Running

Head: MORAL DILEMMA IN CONVENIENCE VERSUS SAFETY 1

Moral Dilemma in Convenience versus Safety

Tara Phelan

James Madison University

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Introduction

As nurses gain more experience, they feel more confident in their skills and decision-

making. When this occurs, nurses may feel comfortable enough to cut corners or skip steps in

order to make their job easier and more convenient. Changing a patient’s bedding is an example

of this. Many nurses view this task as low priority and time consuming, especially if the bed has

to be made while the patient remains in it. However, changing soiled linen is one of the keys to

preventing hospital acquired infections (Mehta et al., 2014). Hospital acquired infections (HAI)

are a huge issue in health care both for the safety of the patient and cost to the hospital.

Contaminated linens serve as a breeding ground for bacteria as the area beneath the patient is

warm, dark, and damp (Fijan & Turk, 2012). Therefore, high importance should be placed on

both inspecting linens of incontinent patients as well as changing soiled linens once they are

noticed. Registered nurses should be cognizant of the need to prevent HAI and set a good

example for student nurses by following procedure.

Background

During my clinical experience, I was working with a patient who was incontinent and

obtunded. A fellow nursing student and I were giving the patient a bath when we realized he had

a bowel movement and his brief needed changing. At the same time the patient’s RN came into

the room. She grabbed us a new brief, told us to clean him up and put on the new brief. I noticed

there was stool that had gotten on his bed pad and fitted sheet, so I said we would change that as

well. The nurse responded, “Oh no, don’t worry about that. I’ve just been wiping it off and its

fine.” She then left the room. The other nursing student and I both looked at each other, confused

by the nurse’s statement. The patient’s brother was standing at the bedside and looked concerned
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by the comment. I decided it was in the patient’s best interest for us to still change the sheets

despite what the nurse said, so I left the room to grab a clean set of linens. The other nursing

student and I cleaned the patient, put a new brief on him, removed his soiled linens, and put a

fresh set on his bed.

In this situation, I decided to go against what the nurse said and do what I thought was

best for the patient and his safety. In class we are taught to change soiled linens, prevent

hospital-acquired infections, and make sure patients are comfortable, clean, and safe like we

would want our own family member. I easily could have listened to the RN and not changed the

patient’s sheets since she is in charge. I could have listened to her order and had the patient

remain lying in linen soiled from his own stool. This situation created a moral dilemma for me. I

was torn between listening to the nurse who was an authority power, or changing the patient’s

bedding because I felt it was the safest thing to do for the patient. It was a challenging decision,

but it was helpful that I was with another student nurse who was experiencing the same

emotional struggle. Between the two of us, we decided to take action and change the soiled

linens to prevent infection and promote the safety and well being of the patient.

Methods and Findings

To analyze this situation, JMU’s Eight Key Questions are very helpful. They provide a

framework of questions to assist in making difficult ethical decisions and consider different

possible outcomes (The Madison Collaborative, 2013). The first is fairness, which involves

balancing the interests of everyone involved. For my scenario, I thought it was not fair for the

patient to have to sit in old stool for the convenience of the nurse. The next question is outcomes,

both short and long-term. In the short term, not changing his sheets would take less time,
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however in the long term the patient could develop a hospital acquired infection or pressure

ulcers. Additionally, a new nurse could come in the room to turn the patient and get

contaminated feces on her hands or the patient’s family may view the hospital’s quality of care

poorly from what they witnessed. For the question of responsibility, it was my duty as a nurse to

provide the safest, most effective care for the patient. Based on research it is much safer to

change soiled linen to prevent contamination or hospital acquired infection. For character, I

thought of what choice would help me become the type of nurse I want to be. I want to be seen

as compassionate, caring, and competent and felt that by getting new linen I would be fulfilling

that and the patient’s family would see that as well. Liberty was tough for me to consider since

the patient was not fully alert to realize what was happening. I thought of it from the perspective

of “do no harm” by preventing infection and contamination. Empathy was a huge factor in my

decision-making. I thought of if my grandma or parents were in this situation, I would want their

sheets changed without a doubt. No one would want to be sitting on sheets dirtied by their own

stool, nor would a family member want to watch and be aware of that. I also thought about

rights, and my right to care for a patient and the patient’s right to receive quality care. To meet

those rights, I had to choose to promote the patient’s safety.

The final question from the Eight Key Questions is authority. For this I referred to the

ANA Code of Ethics. The American Nurses Association states, “The nurse promotes, advocates

for, and protects the health, safety, and rights of the patient” (2015). Going by what the ANA

requires of nurses, I should be promoting my patient’s safety and changing his soiled linen. On

the other hand, the nurse was also an authority figure in this situation, so I considered what she

wanted me to do as well. In my scenario, I found the ANA authority outweighed the authority of

the nurse and had a bigger influence in my decision-making.

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Conclusion

Facing a moral dilemma is challenging, especially for student nurses who do not have as

much experience with dealing with these difficult situations. In my scenario of the nurse

instructing us not to change soiled linens, I think I made the ethically right choice in replacing

the bedding despite the nurse’s instructions. Faced with the same scenario I would do the exact

same thing. I do however feel that the nurse should know what she was doing is unsanitary and

not in the patient’s best interest. As a student nurse though, it may not be my place to tell her.

Instead, I could tell my clinical instructor and see what she thinks we should do. She may be able

to tell the nurse RN to RN, tell the nurse’s supervisor, or decide that no further action is needed.

Overall, I think it is very important for nurses to always be cognizant and place the

patient’s health and safety as top priority. There are plenty of shortcuts to make the job easier or

more convenient, such as not changing the sheets of an incontinent patient, however if they

infringe on the patient’s safety they should not be made. Additionally, nurses should be aware of

the example they are setting for student nurses. Student nurses are the future of the healthcare

field, so we should aim to make them as qualified and educated to promote patient health and

well-being. As a student nurse, I value the knowledge nurses can impart on me. I am watching

everything they do so I can replicate their actions. Nurses should strive to set an example that

teaches students the proper ways of handling situations and making ethically and morally correct

decisions. Fellow nurses should not be the source for ethical dilemmas or distress. On the other

hand, if a situation does arise, students should have the courage to stand up in ethically

challenging scenarios to ensure patient safety and care is held as a top priority above

convenience.
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References

American Nurses Association. (2015). Code of ethics with interpretive statements. Retrieved

from (will put link when the ANA website is available)

Fijan, S., & Turk, S. (2012). Hospital textiles, are they a possible vehicle for

healthcare-associated infections? International Journal of Environmental Research and

Public Health, 9(9), 3330–3343. http://doi.org/10.3390/ijerph9093330

Mehta, Y., Gupta, A., Todi, S., Myatra, S., Samaddar, D. P., Patil, V., … Ramasubban, S.

(2014). Guidelines for prevention of hospital acquired infections. Indian Journal of

Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of

Critical Care Medicine, 18(3), 149–163. http://doi.org/10.4103/0972-5229.128705

The Madison Collaborative. (2013). The eight key questions handbook. Retrieved from

https://www.jmu.edu/mc/Docs/131101%208KQ%20Handout%20Revision.pdf