Describe the role of Staff Nurse for Seva Regional Medical Center.

The Case of the Wandering Eyes – Page 3 of 44

Step 1: Being Attentive
Part 1—Attend to the Context

For this dilemma, you are assuming the role of Staff Nurse for Seva Regional Medical Center. You’ll be examining the ethical dilemma using the perspectives of the Rights/Responsibilities Lens and the Results Lens. Check the Case File below for the details of the dilemma, your job description, and any relevant policies.

The Case of the Wandering Eyes

You are a staff nurse who has just recently passed your licensing exam. Your preceptor, a nurse from your work unit named Pat Summers, has been your friend and mentor during your time as a student nurse.

Your Case File contains emails you’ve received, as well as details from a verbal report you received at the start of your shift and your personal observations after the shift ended. Be sure to review the information on this page carefully.
Case File for JINY

Your Inbox
From Subject
Rian Brown Your Job Description
Pat Summers Congrats!
Shift Report Details from meeting
Shift Report Breach of Privacy
Rian Brown Policies
Dilemma #1

The Case of the Wandering Eyes

Case File #1
Below you will find a summary of your job description for this dilemma. Knowing what is expected of you within your role will help you understand your responsibilities better.

Staff Nurse

Your role is to provide professional nursing care in accordance with physicians’ orders. Essential tasks include treatment of patients, administration of medication and injections according to the time stated on patient charts, health education to patient and family about procedures, assisting during diagnostic testing and follow-up and preparing patients for surgical procedures. Other responsibilities include making rounds and informing the other nurses when there is a change in the shift, accompanying the doctors while they make rounds and updating them on the condition of the patients, ensuring that patients are in a hygienic condition and following all dietary requirements and ensuring that charts of all the patients are accurate and up to date.
Case File #2
Hey,

I’m so glad your licensing exam went well! You’ve come a long way—I remember when you were just starting out. It’s always such a pleasure to act as a preceptor for new nurses, and now we’ll be working together as proper colleagues. Best of luck!

Pat Summers
Registered Nurse
Seva Regional Medical Center
Case File #3
(Details from shift report)

Nurse Manager called a team huddle at the beginning of the shift and reported the patients in room 208 and 209 are at risk for fall, reminding everyone to keep a close eye on the room when passing in the hall. Room 212 is in final stages of dying. There are a lot of additional family members in the lounge and room. And room 203 is a celebrity, requesting privacy, only staff assigned to this room should enter and provide care. Please pay attention to this at meal times and allow only the staff members assigned to take in and remove the tray.
Case File #4
(Personal notes from end of shift)

While passing Room 203, I very clearly saw Pat in the patient’s room, examining her records. Pat is not assigned to this patient, so this appears to be a breach of the patient’s privacy. I should consider having a conversation with Pat. Hard to believe my preceptor would make such a mistake.
Case File #5
When faced with an ethical dilemma at work we have resources at our fingertips to help us decide what to do like our Employee Handbook, key policies and procedures, and standard operating procedures. We also have to be aware of the federal, state and local laws that may apply to the situation. The dilemma you are facing deals with protected health information under HIPAA. Here are the key points you should remember:
Seva will maintain the confidentiality of “protected health information” (“PHI” as defined by HIPAA) and other information that is deemed to be confidential by other laws.
Information considered protected includes, but is not limited to, information on patients, donors, research, employees and all financial and business operations.
Confidential information comes in many forms it can be written, electronic, oral, overheard or observed.
Access is on a “need to know basis” and Seva defines “need to know” as information that is required in order for you to provide patient care successfully.
This should help you as you work through this ethical dilemma. Good luck!
You’ve got a real dilemma on your hands. Pat is in a position of power with you, and yet you must do something about her breeching privacy rules, right?

The second step in making an ethical decision is Being Intelligent. After paying attention and figuring out what’s going on, you have to evaluate the evidence. When you’re being intelligent, you use your critical thinking skills to evaluate the facts and the information about each person’s emotional state to figure out exactly what ethical values are in tension with each other. Then, you’ll be able to frame the issue as a statement that clearly highlights the tension.

As you frame the issue, consider your obligation to yourself both to have good ethical motives and to choose ethical acts. In addition, consider the expectations of the other people involved. For this situation, you’re going to have to initiate a crucial conversation with Pat, but you have a wide range of options for how exactly to frame that talk.

