The aim of this assignment is to reflect back on a critical incident that happened whilst on placement. The incident will include an ethical issue with an elderly lady who has dementia and refused to take her medications whilst under our care. The author will discuss how the situation arose and why there was a need to covert her medication and will look at law and ethical issues surrounding covert medication. Laws on consent and mental capacity which are in place to protect patients will also be looked at.
A model of reflection will be used to reflect back on the incident, looking at each of the stages of Gibbs model of reflection to help breakdown the incident. Moral theories and principles and how they influence decision making in nursing will be discussed and related to the patient. For the purpose of this assignment and to comply with the NMC, (the code 2008) on confidentiality my patient will be called Mrs M. Nurses are required to work within the law and according to the requirements of the NMC the code.
These rules and legal obligations are set out for nurses and midwives who have a legal and professional duty to care for patients when under their care and are accountable for their actions; this is to protect patients so they are not harmed by your acts or omissions (Griffith & Tengnah 2008). Fremgen (2009) quotes that law is a system of principles and rules of human conduct prescribed by society and enforced by public authority. Buka (2008) states for a law to be effective it should have sanctions for punishing those who fail to adhere to its stipulations.
Laws are developed in response to the needs of society and the survival of the law depends on customary usage. With the Human Rights Act in force, Patients Association and other informative organisations, patients and families are becoming more aware of their rights and are more open to challenging healthcare decisions such as end of life issues or do not attempt resuscitation orders (DNAR). Nurses need to understand the law and to make sure they are making the right decisions for their patients.
The NMC the code (2008) states that ‘As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’. Knowledge of legal principles helps nurses to recognise and understand lawful boundaries and act within the law should a situation arise. It is also important for nurses to keep up to date with new legislations. The NMC state that is the duty of the nurse to keep up to date with, and adhere to, relevant legislation, case law, national and local policies (NMC 2008).
Insufficient knowledge of the law is not a valid excuse for breaking the law (Boylan-Kemp, 2009) whilst Dimond (2005) quotes “ignorance of the law is no defense and the nurse should be aware of the limits which the law imposes on her, and also the power it gives her”. As a result nurses must have the knowledge and understanding of the law to work within its boundaries. Ethics can be defined as the study of standards of conduct and moral judgment (Fremgen 2009) whereas John’s (1995) refers to ethics as knowing what is right and wrong and being committed to act on this basis.
The terms ‘ethical’ and ‘moral’ can be used interchangeably (Chaloner, 2007). Masters (2009) describes morals as the ‘must and ought to of life’ and for ethics the ‘why and wherefore’s, the moral being all patients must be treated with respect and the ethics why must all patients be treated with respect’. Individual morals are based on beliefs and determine how a person acts and behaves and being able to determine what is right and wrong. These morals can be influenced by a person’s upbringing, values, religion, experience and education.
Having knowledge of ethics helps the nurse to develop the skills to resolve ethical problems in practice, as well as enabling the nurse to form their own sound ethical beliefs, that can withstand questioning and be used as reasoning in ethical decision making (Allmark, 2005). Beauchamp & Childress (2001) developed four principles which is a principle based approached to ethical decision making. The four principles by Beauchamp and Childress are: justice, autonomy, beneficence and non maleficence.
Ashcroft et al (2007) state ‘the principles are understood as the standards of conduct on which many other moral claims and judgements depend, therefore a principle is forming the basis of moral reasoning’. The principles are applied to actions or situations in a ‘prima facie’ way; which means that the significant features in the incident and the extent to which each individual principle applies to the incident will determine the most important ethical principle in the situation (Dawson, Garrard, 2006).
The principle of respect for autonomy involves: respectful attitude” as well as “respectful action”. That is, it is to be acknowledged that every individual has the right to hold views, make choices and take actions based on personal values and beliefs. Furthermore, the individual’s autonomous actions should not be subject to constraints by others so long as no serious harm be inflicted on other persons (TSAI, 2005). The moral principle respect for autonomy requires nurses to accept choices resulting from personal values made by patients who have capacity, the ability to make their own decisions (Fry and Johnstone, 2002).
Beneficence looks at an act that will benefit and promote the well being of others, the obligation to do good whereas non maleficence is the principle to do no harm to patients. Beneficence has to be considered alongside the principle of non-malifience with the purpose to ensure benefit with as little harm as possible. ‘A nurse must adopt the principle of beneficence; helping patients to help themselves and supporting patients unable to help themselves, and also non-maleficence; not deliberately causing harm to patients and reducing risks that may cause harm’ (Fry and Johnstone, 2002).
