Hypothetical case
Higher than average hospital readmission rates are costing Memorial Hospital hefty financial penalties and all departments are being charged to reduce their rates. Christian DiSandro, the diabetes educator for the endocrinology department, is concerned because the most vulnerable cohort of diabetics is being referred to the university hospital. He suspects the referrals are being made not because anyone believes these patients will receive better care, but because administration has decided that once they are gone, the department's readmission rates will go down. Christian has worked with some of these patients for years and feels the department is abandoning them. He knows some are simply not motivated to achieve the lifestyle changes successful management of their disease demands. He also understands the many environmental factors that make living a healthy lifestyle particularly challenging for this population. He wishes others in the department would understand the social determinants of health and become truly committed to community outreach and population health.
Guidance from the ANA Code of Ethics
Provision 2 of the ANA Code of Ethics for Nurses (2015) makes clear that "the nurse's primary commitment is to the patient, whether an individual, family, group, community or population." Plans of care are to reflect the nurse's "commitment to the uniqueness, worth and dignity of the patient." Nurses are to provide patients with "opportunities to participate in planning and implementing care and support that are acceptable to the patient. Honest discussions about available resources, treatment options and capacity for self-care are essential" (p. 11). The interpretive statements for Provision 2 address the conflicts of interest nurses may experience as a result of competing loyalties in the work place. Christian wants to be a team player and enjoys the respect he gets from his physician and nurse practitioner colleagues, but he also knows that his patients and their families need a strong advocate.
Scenario 1
Christian shares his concerns with one of the physicians he considers a friend. The physician urges him not to try to challenge the referrals and reminds him that the department chief has promised bonuses to everyone if their readmission rates go down. Christian is hoping to get into a nurse practitioner program in the new year and could use the bonus. His physician tells him this isn't really abandoning the patients because the university hospital should have excellent resources. Christian decides to be a team player and go along, but continues to have reservations -- and some guilt -- about the patients they are losing. He also knows that this course of action runs counter to what his code of ethics demands.
Scenario 2
Christian puts himself into the shoes of some of the most fragile diabetic patients the department wants to refer out and knows that rather than helping them, the referrals are likely to worsen their diabetes. For one thing, they will have to travel farther to the university hospital, and transportation will be a problem. Two, they will have all new practitioners to meet and this will require more energy. He decides he has to speak up and make the best case he can for reversing the decision to unload challenging patients. He knows some of these patients seem not to care about their own health, but other patients are challenged by their life situations and require more support. He talks with colleagues about a plan to make this change in care a department challenge that will encourage everyone's best efforts. He begins to research the literature for proven strategies and discovers some interesting studies using shared appointments and motivational counseling that he would like to try. Christian is energized by this effort and hopes his energy will be contagious.
