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How ethical dilemmas induce stress.

In a survey, phlebotomists revealed that they experienced the greatest work-related strain in emotionally draining situations.

In many ways the health care professional is as intricately involved with ethics as any ancient philosopher or modern politician. Fundamental to all that we do, yet hard to define, ethics are written into the very fabric of laboratory policy.

Ethics consists of far more than abiding by rules, procedures, and guidelines. Even the most detailed of laws cannot govern every aspect of our laboratory experience or keep pace with the explosion of knowledge and technology we have seen in the medical field.

Law may be defined as explicit messages stating what we must or must not do to stay in business. Similarly, a regulation represents a minimum standard of behavior that we must meet. Ethics is less closely related to regulation than to accreditation, which entails seeking a level of performance above the minimum required. Simply stated, ethics represents what we should do, not what we must do. It represents an expression of conscience rather than the obligatory fulfillment of governmental fiat.

Ethics transcends the law in that ethical concerns are concerns about people. Situations of this nature emerge in the context of our daily interactions with patients, coworkers, and management. They very nature of our jobs requires us to act responsibly toward those we might harm. We are obligated to our employer to do all we can to insure high-quality patient care.

Frequently a tug-of-war exists between our own conflicting values. In the hospital setting, such conflicts involve making a choice between the opposing needs of groups with competing claims to us. Conflicts may surface as well in the clash of priorities between two different groups of people whose perspectives differ.

The fundamental element in the decision must be the ultimate assignment of individual responsibility. Ethical situations are those in which we ask ourselves, "Should I do this?" "Should I not to this?" "How can I know if this is my responsibility?"

* Five Steps. Ethical decision making can be considered a five-step process:

1. Identify all individuals whose interests are involved.

2. Understand those interests as completely as possible.

3. Visualize the likely effects of alternative actions upon the various interests.

4. Choose a course of action that will reconcile the most interests or otherwise maximize the common good.

5. Justify that choice under one or more generally accepted ethical precepts (Figure I). * Halfway. Unfortunately, the hospital organization meets us only halfway. Provided with job descriptions, policies, and procedures, we are indoctrinated into the institutional culture. We are instructed to use existing systems of communication and advised about the order of the chain of command. These activities restrict policy to the employee's place in the organization. Such policies might include forbidding medical technologists to make statements regarding diagnosis or refusing admitting privileges to pathologists.

Organizational dictums provide no guidance when a person has been injured. In such cases, ethical principles demand that we correct or mitigate the harm done. In the workplace as in other settings, this concept exists independent of our job descriptions. How to handle one employee's accidental destruction of another's personal property, for example, falls under no absolute rule.

Because health service is a lifesaving endeavor, it involves a broader application of the ethical role. Our training and expertise dictate responsibility--an implicit obligation--toward ill persons in whose suffering we have played no part. The medical community provides direct intervention daily, whether in treating disease or in assisting during a natural disaster.

* Organizational view. The ethics of medical institutions differ from those of the skilled laborers they employ. The organization deals collectively with broad-based ethical questions expressed as distinct issues. In these situations, the core issues are easily identified and articulated. Such issues, which are usually distilled to the expression of a single value, deal primarily with the interests of one group. Quality assurance committees and ethical review boards address the ethical nature of these issues under the assumption that the people selected to make such decisions are capable of distinguishing right from wrong. By the time an issue reaches these groups, it has been sharply defined.

The employee within the organization, on the other hand, lacks the advantage of viewing with such clarity, but must proceed through a maze of abstractions. These ethical dilemmas are very much a function of the interpersonal context in which they occur. Difficult to describe, they are concealed within confusing rhetoric until they may not be perceived to contain ethical elements at all.

It is through this labyrinth that we, as laboratorians, must make our way. We may want to do what is right, but lack the support or information that would permit this. Even when we know what we ought to do, we may not have been granted the authority to do so.

Such conflicts demand further scrutiny. Turning an inward eye to our own questions and conflicts in this three-article series may uncover an ethical pattern to help us guide laboratory policy in a new direction.

Moral uniqueness of the hospital as workplace

Today's laboratorian faces a singular dilemma. Although we are part of a sophisticated health care network, we are sequestered within the walls of the laboratory fortress, protected from patient contact. More and more, medical technologists labor behind the scenes, counting cells and manipulating instruments, as phlebotomists become the primary lab representatives to patients.

As a result, have we turned a deaf ear to the special needs of the phlebotomist as a hospital employee? A survey of the phlebotomy staff at our institution was most revealing.

* Ethical perspective. Faced with growing discontent among the phlebotomy team at our cancer treatment hospital, we wanted to identify the reasons for their intense anxiety. Our search led us to one of the most basic issues facing the medical community: the emotional difficulty of observing at first hand the suffering brought on by disease and dying. Recognizing this pointed us in a new direction toward relieving our phlebotomists' stress overload.

