Wanted: Courage on the job
UP professor wants her nurses to ignore job risk, put patients first
Lorretta Krautscheid was growing frustrated. The University of Portland nursing professor knew she was teaching her students right from wrong.
Every one of them took a full semester course in nursing ethics. Theyd had patient protocols drilled into their brains over the course of their four years of study.
And yet, Krautscheid kept hearing from students who had begun working at area hospitals that they were doing things they knew were wrong and that were compromising the health and safety of patients.
They were inserting urinary catheters into patients without following the sterilization protocols that prevent infection. They were giving hospitalized patients medications without first going over the possible side effects. They were watching doctors and senior nurses enter patients rooms without washing their hands. And they werent saying anything about it.
For years Krautscheid had believed that her job was teaching students the right way of doing things and the importance of behaving honorably. Now she was becoming convinced that wasnt enough.
In Krautscheids view, her students were putting their relationships with doctors and senior nurses ahead of their responsibilities to their patients.
How do we teach courage? Krautscheid asks. How do we teach backbone?
Krautscheid started by conducting a study, recently published in the Journal of Nursing Education. The results only increased her dismay. She put unaware students through simulations of precisely the types of situations she had been hearing about, with hidden cameras filming the scenes.
In one, a senior nurse, or preceptor, is watching a young nurse preparing to give heart medication to a real patient with dangerously high blood pressure. As planned, the patients phone rings and he tells the young nurse he has to take the call, and could she please just leave the medications on the table so he can take them later?
Krautscheid figured some of her nurses would go along and some would at least pause, knowing they had to check to make sure they were giving the right medication to the right patient, and that the patient was aware of potential complications.
I thought some of them would say, We learned in school we shouldnt do this, Krautscheid says. Only one did. She turned to the preceptor and said thats not what she had been taught to do. The preceptor told her it was OK, she should just leave the medications next to the bed. Which the young nurse did.
Six other young nurses left the medications without so much as a question.
In a followup study, Krautscheid surveyed 93 young nurses, asking them what they do when a senior nurse gives them bad advice. Nearly half responded that they followed the bad advice. Her takeaway?
Its easier just to go along and get along, and when you drill down on that through one on one interviews, what they tell you is, I have to keep working with these people, and it seems to be part of the culture that this is OK, Krautscheid says.
Tamara Mazelin was one of the students in Krautscheids simulation who did not speak up. Its hard, she says about contradicting a more experienced nurse who is in a supervisory capacity.
Mazelin has worked at a number of Portland-area hospitals and clinics, and she says the simulation mirrored the reality shes confronted. She recalls working at a hospital neonatal intensive care unit and watching nurses improperly inserting a catheter into an infant. Infection protocol requires nurses to discard a catheter if it has fallen out of the bladder and use a new, sterilized one. But when the catheter fell out of the infants bladder several times, she says, nurses simply reinserted it.
They could have given the baby an infection, Mazelin says. I knew it, but I started questioning. These are real experienced nurses. They must know. I started questioning what Id learned.
Mazelin says later she talked to the charge nurse in what she figured was the least confrontational way possible. I (said), I thought this was a sterile procedure, Mazelin recalls. She said, Things are sometimes different in the real world.
Later Mazelin talked to her preceptor, who said she would talk to the other nurses. But she has since seen similar scenarios, including one in which she wanted to tell a physician who had left a patients room and come back that he needed to put on new, sterile gloves. She didnt say anything. Next time, Mazelin says, she will speak up. But it wont be easy.
Weve learned everything we should do that is ethically right, Mazelin says. But we havent learned how to have that conversation.
Learning to speak up
Mazelin says shed like more simulation opportunities aimed specifically at ways to confront authority figures without being confrontational. Nursing school leadership classes might help, she adds. And shed like to see hospitals call meetings with all the nurses on hand where the message is relayed that they want people even the newbies to speak up if they see someone cutting corners.
Justin Britton is one of those students who told Krautscheid how difficult it was to practice to the standards Krautscheid had taught him. Britton is in his last year of nursing school at the University of Portland and has been working as a certified nursing assistant at a number of local hospitals. In one, he was stationed in acute care, where most of his patients were elderly, many with pneumonia or having suffered strokes.
He says one nurse told him he shouldnt take so much time swabbing an IV port with alcohol. Sterilization protocol calls for 15 seconds of swabbing to kill any infectious bacteria. The nurses where Britton worked had a different routine. Theyll do a quick swipe, a once over, and say thats good enough, Britton says.
