Every one of them took a full semester course in nursing ethics. They’d 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 weren’t 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 wasn’t enough.
In Krautscheid’s 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 patient’s 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 shouldn’t do this,’” Krautscheid says. Only one did. She turned to the preceptor and said that’s 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 follow-up 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?
“It’s 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 Krautscheid’s simulation who did not speak up. “It’s 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 she’s 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 infant’s 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 I’d 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 patient’s room and come back that he needed to put on new, sterile gloves. She didn’t say anything. Next time, Mazelin says, she will speak up. But it won’t be easy.
“We’ve learned everything we should do that is ethically right,” Mazelin says. “But we haven’t learned how to have that conversation.”
Learning to speak up
Mazelin says she’d like more simulation opportunities aimed specifically at ways to confront authority figures without being confrontational. Nursing school leadership classes might help, she adds. And she’d 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 shouldn’t 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. “They’ll do a quick swipe, a once over, and say that’s 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, Britton’s preceptor, told him that if the patient got an infection, “Well, that’s 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 didn’t think it was brave because I didn’t confront her and say, ‘Hey, you’re doing it wrong,’” he says. “I felt like I was more protecting myself and my patient by being sneaky about doing it.”
Britton says he’s “not good at confrontation.” He’d like to see nursing schools teach students how to speak to fellow employees in a more assertive fashion. And he says he’s still not sure if he’d 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. Krautscheid’s 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 don’t.”
It isn’t easy to teach people to behave in ways that put themselves at risk, according to Sager. “We’re pretty good at teaching things that most people learn to do. We’re not really that good at teaching people to be exceptional,” he says.
Sager says Krautscheid’s 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 it’s not hard,” Sager says. “The best thing we can do is try to create environments where we don’t 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 authority.”
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 can’t cover every potential situation, but moral imagination can prepare students for situations they haven’t been asked to consider.
“Some people think of ethics simply as applying rules,” Sager says. “It’s 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 doesn’t 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.”