Determining which sources of job stress are related to ethical issues isn't necessarily easy. Asked about this, our phlebotomists were often unable to describe their fears in concrete terms. Instead, they tended to focus on trivial problems our meaningless generalities. This was true not only for those who had learned English as a second language but also for those who spoke English fluently and would have been expected to have no trouble communicating their concerns.

* Unique role. Daily patient contact places phlebotomists in a special niche among the laboratory work force. For the most part, we have trained them in a manual skill and then sent them out to face the unsettling world of the hospital. We take for granted that they will be able to compensate for the lack of "professional processing" their colleagues in the lab have undergone during our years of training and experience.

The professional and educational link between pathologist and medical technologist is not always carried through to the lab assistant performing phlebotomy. This "lack of shared experience"[1] has caused a breach in lab communication that has yet to be bridged by phlebotomy training programs. While ethical issues to be considered by management involve such problems as patient confidentiality and the difficulty of balancing cost and quality, phlebotomists' concerns center around personal encounters, including the fear of inflicting pain on an already suffering patient.

We found that continual contact with terminally ill patients in our outpatient clinic produced an unchecked increase in phlebotomists' job-related stress. In its wake came the inevitable breakdown of performance.

The relationship of stress to job performance, defined early in the century and known as the Yerkes--Dodson Law,[2] can be used to help predict the effects of an employee's inability to cope with stressful situations. What took us by surprise was the strong connection between ethical issues and the level of stress experienced.

When analyzing the symptoms of stress alone, we were, at best, guessing the causes of phlebotomists' anxiety. A partial list follows of some of the symptoms we encountered and why they seemed to cover up the real questions.

[paragraph] Absenteeism. Chronic absence from work without legitimate medical cause is a sure sign that an employee is unhappy. Yet we felt that our phlebotomists were not merely avoiding an unpleasant situation at work; their stress seemed to be genuine.

Taking a closer look, we found much of the absenteeism to be caused by legitimate illness. Nevertheless, illness was occurring at a much higher rate among the phlebotomists than among other lab personnel. Discussing apparent differences between phlebotomists and other lab employees, we found a significant one to be the extent of patient contact.

[paragraph] Employee strife. Persons under excessive stress become irritable and argumentative. Their level of cooperation is reduced. A great deal of pointless discussion ensues about who is to blame for the situation.

The root of the problem is addressed indirectly: "I dread coming to work." "I'm not treated fairly." When pressed for specifics or asked for suggestions, these employees cannot produce clear answers.

Managers may dismiss the situation as trivial or accuse the employee of being a complainer. Often the employee, having shrunk from confronting the underlying ethical issue, is not fully aware of the source of his or her own stress.

* Breaking through. Although we tried various techniques, including group brainstorming and one-on-one counseling, employees remained unable to verbalize their overwhelming fear of confronting illness and death. Most threatening to them was being forced to face their own mortality.

The method that eventually yielded the most valuable information was an anonymous written survey (Figure II). Respondents were asked to rank each of 13 named situations according to the level of stress it contributed to their job. A few blank lines were included at the end for comments. Interestingly, no one wrote anything significant in that space.

Participants ranked each statement from 0 to 10 on an ascending scale of stress produced (Figure III). We considered scores of 7 or above to indicate situations that created significant stress, those given scores of 4 to 6 to cause moderate stress, and those ranking less than 4 points to be nonstress-producing.

* Findings. The results of the survey are astoundingly clear. The more fundamental and profound the perceived ethical conflict, the higher our phlebotomists ranked it as producing stress. The less a situation dealt with ethical issues, the less likely it was to be ranked as stressful.

Dealing with severely ill, mutilated, or dying patients earned the most points, with a mean score of 8.2. Receiving insufficient emotional or educational support had left this group of employees unable to cope with patients' questions about death or the severity of their conditions. Phlebotomists who are inadequately aware of the benefits of their service to patients can become overly depressed about adverse reactions to venipuncture or to the prospect of causing harm or pain. More than three-fourths of respondents (77%) ranked that concern a major source of job-related stress.

The second-ranking stressor, with a mean score of 7.8 points, was the fear of receiving accidental wounds from contaminated needles used on patients with infectious diseases. Fear of HIV infection was considered a major stressor. Patients themselves sometimes ask to be tested for HIV, citing times they may have been exposed to it. This issue represents the other side of the coin for those in physical contact with patients who have fatal diseases. The phlebotomist must not only interact with the terminally ill but also frequently face the possibility of contracting a fatal disease personally.

Although other lab personnel potentially face the same risk, more distance from the patient intervenes. Blood specimens in a rack do not carry the emotional impact of seeing an emaciated patient face to face. While the mean score for this item was slightly lower, a large majority of participants (77%) ranked fear of accidental wounds as a significant source of job-related stress.

