NUR4103 Module 4 ethical decision analysis example

Charted at 1900, Done at 2300: A Travel Nurse Meets a Unit's Habit of Documenting Rounds Before They Happen, Worked Through an Integrated Ethical Decision-Making Model

Student Name

American College of Education

NUR4103: Professional Skills to Thrive as a Travel Nurse

Module 4 Assignment

Instructor Name

January 29, 2029

The Situation

In the third week of my thirteen-week telemetry contract, I worked a run of night shifts with a permanent nurse who had been on the unit for eleven years and had been helpful to me from the start. At 1930, after report, she opened the flowsheets for her five patients and documented hourly safety rounds and turns every two hours through 0700, with the same entries for each hour. She explained that everyone on nights did this, that it saved time on a busy unit and that the rounds would get done anyway. She suggested I do the same so that I would not fall behind on documentation. At 2300 I noticed that one of her patients, charted as turned at 2100 and 2300, had been on his back since before 2000; his sacrum was reddened but not broken.

Step One: Identifying the Ethical Problem

Park (2012) developed an integrated ethical decision-making model for nurses from a review of 20 structured models, with six steps: identifying the ethical problem, collecting additional information, developing alternatives, selecting the best alternative and justifying it, developing practical ways to implement the decision, and evaluating its effects and preventing recurrence. The model suits this situation because it moves from analysis to action, which is where a traveler's decisions are hardest.

The problem has two layers. The first is my own practice: whether to document care before it is given. That is not a dilemma between two goods; documenting care that has not happened is inaccurate, and the code of ethics holds nurses accountable for their own practice and for honest representation of their work (American Nurses Association, 2025). I will not do it. The second layer is harder: what, if anything, to do about a practice that is widespread on a unit where I am a temporary guest, and which I have now seen cause a missed turn. The first question answers itself; the second is where the ethics of being a traveler really lives.

Step Two: Gathering Information

Before acting, I needed more information. I read the hospital's documentation policy, which requires that care be documented when it is performed or as soon as possible afterward and prohibits documenting care in advance. I checked, discreetly, whether the practice was universal; on my next four nights, at least three of the six nurses on the unit documented rounds in advance. I considered why: the unit had five patients per nurse at night, frequent admissions and a documentation system that required separate entries for each hourly round, which made accurate real-time charting burdensome. I also considered the stakes. Documentation is the record other clinicians rely on, and quality nursing documentation depends on being accurate, timely and reflecting the care actually given (Jefferies et al., 2010). A patient charted as turned who was not is at risk not only of a pressure injury but of the next nurse believing the risk was being managed.

Steps Three and Four: Alternatives and Choice

I identified four alternatives. First, say nothing, document my own care accurately and finish the contract. This avoids conflict but leaves patients at risk and fails the duty to act when a colleague's practice endangers patients. Second, report the practice directly to the manager or through the hospital's reporting system. This addresses the risk but, as a newcomer, I might damage relationships and be seen as disloyal, and the report might focus on individuals rather than the system that encourages the practice. Third, speak privately with my colleague about the patient I saw, and about my own decision not to pre-chart. This respects the relationship and addresses the immediate risk, but might not change the unit's practice. Fourth, combine the third alternative with a system-focused conversation with the manager, describing the practice and its drivers without naming individuals, and suggesting a fix to the documentation burden.

I chose the fourth. It meets my obligation to the patient who was harmed and to future patients, respects my colleague, targets the system rather than blaming individuals and fits my position as someone who will leave in ten weeks but whose observations may be useful precisely because I am new. Numminen et al. (2017), in their concept analysis, identify honesty, advocacy, responsibility and the acceptance of personal risk among the attributes of moral courage in nursing. The choice carried personal risk, since the manager could decide the traveler was a problem, but the alternative carried risk to patients.

To check the choice at this step, I added a simple test of my own: could the decision be justified to the patient, to the colleague and to a licensing board? To the patient who lay on his back for three hours while his chart said otherwise, silence could not be justified. To my colleague, a private conversation first was fairer than a report she learned about from her manager. And to a licensing board, a nurse who knowingly documented care she had not given, or who saw a pattern harming patients and said nothing, would have little defense. The fourth alternative was the only one that passed all three tests. It also preserved something practical: a working relationship with a colleague whose help I would need for ten more weeks of night shifts.

Steps Five and Six: Acting and Evaluating

That night I told my colleague that I had found the patient on his back and repositioned him, and that I had noticed the turns charted earlier. I said I could not chart ahead myself because I had seen it go wrong before, and asked whether it would help if we checked each other's patients at 0200. She was embarrassed, then agreed. Two days later I asked the manager for ten minutes and described what I had seen, without names: that advance charting of rounds seemed common on nights, that it was driven by the documentation burden with five patients and admissions, and that it had led to at least one missed turn and an early pressure injury. I suggested that the unit consider a single documented round every two hours covering safety and turning, which the hospital's policy allowed on other units.

The manager thanked me, said she had suspected the practice and would raise the documentation design with the nursing informatics team, and asked me to report the pressure injury through the event system, which I did. To evaluate the outcome, I will note over the remaining weeks whether advance charting continues and whether the documentation change is made. Interviewing fifteen travel nurses, Romain (2025) found that their experience of ethical challenges had qualities of its own, and that they coped by reflecting, building a network of support and weighing carefully how to act, which is close to what this situation required of me. This situation taught me that a traveler's fresh eyes can be a contribution to the unit, not only a risk to the traveler.

References

American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/

Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice, 16(2), 112-124. https://doi.org/10.1111/j.1440-172X.2009.01815.x

Numminen, O., Repo, H., & Leino-Kilpi, H. (2017). Moral courage in nursing: A concept analysis. Nursing Ethics, 24(8), 878-891. https://doi.org/10.1177/0969733016634155

Park, E.-J. (2012). An integrated ethical decision-making model for nurses. Nursing Ethics, 19(1), 139-159. https://doi.org/10.1177/0969733011413491

Romain, S. (2025). Travel nurses' experience with ethical challenges in practice: A qualitative descriptive study. Nursing Ethics, 33(2), 526-540. https://doi.org/10.1177/09697330251393317