As you come to the end of the process, you’ve made the following decision:
Inform Pat of what you saw and tell her that you intend to follow the required HIPAA policy and report the incident to the nurse manager. During your conversation, try to explore Pat’s motive for looking at the patient’s chart, and communicate that motive in your report.
The option you chose was limited to one of the six on the list I provided. Now, however, you have the opportunity to communicate a decision to reflect what you believe is the most ethical course of action. Feel free to change any or all of the conditions to create the option you believe works best.

I’ve laid out for you a method for organizing your thoughts. This format could easily be used as the basis for an email or an inter-office memo, but its primary purpose is to organize the reasons behind your action and to defend your decision. While each section of the memo has a word count limit, a concise memo will often be much shorter. I recommend aiming for roughly one-half of the maximum, but you can always write more if necessary.

In conclusion, I’d like to show you where your choices fell in the possible range of choices that we developed. I have highlighted your final decision in blue.

One way of evaluating ethical maturity focuses on the ethical content, the principles and values we use to make our decision. In the final analysis, ethical maturity is defined by the reasons and strategies we use to maintain social balance between ourselves and others, both individuals and the community.

The two most ethically mature responses focus on a systemic or world view approach to the problem.
Rights/Responsibilities: The best option for the Rights/Responsibilities Lens focused on honesty and the importance placed on Pat’s motive, while adhering to the HIPAA guidelines. And, these are keys to this Lens, which values autonomy and rationality as its core values.
Results: The best option hits the ideal for the Results Lens, as it encourages Pat to consider all the stakeholders involved and the impact on each of them. Ideally, Pat will gain an increased awareness of the ripples created by her actions, but even if she has no remorse, you will have communicated your intent to involve your manager and the reasons why that step is important.
The two good answers focus only on your responsibilities to one or two stakeholders instead of taking the wider systemic perspective.
Rights/Responsibilities: This option works to benefit you and your manager, but minimized Pat’s ability to explain her actions and potentially damaged your ability to work together in the future.
Results: Seeking advice never sounds like a bad idea, but involving another person adds another stakeholder to an already complicated dilemma and may be seen as gossiping. The only stakeholder who truly benefits from this consultation is you. The best options in the Results Lens go beyond self-interest.
The two least ethically mature answers focus only on yourself and your particular interests.
Rights/Responsibilities: This option works against the interests of the nurse manager, who wants to be informed of incidents of privacy violations. Furthermore, you have not protected any future patients from Pat’s prying eyes. Instead, you’ve given her a pass to examine any record she wants as long as she can come up with a justification.
Results: This option gives in too strongly to the temptation to assume the best in Pat. The temptation is strong in the Results Lens to favor the stakeholder most directly linked to you in order to maintain the status quo in the short term. A better option would acknowledge the long-term implications of sweeping this under the rug.
Rights/Responsibilities Results
Best 5. Inform Pat of what you saw and tell her that you intend to follow the required HIPAA policy and report the incident to the nurse manager. During your conversation, try to explore Pat’s motive for looking at the patient’s chart, and communicate that motive in your report. 2. Focus your conversation with Pat on finding a solution. Be open about the impact her actions have had on you and remind her of the damage that would result in the patient’s health records leaking to the public. Explain to her why your nurse manager needs to be informed and involved.
Good 1. Inform Pat of what you saw and tell her you intend to respond by reporting the incident to the nurse manager per hospital policy. Keep the conversation short to avoid being duped by false justifications or appeals to your friendship. 6. Consult with one of your colleagues to get advice on how to have the conversation with Pat and how to file the report with your nurse manager.
Poor 3. Inform Pat of what you saw and tell her you’re considering reporting the incident to the nurse manager. During your conversation, try to explore Pat’s motive for looking at the patient’s chart, and keep the incident to yourself if her motive was admirable. 4. Approach Pat with sympathy based on your prior relationship and your expectation that her actions were most likely the result of a momentary lapse of judgment. Report the incident only if you are not convinced of her good intentions after your conversation.

The Case of the Wandering Eyes – Page 21 of 44

Step 5: Being Reflective
Part 2—Evaluate Your Decision

In conclusion, I’d like to show you where your choices fell in the possible range of choices that we developed. I have highlighted your final decision in blue.

Next, let’s see what the outcome might be now that you’ve made your final choice.

The Case of the Wandering Eyes – Page 22 of 44

Case Closed!

The reason for putting you through this drill is to make sure that you never have to face serious consequences because of a choice you made. Let’s see how your decision played out….

