Running Head: MORAL DISTRESS THROUGH DISHONESTY IN NURSING 1

Moral Distress Through Dishonesty in Nursing

Morgan Timberlake

James Madison University

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Introduction

Integrity, compassion and honesty are all vital characteristics of the nursing profession

and the public entrusts nurses to display these values in their daily practice (Wirtz 2017). “In a

2015 Gallup Poll asking Americans to rate the honesty and ethics of various professions, nurses

ranked highest — for the 14th straight year” (Gupta 2016). While the public expects nurses to

steadily uphold this moral integrity, nurses are routinely faced with situations that question their

moral judgment and honesty. A combination of being overworked, underappreciated and

undercompensated can lead to situations in which nurses may be dishonest, threatening the safety

of themselves, the patient and the hospital.

Background

During one of my clinical rotations this semester I was faced with an ethically

challenging situation that caused me to feel morally distressed. While observing my preceptor

administer oral medications the patient dropped one of the pills on the ground. The nurse

proceeded to pick up the pill and dispose of it in the sharps container, telling the patient that she

would get another pill for him and return back with it later. Before leaving the room the nurse

charted that the patient received all scheduled medications at that time and went on to care for

her other patients. A few hours passed and the nurse had not gone back to give the first patient

the missing pill. Before leaving to take a lunch break I decided to ask the nurse if she had pulled

another pill from the machine to give to the patient, and she responded with, “No, but he’ll be

fine, I think it was just one of his vitamins.” The nurse went on with the rest of her day and we

did not mention the situation again.

This situation was an example of moral distress. While I knew it was wrong to document

that a patient received a medication they did not, I was afraid to confront the nurse in fear of
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upsetting her or coming off in an accusatory way. I had a “gut feeling” that something was

wrong the rest of the day, but after having already mentioned in to the nurse I was unsure of what

else to do, and thought that if she didn’t think it was an issue then maybe it wasn’t. I knew what

actions needed to be taken, I was just afraid of taking them. Looking back on the situation I

should have approached the nurse again at a later point in time asking about the medication, and

tried communicating that I felt uncomfortable that the patient’s chart reflected him receiving a

medication that he did not. If the nurse still did not return to give the pill to the patient, I could

have gone to my clinical instructor with the situation and she could have talked with the charge

nurse and determined a better course of action.

Methods/Findings

The Madison Collaborative at James Madison University compiled a list of Eight Key

Questions to “reflect the best of humanity’s ethical reasoning traditions”. These questions are

meant to be a framework and “serve as prompts at the point of decision making” (James Madison

University). I will be using them to analyze the situation described above.

The first question deals with fairness: “How can I act equitably and balance all legitimate

interests?” In order to answer this question, it is important to identify the “interests” in this

scenario: the interest of maintaining a productive, beneficial relationship with my preceptor, and

the interest of ensuring the patient’s safety and proper care. In order to act fairly and still balance

both interests, it would have been best to first give the nurse the opportunity to correct her

actions in a nonjudgmental way, and then go to someone higher up in the chain of command if

the patient’s needs were still not met.

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The second question involves responsibilities: “What duties and/or obligations apply?” In

this situation the duty to provide the best care to the patient is extremely evident and takes

priority. Nurses have an obligation to give their patients the best care possible.

The third question touches on authority: “What do legitimate authorities (e.g. experts,

law, my religion/god) expect of me?” There are many rules and laws that govern the nursing

practice. The American Nurses Association wrote a Code of Ethics for Nurses detailing the

ethical obligations of nurses. Provision 2 of the code states: “The primary commitment of the

nurse is to the patient…” (National Student Nurse’s Association 2016). Provision 2.1 further

goes on to state that the interests of the patient are primary, meaning that the nurse’s principal

commitment is to the patient’s needs and desires. From this, it is clear that the patient should

have received the medication he was ordered, and any action to ensure this should have been

taken.

The fourth question focuses on rights: “What rights (e.g. innate, legal, social) apply?”

The patient has the right to receive the best healthcare available, and they have the right to

receive any medications ordered for them.

The fifth question discusses character: “What action best reflects who I am and the

person I want to become?” As a student nurse, my goal is to become a respected nurse and

provide the best care for my patients. In reflecting on this goal, the best action to take in the

situation would have been to advocate for the patient, regardless of fears from any repercussions.

The sixth question brings up empathy: “What would I do if I cared deeply about those

involved?” If the patient was a loved one, I would be angry if he did not receive a medication he
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had been ordered. I would want the absolute best care for him, and that would include any and all

medications he needed, even if it was just a vitamin.

The seventh question explores outcomes of the situation: “What achieves the best short-

and long-term outcomes for me and all others?” While maintaining a positive relationship with

my preceptor is important, I think that patient safety and care are the top priority and trump the

desire for a friendly work relationship.

The last question talks about Liberty: “How does respect for freedom, personal

autonomy, or consent apply?” While this question is valid in many different situations, the

concepts of freedom, autonomy and consent does not directly apply to this situation.

Conclusion

Morally distressing situations are just that: distressing. It is difficult in the moment to

come up with the best course of action, but that is why it is imperative to analyze the situation

afterwards and be better prepared for the next time. Through analysis of the situation using the 8

Key Questions I now feel as though I know what actions should have been taken, and I will be

more prepared to take these actions in the future. In answering each of the 8 Key Questions I

have realized that the best action to take would have been to more efficiently and firmly

communicate with the nurse, and then bring the attention of other people, such as my clinical

instructor, to the situation. I could have restated the issue to the nurse and clearly explained why

I was uncomfortable with it. I realize that the needs and safety of the patient should have been

prioritized over my fears of ruining the relationship with my preceptor. Although it can be

difficult to speak up in certain situations, patients expect nurses to always maintain the highest

level of integrity, and that starts with always being honest, both with yourself and with the

patient.
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References

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in

action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml

Gupta, S., Dr. (2016). Why America's Nurses are Burning Out. Everyday Health. Retrieved

March 18, 2018, from https://www.everydayhealth.com/news/why-americas-nurses-are-

burning-out/.

National Student Nurses’ Association, Inc. (2009). Code of Ethics: Part II, Code of academic

and clinical conduct and interpretative statements. Available from http://www.nsna.org

Wirtz, E. F. (2017). The Moral Integrity Development of Nursing Students in Two-year

Colleges. Retrieved March 18, 2018, from

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.616.4022&rep=rep1&type=pdf