The first time Britton saw this, he says, he tried to distract the senior nurse in the room so he could continue to sterilize the IV port. Later they had a conversation. The nurse, Brittons preceptor, told him that if the patient got an infection, Well, thats what antibiotics are for. Britton says he began trying to get into patients rooms early so he could sterilize IV ports properly before his preceptor arrived.
And yet, Britton rejects the idea that he was showing what Krautscheid calls moral courage. I didnt think it was brave because I didnt confront her and say, Hey, youre doing it wrong, he says. I felt like I was more protecting myself and my patient by being sneaky about doing it.
Britton says hes not good at confrontation. Hed like to see nursing schools teach students how to speak to fellow employees in a more assertive fashion. And he says hes still not sure if hed have the courage to talk to a physician who failed to wash his or her hands.
Oregon Health & Science University assistant nursing professor Seiko Izumi says part of the problem is that nurses are in an in between position. They are responsible to their employers, usually a hospital, she says, and also to their patients, to doctors and even to other nurses.
OHSU, Izumi says, is starting to put student nurses and medical school students together in some classrooms so they better understand one anothers roles and develop a more equal (way of) relating.
It might take more than that, says Portland State University philosopher Alex Sager. Krautscheids desire to widely teach moral courage, Sager says, is something of a paradox.
Difficult to teach courage
Moral courage almost by definition is exceptional, Sager says. When we think of people who exhibit moral courage, they do what ordinary people dont.
It isnt easy to teach people to behave in ways that put themselves at risk, according to Sager. Were pretty good at teaching things that most people learn to do. Were not really that good at teaching people to be exceptional, he says.
Sager says Krautscheids simulation experiments remind him of the famous 1971 Stanford University prisoner experiment in which students pretending to be guards were willing to abuse other students playing prisoners (see accompanying story).
People are pretty good at doing the right thing when its not hard, Sager says. The best thing we can do is try to create environments where we dont make doing the right thing all that hard. That means if Krautscheid expects her nurses to stand up to authority, first, someone will have to work on the institutional culture in the hospitals.
Most people are not going to display moral courage, we know that, Sager says. So we need to create institutions where people are encouraged to question
Moral imagination, not simulation
That could start with making hospitals less hierarchical and providing incentives for nurses who speak up when they see shortcuts being taken, says Sager, who says real action might take moral imagination. The idea is that simulations cant cover every potential situation, but moral imagination can prepare students for situations they havent been asked to consider.
Some people think of ethics simply as applying rules, Sager says. Its not really like that in the real world. The real world is complex. ... It takes a lot of time to learn. Moral education is being able to understand and anticipate more and more complex situations.
Sager would have the nursing students read novels where characters show moral courage, and have students discuss the books. And teachers should talk about nurse whistleblowers in the classroom. The key, he says, is that teachers need to stimulate more than just the rational part of their students brains.
Just understanding something intellectually doesnt seem to be enough to motivate you. You have to tie your sentiments into it, Sager says. Begin to stimulate moral imagination and you can prepare yourself to react if you do end up in this kind of situation.
Hospital infections beg for nurses' courageous action
The willingness of nurses to speak up when they see infection control protocols being ignored is about more than just following the rules. It can mean the difference between life and death.
According to the federal Centers for Disease Control and Prevention, one in 25 hospital patients has at least one healthcare-associated infection, and nearly 100,000 people die each year due to hospital-acquired infections. Hospital costs resulting from these infections are estimated as high as $45 billion annually.
Health-care experts have been railing against the high numbers of hospital-acquired infections for decades and only recently have some of the infection rates begun to drop, even as more dangerous, antibiotic-resistant infections such as MRSA have begun to proliferate.
It's one of those things where we're constantly throwing up our hands, says Lisa McGiffert, director of the Safe Patient Project for the Washington, D.C.-based Consumers Union. This is one of the things that is at the heart of what's wrong with how hospitals operate. It's very hierarchical.
It isn't fair to place the responsibility for monitoring infection protocols on the backs of young nurses, McGiffert says, especially when hand-washing studies over the years consistently show that only about 40 percent of doctors follow the strict rules for hand washing. The worst offenders are always the physicians, McGiffert says.
When you're talking about people losing their jobs or becoming ostracized, it's a very powerful peer pressure, and it's insidious in our health care system, McGiffert says.
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