Revisiting: A Personal Response to Moral Distress in Health Care

oil on wood 2008 J.Paradisi
Painting: Oil on wood 10″ x 10″ 2008 by J.Paradisi

This post was originally published February 2009. 

This morning I visited Pauline Chen MD’s Well blog at the NY Times on-line to read comments posted to her Moral Distress article. There were many, mostly from MDs, a few by nurses, and one from a patient, whose life was saved when an ICU nurse challenged the doctors treating him.  The strong emotions reveal the virulence of the topic.

The article resonated for me. I read it after returning home from a particularly busy shift. In the clinic, I saw a patient and knew something had changed since our last encounter. The tension in his muscles indicated pain, but he didn’t ask for medication. He knew better. Let’s just say that his track record of lifestyle choices make him a less than stellar patient. The package of cigarettes in his shirt pocket is his least dangerous vice and negates the purpose of the medication prescribed for his asthma. Still, something was clearly wrong with the man, and my job is to be his advocate, not his judge.

So I looked closer, to see if I could spot the problem. I found it: his calves were swollen to twice their normal size above his ankles; his filthy socks acted as compression wraps, so his ankles were deceptively normal. Taking a stethoscope to his chest, I heard the anticipated expiratory wheezes, but otherwise muffled breath sounds. I suspected CHF, congestive heart failure. We were treating him for another condition, unrelated to his heart, but CHF added itself to his problem list anyway. He needed treatment.

I paged the doctor who ordered his care. The doctor called me from the ICU, where he was treating a seriously ill patient, hopefully a compliant one. He patiently explained he was no longer treating my patient. He had only been brought in as a consult. My patient was not following instructions, and missed appointments. The doctor had sick patients needing his care making the effort to get well. He doesn’t have the time or resources to continue treating a patient thwarting all efforts to improve his condition. I understood.

Choices have to be made. Still, I was the one watching a human being struggle to breathe.  I called another health care provider, familiar with this patient, and he was sympathetic, but my patient wasn’t under his care either. I would guess this provider has fifty to one hundred patients just like this one committed to his care; I cannot accuse him of lacking compassion.

The patient in front of me was now wheezing audibly. Never particularly conversant, now he only responded to my questions in monosyllables.

I made a decision. I seated him in a wheel chair, and walked him to the emergency department. It was a particularly busy day there, but the Triage RN was very kind, and efficient. We were aware that this noncompliant, substance abusing, uninsured, suffering, frightened patient was very ill and would be admitted to an expensive, and hard to come by hospital bed. But what was our choice? In the face of economic crisis, outpatient resources are cut by the minute, leaving emergency departments and inpatient care the only avenues available for the uninsured.

And lately, the faces of the uninsured are morphing in front of me. They aren’t dressed in dirty socks and flannel shirts. Now I see unfunded patients with expensive college degrees who used to have jobs, and they are parents of a child or two, as lay- offs create a new kind of uninsured patient.  Will I be asked to choose which kind of unfunded patient gets care, as resources dry up? This is the moral monster underneath the bed I fear, and even with the lights turned on; it’s not my imagination.

Chickens, Nurses, and Personal Space

photo: jparadisi 2011

It’s a busy morning at work and the schedule is full. IV pumps keep alarming and the phone never stops ringing. Eventually it’s lunchtime. Besides food, I crave a half hour of quiet.

While eating lunch in the staff lounge, I read an article in our local paper about a new Oregon law requiring farmers selling eggs to make changes in how their chickens are raised by 2026. Another nurse, also on her lunch break, chats animatedly on her cell phone. The lounge is small, affording neither of us privacy. To me, a break is a time for quiet. For her it’s for socializing and catching up with the people she loves. People are wired differently, and neither of us is wrong. At least we have a nice place to sit and eat our lunches, even if the room is small.

The article I’m reading says the changes egg farmers must make under the new law include increasing the personal space of each chicken from 67 square inches to 116.3 square inches, which means less chickens per cage, therefore less eggs. Opponents of the law argue that a dozen eggs may cost $8 in order for the farmers to make a profit once all the changes go into effect.

