-and-Midwifery-Board---Framework---Decision-making-framework-for-nursing-and-midwifery---Advance-copy.PDF

Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical dilemmas in nursing: An integrative review. Journal of Clinical Nursing. 27(19-20), 3446-3461. doi:10.1111/jocn.14542 

World Health Organization. (2020). Clean care is safer care. Retrieved from: https://www.who.int/gpsc/5may/background/5moments/en/

Yeom, H.-A., Ahn, S.-H & Kim, S.-J. (2016). Effects of ethics education on moral sensitivity of nursing students. Nursing Ethics, 24(6), 644–652. doi:10.1177/0969733015622060 

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