Moral Courage
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University of Texas at Arlington, College of Nursing and Health Innovation
N5340 Management and Seminar Practice
Cynthia Plonien DNP, RN, CENP
Moral Courage
Nurses are one of the most revered professions today. It is not only that which guides us, but our standards, values, and code of ethics. Nurses are ethically bound to uphold the rights and safety of patients, even when doing so is difficult. As nursing leaders, the duty to display ethical competence is even more essential, especially regarding drug diversion.
Situation
After discussing a recent traumatic experience in my personal life with my team, a nurse, J.T., offered Alprazolam from the medication pyxis. After explaining the tracking process of the medication withdrawal and documentation into the medication administration record, J.T. stated it had already been scanned into the patient’s medical record, and that I needed it more than the patient. I refused and returned the medication. I continued to explain the process of medication withdrawal under the user account, which is linked to a patient account requiring documentation, rationalizing the incident into something understandable, because acknowledging the reality was too difficult (Douglas, 2016). After processing the event overnight, I requested months of controlled substance and pyxis waste reports from pharmacy. Comparison of patient medical records with the medication reports revealed that J.T. was diverting controlled substances. Based off the undocumented medications only, J.T. had an average of 17 undocumented narcotic pills, including opiates, benzodiazepines, and sedatives, every shift. This information, and the Alprazolam event were reported to the manager.
As the nurse supervisor, and charge nurse on duty, I demonstrated moral courage for reporting J.T. to leadership, on suspected controlled substance diversion, for fear of being wrong, fear of being right, and fear of ruining J.T.’s career and life.
Background
Nurses have an obligation to report on suspicions that a fellow nurse is impaired, as this jeopardizes patient safety. Under most circumstances, this event would be reported quickly, without question. This case was difficult, since J.T. was my best friend. It was difficult to comprehend that not only was my best friend diverting and abusing narcotics, but she was doing so right in front of me.
On more than one occasion, J.T. had been on the Controlled Substance High User Alert (CSHU) report for the hospital, but many nurses on the Orthopedic Trauma unit routinely made that list. Ranking the number of opioid prescriptions by specialty, orthopedic surgeons were second, as opioid usage in orthopedics is higher than average (Worley, 2019). Administration of 10 mg of morphine sulfate every hour as needed to an orthopedic trauma patient was routine. Due to the sheer volume of narcotic administrations, the CSHU report was often dismissed.
Assessment
Meticulous scrutiny of J.T.’s controlled substance pyxis withdrawal, administration, and discrepancies revealed multiple areas for improvement. Pyxis settings allowed the user to remove a different dosage than prescribed without creating discrepancies or alerts. Supervisors were supposed to receive the CSHU reports monthly, but due to staffing shortages, the reports had not been generated for the previous eight months.
J.T. had become depressed following a recent miscarriage, and was experiencing insomnia. It was assumed her fatigue and drowsiness were related to the depression, and working on the night shift. When she no longer cared about her appearance, and began to look disheveled her coworkers and friends knew it was time to confront her about her depression. We planned dinners and lunches, but J.T. would cancel last minute, often to work another shift at the hospital. In hindsight, these changes and behaviors we had attributed to depression from the miscarriage, were actually signs of substance abuse. Those diverting medications volunteer to work additional shifts to increase access, offer to medicate patients for other nurses, appear drowsy or lethargic, pay less attention to their appearance, and work night shift when there is less supervision (Pace et al., 2019).
Recommendation
Preventing drug diversion relies upon the ability to recognize the signs of an impaired nurse, and accept that a nurse they know is capable of diverting drugs. Nurses may believe that drug diversion is a problem in healthcare, but would never happen within their organization. While the percentage of nurses abusing controlled substances is comparable to the general population, the nature of their work provides nurses easier access to narcotics (Pace et al., 2019).
Changes to pyxis settings preventing removal of higher dosages than prescribed is a key step in limiting drug diversion. Charge nurses should assess and resolve pyxis discrepancies at the change of shift. These changes in medication practices significantly impacts drug diversion rates (McKnelly & Piacentino, 2016).
Conclusion
Unaware of impaired nurse signs or that drug diversion could happen on my unit prevented me from seeing that J.T. needed help. Unfortunately, by the time she was discovered her addiction was severe. Despite peer assistance programs, J.T. was unable to commit to sobriety, losing her license, and later, her husband. She was divorced, bankrupt, and unemployed within two years of uncovering her addiction. The following year, J.T. died from a drug overdose. Though one of the most difficult and painful experiences of my life, demonstrating moral courage, I made the right choice. And while I was unable to save my dear friend, I continue to share this story with those around me to raise awareness of the prevalence of drug diversion.