As on egg farms, space is at a premium in hospitals too. Not only for patient beds, but also for storing equipment needed to care for patients (big things like ventilators and wheel chairs), examination and procedure rooms, storage of office supplies…it goes on and on.  Nurses’ break rooms do not earn revenue, just like increased personal space for chickens means less profit for the egg farmer who employs people trying to make a living. Perhaps happier chickens lay more eggs than crowded ones; I don’t know very much about chickens.

But I do know a little about nurses. We work in tight spaces under intense circumstances.  Sometimes we gather to vent or laugh a little at the nurse’s station. Often, we get too loud. It’s not right, but it’s human. Maybe we need more personal space too.

Maybe dampening the sound of voices with three-quarter Plexiglas partitions at the nurses’ station is an option. I saw this in a hospital in California, where my father was a patient. Initially, I was put off that I couldn’t talk to a nurse at the desk. However, if I called for a nurse from his room, someone answered my call within minutes every time. Because I was in his room, and not wandering the halls looking for a nurse, I had no idea what occurred in other patient rooms. Privacy prevailed. Partitions make sense when discussing patient information over the phone. Patients and their families wouldn’t hear that either.

Plexiglas partitions are not a good idea in an ICU, where they might block rapid response to a patient’s critical turn of events. An effective alternative I’ve seen is a small alcove where a nurse can sit with a direct view of patient and monitors when not administering care. Every two rooms shared an alcove containing a computer and two phones. This discourages nurses from congregating at the nurses’ station, and perhaps lessens the risk of falling prey to alarm fatigue.

Nurses often need reminders to quiet down in patient care areas, but thoughtful workspace design and consideration of a nurse’s personal space may offer a more consistent solution.

No Winning for Losing

Manga (we've made all your favorite foods) photo: jparadisi

Every year, the day after Halloween marks Opening Day of Seasonal Gift-Eating. Nurses, you know what I’m talking about. All over America, nurse lounges abound with gifts of food given to us by patients and doctors offices. Huge canisters of gourmet popcorn, boxes of chocolate, and homemade delicacies arrive and cover all available counter space. Even if there’s no time for a lunch break, there’s always a few seconds to grab a piece of fudge. So it’s a little unfair, in my opinion, that health care is focusing on the issue of obesity, even though I know it’s right.

Many patients, female in particular, cringe when I ask them to step on the scale at their appointments.  I don’t say their weight out loud, but simply enter it into their chart. In the December issue of the American Journal of Nursing, Carol Potera reports on the emotional impact on patients of words used to describe their weight in Words Can Hurt. The information comes from a study led by clinical psychologist Gareth Dutton. I found the study’s contrast of words used by physicians versus words used by nurses to describe patient weight enlightening.

Medscape published an article Is “Fat Bias” Making You Ineffective? by Marilyn W. Edmunds PhD, CRNP, in which she calls upon health care providers to reflect upon our biases and how they impact our patients. She also asks us to consider cultural differences in perception of weight.

We’re not the only ones looking and judging, however. Recently at an art opening, another artist told me I am the only nurse he’s ever met who isn’t overweight, and it wasn’t the first time someone has said this to me. I find this public stereotype of nurses more troubling than Dr. Oz’s sexy nurses, who were really women who lost weight, although I agree the entire debacle was in poor taste.

I want to throw one more point into this post. A patient came in raging about fast food chains. I didn’t really get it until he explained that fast food is cheap, so for people living on the limited resources of disability, it is affordable. All the fat, all the sodium, the lack of nutrients from over-processing, is all he can afford. And then he comes in for his appointment and gets lectured on his A1C Hgb results, hypertension, and obesity. In his opinion, there’s no winning for losing.

Water Envy


Today, JParadisi RN joins thousands of other bloggers around the world in support of Blog Action Day 2010 with a post about water.


photo by jparadisi 2010

Some readers know I was born on Catalina Island, and grew up surrounded by the waters of the Pacific Ocean. When I lived there, Islanders relied on rainwater collected at several sites for our drinking water. A lack of a dependable drinking water supply for the island prevented the Union Army from establishing a permanent army base for the U.S. government during the Civil War. Over a century later, a reliable supply of drinking water for the inhabitants and the tourism industry that supports the local economy is a source of concern. I remember one year, when it was a serious problem.

