How to ensure quality patient care while following your moral compass.

Takeaways:

• A foundational value of nursing is to respect the worth and dignity of all patients. Nurses also are expected to extend the same duties to themselves as they offer to others.
• Conscientious objection provides a structure by which nurses can stay true to their personal values while ensuring that patient care remains safe and effective.

05:45, Monday:

You’re a nurse in the operating room on the general surgery service. After changing into your surgical scrubs and grabbing that ever-important cup of coffee, you review the list of cases assigned to your room for the day. The general surgery service caseload is low, so you’ve been assigned to plastic surgery, which isn’t uncommon.

As you scan the schedule, you see that the first case at 07:00 looks like a long multispecialty procedure. Patient Hammel*, age 32, is scheduled for a vaginoplasty (part of gender-affirming surgery). The rest of the case details fade into the background as you fixate on the fact that for the first time, you’ve been assigned to take part in a gender-affirming procedure. You’re a conservative, devoutly religious, experienced nurse whose upbringing teaches that changing one’s biological gender is wrong. What are you going to do?
*Name is fictitious 

Nurses regularly face difficult and challenging scenarios, ranging from concern for safe patient care delivery in the face of inadequate staffing ratios to the emotional distress of sitting with parents as their child succumbs to metastatic cancer. Most nurses feel it’s an honor to enter into the lives of patients and families and provide them with the care they need and the hope that tomorrow might be a little bit better than today. But how do we prepare for or handle a situation that gives us pause in the core of our being; a situation that challenges our most deeply held personal moral, religious, and ethical beliefs?

A two-way view

Nurses are charged with providing all patients with the same level of exceptional care. The American Nurses Association Code of Ethics for Nurses with Interpretive Statements (the Code) is an aspirational statement of what nurses are expected to be and do. One of the most foundational values of nursing is to respect each patient’s “inherent dignity, worth, unique attributes, and human rights.” This respect extends to all individuals whether we agree with their life choices or not. The Code states that nurses should practice by “setting aside any bias or prejudice” and work to establish a relationship that’s trusting and focused on the patient’s needs.

The Code also expects nurses to extend to themselves the same duties they offer to others. Nurses are to preserve their own integrity and wholeness of character. We shouldn’t compromise our core values and beliefs. The concept of conscientious objection (CO) provides a structure by which healthcare workers can stay true to their personal values and beliefs while ensuring that patient care remains safe and effective.

CO and the nursing process

CO is defined as an objection to providing or disclosing information about legal, professionally accepted, and otherwise available medical services based on a healthcare worker’s judgment that doing so would be wrong based on his or her personal moral, religious, or ethical beliefs. ANA further clarifies that the nurse is “justified in refusing to participate on moral grounds” in a requested clinical care or procedure that conflicts with his or her personal moral beliefs. However, the act of making a claim of CO can be confusing, complex, and intimidating.

We’ll explore how the nursing process (assess, diagnose, plan, implement, evaluate) can be used as a framework to help you make a CO claim.

Assess

To increase the likelihood that your CO claim will be accommodated, begin by assessing the factors associated with it so you can mitigate any negative impact on yourself, patients, and colleagues.

First, identify that the situation is in conflict with your personal beliefs and that you’re firm enough in those beliefs to feel uncomfortable acting against them. You have a responsibility to yourself. In this case study, your religious belief teaches you that humans are born as either male or female and that they shouldn’t transition, modify, or change the body to the gender they believe themselves to be. You’re identifying that this situation conflicts with your conscience.

Next, consider the impact your objection will have on the patient.

Patient Hammel has just arrived in the preoperative area. The patient is being prepped for surgery, meeting with the surgeons and the anesthesia teams to give final consent, and asking a few questions before entering the operating room. This is a major surgery, both physically and emotionally, for this patient. The last thing the patient would want to hear is that surgery is being delayed or, worse yet, cancelled.

Finally, consider the impact your objection might have on your colleagues. Nurse staffing is an ongoing challenge and hospitals frequently are asked to provide care for more patients with fewer resources. Also, consider the impact your claim may have on other disciplines involved in the case.

The first cases will begin soon. You’re assigned to the room to which both this patient and subsequent cases are assigned. It would be highly unlikely the patient would be reassigned to another room given the multispecialty involvement. Would it be possible to rearrange your assignment to this room? How efficiently can your assignment be changed to limit the effect on cases later in the day, other operating rooms, and the other surgical services’ schedules?

Diagnose

Identifying (naming or labeling) your CO is essential. A healthcare worker deciding to object to providing requested care based on a moral conflict must be able to clearly name the conflict.

“I cannot assist in Patient Hammel’s case because reassignment of or changing one’s gender is strictly against my personal, strongly held, religious and moral beliefs.”

In reality, you’ve held and defined these beliefs long before this case assignment occurred. However, you may never have considered how this situation might present itself in real life and the moral challenges it would create.