References
Douglas, V. (2016). One of our own. Nursing, 46(2), 48–49. https://doi.org/10.1097/01.nurse.0000476231.72761.96
McKnelly, A., & Piacentino, M. (2016). Spotting signs of drug diversion. South Dakota Board of Nursing. https://4f98c102-a071-4b6b-b5d2-d055bf2194ef.filesusr.com/ugd/3cce66_a05f6d1418cc4f4eb53bee3ac60a9842.pdf
Pace, E. M., Kesterson, C., Garcia, K., Denious, J., Finnell, D. S., & Bayless, S. (2019). Experiences and outcomes of nurses referred to a peer health assistance program: Recommendations for nursing management. Journal of Nursing Management, 28(1), 35–42. https://doi.org/10.1111/jonm.12874
Worley, J. (2019). Managing opioid use in orthopaedic patients through harm reduction strategies. Orthopaedic Nursing, 38(2), 129–135. https://doi.org/10.1097/nor.0000000000000524
SBAR Report: Moral Courage
Application Assignment:
Identify and analyze an act of moral courage in which you have been a participant or have observed. Use an exemplar from your current or past work setting.
Develop strategies that could be used by nurse executives to create an organizational climate of support to acts of moral courage.
Create a report utilizing the the SBAR Communication Tool
Points = 100
SBAR is a communication tool often used in clinical care of patients among inter-disciplinary teams. It is frequently used to share information between nurses and physicians related to changes in patient conditions. It can also be a powerful tool in management and administration providing succinct information related to recommendations for improved processes. Using the SBAR Communication Tool, identify and analyze moral distress and an act of moral courage. Include
S – Situation (include the act of moral courage in this section). 20 Points
B – Background (include precipitating moral distress in this section). 20 Points
A – Assessment (include leadership responsibility). 20 Points
R – Recommendations (include strategies to create an organizational climate in support of acts of moral courage. 20 Points
Correct use of the SBAR Tool – 10 Points
APA Formating and Organization – 10 Points
Include Title Page and References (Minimum – 3). Content: 500 – 1000 Words.
Here is my situation- I have included one of the 3 references needed. I did not use the SBAR sorry. I will attach a sample paper as well as the rubric.
MY CHOICE- In transplant we often list patients with alcoholic cirrhosis. One patient in particular stands out to me where I observed and participated in the act of moral courage. This patient was referred to us for liver transplantation and was very sick. He had been diagnosed with alcoholic cirrhosis and told to quit drinking and attend AA so that he could be placed on the transplant list. He complied and received his new liver. However, after a patient gets there new organ they are still required to do follow up labs. This particular patient has random Peth test to make sure that he was not drinking after his transplant. About a month ago the patient called me stating that he was not feeling well. He was having abdominal pain, nausea/vomiting and unable to keep his antirejection medications down. I was reading the notes in his charts and is coordinator had been trying to get him to get to come to post clinic for follow up for the last six months as well as have labs drawn. This day I instructed him to go the ER for evaluation. He was full of excuse. I ended up talking to his son and ultimately his son brought him in. In the end it turned out that the patient had quit taking his medication and had been drinking again. Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one’s moral values. As nurses it takes moral courage in all areas and at all levels of nursing (Numminen et al., 2016). This was a challenging situation as this patient was in acute rejection and also was clearly not adhering to the major rules outlined by not only our program but also the governing body of organ sharing. These types of situations not only put our program in moral and ethical dilemma’s but also the nurse coordinators that care for these patients. We are called upon to stand up and up and speak out for what is right and correct. For this patient to receive another liver, a gift of life would not be right or ethically correct.
Reference
Numminen, O., Repo, H., & Leino-Kilpi, H. (2016). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878-891. https://doi.org/10.1177/0969733016634155
Moral Courage
Student’s Name
Institutional Affiliations
Moral Courage
Nurses are often faced with situations that present ethical dilemmas as they continue to work with patients with varied needs. To effectively deal with such issues, nurses need to apply moral courage and sensitivity throughout the analysis process before settling on the best action to take (Goktas et al., 2022). As Numminen et al. (2016) point out, moral courage is an important virtue that nurses require at all levels of professional practice. By understanding their levels of moral courage, nurses can make ethical decisions that will result in the realization of positive patient outcomes. The situation-background-assessment-recommendation (SBAR) is a tool that guides nurses to share patient care information with members of interdisciplinary teams for enhanced understanding (Ding et al., 2022). The purpose of this assignment is to utilize the SBAR tool to identify and analyze moral distress and an act of moral courage based on a past patient care scenario.