Late in the 1970’s, after several years of drought, the Catalina’s reservoirs were well below the needs of our community. That summer strict water rationing was put into effect for every household. Bottled water flew off the shelves of our two, tiny grocery stores, which were supplied twice weekly by barge shipments from overtown (the mainland). For an early adolescent girl, the idea of showering every other day for no more than 5 minutes was alarming. “Day after” hair was not cool in the 1970’s, where the shampoo ads encouraged us to have “squeaky clean hair.” Water meters were scrupulously monitored, and households using more than their ration had the water supply to their house turned off until the following month. I knew a woman who had an undetected water pipe leak under her house. She went over her ration the first month, and there was no mercy. She bought soap that foamed in salt water, and went to the shoreline each morning in her bathing suit to wash, until her water was turned back on.

There was no water rationing for the tourists in the hotels, however. Because the Island’s economy depends on tourism, civic leaders did not restrict tourists from taking showers. They were encouraged to be considerate, and asked to reuse their hotel towels. They were asked not to request glasses of water from the restaurants that served them unless they intended to actually drink the water. I remember feeling envious of the tourist girls my own age that had clean, shiny hair, smelled fresh and clean every day, and returned to homes where long, hot showers were not a crime against a community.

We were saved from further rationing by a winter of strong, steady rain. I have not forgotten what it is like to be afraid that there might not be enough water.

Today one out of every six people lives in a world where there is not enough water. 1.1 billion people in the world do not have access to safe drinking water. Another 2.6 billion people lack adequate sanitation.

A physician I knew volunteered his time and skills in a clinic in a third-world village, dispensing immunizations and antibiotics to children. He said that by the end of the week, he realized that without safe drinking water and sanitation, the medications were practically useless. He spent the remainder of his time in the village digging ditches for water pipe.

You can help. Go to Learn more. Sign the petition. Fund raise, or donate. It’s a human right to have access to safe drinking water and sanitation.

We May Not be Able to Control What Happens to Us, But We can Control How We Treat Each Other

Please be sure to read this most inspirational post about Charity Hospital’s 9 West medical first responder team, and their courage in caring for their patients and each other. The team was stranded for six days during Hurricane Katrina. Dr. Ruth Berggren tells her story to Dr. Pauline Chen for the New York Times Well Blog.

Sliding Down the Emergency Chute into the Rubber Room

Sometimes a Surgical Mask feels like a Gag by jparadisi

Insanity is doing the same thing over and over again, expecting different results.

Albert Einstein

The health care industry likes to compare itself to the airline industry on issues of reporting safety concerns and quality control. In a weird way, there is a parallel comparison between flight attendant Steven Slater’s dramatic exit from a jet last week and nursing. While the media and lawyers discuss Slater’s actions, I find myself wondering which daily, routine complaint about nursing is the one that could make me grab a couple of pudding cups out of the patient nutrition fridge and run screaming “I quit” through a fire exit during a hospital fire drill? Maybe I should have a few head shot photographs on hand for the media if it happens. You want a reality nurse show? I’m your girl.

A pilot told me the most common reason a flight is delayed for take off is because someone forgot to order ice for the beverage cart. It takes fifteen to twenty minutes to correct the oversight. The most common reason patient care is delayed in a clinical setting is a lack of physician orders.

Physician’s (or Nurse Practitioner’s) orders are the foundation of bedside nurse practice. Even with a patient sitting in front of you, demanding care, a nurse can do very little without a clearly written, dated, signed order with two patient identifiers (name and date of birth).  These precise rules of communication are safeguards of patient safety. Enforcing them does not reflect obstinacy on the part of the nurse. Because of this, trauma centers and high acuity areas like intensive care have protocols and collaborative practice order sets so nurses can start treatment in the absence of a physician, should crisis occur.

The patient with an appointment at an infusion clinic is usually not in crisis. The most common reason their appointment is delayed is the lack of physician’s orders. Often, there is an order, but it has the wrong date. Or there isn’t a patient’s name on it. Or the dose, or licensed practitioner’s signature was omitted. Or the MD’s office receptionist, who isn’t licensed, signed it. The variables are endless. When I pick up a chart and find an incomplete order, I call the doctor’s office for a legal order so that the appointment doesn’t have to be rescheduled, but there’s usually a delay. Physicians are as busy as nurses. If they are on, they are with patients, either in the office or at the hospital. Or they’re in their car somewhere between the office and the hospital (the era of them being on the golf course is long gone since before I was a nurse).

