Nursing practice

1. Introduction

This paper presents a ‘Portfolio’ of exemplars from nursing practice, which explores the professional role of the nurse as an advocate with adult patients, where ethical dilemmas are central. The paper begins with a brief description of the advocacy and empowerment exemplar, followed by a detailed analysis of the empowerment exemplar with regard to the professional role of the nurse, the legal and the ethical framework. It critically reflects on the issues that pose conflict and the role of the nursing staff who are faced with an ethical dilemma. The ethical decision making model is also applied to the exemplar presented, to gain a better insight into the possible course of action. The portfolio concludes with an action plan that can be implemented based on the reflective analysis.

2- Exemplar 1 -Advocacy

Advocacy is defined as : “the process of befriending and where necessary, representing a patient, client, partner or prot�g�, in all matters where the nurse’s help is needed in order to protect the rights or promote the interests of that person” (cited by Frizell, 2005)

Mrs. A, 59 yr old widow, was admitted with shortness of breath and acute exacerbations of COPD. Doctors suggested Bipap treatment twice in the course of treatment but both the times Mrs A was alert and she refused consent. The daughters were aware of this situation. When Mrs. A became unresponsive on the fourth day, the daughters agreed with the doctor and Mrs. A. was put on Bipap. As an advocate for Mrs. A, the student nurse and her mentor felt that the treatment was ethically and legally inappropriate.

3. Exemplar 2 – Empowerment

Empowerment is defined by Hokansan (1992) as an interpersonal process between the nurse and the patient which aims at facilitating healthy behaviors.

Ms M, 28 yrs old separated female was admitted in A&E with severe abdominal pain. She was accompanied by her boy friend and two children. A urine test confirmed pregnancy. Ms M disclosed to the student nurse and the mentor that she was HIV positive but did not want this information passed on to her boyfriend. The mentor tried to convince Ms M to confide in her partner, since it was both ethical and legally binding. The mentor and the student were left in dilemma on the next steps.

4. Analysis

The above exemplar concerned with the issue of empowerment, leads to a conflict in the minds of the student nurse and the mentor on the right course of action. In the above exemplar the student nurse observed the mentor trying to negotiate with the patient to disclose her HIV status to her boyfriend. The mentor tried to convince the patient, but was unable to obtain consent. It was observed that the mentor tried to initiate the dialogue with the patient, and listened to the patient’s concerns as well. However, the patient’s resistance to the nursing staff’s suggestion of disclosing the information, posed a conflict for them. In an effort to choose a course of action, based on ethics, the mentor gave time to the patient to explore her values and become ready to communicate (Daniels, 2004) but it did not help. The situation poses professional, ethical and legal issues for the nursing staff. This is discussed below:

4.1 Professional Issues

The professional issues facing the nursing staff are explored below.

– Principle of Autonomy and Fairness (Beauchamp & Childress, 2001)- The nursing staff had a duty to respect the patient’s autonomy and her decision which could result in harm to another individual, while also upholding their duty to fairness and justice. In the above exemplar, duty to protect the patient’s partner, conflicts with the principle of to autonomy that the patient is entitled to.

* Principle of Loyalty (Beauchamp & Childress, 2001): They were torn between being loyal to the patient and owing a duty to society in controlling the spread of this infection, by putting another member of society at risk. However as the patient’s advocate, the nurse has to consider the wishes of the patient (NMC, 2004). Yeoman (2007) suggests that “the autonomy to make decisions remains with the patient. For patients who test positive for HIV this is particularly important because disclosure could result in discrimination and social isolation”. However since the patient’s behaviour could result in harm to another individual, is it ethical for the nursing staff to ignore patient’s autonomy? This is discussed later in the paper.

* Confidentiality: Confidentiality of patient records and patient’s discussions is a professional requirement. However, if maintaining confidentiality results in harm to another member of society, the healthcare professional is faced with the challenge on the course of action. Literature suggests that patient confidentiality cannot be an absolute concept and it may even be acceptable to breach this sometimes in favour of a larger good (Wilks, 2004) and there can be “exceptions to the rule” (NHS Code of Practice, 2003).

The mentor’s approach in trying to convince the patient to disclose her HIV status was in line with the NHS Code of Practice (2003) which emphasises three tenets:

Protect- “look after the patient’s information”. The mentor or student nurse did not go ahead and disclose her HIV positive status to anyone.

