Journal of Clinical Research & Bioethics

Decision making through the Lens of Fidelity: Ethical Dilemma

Fouzia Bashir^* Ms Nursing Student, Department of Nursing, University of Lahore, Lahore, Pakistan
^*Correspondence: Fouzia Bashir, Ms Nursing Student, Department of Nursing, University of Lahore, Lahore, Pakistan, Email:

Received: 20-Feb-2020 Published: 12-Mar-2020, DOI: 10.35248/2155-9627.20.11.347

Case Scenario

Miss Saba (pseudo name) is nursing supervisor of medical ward. She had 5 staff nurses who work under her supervision. Staff nurse Nazia (pseudo name) is on morning shift. She has slow reflexes and often malpractice among his colleagues but her supervisor compensates her. Once she was assigned three patients with diagnosis of CVA, cellulites and fungal infection. On that day while doing medication she injected injection tanzo 4.5 gm to the patient who has CVA without seeing the prescription on file while advice was for injrocephin 1 gm. Due to staff negligence patient's pressure shoot to 180/100 and heart rate 130 beat/min and SPO2 also dropped to 80%. On duty registrar came and manage the patient B.P and SPO2. Patient suffered because of staff negligence. Being a supervisor Miss. Saba was in confusion to report the negligence or not, because reporting of this error can terminate the staff nurse, and not reporting can endanger the patients and organization.

Introduction

Health care leaders play an important role in the success and failure of an organization. Health care professionals have a commitment towards health and well-being of patients but sometime they face challenges to choose loyalty to clients, to employers, and health care organization. They have to maintain a trustworthy relationship between primary stakeholders of an organization which include patients, providers, and payers. HCLs acts in a way to support and prevent any harm to patient, employees and organization. The success of a health care organization depends on the quality of care that is provided to patients and community, the failure to do so would decrease the organization ’ s ability to meet its mission. Sometimes HCLs encounter challenges concerning quality of care, efficiencies, limitation of resources and producing benefit for organization [1]. However, ethical decision making can increase collaboration and the performance of HCPs to achieve a common vision and goal.

The code of ethics for registered nurses [2] guides all nurses to make ethical decision whether they are engaged in clinical practice, administration, education, or research. Therefore organizational policies based on ethical principal enable the employees to work ethically.

1^st Position (From The Lens Of Health Care Leader)

In health care organization, health care providers follow ethical principles to provide a safe, high quality and cost effective care. In health care setting, nurses play an important role to maintain the standard of care and organization reputation. In addition, nurse directly support and coordinate health care team, families, and patients to provide high quality care to maintain the health of patient. Therefore negligence behavior towards the care of patient cannot be accepted because that can endanger the life of patient and can spoil the reputation of an organization. Health care providers especially nursing clinical leaders play a central role in providing supportive, productive, and cost effective nursing services [2]. Nursing leaders should be knowledgeable and skillfully to resolve the challenges that can harm the organization, colleagues, and patients. Furthermore, nursing leaders should be ethical decision maker and should prove their point through evidence based research. In our scenario Ms. Nazia, being a nursing team leader cannot take ethical decision to report the error of her colleague. In such situation where leaders cannot report the malpractice then who will take this role. Patients revert after critical condition and such situation sometimes lower the reputation of an organization. Instead of reporting the error and educating the staff, nursing leader hide the truth from organization. It shows the incompetency of nursing leader to take ethical decisions.

Moreover, when nursing leaders fail to perform their duty, as reporting the error then malpractice became in hand of every HCP and no one performs their duty faithfully. In this scenario Ms. Nazia’s reporting would show her loyalty to organization. Employees should loyal to their organization and should maintain the reputation of organization.

In other words, not telling the truth and hiding malpractice of employees is evidence of going against the pledge of nursing which says

“ I will do all in my power to elevate the standards of my profession and I will hold in confidence all personal matters that are committed to my keeping. I will work to prevent disease and to promote wellness in individuals, families, and communities”.

The code of ethics justifies that employees have a big responsibility to be loyal to organization and patients. Nursing leaders any action that can harm the organization is against ethics. In addition, the American Nurses Association (ANA) also emphasizes on making ethical decision that improve the quality of care (ANA 2016). Telling truth is an important ethical principal which should be considered while involving the care of clients because it indirectly effects the organization. Lying cannot benefit any person, whether colleague, organization and patients. Every religion also preaches the slogan of telling truth because lying is always harmful for everyone. As Allah says in Surah Al ahzab

“O you, who have believed, fear Allah and be with those who are true.”

On contrary, the decision of nursing team leader was in favor of her colleague because she wants to save her from punishment while her action was against the ethics. As every health care organization has different policies and might be possible that reporting of malpractice became the cause of her fire the institution. Moreover, the nurse might be facing any emotional stress and domestic problem due to which she was committing mistakes. Therefore Ms. Nazia may be true in its position of hiding the truth.