Lots of things have changed during my twenty+ years of nursing, but what constitutes a valid doctor’s order has not. We’re all human, and busy, and things get missed. Some doctors have software on their office computer that prompts them to write a complete order, and provides an electronic signature. This way, their office staff can pull it up and fax it to the clinic without interrupting the physician when they’re called for unsent or misplaced orders. Many hospitals are converting to physician computer order entry to prevent treatment delays and errors. However, most urban physicians admit patients to multiple hospitals, and this solution requires them to learn multiple computer programs. Understandably, many are resistant to do so.

And this is the quandary: Hospitals and infusion clinics depend on physicians to admit patients to them. Keeping them happy is a part of customer service. So, hospitals and infusion clinics are reluctant to mandate physician computer order entry. However, this creates another customer service problem: the delay or rescheduling of a patient’s treatment, resulting in unhappy patients who may choose to go elsewhere for services.

Sometimes when I phone a physician for orders after the patient has arrived for their appointment, he or she will say, “My office faxed those orders three days ago. Why am I getting called on the day of the appointment to fix my orders?” That is a very good question, and it’s the one that makes me feel like I’m taking crazy pills. How does a patient get an appointment scheduled if they don’t have valid orders, or any orders at all?

Someone forgot to order ice for the beverage cart. Someone forgot to look over the orders when they came through the fax machine.

People are human and mistakes happen. When the same problem occurs frequently, over and over again, something is wrong. There are many factors in health care beyond the control of physicians, nurses, and management, so that when there are factors that can be controlled, we should do so.

Before someone grabs a couple of beers and slides down the emergency chute.

Portland, Oregon: Nurse Practioner Provides for City’s Children & Needs Your Support

     Fellow Portlander, Registered Nurse, and blogger Peggy McDaniel posted this on my Facebook Wall yesterday:

Make a difference and help out Dr. Janie. Copy and paste this as your profile status. Help underprivileged kids get critical medical care by voting for Rose City Pediatrics Pepsi Refresh grant. Vote today and every day through the end of the May.


Pepsi is giving away millions each month to fund refreshing ideas that change the world. The ideas with the most votes will receive grants, so vote for your favorites. Do you have an idea that needs support? Learn how Pepsi can help.
The American Journal of Nursing has posted it nationally on their blog Off the Charts.
So, click on the Pepsi Refresh link above, and vote for Dr. Janie’s (a pediatric Nurse Practitioner) project providing health care to Portland’s uninsured children.
Peggy also sent a link to this article from the Portland Tribune,  providing more information about the project. Please join me in supporting it with your vote.

What You Focus on Expands

    Yesterday morning, I attended an awards breakfast at the hospital I work for, honoring 105 nurses with Certificates of Nursing Excellence. My colleagues were recognized for developing patient safety and education programs, precepting, and academic or certification achievements. I received recognition because the American Journal of Nursing published my painting Love You to Death on its October 2009 cover. I was scheduled to work during the breakfast, but two days earlier, our manager arranged patient scheduling so I could attend, without burdening my coworkers with extra work.

     The usual hospital administrators, with the addition of a Chief Nursing Officer, presented the awards. This executive nurse sits on our hospital’s Board. To my knowledge, she is the first nurse to sit on the Board. She makes significant contributions to nursing management.

     Home from work, I checked my email and found that senior art editor Sylvia Foley mentioned both of my blogs, JParadisi RN’s Blog and Die Krankenschwester in a post on the AJN blog Off the Charts.

     Recognition for hard work feels good.

     There are more than 105 excellent nurses working at our hospital. Many simply did not fill out the form required to receive recognition. They choose to work hard without it. We are all wired a little differently, in that respect.  I used to prefer staying under the radar too. But part of taking care of me is taking time to celebrate accomplishments, instead of keeping track of failures. What you focus on expands.

     Happy Nurses Day.

If They Could See What Nurses See: Health Care Reform Passes

Opening Skies photo: JParadisi

     I wish declaring war on Iraq had stirred the same amount of energy which Health Care Reform has. Each endeavor involves spending huge sums of money and pivots on lives in the balance.