You chose the following option:
Inform Pat of what you saw and tell her that you intend to follow the required HIPAA policy and report the incident to the nurse manager. During your conversation, try to explore Pat’s motive for looking at the patient’s chart, and communicate that motive in your report.
On a scale of 0 to 5, from low to high risk, your decision rates a 0. It represents virtually no risk.

Pat explains that the patient’s nurse was having difficulties and wanted Pat’s advice, so Pat was looking over the patient’s information. She admits that it was inappropriate, and offers to speak with the nurse manager herself.

Settled Law

The first issue that should jump out at you is the question of whether Pat has violated the HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Rule. Broadly speaking, HIPAA governs the collection, maintenance, and transmission of health information. According to the U.S. Department of Health and Human Services Summary, “A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well being.” If Pat was indeed assisting the assigned staff person in providing appropriate care for the patient, she probably did not violate HIPAA, although she may have violated hospital policy.

This distinction is important because a violation of HIPAA triggers a reporting obligation pursuant to statute. When you comply with hospital policy and report what you saw this sets in motion the series of internal reporting that allows the hospital’s Compliance Office to determine what if any obligation they have under federal law. You don’t need to be an expert in HIPAA; you simply need to understand the basics of how the law impacts your job. Like any other employee, you are expected to know and understand hospital policy. The legal experts the hospital has hired rely on everyone doing their job consistent with hospital policy, including appropriate reporting, so that they have the information to do their job. At the end of the day, their job is to keep your job secure and allow you to provide appropriate care for patients.

The distinction is also important because you might otherwise be tempted into one of two dangerous extremes. In similar situations, some people assume the worst, frame what they saw in unhelpfully judgmental ways, ruin friendships and contribute to suspicious working relationships. Others fail to take appropriate action because they don’t want to believe friends could do anything bad. Unnecessary damage is done in both situations. Assuming the best intentions in those with whom you work needn’t prevent you from reporting what you saw or from clarifying concerns.

Emerging Trends

Workplaces that collect, retain or use personal information have policies about employee access. Employers (and those whose data is collected) trust employees to start with common sense and courtesy. If questions remain, institutional policies should clarify what is required. Generally, databases may not be treated as one’s personal library. The line between accessing information necessary for your job and poking about in other people’s business is not so fine. Pat’s intervention though apparently inappropriate may mean the difference between appropriate care for the patient and permanent damage. You don’t have to make that assessment yourself. Doing your job and doing the right thing is enough.

The Case of the Confounded Colleague – Page 24 of 44

Step 1: Being Attentive
Part 1—Attend to the Context

For this dilemma, you are assuming the role of a Charge Nurse at Seva Regional Medical Center. You’ll be examining the ethical dilemma using the Relationship Lens and the Reputation Lens. Check the Case File below for the details of the dilemma, your job description, and any relevant policies.

The Case of the Confounded Colleague

During a particularly busy shift, you notice one of the nurses, Jared, acting oddly. The notes below provide the details…but what to do is up to you.
Case File for JINY

Your Inbox
From Subject
Rian Brown Your Job Description
Shift Notes Observations
Rian Brown Policies
he Case of the Confounded Colleague

Case File #1
Below you will find a summary of your job description for this dilemma. Knowing what is expected of you within your role will help you understand your responsibilities better.

Charge Nurse

Your role includes managing the day-to-day clinical patient care on a specific shift and unit. In addition to coordinating staffing with the Nurse Manager to cover call-ins and make float assignments as needed, you are also responsible for compliance with all policies, procedures, and assignments. Other duties include performing regular nursing assignments, such as patient care, maintaining medicine and supply inventories, organizing and maintaining patient records and assisting in developing hospital patient care programs and field complaints and questions from both patients and staff. Additional duties may be conducting education or training programs for new nurses. Strong leadership and clinical skills are required.
Case File #2
Jared seems to be acting oddly. I can’t put my finger on what it is, but he’s definitely off. He’s been laughing at inappropriate times and has made several unusual comments, as if he’s reacting to the conversation slowly, or hearing things that aren’t being said. He’s typically more animated—today his affect is flat.
Case File #3
When faced with an ethical dilemma at work we have resources at our fingertips to help us decide what to do like our Employee Handbook, key policies and procedures, and standard operating procedures. We also have to be aware of the federal, state and local laws that may apply to the situation. The dilemma you are facing deals with substance abuse. Here are the key points you should remember:
As a term of condition of employment, all employees are prohibited from the unlawful manufacture, sale, dispensation, possession or use of any controlled substance. Abuse of alcohol and drugs is both a societal and industrial problem. Not only is such abuse potentially illegal, but it can adversely affect your work performance, efficiency, safety and health and therefore seriously impair your value to the Company—regardless of whether it occurs on or off the job.
In addition, the use or possession of controlled substances on the job constitutes a potential danger to the welfare and safety of other employees and exposes the Company to the risks of property loss or damage, or injury to other persons.
To your knowledge, Jared has had no previous history of these symptoms; however, you do not have access to his personnel file. If you decide to take Jared off of patient care, it would require reassigning his patients, increasing the burden on the other nurses. If you leave him on the unit, there is a greater risk to the patients.

