The Nursing Ethics Blog

Nurse gets struck off for racist comments in first hearing of its kind – then walks out during karakia [by Stephanie Ockhuysen, for Taranaki Daily News]

A Taranaki nurse has been deregistered for making racist comments against Māori on social media – and then walked out during a karakia to close proceedings against her.

On Wednesday, the second day of proceedings, the Health Practitioners Disciplinary Tribunal found two charges against Deborah Kathryn Hugill were established, amounting to professional misconduct….

This is a story that every nursing student should read. It’s not a happy story. And—as far as we know—it’s not a story about a common problem. But it’s a case that gets to the heart of what it means to be a nurse, and a professional.

B.C. nurse hit with precedent-setting fine for financially exploiting elderly couple (by Pamela Fayerman, for the Vancouver Sun)

The College of Registered Nurses of B.C. says a precedent-setting penalty to a nurse who financially exploited an elderly couple should serve as a deterrent to others thinking about enriching themselves at the expense of patients in their care.

Former nurse Laurie Tinkham, of Nanaimo, is the first B.C. nurse ever to be fined by the college for professional misconduct. In its decision, the college said Tinkham can’t apply to have her licence reinstated for at least five years. Her fine totalled $17,500 — half the maximum fine under bylaws — after a three-year investigation and hearing process concluded she breached numerous ethical and professional standards while caring for a now-deceased elderly couple. She was also ordered to pay investigation costs to the college of $16,536.

The nurse’s misdeeds include being the couple’s power of attorney and putting her name on the title of a $30,000 mobile home (which she still owns according to B.C. Assessment Authority records) that was bought by the couple. As well, the couple paid for her dentistry, vision care and $1,600/month in medications. All of this was on top of a monthly stipend for her services which was kept to a certain threshold ($800) a month so that it would not jeopardize her taxpayer-funded long-term disability payments of $900 a month.

According to the college: “Her failing to maintain appropriate boundaries involved her reaping substantial financial benefits from an infirm client, and her also gaining access to assets through a power of attorney. Such conduct stands to significantly erode the public’s confidence in nurses….

Please read the whole thing!

In a recent news story out of Prince Albert, Saskatchewan, Carolyn Strom, a nurse, was found guilty of professional misconduct for a post on her personal Facebook page, citing problems in her grandfather’s care at a local long term care centre. You can read the CBC story about the case here.

In her Facebook post, which you can read more about here in the redacted version of the disciplinary committee decision, she praised but mainly criticized the quality of care that her grandfather received. The excerpt of the posting that the CBC and other news media have presented cite her dissatisfaction with the care her grandfather received while he was in palliative care in the facility, in the last week(s) of his life. The more complete version of the posting, as appears in the redacted decision, goes on to state that the problems and dissatisfaction with her grandfather’s care were ongoing and she warned others whose loved ones were in the facility to “keep an eye on things and report back anything you Do Not Like!”. The post suggested that she had tried to take other steps to address what she calls “subpar” care for her grandfather, and that “not much else seems to be working”.

A disciplinary committee for her provincial regulatory body found her guilty of professional misconduct for posting what she did, and in the manner that she did so. Many argue that this is a “silencing” of discussion over inadequate and poor quality health care for seniors and those at the end of life. Others counter this argument by suggesting that her posting was unprofessional, and inappropriate.

Nurses – and all health care professionals – have a complicated relationship with social media. Is my “personal” Facebook page separate from my identity as a regulated health care professional, with particular obligations and responsibilities? Can I separate out the professional from the personal cleanly and easily? No, it’s not easy nor straightforward. In this case, the personal and professional are clearly enmeshed – Strom is making clear accusations of very poor quality of care, and stating that problems related to care were ongoing. As a nurse, she has particular knowledge of how to work within the system to have her voice heard and a clear idea of what “good quality” care might have looked like. As a family member, she obviously has an emotional reaction to what she viewed as poor care for her loved one, and her post reflects a deep entanglement of these perspectives – which can be, and was, seen as problematic, at least by the provincial regulatory body. Be clear: social media platforms very much want you to mix the personal and the professional. They have a strong desire for you to have a bigger social media reach, offering us more “suggested friends” and “connections” every day. But as health care professionals, with particular and unique obligations – such as maintaining confidentiality – that extend beyond formal working hours, we must use social media more judiciously than many others, and with awareness of those obligations that continue even when we walk out the hospital doors at the end of our shift.

The nurse in this case used her personal Facebook page to engage in a form of professional whistleblowing. One can pick up on her obvious frustration, sadness and anger at the care of her grandfather, in the posting. But was this the most appropriate and effective way to address the problem? Whistleblowing can be effective as it calls attention to what is usually a serious problem, but in most cases, it should only be used as a last ditch effort and with full knowledge of the potential fallout that can ensue for the person bringing light to a particular problem. When all other avenues of possibility have been exhausted, then whistleblowing may seem like a timely and often desperate plea for change or action. It requires moral courage and stoicism and sometimes, personal sacrifice. Whistleblowing was discussed in great public detail as the instigating force behind the investigation into the deaths of 12 children, (between the ages of 4 months and 2 years, who died while in hospital for cardiac surgery in Winnipeg) and the subsequent Manitoba Paediatric Cardiac Surgery Inquest led by Justice Murray Sinclair.

