Refused to help with a circ today, rather long vent...

[haurelia]

Hi all!

I am a seasoned OB nurse, and, after some time away from work due to a move and being a SAHM, I started working again this month at a very small regional hospital as a contingent nurse.  Where I worked before, I was not expected to assist with circumcision, as this was the responsibility of the tech in the nursery.  I have a strong personal belief about circumcision--I will not participate in this procedure.

Anyhow, I had a baby boy in my care today, and I refused to help with the circ (restraining, etc). The pediatrician responded very angrily that it wasn't ok for me to refuse.  I replied that, in fact, it was, since I had been told at my HR orientation that if I was uncomfortable with something I was asked to do, I was supported in declining, as long as it was not endangering/delaying care/etc.  Another nurse was willing to help, so she stepped in. I stood by to ask the other nurse some questions about the after-care protocol at this institution, as the ped muttered about how I'd get along with the "anti-circ" pediatrician in his office.  He then asked me if I had children, and where I took them for medical care.  

After the circ, the baby was crying, breathing fast and clearly uncomfortable.  I asked if there were orders for tylenol placed, and he scoffed, saying "they don't need that, they tolerate this just fine."  He left (leaving all the dirty instruments, scalpel, and foreskin just sitting out on a table), and went to the mother's room to update her.  I brought the baby back to her, and placed him in her arms, planning to help her get the baby undressed and skin to skin; she mentioned the baby's noisy fast  breathing.  I told her we'd place the baby skin to skin, and he'd likely calm right away.  The pediatrician looked at me like I was crazy, and demanded that the baby be brought back to the nursery for monitoring.  Once there, all was well, monitoring was reassuring and he told me "bring him back in a little while."  When I asked him to tell me what he meant by a little while, he huffed and said "when you think he's stable." I replied that, in my judgement, the baby needn't have left the mother's room at all (since he was in no apparent distress other than pain and need for comfort).  He rolled his eyes, and asked the other nurse to look after the baby; he then left the unit.  I brought the babe back to mom, put him skin to skin and his breathing slowed, evened out and he closed his eyes and rested. 30 minutes later he chose to nurse.  

Shortly after, I was called to my manager's office to discuss the phone call she'd gotten from the pedi. I was very comfortable representing myself, and made it clear that I wouldn't assist with circs. I reviewed the conversation from my point of view.  She kept trying to work me around to saying that I would if nobody else was available. I will not. I'd rather not work there, or just work night shift, when circs are not done.  The same "anti-circ" pedi I mentioned above is not questioned or challenged on his refusal to cut boys' genitals.  I brought this up, and got no satisfactory reassurance that I would be held to that same standard.  Basically, she said that she thought the pedi treated me this way because he thought I was challenging him. Duh. But, that doesn't make it okay!! Professional communication is NOT a strong suit in many hospitals, but it's certainly something to shoot for!

I'm frustrated, angry and sad. Yet, I'm also feeling very good that I stood up for my beliefs and didn't get bullied into it. The confrontation with the pedi that followed was very unprofessional, as were the pedi's questions about my children and their medical care.  I let my manager know that, and also shared with her that this was not the first unprofessional interaction I've had on this unit (4 weeks into working there).  I let her know that I'd be happy to have a mediated discussion with the pedi, but that his behavior was not ok with me.

Thanks for reading, and any feedback is welcome.  Mostly, just needed to vent, and review this after my shift. 

[Dandelionkid]

It is so awesome you were able to stand up to the pedi. I love how you advocated for your little patient for skin-to-skin contact. I don't understand the lack of pain management for newborns. Why are so many mat/child units in the dark ages still?? Evidence-based practice seems to lose every time when it comes to tradition and hospital policy.

[ElliesMomma]

why do you think he was asking about your children and their medical care? did you tell him who you see? do you think he will go to that pediatrician and bad mouth you in any way?

let us know how it turns out for you in the weeks ahead. 

i think the best thing you can do is stay calm. at least you have given the ped something to think about.

[PuppyFluffer]

I commend you for refusing to participate in the violation of a child's bodily integrity!  You are type of compassionate people that are needed in the medical community.

That a child is forced to undergo surgery without anesthesia is unethical and horriffic.  That comfort measures from his mother were denied to him adds insult to injury.

I am not surprised at the lack of professional conduct from the ped. 

[WaitingForKiddos]

Good job Mama!!

