Nurses Narrative Examples of Moral and Ethical Drift in Response to Health Information Technology Protocols

Monday, 9 November 2015

Jennifer A. Browne, MSN, RN -BC, CCRN
School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, USA

     As technology applications in intensive care multiply, change and influence nursing practice the ethical implications of utilizing new technologies are difficult to anticipate.  Because technologies do differ, the issues that nurses face change from organization to organization resulting in under-identification of ethical concerns.  Additionally, when an information system is meeting clinical and organizational goals there is a reluctance to bring forward these “hidden” dilemmas.   

     There are situations in acute care where professional and ethical values can conflict with management and administrative goals.1  Kleinman 2 describes ethical drift as “an almost indiscernible move toward cutting corners when making the best of a bad situation”.  Moral drift is a behavior whereby the choice between “the lesser of two evils somehow makes it right”.2, p.73   Conflicts of interest can occur when personal or private interests interfere with a nurses professional responsibilities.  All three scenarios can contribute to moral distress, defined as “when one knows the right thing to do but institutional constraint make it nearly impossible to pursue the right course”. 3, p. 6

              This dissertation study was a mixed methods survey conducted in collaboration with American Association of Critical Care Nurses and approved by The University of Texas Health Science Center IRB.  A sample of 297 AACN Registered Nurse Members voluntarily responded to an email survey and described the problems and workarounds they encountered using health information technology (HIT) at the bedside.  The Ad Hoc findings reported here were not part of the dissertation research questions but emerged from the qualitative data. The data was re-analyzed using MAXQDA software and nurse narratives characterizing moral and ethical drift were simply categorized as such.

         Eighty seven percent of respondents were female, 13 percent male (n=279). The age of respondents (n=295) was most heavily represented in the 45-54 age group (35%) and in the over 55 age group (23%).  The smallest age group was 18-24 (3.4%) followed by 25-34 (16.9%) and 35-44 (21.4%).  Similarly, nurses with 21 or more years of experience (29.7%) and 11-20 years of experience (28%) represented over 50% of respondents (n=292).  Nurses with less than 2 years of experience represented 10.6%, 3 to 5 years of experience 12% and 6 to 10 years of experience 18.8%.

         Almost 50% of the nurses had a bachelor’s degree in nursing (48.3%), 20.6% an associate degree and 19.9% had a masters degree (n=291).  The mean level of self-reported ICU nursing experience was 4.48 (SD= +/-.95) which on a 1 to 5 scale with 5 being expert equates to midway between a proficient and expert level.  The average size of the units the nurses worked on was reported in number of beds with the mean number of beds being 19.5 (SD=+/- 10.1).  Seventy five percent of nurses reported a 1:2 assignment (1 nurse for every 2 patients), while 14.7% reported a 1:1 assignment and 14.5% reported a 1:3 assignment (n=296). 

       Forty two percent of the nurses worked in mixed intensive care units, 11 % in surgical intensive care units, 10.5% in coronary care and 9.5% in medical ICU units. The acuity of the patients the nurses were caring for were reported as: 61.8% critical, 28.7% guarded and 9.2% stable.  The workload of the nurse was reported as heavy (40%), moderate (58%) and light workload (2%) (n=296). The software vendors that were represented in this study included: KBMA (Allscripts), Carefusion, Cerner, Epic, Meditech, McKesson (Horizon and Paragon), Soarian, eICU, Endotool and Glucostabilizer.

   In fifteen percent (n=45) there was an ethical or moral dilemma identified.  The narratives are presented in the broad classifications of ethical or moral drift.  A third classification lists narratives which contain inferences to conflict of interest as there was evidence that on occasion what and how the nurse documents can be influenced more by a nurses’ own year-end performance evaluations than by what was true or by what actually occurred.  


Ethical Drift: Incremental deviation from ethical practice that goes unnoticed and is justified as acceptable. (Kleinman, 2006, 73).  Ethical drift occurs over time and the actions rationalized as reasonable given the set of circumstances or challenges in the workplace. (Duffy, 2009)

  1. “When bar code of an insulin bottle will not scan, I take barcodes off the mutli-use vial and tape them to my badge”

  2. “Frequently the computer is unresponsive for up to 10 minutes.  I administer meds without scanning and then scan empty drug wrappers when system comes back up”

  3. “I don’t list all my IV medication titration changes that just to keep from having to beg someone to put in their password several times for each change”

  4. “Scan barcodes and all meds outside of room, especially if patient is on contact precautions”

  5. “Changes to IV pump settings for “drips” requires finding a 2nd RN who must also enter their info two to three different times for each witnessed event.  It was discovered that changes can be entered all day without a witness and then at the end of day the witnessing RN only has to sign once and all fields fill in automatically” 

Moral Drift: A behavior whereby the choice between the lesser of two evils somehow makes it right (Kleinman, 2006).

  1. “Doctors unable to enter orders correctly; particularly medication orders. I put the order in myself”

  2. “When initially signing into computer a “required” screen comes up and the RN has to enter a height and weight.  To get past that you have to enter any number no matter what, then change it later”

  3. “Titrating drips to fit the order, even if actual titration different”

  4. “Many places on assessment have only certain choices and no place to free text what is not on the list.  You must either leave it blank (and get in trouble) and put what is closest to the patient condition and this is not right either”

  5. “Nurses check badges instead of medications when obtaining a double verification. The computer and admin are happy but the medication does not get double checked.’

  6. “I frequently need to complete documentation that is “required” by institution policy but is not available from the patient or truly assessed.”

  7. “Change the real administration time. Otherwise the system wants an explanation why medication wasn’t given on time.  Set yourself up for an investigation”  

Conflict of Interest:  A conflict between the private interests and the official responsibilities of a person in a position of trust 4

  1. “If barcode not readable give med without scanning and chart reason as “other patients care” whether it is true or not.  I/ we could chart as “barcode not readable” but this means counseling from management for each non-scan”

  2. “Our scan rate percentages on our end of year evaluations must be greater than 95% so if we “full document” by saying med was given but not scanned we are tagged.”

  3. I could not scan one medication. If you do not scan your medications it will reflect in your personal scan rates.

  4. A barcode mismatch option is to trick out the computer by choosing “not given” with a reason code like “schedule adjust”, then proceeding to next screen where you are supposed to scan the patient. At this point you can change it back to “given” and proceed with the patient scan.  Apparently this does not count against your scan rates”

  5. “Organization is using computer charting as audit and disciplinary tool”

          These narratives describing nurses’ problems and workarounds when using technology are indicative of a larger problem that threaten the moral integrity of the nurse.3  As is found frequently in the literature, ethical dilemmas and moral distress can negatively impact a nurse’s well-being.3   As we progress in the utilization of technology in intensive care, vendors, administrators and informatics nurses have a responsibility to look for and evaluate ethical mismatches in workflow analysis and to safeguard the nurse from moral distress precipitated by technology.