It's unprofessional not to QUESTION the QUESTIONABLE
Code of Ethics mandates nurses speak up
By Angela Woodford

The days when nurses were expected to follow physicians' medical orders without question are long gone. Cooperation between nurses and physicians is vital to patient care, but nurses across Virginia agree that nursing is an autonomous profession, and nurses are obligated to question orders that seem inaccurate.

Jeanette Lancaster, dean of the University of Virginia School of Nursing for 19 years, said academic healthcare systems historically encouraged nurses to question orders, but nursing autonomy was not always universally recognized.

"The world these new graduates enter will be very different," Lancaster said of UVa's nursing students. "There was a period when new nurses didn't talk about the interdisciplinary team; we just lived it."

One factor contributing to nursing autonomy is the extensive academic training required of today's nurses. As the profession becomes increasingly sophisticated, many facilities expect and encourage nurses to enhance patient safety by fl agging questionable orders. Barbara Deets, associate professor of nursing at John Tyler Community College, explained that, "The key is being competent. There is no substitute for knowledge." Nurses will not have the knowledge to catch errors in every case, she added.

However, if nurses know they should have questioned an order and choose not to, that nurse faces job loss for unprofessional behavior and even loses of state licensure, Deets said. Speaking up for the patient is a nurse's ethical obligation.

Janet B. Younger, associate dean of Virginia Commonwealth University School of Nursing, mentioned the widely publicized death of two cancer patients at Dana-Farber Cancer Institute in Boston as a case that brought the importance of nurses questioning orders into the public spotlight.

In 1999, the Massachusetts Board of Registration in Nursing took disciplinary action against 18 nurses who carried out a physician's orders for fatal doses of intravenous chemotherapy for the two patients. The Massachusetts Board of Registration in Medicine suspended the physician's right to practice for three years.

"One group was found incompetent, and the other was found unethical," Younger said. "They knew, but they did not do - and they failed the ethical standards of [ensuring patient safety]." Younger said that today there is a greater expectation of expertise, educational level and accountability in nursing than in years past.

"The day [students] walk in the door, we are teaching safety and we are teaching ethics from a philosophy that you are a leader; you will be on the front line; you are the last line of defense for the patient; and you are there for the patient, not for the physician," Younger said.

UVa's Lancaster said she uses her guest lectures to drive home to students a nurse's ethical obligations. "The nursing Code of Ethics mandates that you do speak up, and there are situations when people are intimidated, but many young physicians express the gratitude they feel toward the nurse who helped them not make mistakes." Facility support

Many facilities now have formal support systems for nurses who question physicians' orders, and they commend those who catch potential errors. At Norfolk-based Sentara Healthcare, a questioning attitude is expected of every staff member, explained Carol Sale, Sentara's director of patient safety.

"I've been very impressed with the whole way interactions have changed between physicians and nurses," Sale said. "It's not a defensive situation, it's a conversational system [rather than hierarchical]."

At INOVA Fairfax Hospital, Chief Nurse Executive Patricia Conway- Morana said the facility's push for nurses to question physicians' orders has resulted in a substantial decrease in adverse patient outcomes.

"When we did an analysis of safety events over several years, one of the major reasons was because nursing staff did not question an order," Conway- Morana said.

Conway-Morana said she commonly hears of potentially bad situations that come to good endings because a nurse spotted an error, and she makes a point of personally thanking each nurse who does so. INOVA Fairfax also has a monthly newsletter called "Good Catches," which celebrates nurses questioning orders, and has ordered pins in the shape of a baseball catcher's mitt to give to those nurses. Moral exceptions

Nurses may also refuse to participate in medical procedures they feel violate their personal moral standards. John Tyler's Deets advises students to seek nursing positions that avoid such dilemmas in the fi rst place. For example, nurses whose religions don't support blood transfusions may choose to work as school nurses rather than in surgical units.

"We encourage students to analyze their own value systems," Deets said. She recommends nurses also communicate their moral confl icts to supervisors well in advance so they can avoid taking patients who are scheduled to undergo procedures they don't support.

That being said, Deets added, nurses are legally and ethically bound to not abandon patients they have already taken. For example, if a nurse begins her shift caring for a patient who is suddenly scheduled for a procedure she does not support, that nurse is expected to see the patient through. Managers are less understanding in these situations, Deets said.

UVa's Lancaster said nurses may also feel certain medical procedures are beyond the scope of their training and experience. When a facility is missing several nurses in one department, managers may ask nurses from other departments to fi ll in.

Most of the time, managers will tap nurses with compatible training or fi nd nurses who have experience in both types of care. However, patient safety comes into play when a nurse feels ill-prepared. Nurses should use the same tactics in these cases that they use for negotiating other confl icts, she added.

"Be respectful, and keep focused on the 'I,' ", Lancaster said. " 'I feel unsafe to do that. Anytime it's a 'You can't make me do that,' people get defensive. Focus on what you do and what you know. Problem-solving is always easier when the anxiety level stays low." Support for new nurses

Nurses who are just beginning their careers may miss a physician's order as they struggle to adjust to the fast-paced world of nursing. INOVA Fairfax supports these nurses throughout their initial six-month fellowships by giving them badges that designate them as fellows.

This alerts medical staff that they are dealing with a new nurse, Conway-Morana explained. If a new nurse should miss a medication order, for example, the physician will often take that nurse aside and explain the medication's importance.

"This is creating an atmosphere that encourages teaching moments instead of pointing fi ngers and placing blame," she said.

VCU's Younger advises new nurses that ethical dilemmas such as questioning physician's orders are normal, and even experienced nurses deal with some type of ethical issue every day.

"Be an expert until you are an expert," Younger said, "And in the meantime, hang out with an expert... The goal of educating everybody is to keep your front line sound, and the last line of defense is to keep it ethical. It requires knowledge and character to do that."