The third-ranking stressor, dealing with demands made by physicians, nurses, and medical technologists, gained a mean score of 6.1 points, substantially less than the top two. The most stress is produced in situations requiring the greatest degree of patient contact.

Phlebotomists who regularly worked in pediatrics ranked patient contact as more stressful than fear of accidental wounds. Why? Perhaps because HIV infection is perceived to be less prevalent among children than among adults.

In addition, concern by nurses and physicians for pediatric patients may overwhelm the phlebotomist. Pediatric phlebotomists who expressed fear that their own children might be stricken with a catastrophic disease tended to overestimate the incidence of such diseases. Coping with the demands of other hospital personnel was ranked as a significant source of stress by 62% of those surveyed.

The fourth most worrisome item on the list, excessive work-load, was considered a significant source of stress by only 31% of those surveyed. Fear of failing to obtain a blood specimen ranked fifth. All other items on the list involved issues within the laboratory. None were directly related to patient care.

The phlebotomy supervisor was asked to fill out the questionnaire as though she were on her own phlebotomy team. Her top three choices were the same as the staff's. In addition, when we repeated the survey this spring--about a year later--the results were virtually the same.

* Relief. We learned that ethical questions dealing with patient behavior, suffering, and mortality produce the most stress for phlebotomists. Our solution was to provide these employees with in-services given by hospital social workers. The sessions, which continue intermittently, include activities such as role-playing with "patients" asking whether they are going to die.

Patients often ask their phlebotomists for information about blood tests that have been ordered or the progress of their treatment and disease. We hope to bolster their confidence and understanding by responding to such questions properly.

* Reducing turnover. One reason we initiated our survey was to counter a high rate of turnover among the phlebotomy staff. Although we have no hard figures to prove it, we feel that a reduced turnover rate has been a direct result of urging the staff to air their concerns.

Laboratory phlebotomists are faced with a number of ethical dilemmas simply because health care is a people-intensive industry whose business is life and death. Patients may flinch or complain during venipuncture as though the phlebotomist is somehow to blame for the pain and suffering connected with their condition.

Sometimes the phlebotomist must choose a site on arms, hands, or feet in which veins are bruised and sclerosed. Without emotional support and a clinical background, the phlebotomist may well question the need for laboratory testing on severely deteriorated patients. The ultimate result may be a loss of focus and a questioning of the value of that work to patient care or its importance to the laboratory.

As a cancer hospital, we have a larger proportion than general hospitals of patients receiving aggressive treatment. Although more of our patients are

dying, the level of stress for phlebotomists is really no difference from that of any other hospital. We have no neonatal intensive-care unit, psychiatric ward, or emergency room in which patients' infectious status is unknown. Our patients' charts are long and full. In any hospital setting it is crucial to be prepared for an unusual and traumatic event.

Ironically, the laboratory employee whose contact with patients is greatest has been least well trained in the purpose of laboratory testing. This strong indictment is an ethical consideration for management. We must govern and direct a group of employees who have little or no clinical experience, yet who are entrusted to perform a basic invasive procedure. Are we sending them to the floors ill-prepared?

* Future focus. It is to be hoped that phlebotomy training programs in years to come will do better at training students to deal with ethical issues related to the patients they will visit each day. Initial advice is not sufficient; ongoing support programs should be made available for phlebotomists' use throughout their careers. Ethical health care issues should become an integral part of laboratory phlebotomy training. [1]Numerof, R. "Managing Stress: A Guide for Health Professionals." Rockville, Md., Aspen, 1983. [2]Yerkes, R.M., and Dodson, J.D. The relation of strength of stimulus to rapidity of habit formation. J. Compar. Psychol. 18: 458-482, 1908. General references: Backer, B.; Hannon, N.; and Russell, N.A. "Death and Dying: Individuals and Institutions." New York, John Wiley and Sons, 1982. Blake, S.L.; Brimigion, J.; Diran, M.O.; et al. "Dealing with Death and Dying." Horsham, Pa., Intermed Communications, 1981. McQueen, M.J. Ethics and laboratory medicine. Clin. Chem. 36(8): 1404-1407, 1990. Michael Bissell, M.D., PhD., M.P.H., and Teri Cosman, MT(ASCP) Dr. Bissell vice president and medical director of Nichols Institute Reference Laboratories. San Juan Capistrato, Calif. Cosman is a medical technologist in the clinical chemistry section of the laboratory at City of Hope National Medical Center, Duarte, Calif., where Dr Bissell was director of clinical pathology when they wrote this article. At City of Hope. Dr. Bissell was chairman of the hospital's institutional review board for research involving human subjects and vice-chair of the bio-ethics committee. He drafted the institution's policy on withdrawing or withholding life support therapy.
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Title Annotation:Ethics and the Clinical Laboratory, part 1
Author:Bissell, Michael; Cosman, Teri
Publication:Medical Laboratory Observer
Date:Jul 1, 1991
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