2^nd Position From The Lens Of Organization

In a trustworthy organization, health care professionals follow the rules and policies of organization and tried to provide high quality care while following ethical principles. The practice of HCPs directly affects the organizational reputation. Organizations based on ethical principles have set rules of safe practice, which provide safety to patients and employees.

Similarly all employees work sincerely under standard of practice of an organization. The standard of practice should be based on ethics not someone’s personal will. If employees did not the ethical principles, then there would be the chances of malpractice. Err in human is a common thing but hiding the error is big mistake. As in my scenario, nursing team leader Nazia conceals the malpractice of her colleague considering the reputation of her colleague. However, she also has some loyalty towards organization which paid her and provides her a comfortable atmosphere.

To maintain the standard of practice, every health care organization should have written policies which should be conveyed to every HCP. In our scenario Ms. Nazia’s behavior of concealing the malpractice is based on organizational lacking of hiring an incompetent person who has no skill and knowledge for making ethical decision. Sometimes organizations hire an incompetent person for management who has no knowledge of safe practice and skills of management. While considering their benefit, organization usually hires employees on the basis of favoritism not on the basis of knowledge, practice and skills. Organizations should hire competent persons and should make ethical committee to deal such cases in a way that everyone report errors or malpractice to provide high quality care.

A research conducted by Attia Bari, described the extrinsic and intrinsic factors which are the causes of malpractice. Fatigue due to long duty hours, inadequate experience, and inadequate supervision were the basic factors that enhance the errors. Organizations need to take some steps to avoid such malpractice. First is to implement written policies for safe practice and reporting of errors. Second step is to hire competent persons who understand the ethics while practicing. At last the leaders should be trained to tackle the difficult situations and can make ethical decisions [3].

My Position

In my viewpoint, Miss Nazia should take ethical decision and should report the error because she also has loyalty towards organization. Committing errors is common in our health care setting but reporting those errors is not common. In addition, HCPs conceal errors to avoid shameful results that can lead to bad consequences. Moreover, majority of the organizations has no written policies of reporting errors and they do not appreciate the error reporting persons. Therefore many of the employees do not report error because this would highlight him in the eyes of organization. In addition, training and education programmers are not common which leads to create such dilemmas. Institution should have document policy of reporting the errors and should teach all employees at the joining the job. HCPs should feel guilt for committing errors and not reporting

Counter Arguments

On contrary, the nursing team leader decision was in favor of colleague because she did not do it deliberately and concealing of error is suitable because immediate disclosure may fatal be for her colleague. Many organizations do not appreciate the reporting of errors because if they would file the incident that can create hurdle to maintain the reputation of organization. In addition, concealing of error may be due to the fear of punishment and lawsuit. Being a supervisor, she support her staff but she harm the repute of organization and health of community. Moreover, team leader might be not capable of taking ethical decision; therefore she can’t take a solid decision in this regard.

Possible Consequences

Organizations based on ethical policies minimize the errors and malpractice of employees. Concealing of errors might result in disastrous output. In my case scenario dilemma occurred between two principles of ethics. One is from the side of colleague for not reporting the error and second is from the side of organization to report the error. If nursing team leader conceal the error this is her fidelity towards her colleague to save her from harmful consequences. On contrary, reporting of error will enable the organization to uphold its position. Punishment for wrong doing is necessary because this would provide safe atmosphere to patients. A research conducted in America presented that more Americans die as result of medical errors rather than other reasons [4]. Disclosure of error would lead to penalties, which are necessary to stop or minimize the malpractice. Fidelity is very important ethical principal and when clash create between fidelity towards colleague and towards organization then HCPs should consider the reputation of organization.

Recommendations

Whistle blowing is an important recommendation to minimize the errors. HCP should report and documented the medical errors in order to save the life of patients and hospital management should take action as per institutional policy [5]. The culture of whistle blowing eases the employees in speaking up, when necessary. Organizations should make written policies to report the incidence and should keep the reporting person in confidentiality. After reporting of incident complete inquiry should be done and reporting person should be awarded with some prize. Quality department should implement policies for proper filling of any incident. In addition culprit should have penalty so that other employees fulfill their duties carefully. Moreover, indoor patients should be guided about their medication so that is staff unintentionally injected wrong medicine, patient would oppose on the spot. Quality department of that organization might be not good that does not support the reporting persons, instead of appreciating the create clash between whistle blower and reported person[6-8].

Moreover, quality department of organization should conduct workshops on reporting the incident. So that employees would understand the importance of whistle blowing. However nursing leader while reporting the error can request the quality department to punish the employee but not fire from job [9].

Conclusion

Ethical principles demand its implication in clinical practice to provide high quality care to patients and family. HCPs should disclose errors and negligence so that malpractice is corrected. In critical situations where HCP has to choose between colleague and organization, HCP should consider truthfulness in mind to prevent harm. The major theme of practice should be to serve humanity and uphold the reputation of organization.

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