Mr. Jones, a patient who is 100 pounds overweight, has been put on a 1,000 calorie weight-reduction diet during his stay at a long-term-care
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facility until his leg ulcers heal. He receives one half of a hamburger, a few vegetables and pieces of fruit, and black coffee for lunch. Mr.
Jones's resentment about his dietary restrictions and lack of dietary control builds every day. Will this dietary regime provide any long- term benefit for Mr. Jones? Hardly. Mr. Jones will probably eat even more when his stay in the long-term facility is over. Good luck to Mr. Jones.
Second Scenario
Nurse Smith understands how to make a real difference with Mr.
Jones. She asks his doctor to order a regular diet, enabling him to make his own food choices. She, along with the dietician, works with Mr. Jones to learn how to make better food choices. She asks the food service to provide Mr. Jones with high-bulk, low-calorie foods such as stir-fries and vegetable soups. She reminds him how weight reduction can improve his quality of life and enable him to return to his hobby of fly-fishing. Motivation, flexibility, and patient involve- ment make a big difference to Mr. Jones, who continues to gradually lose weight after discharge.
In the first scenario, the staff required Mr. Jones to follow a rigid, senseless plan. In the second, nurse Smith thought critically and used a flexible approach. Although Mr. Jones was not able to lose a dramatic amount of weight immediately, nurse Smith's thoughtful intervention started him on the road to healthier living.
Flexibility Strengthens Medical Ethics
Organizations often think that their rigidity is the best way to provide ethical care, but that is not so. Read what Marvin T. Brown says in his book, Working Ethics (1990):
People... interested in ethics will understand the differences be- tween an ethics of rules, which attempts to control behavior, and an ethics of decision making, which empowers people and organizations.
—Marvin T. Brown
Staff empowerment is again considered to be vital for effective management. Consider how this concept can be applied to the nurs- ing crisis. A charge nurse discovers that a patient is in physical decline. She reports the patient's deteriorating condition to the phy- sician who fails to grasp the severity of the situation. The charge nurse also takes her ethical responsibility to her patient seriously and confers with the supervisor. Supervisors generally choose one of two options: (a) They do what is easy. If they fear offending the physician, they play it safe and fail to act, which leaves nurses without any support while they advocate for patients. Or (b) supervi- sors do what is right. Great supervisors choose the second option and do what is right despite potential criticism.
Consider this example of doing what is right: After a supervisor conferred with a charge nurse about a patient's deteriorating condi- tion, she called the physician back herself. Although the physician lived 30 minutes away and it was 10:30 at night, he arrived at the hospital to examine the patient within 45 minutes.
This illustrates the ethics of decision-making that empowers peo- ple. The supervisor, as an empowered manager, intervened appropri- ately to promote the patient's best interest.
Consider the following example about the need for flexibility as reported by W. Mitchell (1997), a paraplegic patient who was under- going rehabilitation. He had already recovered from severe burns from a prior accident.
I had to fight mighty battles for privileges that are taken for granted in the real w o r l d . . . For example, there was the battle of the telephone system. When this second accident had occurred, I was quite a successful businessman with interests and investments all across the nation. On a normal day, I made perhaps thirty telephone calls, and I had no intention of changing that. The insistence on rest and quiet in hospitals is often just an invitation for the patient to worry about his awful fate. I chose to get on with my life.
The hospital's telephone system required every call to go through an overworked operator, and it shut down completely at 8 p.m. It was ade- quate for chatting with one's wife about how the kids are doing in school.
It was a disaster for someone with needs like mine.... I actually became the first patient in the history of that hospital to have a private, outside line strung into my room at my request, and at my expense, of course.
(Mitchell, 1997, p. 63)
Mitchell's long-term goal in his chart was probably something like the following: Achieve maximum physical and mental functioning.
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Following hospital policy to the letter and denying Mitchell the phone line sabotaged this goal and would have decreased his mental and physical functioning, the opposite of his plan. Was his request illegal, unethical, or harmful? No!
Consider how a lack of critical thinking would have interfered with Mitchell's recovery had he not insisted in having his needs met:
It would have reduced his rehabilitation potential.
It would have disrupted his relationship with the treatment team.
It would have compromised his ability to function as a success- ful businessman.