Life is filled with challenges. Sometimes, we are faced with situations in which we know a person has acted inappropriately, but, it may be difficult to confront them that to them because we are not in a position of authority level. Following through on a decision that is ideal, but there is not a clear cut solution in all situations. For example, a situation where a nursing student is doing a clinical placement on an adult medical floor, and has to do a complicated surgical change. The Clinical Instructor agrees to have the RN help the student with the dressing change. During the dressing change, the RN makes rude comments about the wound i.e. “yuk” “this is gross” and shows looks of disgust. The patient who is aware and oriented says nothing but looks very upset.
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In this situation, the Student Nurse is faced with three basic choices, do nothing because it is not their problem, confront the RN in a polite manner, or discuss the situation to the clinical instructor, and let the instructor guide the Student Nurse with a resolution. This is a situation which presents the Student Nurse with an ethical dilemma. An ethical dilemma arises in situations where the ethical course of action is not clear, where there may be a strong moral reason to support each of several positions, or in which a decision is based on the most right or least wrong choice of action (Keating & Smith, 2009).
ELEMENTS OF THE DILEMMA
This situation is an ethical dilemma for a number of reasons. The first of which is that patients right to receive care in a respectful and dignified manner are not being met. Secondly, The Student Nurse does not have any authority in this situation. If she says anything to the Nurse, then the Nurse may take offence; after all RN is a “professional”, and has more experience and knowledge. Thirdly, the student could discuss the situation with the clinical instructor, however, if the Clinical Instructor decides to speak to the RN or the charge nurse on the floor then the student nurse may be seen as a “tattle-tale”, because the RN was doing the student nurse a favour, complaining about the RN is probably not the best way to show gratitude.
Role of the Student Nurse. At its most basic, the situation is an ethical dilemma because the comment is made by an individual whose profession is rooted in caring for the sick. The student nurse will recognize the situation as either right or wrong. If the student nurse views the situation as wrong, then the student nurse is an obligated to advocate for the patient. Part of the objective of being a nursing student is to be an evolving professional, knowledge worker, and effective communicator. The Student Nurses are guests in the clinical agency in which they are placed and must respect the policies of that health care agency. The primary goal of any health care agency is to provide the best possible care for their patients. By inviting Nursing Students to the floor, they are saying, “We uphold our policies and conform to the standards of the college of nurses, come learn from us.” A student nurse is also required to seek help of the clinical instructor or a Unit Nurse if they are not sure about conditions or expectations. If the Student Nurse sees the RN comment as a breach of their values, the values of College of Nurses (CNO), the values of the patient, and the values of the agency, then she should discuss the issue with the Clinical Instructor and get their insight into the problem. The Student Nurse is training to be an RN and one of the obligations of the RN according to CNO is to report inappropriate behaviours – emotional, verbal, and/or physical to the appropriate authority (CNO, 2002).
Role of the RN. The role of the RN is to uphold not only to the standards of the agency, but also the standards of the CNO under which they are registered. In this situation, the RN fails in regards to the CNO standards of a RN, for a leader and an educator, while failing to establish a therapeutic nurse-client relationship, or even a professional relationship. She ignores the mentality of Client-Centered Care, which focuses on respect and human dignity.
Role of the Clinical Instructor. The Clinical Instructor’s responsibility is to teach the Student Nurses, and demonstrate behaviours that are in accordance with the CNO Standards of Practice. The clinical instructor may have trusted the staff nurse to teach a student nurse because they believed the RN to be professional role models. However, the Instructors are not responsible for teaching the staff, and while morally they may be obligated to report improper behaviour on part of the RN the situation is by the fact that they are guests to the floor, and it can be challenging to build a rapport with the Nurses at the agencies. Reporting the RN may lead to the hospital having a negative opinion about nursing students, and the nurses may not be happy about students visiting and learning from them in the future.
Role of the Agency. The role of the agency is to model professional standards of care. As an organization, the hospital and the staff are accountable to the patients for providing care in a respectful and dignified manner. They need to be aware and take proper action towards RN’s that are up to the standards of their hospital and the organization the RN’s are registered under, the CNO. The CNO is committed to the public, and they want to promote the profession of nursing to say that they are doing everything they can to protect the public; however, these goals will be impossible to achieve if the public is receiving first-hand experience of unprofessional behaviour.
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The College of Nurses of Ontario (CNO) is the governing body for registered nurses. The CNO sets practice standards and guidelines and regulates nursing practice to ensure that safe and ethical care is administered to the public (CNO, 2002). This situation is ethically distressing because it goes against some of the core values of Nursing. These values include – providing safe, compassionate, competent, and ethical care, promoting the health and well-being of the client, preserving patients’ dignity and worth by providing care in a dignified manner, and promoting justice by providing care equally to all patients irrespective of their illness (CNA, 2010).
In my opinion, I think the values of respect, human dignity, leadership, effective communication and competency were not maintained by the RN in the aforementioned situation. The RN failed to provide to provide care to the client in a respectful and dignified manner. Nursing is a profession that is rooted in care. It is also a profession where one may see and smell some very unpleasant things; however, being able to control your emotions and responses is critical, if one wants to ease patient discomfort. If the RN is not able to provide their client with a feeling of well-being and self-worth, and is not able to gain their clients trust, then they are being incompetent in their practice regardless of their supreme technical skills. Skill perfection is nothing without the right attitude and having a positive attitude is a necessity. In the situation, when the RN decided to accept to help the student with the dressing change, she is taking the role of the educator and leader and with that she is accepting the responsibility of role modelling positive professional values and beliefs, providing direction, and sharing knowledge (CNO, 2002). When the RN says “Yuk, this is gross”, the patient hears this as, “I am gross.” The patient is not going to feel good about them, the nurse, their condition or nursing care in general, and all of this has a negative impact on patient’s progress. Finally, the nurse is being incompetent by practicing in an unethical and inappropriate manner by breaking the standards of nursing practice.
In this situation, the Student Nurse has variety of choices. One possibility would be to confront the RN, perhaps after the procedure is done, and say to the nurse, “thank you so much for helping me. The patient didn’t look very comfortable and seemed to close off when you said, “yuk, this is gross.” I think that comment may harm the patient’s progress, and when I try to do the dressing change next time he may not want me to help him. Do you mind if I talk to him? Or perhaps you could come with me and speak to the patient about how the procedure went for him?” Another possibility is for the student nurse to do nothing, because it is not their problem. The third possibility would be to say nothing to the Nurse, talk to the patient in private about the procedure and acknowledge the RN’s mistake, and apologize. The student nurse can then follow up by asking the patient if they would like to speak to someone about the situation such as the charge nurse or nurse manager. The benefit of this choice is that the patient may feel that they have regained control of their situation and it will help them to see nurses in a positive way. It would give them the impression that there is someone who is concerned about their feelings. The disadvantage of this choice is if the charge nurse or nurse manager speaks to the RN. The RN may ask the student nurse why they did not come to them with the problem instead of going directly to the charge nurse. The fourth choice would be to discuss the situation with the clinical instructor and get their opinion about the situation. The benefit of this choice is that the clinical instructor will know how to best handle the situation.
Personally, I think the best course of action would be to speak to the clinical instructor about the situation first and see what they say. Clinical Instructors not only have more experiential knowledge, but they also are more aware of the university’s or agency policies.
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