Masters (2009) say that ‘conflict can occur when a ‘nurse may decide to act in a way that they believe is in the patients best interest rather than allowing patients to exercise their autonomy’. Justice is the fourth principle ‘ it demands fair, equitable and appropriate treatment in the light of what is due or owed to persons. Injustice, therefore, means a wrongful act or omission that denies peoples their due benefits or fails to distribute burdens fairly (TSAI 2005)
All individuals must have equal access to healthcare and the nurse must assign resources ethically to match patient need (Fry and Johnstone, 2002). Deontology and Utilitarianism are both theories which offer a framework to develop a comprehensive understanding of the specific meanings of moral value and moral worth when applied to thinking, values and beliefs and choice of action in practice. (Kenworthy et al, 2002). Utilitarianism is the theory where an action is morally right if it brings about good consequences, the goodness or badness of the consequence of the action that makes it right or wrong.
Tuckett (1998) states an action is morally ‘right’ if it increases happiness and reduces unhappiness. However ethical decisions made using the utilitarianism approach to have limited reasoning as they are based on no other factors than the actions predicted consequences (Robertson and Walter, 2007). Deontology is when an action is right if it accords with a moral rule or wrong if it violates such a rule, regardless of the end or purpose of the action (Gillon, 1990).
This perspective makes decision-making easier as its requirement is to obey rules and by doing so, one is doing the right thing regardless of its consequences (Naidoo and Wills 2000). As part of continued professional development reflection is a necessary part of the nursing profession, it is a useful tool to make sense of practice and to help integrate theory and practice. Reid (1993) states ‘Reflection is a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice.
Whilst Boyd and Fayles (1983) states: ‘Reflection encourages a deeper approach to learning. Reflective learning is the process of internally examining and exploring an issue of concern, triggered by an experience which creates and clarifies meaning in term of self, and which results changed conceptual perspective’. By engaging in reflection it allows professionals to develop their way of thinking, it encourages individuals to make sense of situations and to promote best practice, thinking of alternative solutions if needed and to improve on existing knowledge.
Reflection can be divided into two types which were identified by Donald Schon (1983). These are reflection in action which involves reflecting whilst in practice, being able to consciously think and evaluate simultaneously and make changes while an incident occurs. Johns (1998) emphasises this view as he believes that reflection-in-action is a way of constantly monitoring the self in the situation. While Schon (1991) believes for nursing this means practice is enhanced as it is carried out.
Reflection-on-action involves looking back at practice in order to uncover and analyse the knowledge used (Fitzgerald and Chapman, 2000). Reflection on action is turning information into knowledge and being able to reflect on how the situation be handled differently if needed. The nurse reflects due to either; knowing or feeling that something is ‘not right’ or experiencing positive emotions about a situation (Johns, 2006). Skills necessary for developing reflective practice according to Atkins and Murphy (1993) are self awareness, description, critical analysis, synthesis, judgement and evaluation.
Bulman and Schutz (2004) state to be self aware is to be conscious of one’s character, including beliefs, values, qualities, strengths and limitations. Being self aware gives a better understanding of ourselves, it enables us to make changes and to build on our strengths and makes us aware of our weaknesses. Reflection’s outcome is that the nurse comes to a new point of view which influences the nurses thinking and possibly their practice (Atkins and Murphy, 1993).
On the use of reflection in nursing an article by Philip Burnard (1995) entailed ‘nurse educators’ perceptions of reflection’ looks at findings from 12 nurse educators from different teaching institutions who were interviewed regarding how they perceive reflection. Burnard (1995) found the study to be ‘positive and reflection to be a useful and helpful way of improving the work they did as nurses’. The researcher also returned to the nurse educators on 3 separate occasions to interview them and to clarify answers to prevent research bias.
LoBiondo-Wood & Haber (1994) confirm that sample sizes in qualitative studies tend to be small, and suggest that interviewing should continue until ‘data saturation’ has occurred, that is, until no ‘new’ ideas or thoughts are identified by the respondents In this study, this occurred by the eighth interview, and the research continued until 12 interviews had been completed’. The majority of the respondents expressed very positive feelings about use and application of reflection in nurse education and agreed it increases self awareness, enhances communication and encourages research.