There’s a lot in Strom’s more complete posting when you read through it. There’s a list of accusations and claims beyond her grandfather’s palliative care. There are accusations of poor quality care, of ongoing and unresolved practice issues, of particular staff providing subpar care, of lack of education of staff, of efforts to address these problems without resolution, accusations of complete lack of compassion and care, of treating patients in a way that fails to respect their dignity and a charge to others to be vigilant about the care of their loved ones – inherently suggesting that the problems cited are systemic, rather than tied to individuals. It’s also not clear if she really did exhaust all possible avenues of seeking better quality care for her grandfather. Did she voice complaints to the staff, the manager, the institution, the Board or health region, the regulatory body, the Ministry? Did she report particular nurses, as is our professional obligation, if the situation demands such? Her complaints cite a specific need for education into palliative care, quality care and compassion for some of the nurses in that unit and a demand for them to “step back” – but don’t clearly state what particular professional problems or inappropriate practices she may have witnessed that would underpin that comment. And if these problems are as she has described, the provincial regulatory body should have been involved. There are clear avenues to bring practice problems to the attention of the regulatory body, who are required to take these types of claims very seriously.

As nurses, we often may not be in positions of “enough” power to have our voices heard in the way we would like, but that does not mean we should abandon the avenues that we do have. We must still persevere, in professional and ethically responsible ways, to be heard and to voice our valuable and needed perspectives in ways that can help enact change. As a family member and an RN, Strom had a clear and deeply emotional stake in the care of her grandfather and was able to see where his care could – and should – have been better. We can all imagine – and some may have well experienced – how it feels when you have knowledge about what constitutes high quality care and you see that the care of your loved one is not up to the standards you would expect. It would be, without a doubt, deeply morally distressing. But the question remains, should she have pressed the “post” button on her personal Facebook page to voice her professional views on her grandfather’s care? And if the answer is no, she should not have done so, the subsequent question for many is – does this then shut down discussion of quality health care and problems within our systems and institutions? No, I don’t think it does, and many might argue Strom may had other options to engage in such a discussion more professionally and effectively, even publicly.

There are ways to make whistleblowing ethically permissible as long as other avenues are explored first and you have reasonable evidence that whistleblowing might work. It’s a high risk avenue of action, and without being clear that it might effect change and ensuring that the message is crafted in a way to be most effective, some might claim it is then potentially ethically problematic. It’s not clear here if this posting has resulted in any kind of change or attention to the alleged problems in the named long term care facility  – as was Strom’s intention – or if the case has simply just raised more discussion on how nurses should use social media.

A Facebook posting, “rant” or “vent” is an easily accessible mechanism that absolutely any person with a device can utilize as a tool. There’s nothing particularly professional or effective about a Facebook “rant” and due to their ubiquity, and the fact that many are written “off the cuff” or in passing emotionally-driven moments, they’re seen as very weak or, at best, very limited forms of advocacy. Strom posted a deeply emotional Facebook posting on a very personal experience, and used her unique knowledge and professional position to inform her posting and to underpin her claims of poor care and lack of compassion. As a nurse, she has far more sophisticated tools at her disposal, with knowledge of how to advocate personally and professionally, knowing systems and how to maneuver through them (even problematic systems, as she suggests in her post). It’s not clear if she was driven to this, exhausted by lack of action through these other avenues – but this case will continue to raise questions about how we, as health care professionals,  manage the personal and professional intermingling that social media involves. The message from the Saskatchewan Registered Nurses’ Association is clear: Don’t mix them up. Use social media with care.

As health care professionals, sitting in front of a screen when we are upset, angry or disheartened by the systems in which we work can result in problems – and for many of us, that may be the time for us to close our browser window, step back and return later, or look to other avenues to have our voices heard.

The piece linked below makes what might strike some as an odd claim: namely that the nursing program discussed should be considered odd or innovative for teaching ethics.

Penn professor calls for more focus on ethics in nursing

Nursing students at Penn learn valuable skills in biology and physiology, but they also study a more unusual subject: ethics.

While there isn’t a significant amount of research on ethics in nursing, bioethics as a whole enjoys a greater presence at Penn than it does at many other universities.

“One of the unique aspects of Penn Nursing is that we do have a bioethics course,” School of Nursing professor Connie Ulrich said. Ulrich is the only nurse bioethicist at the University, but the Department of Medical Ethics and Health Policy itself has over 40 primary and affiliated faculty. “I think we recognize that nurses have to think about the ethical decisions that are made on a daily basis related to their patients….”

So, question for discussion: does (or did) your nursing school have a course on ethics? Is it a required course?

