Nurse P is a staff nurse in the coronary care unit of a large medical center. One morning he is informed that a patient from the recovery room will soon be admitted to the coronary care unit and assigned to him. The patient, a white man, 67 years of age, with known history of myocardial infarction, also has cancer of the prostate. The initial hospital admission was for a transurethral resection, which had been aborted in the operating room when the patient developed cardiac changes following spinal anesthesia. The patient had been transported to the recovery room with the diagnosis of possible myocardial infarction and was to be transferred to the coronary care unit for management and evaluation.

Nurse P heads to the recovery room with a bed to pick up the patient. When he arrives, the patient is being coded. He had apparently gone into ventricular tachycardia/ventricular fibrillation in the recovery room and had required countershock, cardiopulmonary resuscitation (CPR), intubation, lidocaine, and vasopressors to maintain his blood pressure. A Swan-Ganz catheter was put in place. Recovery rhythm was sinus bradycardia to sinus tachycardia with occasional pauses. The patient was acidotic, in pulmonary edema by chest x-ray with an alveolar oxygen partial pressure (PaO₂) of 50–60 mm Hg, a fraction of inspired oxygen (FIO₂) of 100%.

During the events of the code, an attending cardiologist (Dr. D) passed by, observed the code, and made the following statement to the recovery room staff and coronary care unit resident: "Say, that's Mr. S. I know him from his last hospitalization of 1 month ago when I was attending in coronary care unit. I believe he has a living will." While the patient is stabilized, Dr. D calls the patient's relative, who happens to work in another part of the medical center. The relative also expresses the belief that Mr. S has a living will and does not want to receive extraordinary support measures. Dr. D relays this information to the other physicians, and there is general agreement that conservative measures to ensure support are indicated while the living will is located.

The coronary care unit resident and Nurse P transport Mr. S to the coronary care unit. When admitted, the patient's systolic blood pressure is 70 mm Hg while on dobutamine 8 mcg/kg and dopamine 26 mcg/kg. The patient occasionally responds to verbal commands, opens his eyes, grips Nurse P's hands, and responds to pain in the upper extremities (his lower extremities are still under the effects of the spinal anesthesia). Cardiac monitoring shows that the patient is still having sinus tachycardia.

At this point, the coronary care unit resident and an intern approach Nurse P and inform him that they believe that the present treatment of the patient is cruel. Upon locating old medical records, they learned that the patient had been designated "do not resuscitate" (DNR) on his last admission, and the patient is supposed to have a living will, although it has still not yet been located. They order Nurse P to slowly turn off the intravenous (IV) drip of dopamine and dobutamine. Nurse P is faced with an ethical dilemma.

Patient M, a woman, 34 years of age, is in critical condition and is scheduled for emergency surgery following a severe motor vehicle accident. You have been informed that her two children have been killed in the crash. She is almost hysterical and is asking you repeatedly about the condition of her children as you prepare her for emergency surgery. Do you tell the mother the truth about her children at this time or wait until after the surgery?

Patient J, a man 35 years of age, was involved in a fight and sustained a large laceration to the center of his forehead. The patient presents to the emergency department alert and oriented without significant findings other than the 10-cm laceration. However, his speech is slurred, and he readily admits to drinking 10 beers during the last few hours. The emergency department is very busy with more urgent cases, and the patient becomes impatient because of the wait. Patient J wishes to leave but is urged by the ED staff to wait and is told that he should not drive. He is clearly lucid and states that he will not wait any longer and intends to drive himself home.

(From the book Leadership Roles and Management Functions in Nursing: Theory and Application, in a chapter entitled "Ethical Issues" [45].)

You are a nurse on a pediatric unit. One of your patients is a girl, 15 months of age, with a diagnosis of failure to thrive. The mother has stated that the child appears emotional, cries a lot, and does not like to be held. You have been taking care of the infant for the two days since her admission, and she has smiled and laughed and held out her arms to everyone. She has eaten well.

There is something about the child's reaction to the mother's boyfriend that bothers you. The child appears to draw away from him when he visits. The mother is very young and seems to be rather immature but appears to care for the child.

This is the second hospital admission for this child. Although you were not on duty for the first admission six weeks ago, you check the records and see that the child was admitted with the same diagnosis. While you are on duty today, the child's father calls and inquires about her condition. He lives several hundred miles away and requests that the child be hospitalized until the weekend (it is Wednesday) so that he can "check things out." He tells you that he feels the child is mistreated. He says he is also concerned about his ex-wife's four-year-old child from another marriage and is attempting to gain custody of that child in addition to his own child. From what little the father said, you are aware that the divorce was very bitter and that the mother has full custody.

You talk with the physician at length. He says that after the last hospitalization he requested that the community health agency call on the family. Their subsequent report to him was that the 4-year-old appeared happy and well and that the 15-month-old appeared clean, although underweight. There was no evidence to suggest child abuse. However, the community health agency plans to continue following the children. He says the mother has been good about keeping doctor appointments and has kept the children's immunizations up to date.

The pediatrician proceeds to write an order for discharge. He says that although he also feels somewhat uneasy, continued hospitalization is not justified and the state medical aid will not pay for the additional days.