[QueenOfTheMeadow]

Great job!! My mom was a maternity nurse, and now a hypnobirthing instructor and IBCLC. She is the reason my 3 boys are intact. It's good to know there are some medical profesionals out there that feel the same way.

[tennisdude23]

Wow, it's remarkable how professional you were and how unprofessional that physician was.  To begin with, if you are anti-circ, dealing with this kind of situation, pre-op or post-op, is unsettling and I think you did an awesome job.  He had absolutely no right to ask you about your kids.  I hope you won't have to work with him in the near future, but if you do, your idea for a mediated discussion is great.  

[glongley]

I haven't posted here in a really long time, but happened to be browsing today, and how perfect that your post was at the top of the list! I have a similar story to tell from last Fall. Please feel free to PM me if you want to correspond more about this, as I probably won't be checking the board again. Hopefully some of my story will provide you emotional support and concrete ideas for dealing with you own situation.

I am an RN working in newborn nursery and NICU for the past 11+ years. I have twice been threatened with termination for refusing to assist in circumcisions and getting reported by several docs involved who took offense to it (others were perfectly fine with asking someone else to help). The first time it happened years back, I was taken by surprise on the disciplinary action they undertook against me, and I didn't know how to defend myself. So I ended up walking on eggshells and feeling very disempowered for a long time. Then last Fall, I had to defend myself again, over a very stressful 3 month period, in which they really were on the verge of firing me if I didn't agree to their conditions. But this time I wasn't going to let them walk all over me. I negotiated my way through 3 difficult meetings with my supervisors and HR all by myself, wrote position statements and policy proposals, met with the head of the Ethics Committee, consulted with lawyers, looked up JCAHO and federal healthcare conscience protection regs, and also sought out support and advice from others who had been down the same path - Marilyn Milos, Mary Conant, and Betty Sperlich (of Nurses for the Rights of the Child) among them. It very scary, very stressful, and very exhausting, but the short story is, I am still employed, and no I still don't assist with circumcisions.

They felt they were being accomodating by saying that, OK,  I didn't have to assist myself in circumcisions, but that if asked to assist, I at least needed to get someone else to assist. This was where we could not find common ground. Although I told them I would assist if there were a medical emergency during the circumcision, and that I would do whatever after care and teaching was needed, I maintained that I would not get someone else to assist with the performance of the regular circumcision itself, since that to me was being complicit with an unethical practice and system as much as doing it myself.

JCAHO regs support the principle of health care conscientious objection, with the stipulation that it must not delay, interrupt, or compromise patient care, and each hospital must have a policy on this. (Of course, circumcision does not constitute any kind of medically valid "care", but they didn't buy that argument.) My hospital's policy included in three places that care must not be interrupted, and while it listed multiple factors that were to be taken into consideration in responding to employees' objections to participation (e.g. the ethical issue itself, alternative means of providing staffing, avoiding future problems with the same issue), all of these were ignored. All they cared about was that the provision of circumcisions must not be interrupted. Bleah! When I countered that federal policy allowed for healthcare professionals not to have to participate, they said that they had checked with "corporate legal" which had said that my contract states that I have to do whatever they tell me to do ("other tasks as assigned").

If we had failed to come to agreement on this point, they were going to terminate me, with my only recourse being appealing to the Ethics Committee, part of the HR conscientious objection policy. The chaplain who was the head of the ethics committee had been intrigued by the information I had given him, but he did not seem like he was going to stick his neck out to fight for me. I was told I could present to the Ethics Committee, but I could not talk about the ethics of circumcision, only my case for why I should not have to participate in getting someone to assist, and only for about 15 minutes. Plus they wanted the Ethics Committee to meet within the next few days (the week before Christmas!), and come to an immediate decision, because the negotiations had dragged on long enough in their opinion. If the Ethics Committee approach had failed (which I'm sure it would have under the conditions), I believe I would in fact have been terminated, and my only other recourse would have been to undertake an expensive, ugly, and hugely stressful lawsuit, which I believe also probably would have failed.

But at the last moment, they batted an eye. In wrapping up my final meeting with them, I said that I valued my job at the hospital, and I had considered every way I could think of to make this situation work. The only options I could see for myself were to either 1) make myself unavailable everytime a doc came into the nursery to do a circ (thus taking away from care of my other patients), 2) doing what I was asked to do (assist) and feeling I was compromising my conscience, or 2) having a conversation about my ethical stance with any doc that asked for help (right in the middle of them doing the circ), asking that they get someone else to help them, and hoping for the best. My supervisor then got the aha! idea that I could write a letter on hospital letter head and with her express support to communicate to all the docs that did circumcisions that I had ethical objections to circumcision, and respectfully asking them not to ask me to assist, also listing the situations under which I would assist (eg. emergency). To make a long story short, that's what we did, and the episode was over. Not an ideal solution, but a shift on their part, and the best communication to doctors and the best support I had gotten from them in the 11 years I had worked there.