     The anger of those opposing Health Care Reform is vehement. Crowds shouting slurs at senators, threatening them with violence in voice messages for voting in favor of the bill, while prominent citizen and member of the opposition Sarah Palin tweets Don’t Retreat, instead RELOAD! to her followers demonstrates that no one is safe from bullying and workplace violence

     I would like Health Care Reform to go further, still, it’s a big step towards the betterment of the lives of our citizens. Its importance became real to me last week, just days after the bill’s passage, as I listened to young patients living with treatable, chronic illnesses tell me that they are enrolling in college, or taking the job offered to them, because they no longer have to plan their lives around qualifying for disability payments for their pre-existing conditions. Hearing young adult patients express how a future of independence has suddenly opened up for them, because Health Care Reform passed brought tears to my eyes. I wonder if those who oppose Health Care Reform are so blind that a tear could not escape from their eyes too, if they could see what nurses see.

Comparing Apples to Oranges: Pharmacist Eric Cropp & Registered Nurse Anne Mitchell

     On Tuesday, February 16, 2010, JParadisi RN’s Blog had the most site hits since its debut in January, 2009. The day is notable, because the blog’s post Whistle Blowers & Patient Advocates: When the Nurse Stands Alone was mentioned by Shawn Kennedy on the AJN blog, Off the Charts.  I assumed the two events were connected. Imagine my surprise: they are not. The stats for JParadisi RN’s Blog show that the most popular post on February 16 was an older post:  Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient. For the entire week that post and the posts with updates about Eric Cropp were the most viewed on my blog.

     Eric Cropp served 6 months of imprisonment for involuntary manslaughter in the death of 2 year-old Emily Jerry. Emily Jerry died when she received a chemotherapy solution containing a lethal dose of sodium chloride mixed by a pharmacy technician at the hospital where Eric was the supervising pharmacist. The Ohio Board of Pharmacy stripped Eric of his license prior to his conviction.  Now a convicted felon, he will never practice pharmacy again.

     Why the renewed interest in the Eric Cropp case, during the immediate aftermath of the Anne Mitchell trial? Anne Mitchell, RN was publicly supported by the Texas Nurses Association and the American Nurses Association. The TNA donated funds for Mitchell’s legal defense, and the Texas Medical Board acknowledged Mitchell’s duty as a patient safety advocate. Mitchell was found not guilty. There were no fatalities in the Anne Mitchell case. The most obvious difference drawn from a comparison of the two trials is that a child’s death initiated the criminal charges against Eric Cropp. Perhaps this explains why pharmacist professional associations appear silent on the matter. Searching  two prominent organizations websites with the keywords “Eric Cropp” I found only one article about the case on one site, and none on the other. Granted, defending a person accountable for the accidental death of a toddler creates an unpopular challenge in public relations. 

     Physicians are familiar with lawsuits involving the death of patients.  It is rare for a doctor to go to prison or be stripped of his or her license in such a case.  Eric Cropp was convicted of criminal charges in the absence of public support, except for  Michael Cohen of ISMP.  Whether this is right or wrong is a matter of opinion.

     The  pharmacy profession lost an opportunity to speak about patient safety systems, staffing issues, medication compounding practices, pharmacist to technician ratios, and other problems similar to those nurses have brought to public attention for years.  In contrast, the TNA, and ANA used Anne Mitchell’s trial to educate the non-medical public about the patient safety advocate role of nurses. It is important to remember that the non-medical public is unfamiliar with common hospital practices. In my opinion, there is an expectation for professional organizations to educate the public on the scope of practice of its members. It is unfortunate that this opportunity was missed during the Eric Cropp trial. 

     Did a lack of support and public education lead to the setting of  a disturbing  precedent: the criminalization of medication errors? (Will the Criminalization of Medication Errors Make Patients Safer in Ohio?).           

     Eric Cropp was released from jail on February 15, 2010, and this explains the increased traffic to JParadisi RN’s Blog on February 16, in the aftermath of the Anne Mitchell case. It was only a coincidence. Whether or not pharmacists compare the two very different outcomes of these trials, I do not know.

      I am married to a pharmacist.  However, for most of my career, I was a pediatric intensive care nurse dedicated to saving the lives of children like Emily Jerry. I saw firsthand families devastated from losing a child under less unusual circumstances. The opinions expressed in this post do not diminish my sympathy or empathy for the family of Emily Jerry.