When the mother and her boyfriend come to pick her up, the baby clings to you and refuses to go to the boyfriend. She is also very reluctant to go to the mother. All during the discharge you are extremely uneasy. When you see the car drive away, you feel very sad. What should you do?

Upon returning to the unit, you talk with your supervisor, who listens carefully and questions you at length. Finally, she says, "It seems as if you have nothing concrete to act upon and are only experiencing feelings. I think you would be risking a lot of trouble for yourself and the hospital if you acted rashly at this time. Accusing people with no evidence and making them go through a traumatic experience is something I would hesitate to do."

You leave the supervisor's office still troubled. She did not tell you that you must do nothing, but you feel she would disapprove of further action on your part. The doctor also felt strongly that there was no reason to do more than was already being done. The child will be followed by community health nurses. Perhaps the disgruntled ex-husband was just trying to make trouble for his ex-wife and her new boyfriend. You would certainly not want anyone to have reported you or created problems regarding your own children. You remember how often your 5-year-old bruised himself when he was that age. He often looked like an abused child. You go about your duties and try to shake off your feeling.

From the Journal of Nursing Administration, we find a case to study regarding the public and professional responsibility of hospitals [46]. Hospitals throughout the country are held in high esteem within their communities for public service. They earn the public's trust by providing safe, good quality patient care. Many community hospitals serve as teaching sites for students' practicum programs, as did the hospital in this case study. Health facilities also have an obligation to share the responsibility for the quality of the nursing program by providing practice sites and nursing role models. In the case presented, the hospital should have been more proactive in addressing the quality of this practice issue.

MW is a senior nursing student at a local university. The university's nursing program requires a 200-hour practicum be completed six weeks before graduation. MW chose the intensive care unit (ICU) at a community hospital for her practicum site. MW contracted with one of the ICU staff nurses to serve as her preceptor for the six-week time period. The nurse preceptor is responsible for assisting MW to meet the course objectives. MW, the nurse preceptor, and the nursing instructor met before the practicum to discuss course objectives and expectations.

During the six weeks, MW was assigned to work the same schedule as the nurse preceptor, which was the night shift. Within the first week, the nurse preceptor reported to the ICU nurse manager that MW had displayed some inappropriate behaviors. These behaviors included inappropriate dress for work, an arrogant attitude toward the staff nurses, and considerable discussion about the amount of money MW would make as a nurse. The nurse manager and nurse preceptor discussed these issues with MW, and the behaviors improved somewhat.

By the end of the second week, the nurse preceptor reported another disturbing incident to the nurse manager. During the previous shift, MW and the nurse preceptor cared for a peritoneal dialysis patient. The nurse had explained the dialysis process to MW, and MW assisted with some of the procedure. After one of the dialysis exchanges, MW was instructed to empty and measure the dialysate output. Under the nurse preceptor's supervision, MW completed this procedure. MW and the nurse preceptor concurred that the amount of fluid removed from the patient was 1,400 cc. MW was given the responsibility of recording the amount on the dialysis flow record.

At the end of the shift, when intake and output was being calculated, the nurse preceptor noticed that the amount of dialysate fluid recorded by MW was 1,000 cc. When questioned about the discrepancy, MW responded that the recorded 1,000 cc amount was similar to the amounts recorded by other nurses. The nurse preceptor explained that the dialysate had been changed for the purpose of removing more fluid; thus, a greater amount of dialysate output was desired and expected from this dialysis exchange. MW stated that she did not want her recorded amount to be dramatically different from other recorded amounts. The nurse preceptor reinforced the reasoning behind the dialysis orders and that the actual amount removed is what needed to be recorded. When MW did not correct the dialysis flow record, the nurse preceptor recorded the actual dialysate output.

The nurse manager documented the incident and contacted the nursing instructor. The nurse manager informed the nursing instructor that MW's practicum in the ICU was terminated, and she would not be allowed to return to the ICU. The nurse manager requested that the incident be reviewed by the university's nursing program before MW continued the program.

The nursing instructor discussed the incident with MW. Later, the nursing instructor told the ICU nurse manager: "The incident does not appear to be serious. MW is completing her practicum requirement at another hospital and is doing great. She will be graduating with her class." Following this conversation, the ICU nurse manager discussed the incident with the hospital's director of nursing and sent a letter to the dean of nursing at the university documenting her concerns about MW's performance. The nurse manager never received a response to this letter. MW went on to another ICU clinical site to continue her practicum. When the nurse manager at the new facility was alerted to the previous incident, she monitored MW closely. She and the charge nurse of the ICU unit found similar inaccuracies in documentation. Further, documentation was made for vital signs by MW. However, she was observed during one shift to have not taken a blood pressure cuff or thermometer into any of her patient rooms. When the charge nurse took her own vital signs on the patients, none matched the documentation of MW.

When approached, MW indicated that "vital signs don't change much in four hours and probably don't need to be monitored that often." When questioned about the vital signs she had recorded, MW stated, "I don't want my charting to stand out and be different. None of my patients have been harmed, so I don't see what the problem is." MW was terminated from this practicum site as well and told she could not apply for a position there after graduation.