Ethics: creating a culture of ethical watchfulness.

Anita's husband was recently hospitalized for an acute intestinal obstruction that needed to be corrected through surgery. Around the same time, her friend Pat took her 87-year old father to the emergency room of another hospital, as he had suddenly become ill with low blood pressure, dizziness, and confusion. In each of these situations Anita and Pat, both of whom were nurses, were impressed with the knowledge, expertise, caring, and advocacy of some of the nurses they encountered during their family members' extensive hospital stay. One nurse appropriately interpreted signs of internal bleeding when three physicians failed to recognize the pattern of symptoms. Another nurse ignored protocol and called the attending physician for an urgent problem when first- and second-year residents did not answer her calls. Another nurse initiated a dialogue with the physician to implement recommended measures to prevent central line-associated bloodstream infection (CLABSI).The situations above illustrate the power that individual nurses have to keep their patients safe. Recommendations for nurses to play an increasingly important role in health care were laid out in the 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, which was the culmination of two years of work by the Robert Wood Johnson Foundation Committee on the Initiative on the Future of Nursing. Four key recommendations:1. Nurses should practice to the fullest extent of their education and training;2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;3. Nurses should be full partners with physicians and other health care professionals in redesigning health in the United States; and4. Effective workforce planning and policy making require better data collection and an improved information infrastructure (Institute of Medicine, 2010, p. 4).In less than two years since the publication of the IOM report, nursing administrators, educators, researchers, and clinicians have discussed ways to implement the report's recommendations for nurses to take an instrumental role in improving United States (U.S.) healthcare. Much of the discussion has focused on the need for higher levels of education and training, interdisciplinary practice, and improved data collection and information infrastructure. There has been less emphasis on the recommendation that nurses should use their present education and training to practice to the full extent of their license. The IOM report identified many barriers to meeting this goal. However, in order to ensure ethical practice, it is critical to focus not on what nurses cannot do, but what they can do.Stevenson (2010) stated that it is timely to envision the notion of watchfulness and the teaching stances of monitoring, role modeling, and mentoring as a springboard for rethinking expertise and articulating nurses' scope of practice. She noted the difficulties of nurses being called upon to practice to the full extent of their license in today's complex health care environments, which include institutional and health care policy changes, high patient acuity, and sophisticated advances in technology, while continuing to demonstrate a focused and intuitive watchfulness. The stresses on front-line nurses in the acute care setting are incredible. Yet should not every patient expect to be cared for in a culture of safety, no matter what the barriers? Certainly ethical practice demands this.Benner, Hooper-Kyriakidis, and Stannard (2011) have referred to the "fragility of practice," as well as the "trustworthy watchfulness" that is needed for safe and effective patient care (p. 406). How can nurses ensure practices of watchfulness amidst today's fragile practice? Intelligent and assertive actions of nurses were noted in the scenarios at the beginning of this column, but there is more to the story. …