The disadvantages of the study were that it only used the perceptions from nurse educators, no practicing nurses’ perceptions were used to give an accurate view of reflection. It was a female based study and no ethical approaches were used, more research was needed to prove reflection enhances nursing practice. It is necessary to consider when reflecting back on my critical incident the use of Gibbs model of reflection (1988). It allows us to go into depth throughout the 6 stages of the model to critically analyse thoughts and feelings and relate theory to practice where it allows.
Carper (1978) identified that ‘individuals have different ways of thinking and knowledge differentiates it and is sometimes helpful to refer to a framework to assist reflection’. The Gibbs model was chosen as it provided sufficient guidance to help me through the reflective process. It helped evaluate the incident with its questions, to make sense of what happened and to consider options if the situation arose again. It takes into account feelings and emotions which many other models do not apart from Boud reflective model.
John’s model of reflection appeared too complex for my critical incident with some of the questions not being relevant to the incident. I felt John’s model of reflection would be good for decision making and as a student did not find this helpful as do not have that kind of responsibility. The incident did not involve me making any decisions; it was my mentor making the decisions. The first stage of Gibbs model of reflection is description in which I will describe my critical incident. I nursed an elderly lady called Mrs M, who had been admitted with a urinary tract infection (UTI).
Mrs M. had a past medical history of dementia, general confusion, hypertension, heart failure and recurrent UTI’s. During Mrs M’s admission there had been an outbreak of gastro-enteritis which she had contracted. Mrs M soon started to refuse her medications as felt the vomiting was associated with taking her medications. The only tablet Mrs M would take was an anti-sickness tablet but as her symptoms from the gastroenteritis subsided Mrs M continued to refuse her medications as was anxious the vomiting would return.
Mrs M was on medications for her hypertension and heart failure and as she had not taken her tablets, her observations were starting to show a raised blood pressure and heart rate. During a drug round, once again Mrs M declined her medications and requested her anti sickness tablet. After several moments thought, my mentor then decided to give either her hypertensive tablet or digoxin tablet, relying to Mrs M it was her anti-sickness tablet. Mrs M was unaware of what had been done and swallowed the tablet.
Further drug rounds after that were spent alternating between her digoxin tablet and hypertensive tablet making sure she had her recommended prescribed daily dose. Mrs M eventually started taking her medications with reassurance from her consultant and feel as her confusion lessened due to her UTI clearing, felt this contributed to Mrs M making the decision to take her medications. The second stage of Gibbs’ model is to discuss thoughts and feelings: At the time I did not feel this was a wrong thing to do.
I believed it was best for Mrs M to be taking her tablets for her health problems. I trusted my mentor completely and knew she had Mrs M’s best interests at heart. Due to my inexperience this makes me feel gullible and easily led and feel this is now a weakness that I need to be aware of. Evaluation is the third stage of Gibbs’ model. This stage requires the reflector to think about what was positive and negative about the event. The positive part of the situation was that Mrs M was taking her tablets which would eventually alleviate her side effects.
A bad point of the incident is that we were deceiving an already vulnerable adult and overall it would not solve the problem, it would not be a suitable solution to the problem. Analysis is the 4th stage of Gibbs’ model. This stage requires the reflector to analyse the event and to make sense of the situation. The first issue to be discussed is consent. The Department of Health (DoH) (2009) provides detailed guidelines regarding consent to treatment and states: Seeking consent to treatment must be about enabling patients to make healthcare choices which are right for them, and recognising that different patients will make different choices in apparently similar situations’.
The NMC (2008) informs registrants that they must make the care of people their first concern and ensure they gain consent before they begin any treatment or care. Before any care or treatment takes place, consent must be given by a competent person. This consent is agreeing for healthcare professionals to provide the care that is needed for individuals and allows the patient to determine what happens to their body.
Lord Donaldson pointed out in Re W (A Minor)(Medical Treatment: Court’s Jurisdiction) , consent has two purposes. The first is a legal defence to an allegation of trespass to the person. The second is a more pragmatic clinical reason that acknowledges that care and treatment requires the cooperation of the patient if it is to be carried out successfully. Therefore, it is clear that consent provides protection to healthcare professionals against trespass to the person and it allows a patient to express their autonomous wishes.