Having a “crucial conversation” with a nurse is a delicate balance between protecting clinical standards, providing a teaching moment, and even protecting patients and the clinical organization you serve.

When the issue that needs to be addressed is an unethical situation, the conversation can sometimes require moral courage in addition to supervisory skills. But what if the situation is more peer-to-peer? How can nurses or other clinical providers address unethical situations in ways that protect themselves and the patients they serve?

Case Study: An Ethical Dilemma in Ohio and What We Can Learn

CNN reported recently on a hospital network in Central Ohio where 34 patients died after receiving excessive amounts of fentanyl. Twenty-three clinical staff members have been placed on administrative leave so far, and eight wrongful death suits are pending – so far. While the clinician ordered what appear to be lethal doses of this dangerous pain medication, there was clearly a breakdown across the clinical care team.

What happened in this case? Surely someone noticed something was wrong? While we may never know what exactly happened, this terrible situation illustrates the necessity of speaking up when troubling conduct occurs, whether the situation affects nursing teams, doctors, or other staff or clinical providers. In this case, is it possible that lives could have been saved had someone raised a red flag more quickly?

American Nurse Today provides some guidelines for addressing unethical situations in a medical setting. They suggest addressing these issues requires moral courage, which they define as:“The willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks (such as stress, anxiety, isolation from colleagues, or threats to employment).”

They suggest some of the barriers to the use of moral courage to address unethical situations include:

• an organizational culture that discourages interdisciplinary dialogues necessary to curbing the unethical behavior;
• lack of concern by staff that lacks the moral courage to act;
• unhealthy groupthink that discourages independent thinking and moral behavior; and
• a culture that accepts unethical behavior as the norm.

American Nurse Today suggests that clinical supervisors and staff can use a mnemonic CODE to help guide their actions when confronting unethical situations. CODE stands for:

• Courage to address the situation.
• Obligations to honor the Code of Ethics for Nurses from the American Nurses Association.
• Danger management to alleviate your fear of standing strong to confront the situation while also protecting yourself from harm.
• Expression and action via negotiation, communication, and assertiveness to make everyday ethical decisions and confront unethical behavior when it occurs.

Creating an organizational culture supports moral courage requires open communication, policies and procedures that support ethical practices and a strong sense of empowerment and peer-to-peer support that permeates the organization.

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