Of course, now they have changed to a new staffing model recommended by AWHONN in which a nurse has to be present for every circumcision. So now instead of random occasions of request for assistance, ALL nurses are in a position of being expected to assist, including all the postpartum nurses who never had to do it before. Besides making me sick to see all the nurses being inculcated into taking on this role in sheep-like manner, it leaves me again in an unsupported position, as so far no alternative system of staffing when a nurse objects to participation has been put in place. If I had a patient who was going to get circumcised on a given day, I would again be put in a position of having to get someone to take my place. As far as I know, the charge nurses all understand my position and basically respect it, but there is no directive from management for what they should do if I refuse to assist. So for now, I just try to ask for assignments in the morning of boys that are known to not be getting discharged (or circumcised) that day so as to avoid the problem. Back to having to be a rat trying to stay out of the streetlight. Having just gone through all this in the Fall,  I don't have the stomach to go in and rabblerouse for a conscinetious objection policy all over again now for this new staffing arrangement, especially since I am already a persona non grata in their eyes in this regard, and they are swamped with lots of snags and annoyed employees with the new staffing system, for other reasons. I guess that's part of their strategy, to wear you down.

Although my supervisors were not nasty to me throughout this episode, they did lay some trips on me like "you're imposing on your fellow nurses when you refuse to assist" "other nurses resent when you do this" "if you care about babies, why won't you do everything you can to relieve their pain?" (i.e. stand there an hold a pacifier in their mouth!!) "you're not a team player", "you have to make a decision whether you want to work here or not," and pulling out the big guns like "corporate legal" etc. Still,  in honesty, they were mostly sympathetic, good listeners, and patient mediators. It could have been much worse.

I think there were some things that helped this work out as positively as it did (at least before the change to the AWHONN staffing), which might give some indicators to help you. First, I had already been there for 11 years, and we were all familiar with each other, and I was a valued part of the staff there. I really don't think they wanted to fire me, but they had boxed themselves into a position, so I think they were happy to jump at a solution that seemed to bridge our two positions (the letter to the docs). Since you've only been there a month, I think you will have to show a lot of professionalism and good will in negotiating this with them, since the rapport and trust is not already in place. Second, I think the fact that this played out over several meetings over several months (I asked for time to work up responses, and then there were interruptions in my supervisor's availability) gave them time to do some internal processing on this, rather than force a hard-line solution immediately. Hopefully, you can use this to your advantage in this situation too.

Also, I would show your willingness to contribute solutions to the situation, not just refusing, such as suggesting alternate staffing arrangements, or communications processes. I would also suggest you write up this recent interaction with the doctor in detail to refer to later if other accusations or episodes come up later. (The same doctor became involved in both of my disciplinary actions, and I should have recorded all the details of our original interaction to prove that he was being an a**hole the first time around). Also, I would write up some kind of position statement that describes your ethical stance, what you are or are not willing to do, expresses a good faith desire to collaborate with them to find a solution. Also, I would become familiar with the language of the hospital policy on staff rights to refusal to participate in procedures to which they have ethical, religious, or cultural objections. Also, try to find other literature and policy statements that relate to conscientious objection in heatlh care settings.

I hope you will send me a PM. I am very happy to correspond with you on this. You are not alone, and each one of us that goes through this is educating our colleagues and paving the way for making it easier for those that come after us. One big thing that will lead to the end of circumcision, is when health professionals are educated enough, and feel supported in standing up and saying "I will not participate in this." Good luck. Gillian RN

[transylvania_mom]

wow, way to go haurelia and Gillian. Hospitals need more professionals like you.