The piece linked below is by Pamela Cipriano, president of the American Nurses Association. It’s about the US Navy’s decision not to punish nurses who refused to force-feed prisoners at Guantanamo Bay

“Let nurses do the ethical thing: Patients’ interests should trump all other obligations.”

…The decision reflects the Navy’s recognition of the right of nurses to make independent, professional judgments and to object to participating in treatment they find unethical, without facing retaliation. The decision also recognized that — first and foremost — the nurse’s duty is to the well-being of the patient, regardless of who employs them or where they’re caring for someone….

The tension reflected in this case — that of duty to patient vs duty to employer — is one that is common in all licensed professions. Should the engineer employed by a construction company to help design a bridge draw up plans that specify cheap materials, or materials that will be structurally sound? Should the accountant employed by an industrial corporation keep the books the way the boss says, or the way her professional standards require? In most cases, the answer is pretty clear. But these kinds of cases (and comparisons) still warrant discussion, not least because of the incredible moral stress they frequently imply for individual professionals.

Sexual contact with a patient is never a good thing. But the case cited below is an extreme one, and serves as a good reminder of just how big a problem it is, and just how many factors make it so problematic.

Nurse re-instated after sex with inmate

A NSW nurse who struck up a relationship with a mentally ill teenage inmate will be able practise again after telling a tribunal she does yoga to manage stress and has taken ethics courses…

…In a decision handed down this week, the Civil and Administrative Tribunal said the young man was “in a particularly vulnerable position as an incarcerated 19-year-old Aboriginal man with a history of self-harm and a serious mental illness”….

Women earn less, on average, than men in our society. That’s perhaps not surprising in male-dominated professions. But in nursing?

Female nurses make nearly $11,000 less per year than registered male nurses

New research shows that in America, registered nurses who are male earn nearly $11,000 more per year than those who are female. Only about half of that difference can be attributed to factors like education, work experience and clinical specialty, which leaves a $5,148 salary gap that is discriminatory towards women….

What specific factors might lead to such a gap? If it’s discrimination, at exactly what point does it operate?

By the way, here’s an explanation of the general wage gap between men and women, by Harvard economist Claudia Goldin.

Labour disputes are tough, both financially and ethically. The nurse writing the commentary below highlights the conflict between the moral obligation to fellow obligations to members of one’s bargaining unit, and the obligations more standardly referred to in relation to nursing.

California Nurses Association bullies, divides hospital staff: Guest commentary

…A CNA flier reads, it is your “moral obligation” to strike with fellow nurses.

The CNA does not know my morals. Patient safety is a moral principle to me. I am asked to understand the bigger picture in regard to patient care and why we are striking, and I did….

Today, 21 years after Sue Rodiguez’s story made the headlines, history has been made again in Canada with the striking down of the current assisted suicide laws – sections 241 and 14 in Canada’s criminal code which, essentially, prohibit aiding or counselling another person to end their life.

Here is a link to the Supreme Court’s actual ruling which outlines that a physician may not help someone end their own life. There are specific conditions attached to this ruling: First, the person involved must be a competent adult who consents to have their life ended. Second, the person must be experiencing what they have called “endless suffering” as a result of a “grievous or irremediable” illness, disease or disability.

This ruling will now be turned over to the government, as the two sections of the Criminal Code which prevent people from consenting to their own deaths or allow others to aid in their suicide become no long valid after a year. So the government will have to draft new rules and ensure policies and safeguards in place to protect those most vulnerable while also ensuring that the new rules reflect the aims and values underpinning the ruling. They’ll also have to anticipate how this might play out as there will be both federal and provincial involvement in any new legislation. Quebec already has its own right to die law which came into effect in June 2014.  Finally, any new legislation that is eventually brought forward based on this ruling may well be appealed, again.

You can read more about the ruling here and here.

Here’s a tragic story from Cape Dorset, which is in Nunavut, a territory in Canada’s far north. Cape Dorset is a town of just 1300 people.

“Nunavut nurse admits to failing to see infant and other allegations”

A nurse the Nunavut government promoted to a top nursing job after nearly 20 complaints were filed against her has admitted to a number of the allegations, CBC News has learned.

Among the most egregious complaints against Debbie McKeown was that she refused to see a three-month-old Cape Dorset boy, Makibi Timilak, when his mother phoned her one evening in early 2012 saying the child was ill and needed attention. The boy died hours later.

Nunavut rules dictate that nurses on call in the evening must open the health centre to see an infant under the age of one who might be ill.

A CBC News investigation found that territorial government employees admitted in emails that they put the hamlet of Cape Dorset “at risk” by mishandling complaints against McKeown. She was promoted to the top nursing post in the community despite conditions on her licence preventing her from treating children. ….

It’s hard not to see the connection with the scale of healthcare operations in a wee hamlet like Cape Dorset. Yes, obviously services are bound to be limited. But consider also that in a larger place, at a larger clinic in a larger town, there would likely be much more going on in terms of formal and informal peer review and oversight.