Situation
Patients who receive organ transplants need close care and monitoring for enhanced recovery. When handling organ transplant cases, healthcare professionals often list patients with alcoholic cirrhosis. One patient stands out to me where I observed and participated in the act of moral courage. This patient was referred to my facility for liver transplantation and was very sick. He had been diagnosed with alcoholic cirrhosis and told to quit drinking and attend AA so that he could be placed on the transplant list. He complied and received his new liver.
About a month ago the patient called me stating that he was not feeling well. He was having abdominal pain, nausea, and vomiting and was unable to keep his antirejection medications down. I was reading the notes in his charts and his coordinator had been trying to get him to come to post clinic for follow-up for the last six months as well as have labs drawn. This day I instructed him to go to the ER for evaluation. He was full of excuses. I ended up talking to his son and ultimately his son brought him in. In the end, it turned out that the patient had quit taking his medication and had been drinking again.
Background
Patient evaluation is important in nursing because it allows the nurse to determine how a patient is responding to therapeutic interventions. This explains why it is important to conduct patient follow-ups after a hospital discharge. After patients receive their new organs they are still required to do follow-up labs based on a clearly outlined schedule developed with the guidance of a healthcare provider. Additionally, patients who have received liver transplants are prohibited from drinking alcohol (Johns Hopkins Medicine, 2021). This patient has a random Peth test to make sure that he was not drinking after his transplant. However, the patient ignored the provider’s advice, a factor that significantly put his life at risk.
Assessment
For nurses to remain moral in their practice decisions, they require courage that will guide them to do what is right while upholding their moral values. Moral courage is applicable to all areas of nursing, including organ transplantation (Numminen et al., 2016). The scenario that I faced in practice was a challenging one as the patient was in acute rejection. He was also clearly not adhering to the major rules outlined by not only our program but also the governing body of organ sharing. Realizing the desired patient outcomes can be very difficult when the patient does not adhere to the recommendations provided by the healthcare provider. The consequences of non-adherence can be so severe that no actions can be taken to help the patient attain positive health outcomes.
Recommendation
Nurses, even when faced with ethical dilemmas, are still charged with the responsibility of offering recommendations to their patients to enhance their well-being and improve their quality of life. Situations such as the one described above not only put our program in moral and ethical dilemmas but also the nurse coordinators that care for these patients. We are called upon to stand up and speak out for what is right and correct. For this patient to receive another liver, a gift of life would not be right or ethically correct. According to Numminen et al. (2016), some of the core attributes of moral courage include responsibility, advocacy, and honesty. In the current scenario, the best action to take is for the nurse to remain honest with the patient by informing him that he does not deserve to get another liver owing to his careless behaviors. The nurse should advocate for the implementation of telehealth technology in the organization to improve follow-up and monitoring of patients who have received organ transplants to ensure that they adhere to their treatment regimens for enhanced recovery.
Conclusion
Follow-up care is important, especially for patients who require close monitoring post-discharge. A patient who has received a liver transplant and fails to adhere to the provider’s advice does not deserve another organ considering the costs and the logistics involved. It takes moral courage for a nurse to make an ethical decision that best fits the situation at hand.
References
Ding, Y., Wang, G., Chen, H., Kang, J., & Wu, Z. (2022). Application effects of SBAR communication mode in ICU nursing physical restraint shift. Alternative Therapies in Health and Medicine, 28(6), 112–117.
Goktas, S., Aktug, C., & Gezginci, E. (2022). Evaluation of moral sensitivity and moral courage in intensive care nurses in Turkey during the COVID-19 pandemic. Nursing in Critical Care, 10.1111/nicc.12820. Advance online publication. https://doi.org/10.1111/nicc.12820
Johns Hopkins Medicine. (2021). Destigmatizing liver transplant for patients with alcohol use disorder. https://www.hopkinsmedicine.org/news/articles/destigmatizing-liver-transplant-for-patients-with-alcohol-use-disorder
Numminen, O., Repo, H., & Leino-Kilpi, H. (2016). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878-891. https://doi.org/10.1177/0969733016634155