[Night_Nurse]

Haurelia, I think you did a great job advocating for yourself and your patient. I recently left my job as an OB hosp. nurse because Maternity and Newborn departments were merging to "mother-baby" care. I would have had to at least help w/ circ care, teaching, etc. and I couldn't do that (I think they would have expected me to assist w/ circs also but I'm not 100% on that now). Anyway, I was ready for something else for a while and it just seemed like the right time to leave. I think you handled the situation w/ grace & tact. I don't see how an employer could force you to assist w/ it if it goes against your ethics. They can't force a nurse to assist w/ an abortion if she doesn't want to. Of course, one would have to if they took a job at an abortion clinic but seeing as you didn't hire on to work in a "circ clinic", I don't see how they could force you. I'm also not trying to debate abortion or not, only that some people in the medical field are very much against it, others are not (feel I must say that otherwise someone at this forum might feel I'm trying to debate preg. termination).

Anyway, I wish you would have asked the doctor "Why do you ask? Who is the health care provider of your children"??? Maybe that would have shut him up. I agree w/ others that he got miffed because he felt questioned as a doctor and many have huge egos that can't handle that! But who knows, maybe his "anti-circ" doctor he works with has been giving him a hard time and maybe he's starting to question it. Probably not. It's good to know there is an anti-circ doctor in your area. Maybe find out his/her name and post it so others can use him.

Stick to your guns, you did a good thing! You didn't say (that I see) if the Dr used a penile block or EMLA before the circ. If it's not a mandatory protocol at your facility, I wonder if you could bring it up and suggest it to your manager?

[haurelia]

Thanks to all for reading and replying.

Glongley, I am going to PM you. Thank you. 

Night_Nurse, I used the abortion example for my manager, as it was one I was most familiar with in my previous workplace (where 2nd trimester abortions were commonplace and staff who weren't willing to provide care to those women were excused).  To answer your question, the doc did use a penile block for the circ. 

I wish more health care providers would be open to really looking at what a circ is, and reconsidering their position.  First do no harm! 

[Fellow Traveler]

Bravo to all of you. We need more ethical health care providers such as yourselves!

[teraze]

You nurses are heroes!  I'm glad you both stand up for your beliefs and for babies!

[Dan Bollinger]

Stopping circumcision may very well reside in conscientious objectors like yourselves. Kudos for stepping up! Someone in the "circumcision machine" has to say no. The baby is saying no, but he isn't given a say in the matter. Someone in the cycle has to say no for him: nurses, doctors, parents, insurance companies, or legislators.

[Greg B]

You both deserve commendations for holding to your principles and professionalism in the face of unprofessional brow beating and pressure tactics.  Great job!  I understand how difficult it can be, having been through some occassions similar, though unrelated to circumcision.  That took not only courage but maintainig a clear head.

Regards

[Arduinna]

I can't believe he had the nerve to ask about your own children and who their care provider was. Clearly none of his business and not pertinent to the situation at hand. 

And yes we need more health care providers like you both.

[minkajane]

Reading this scares me to death. I'm starting nursing school this fall with the ultimate goal of becoming a CNM. This would necessitate working in L&D or postpartum before grad school. I am terrified that this is going to be an issue. I absolutely will not have anything to do with circumcision - I will not set up, assist in any way (except in emergencies like hemorrhage), or find someone to assist in my place. I figured it would be a good idea to tell them up front when I get hired, but I worry I won't get a job if I do. I also don't want to be in the place of having to assist in childhood circumcisions during my surgery rotation. Since I know that 99.9% of them are unnecessary or iatrogenic, I don't feel I could assist in those as well.

[hakunangovi]

'haurelia',  Gillian and 'Night Nurse:  I applaud all of you for your courage in standing up for what is right and ethical.  It disturbs me greatly that you have to do this and face threats of disciplinary action.  Needless to say, stories such as yours do nothing to invoke trust in our doctors, or for that matter the management (and ethics commitees) in our hospitals.

[jessjgh1]

I didn't have time to read everything above... but there are some good resources:

NURSES FOR THE RIGHTS OF THE CHILD

http://nurses.cirp.org/

including a link to this article: R.N. Conscientious Objectors to Infant Circumcision: A Model for Nurse Empowerment  http://nurses.cirp.org/R.N._Conscientious_Objecto.html

http://www.circumstitions.com/nurses.html

The Nurses of St. Vincent: Saying "No" to Circumcision

http://www.youtube.com/watch?v=VOjYrxzCMmI#F6gQHc54mJ

This also has come up on this board several times over the years, so you might be able to pull more info or contacts up.

Good luck.

Jessica

 

[BrightLights]

Since newborn circumcisions are never an emergency medical necessity (and I suspect are pretty much never medically necessary emergency or not), I wish "baby friendly" hospitals would throw away their circ equipment.