he Case of the Confounded Colleague – Page 25 of 44

Step 2: Being Intelligent
Part 1—Explore the Values in Tension

You’ve got another difficult problem to solve. However, now that you’ve had some experience using the lenses, we know that you can sort your way through this second problem. The scenario with Jared is manageable if we just think our way through the problem.

As you remember, the second step in making an ethical decision is Being Intelligent. As you reflect on the communications from the previous screen, use your critical thinking skills to evaluate the facts (what is Jared’s behavior and how is it different?) and each person’s emotional state (what might the odd laughter indicate, if anything?) to figure out exactly what ethical values are in tension with each other. Then, you’ll be able to frame the issue as a statement that clearly highlights the ethical tension.

As you frame the issue, consider both who has access to resources and power as well as the expectations of your role. As a nurse, you want to help anyone you can, especially a peer if that peer is suffering from some unknown stress. However, as the charge nurse, the responsibilities of your role also include ensuring the safety of the patients, first and foremost.
The Case of the Confounded Colleague – Page 42 of 44

Step 5: Being Reflective
Part 2—Evaluate Your Decision

In conclusion, I’d like to show you where your decision fell in the possible range of choices that we developed. I’ve highlighted your final decision in blue.

The two most ethically mature responses focus on a systemic or world view approach to the problem. From an individual point of view, you consider your relationships and place within the whole system, as in this situation where you had supervisory responsibilities and fiduciary responsibilities to the hospital. From an interpersonal point of view, you work to accommodate your self-interest to common interests.
Relationship: Using the Relationship Lens, the best decision tilted toward rationality as you prioritized testing Jared and ensuring he gets help if he needs it.
Reputation: Using the Reputation Lens, the best decision tilted toward sensibility as you found a solution that favored compromise and helped create a culture of trust and cooperation.
The two good answers focus only on your responsibilities to one or two stakeholders instead of taking the wider systemic perspective.
Relationship: Using the Relationship Lens, the good decision limited the scope temporarily to just the two of you, while giving consideration to both Jared and the patients. Thus, the considerations were good ones, but the scope was too narrow and potentially opened the door to further complications.
Reputation: Using the Reputation Lens, the good decision avoids being shorthanded on the shift, but incurs most risk as Jared could still make a mistake even though you’re keeping close tabs. A further step to solve the issue would be better, i.e., talking to Jared after the shift at the least.
The two least ethically mature answers focus only on yourself and your particular interests.
Relationship: Using the Relationship Lens, with the poor decision the option abdicates responsibility by placing the CNA with Jared. Your position obligates your interaction, and trust is completely lost otherwise.
Reputation: Using the Reputation Lens, with the poor decision the loss of privacy and potential for gossip run selfishly in direct opposition of the Reputation Lens.
Relationships Reputation
Best 6. In order to protect Jared’s patients, escort Jared to the ER for testing. Follow hospital policy based on the result. 4. In order to show empathy, keep Jared on the floor for this shift, but do what you can to keep him alert. At the end of the shift, speak with him about your concerns so the organization as a whole doesn’t suffer.
Good 1. In order to show fairness to Jared, cover for him for an hour, send him on a break, and then assess his condition again when he comes back. 2. In order to address the immediate problem, leave Jared on the floor and watch him very carefully to make sure his patients are safe.
Poor 5. In order to set Jared straight without taking up your time, pair Jared up with a CNA and ask the CNA to report to you any suspicious behavior. 3. Ask another colleague what they think about Jared’s behavior and use that information to make a final decision. Ensuring Jared’s capability is more important than protecting his privacy.