Refusing to provide care for a patient can’t be based on your personal preference, bias, prejudice, convenience, or other arbitrary reason. A claim of conscience must be made against an act or procedure, not against the patient. The concept of making a CO claim is designed to protect your moral integrity, respect your personal beliefs, and allow for the best patient care. Simply refusing to provide care because of personal differences or comfort isn’t acceptable, and it’s not protected by CO.

Plan

You should disclose your CO as soon as possible to avoid compromising patient care.

Your objection, if not disclosed early, could compromise not only Patient Hammel’s care but also the care of other patients listed for surgery today.

To whom should you disclose your CO? It may be your nurse manager, supervisor, or charge nurse. The person to whom you disclose should have the authority to address the disclosure and make assignment changes as necessary.

If possible, disclose your CO before you’re confronted with a situation that you object to. Organizations should have CO policies. Some offer regular opportunities for claiming an objection and may proactively inform staff about new procedures that may raise objections. For example, an OB/GYN surgery unit nurse manager could distribute an annual questionnaire to staff eliciting their willingness to participate in pregnancy termination procedures and use that information to assist with staffing.

Ideally, you should have disclosed your objection to participating in gender-affirming surgeries when your organization began performing them. This disclosure might have avoided your assignment to the case.

Plan how you will frame your disclosure to show that you’re looking out for all patients’ best interests and not out of personal convenience. For example, in this situation you could say, “I can’t participate in this gender-affirming surgery because it strongly conflicts with my personal religious beliefs. However, I want to collaborate on a solution that first and foremost ensures that patient care isn’t delayed or compromised, yet also allows me to be true to myself and my personal beliefs.”

Implement

Disclose your CO claim in a neutral, open, and respectful manner. Be sincere, and make clear that you’re not making the claim for personal benefit or convenience but in the interest of patient care.

Meet with your charge nurse or nurse manager so you can clearly and honestly express your concern about being assigned to a gender-affirming surgery. Collaboratively discuss how to best resolve the CO claim so that it doesn’t negatively impact patient care.

Accommodating an objection immediately (or at all) may not always be possible. As nurses, we’re obligated to ensure that safe patient care is provided to each patient and that patients aren’t abandoned. We’re individually responsible for our patient assignment until a feasible reassignment has been made. According to the Code, “Acts of conscientious objection may be acts of moral courage and may not insulate nurses from formal or informal consequences.”

Organization policies should be designed to balance patients’ needs with the healthcare staff’s integrity, but they will likely leave room for corrective action or ultimately termination for insubordination or patient abandonment under certain circumstances. Check your organization’s policies, speak with human resources, and take advantage of resources such as consultation with the ethics service. Ensuring timely and appropriate disclosure may reduce potential claims of patient abandonment and job-related consequences. (See Professional consequences of conscientious objection.) And remember that safe, quality care for all patients is nursing’s top priority.

Evaluate

You’ve disclosed your CO to assisting with Patient Hammel’s procedure based on your personal religious beliefs. You disclosed the objection early so that your claim could be accommodated and the surgical case wasn’t compromised.

That’s the ideal conclusion to this case. However, turning theory into practice isn’t always easy. After you encounter a situation in which you make a CO claim, evaluate the outcome. Did you identify your CO as soon as possible when the situation presented itself? To whom did you disclose your CO, and what was the reaction? If possible, follow up with that person to determine how to ensure the situation doesn’t occur again. Could you have disclosed your CO earlier to prevent urgent reassignment? Was any patient care affected by your CO? How can the process be improved? Did your disclosure impact your job satisfaction, well-being, or the care you’ll provide in the future?

Uncompromised patient care

Nurses encounter complex patient cases and scenarios every day, and we must provide the best care possible to each patient. However, some cases may challenge our personal beliefs in ways we never could have imagined. The decision to declare your CO as early as possible to ensure your moral compass isn’t shaken and patient care isn’t compromised is the sign of a nurse who’s committed to upholding the dignity and worth of all people and providing the best care possible to all patients.

The authors work at the Mayo Clinic in Rochester, Minnesota. Robert Anderson is a critical care nurse practitioner. Joan Henriksen is the ethics consult program coordinator.

Selected references

American Nurses Association (ANA). Code of Ethics for Nurses with Interpretive Statements. 2nd ed. Silver Spring, MD: ANA; 2015.

Association of periOperative Registered Nurses (AORN). AORN’s Perioperative Explications for the ANA Code of Ethics for Nurses with Interpretive Statements. Denver, CO: AORN; 2017.

Lachman VD. Conscientious objection in nursing: Definition and criteria for acceptance. Medsurg Nurs. 2014;23(3):196-8.

Lamb C. Conscientious objection: Understanding the right of conscience in health and healthcare practice. New Bioeth. 2016;22(1):33-44.

Lewis-Newby M, Wicclair M, Pope T, et al. An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med. 2015;191(2):219-27.