By Aleisha Rosso, RN, guest columnist
Lily is a nursing student working toward her BSN. Even though she is the single mother of two young children, she felt returning to school after her ADN program was important to her professional development and personal goals. Lily has been struggling to juggle school, work and family life and is in danger of not passing the term. She is hoping her performance during her clinical rotation will enhance her grades and show her love for nursing. Her instructor also is employed at the clinical facility and is good friends with many staff members on the unit. Lily is working diligently to impress other staff nurses, knowing they will report her actions back to the instructor.
During the middle of the semester, Lily encounters a patient who was just informed of terminal cancer with a poor prognosis. The cancer was not previously known and the patient might have just months to live. He is tearful and anxious and does not have family in the area. Although the nurse assigned to him usually is compassionate toward patients, she is known for being extremely opinionated and abrupt with students. Today, however, she is brisk and hurried with the patient and seems to be annoyed with having to answer his questions. The patient tearfully tells Lily he doesn’t know why the nurse is angry with him, but he is devastated about his diagnosis, and the nurse’s attitude is increasing his anxiety.
Guidance from the ANA Code of Ethics
Provision two of the ANA Code of Ethics puts strong emphasis on making the patient the nurse’s primary concern, even when there are competing personal issues and loyalties, stating “the nurse’s primary commitment is to the patient.” The situation is difficult because of Lily’s personal struggles and the peer relationship between Lily’s instructor and the staff nurse. Student nurses often are encouraged to avoid questioning nursing methods during school for fear of losing the facility for clinical experience or personal reprimand from staff nurses. The obligation the nurse has to the patient, regardless of her student status, is primary as long as it does not compromise the ethics of the profession. Provision 3 of the ANA Code of Ethics states “the nurse promotes, advocates for and protects the rights, health and safety of the patient.” Combining both of these provisions asserts that Lily’s primary responsibility is the patient and she should advocate for his needs, even though it will take immense courage.
Lily decides to help her patient in other ways, but she cannot risk speaking to the staff nurse or her clinical instructor. She does not feel as though either party would be receptive, and the potential implications to her grade and family are far too great. Lily spends extra time with the patient answering his questions, and feels morally distressed that she did not intervene. During postconference, she tells her clinical instructor and is praised for not rocking the boat. Despite struggling initially with the decision, her instructor’s verification that she did the right thing gives her and the other students affirmation that it is acceptable to overlook the ethical responsibility to the patient if the personal risks are too high. The patient is left without an advocate and the students’ future decisions regarding moral courage are shaded by the instructor’s advice.
Lily decides it is her ethical and moral responsibility to speak up for her patient. She knows the possible ramifications, but feels as though she can approach the nurse effectively by appealing to her usual sensitive nature toward patients. Lily tactfully conveys the best possible nursing care the staff nurse could give to this patient might be letting another nurse take the assignment. Lily stresses her respect for the staff nurse and states she has observed her kindheartedness with previous patients. The staff nurse responds to Lily by explaining that due to personal stressors she is exhausted and was unaware of the effect she was having on the patient. She apologizes to the patient and asks another nurse to trade assignments. Lily feels she was an effective patient advocate and returns later to find her patient is experiencing less anxiety. During postconference, Lily’s instructor applauds her for making a difficult decision and displaying moral courage. She uses it as a teachable moment for the other students, stressing the ANA Code of Ethics’ importance to the professional nurse.