Now, let’s consider what could happen as the result of your final choice.

he Case of the Confounded Colleague – Page 43 of 44

Case Closed!

The final step, Being Reflective, doesn’t end when you’ve made your choice. This step is an ongoing process as you watch the consequences of your decision unfold. Would you make the same choice again? Were you happy with the results? Of course, it’s important to take the time to think about hypothetical consequences before you carry your decision forward. Let’s see how your decision played out….

You chose the following option:
In order to address the immediate problem, leave Jared on the floor and watch him very carefully to make sure his patients are safe.
On a scale of 0 to 5, from low to high risk, your decision rates a 3. It represents moderate risk.
Although Jared gets through this time, as you merely keep an eye out but don’t report the incident or the behavior. Eventually, the behavior is discovered as Jared’s single lapse becomes a pattern. You’re held accountable for not mentioning the previous incident.

Settled Law

This dilemma requires that you find the balance between assuming too much and doing too little. Legal and health consequences flow from getting your assessment of the situation wrong on either end of the spectrum. If this employee is impaired—either because of the misuse/abuse of a controlled substance or because of a personal medical or mental health issue—he could pose a serious risk of harm to himself and to his patients. If you fail to take appropriate action and a patient is harmed by this employee, the hospital could be sued for negligence.

You need to find out what is going on. However, you must do so in a way that does not violate this employee’s rights. Potential pitfalls include slandering the employee if you suggest to his peers that he is under the influence of a controlled substance and he isn’t. In addition, although the hospital has the right to prohibit employees from using controlled substances (even legally for medical purposes), employees still retain certain privacy rights. You don’t want to violate these rights. If you violate an employee’s rights, then you may expose the hospital to a lawsuit by the employee.

Be sure that you understand the hospital’s policies for disciplining employees. Even as you check to be sure this employee is not suffering from a medical or mental health issue requiring help rather than discipline, make sure the steps you take are consistent with disciplinary policy as well. Here as in the previous case, you want to assume the best while ensuring that the hospital can discipline or terminate the employee if necessary. If formal action isn’t necessary, but some other assistance to the employee is, you are still in a position to provide that assistance. The key is to gather information and take action without jumping to conclusions.

Emerging Trends

Building and maintaining an ethical corporate culture requires a consistent, fair, and temperate hand when it comes to employee discipline. As a supervisor, you build trust among your employees when you take discipline issues seriously, but not too harshly. The classic notion of justice requires both punishment and reward in appropriate measure. No matter how certain executives are that confidentiality has been honored, employees tend to know how their fellow employees were treated. Word of fairness in individual cases travels and increases employee confidence to speak up when necessary to address concerns in a constructive manner. Employees who see that their employer cares about their needs are more likely to communicate problems before they become lawsuits. When both people and rules are honored, everyone ends up better off.
he Case of the Confounded Colleague – Page 44 of 44
Ethical Mastery

Congratulations on completing this Hot Topics simulation!

By now, you’ve solved two ethical dilemmas and used all four of the Ethical Lenses. You can use the knowledge you’ve gained to solve the ethical dilemmas that arise in your everyday life. Just remember the steps:
Being Attentive: Collect the facts and notice what’s being said.
Being Intelligent: Find the underlying issue and determine who’s really involved.
Being Reasonable: Use the lenses to consider what is good, what is true, what is fair, and what is virtuous.
Being Responsible: Make an ethical choice based on your analysis.
Being Reflective: Defend your choice with careful thought and observe the aftermath closely.
With time and practice, the conflicts inherent in moral dilemmas can become opportunities for developing your ethical self. When you encounter disagreement, remember that we all have our preferred lens. Arguments over the “right thing to do” often stem from differing definitions of what actions are ethical:
Rights/Responsibilities Lens: Ethical action fulfills your duties and honors the rights of the individual.
Results Lens: Ethical action respects the desires of others and seeks win-win solutions.
Relationship Lens: Ethical action is fair and guarantees fundamental liberties for all.
Reputation Lens: Ethical action lives up to the standards of the community and follows established virtues.
To achieve ethical mastery, we must be aware of the priorities of all four lenses and know how to communicate with and draw ideas from those who favor other lenses. The development of mastery is an ongoing process—not an end, but a means to continual improvement.

Remember that you can review any of the previous pages to refresh your knowledge of the decision steps or the lenses. Once again, congratulations on your accomplishments. I’d wish you luck in your future dilemmas, but you shouldn’t need luck now that you’ve had practice