Inform – “ensure that patients are aware of how their information is used”. By negotiating with the patient, the mentor tried to explain the risk involved for her partner and how she would feel if she would put in the same situation.

Provide Choice- “allow patients to decide whether their information can be disclosed or

used in particular ways” The mentor also gave the patient time to rethink her resistance but was left in a dilemma on what to do next if the patient did not consent.

4.2 Legal Issues

The “common law of confidentiality” is not codified in the Act of Parliament but is built on case law where practice has been established by individual judgments and law is not very clear on this issue (NHS Code of Practice, 2003; Hayter, 1997). Judgments establish that confidentiality can be breached ‘in the public interest’ however it is all dependant on a case-to-case basis. NHS Code of Practice (2003) states that according to the existing regulation, the one situation, in which confidentiality related to HIV positive status of a patient can be breached is for the purpose of treatment or prevention. In this particular exemplar, the reason why the nursing staff need to disclose the information to the boy friend is to ensure “prevention” and perhaps even “treatment” which is in line with the regulation. The UK courts have recognised that some breaches of confidentiality may be allowed if they are in the public interest (Yeoman, 2007).

The other situation to consider is where healthcare professionals fail to disclose HIV positive status to boyfriend. In that situation liability could apply as the healthcare staff owe a duty to warn someone of potential risk (Yeoman, 2007) ad protect him from harm (Beauchamp & Childress, 2001).

4.3 Ethical Dilemma and Decision Making

Ethical framework for nursing is based on the rights of the patients and duties of nurses. When a nurse experiences a conflict in duty to care, ethical dilemmas arise. In order to reach a decision in such situations, it is necessary for nurses to be fully aware and have knowledge of the various “ethical positions” to reach a “morally defensible decision”. (Monaghan and Begley, 2004).

According to the code of conduct, nurse practitioners need to conduct themselves and practice within an ethical framework based fundamentally upon respect for the well-being of patients and clients (NMC,2004) .

Ethical dilemma leads to moral issues. Buckhardt and Nathaniel (2002) describe these as:

* Moral distress which is related to institutional restraints, practical concerns

* Moral uncertainty (aware that there is a problem but not sure of action)

* Moral outrage (someone in the healthcare setting performs an act that the nurse believes is immoral)

* Moral dilemma (difficult problem with no satisfactory solution, when all solution seem equally favourable)

In the exemplar above the nursing staff is faced with moral uncertainty. They are aware that a problem will arise if disclosure is not made to the patient’s partner but are not sure how to proceed further. Their negotiation with the patient does not bring the desired result but this must also be viewed as an opportunity for education, cooperation and building trust.

Deakin et al (2005) point out that patient education programmes can help in building trust and opening communication. In line with the empowerment parctice the nurse needs to practice “being with” the client rather than “doing to” them (Oudshoorn, 2005). For effective nursing, therapeutic relationships need to be built with patients and their family. The importance of the concept of “knowing the patient” to the quality of care provided has been highlighted in nursing practice. (Nordgren S & Fridlund B, 2001;Luker et al 2000; Mc Cabe 2004 ; Mok & Chiu, 2004). Referring such clients to Expert Patient programme and arming them with resources so that they can feel more in control of their life can facilitate the way to a morally acceptable decision (Expert Patients Programme, 2008). Peer support and community support may be necessary for such patients and it may be advisable to refer them to AIDS and HIV Support group (Patient UK, 2008)

Burkhardt & Nathaniel (2002) describe six steps ethical decision-making model which has been applied to this exemplar.

Step 1. Gathering data and Identifying conflicting moral claims. In this particular case nursing staff owe a moral duty to care for the patient who feels threatened by disclosure and feels fear of rejection and isolation. This duty to care conflicts with the nursing staff’s duty to protect another individual at risk. The nurses owe loyalty to the patient but they also owe loyalty to the society.

Step 2 Involves Identifying Key Participants

The key persons involved in this case are the student nurse, mentor and the attending doctor. The final decision to disclose the information lies with the attending doctor. It would be inappropriate for the nurse to disclose this information to the patient’s partner without the doctor’s approval. The student nurse and mentor also need not take on the full burden of ethical decision on their shoulders. However, they can serve as useful resources in facilitating the decision by educating, collaborating and providing emotional support to the patient so that his consent is obtained.

Step 3 Determining the Moral Perspective and Phase of Moral Development of Key Participants

The patient enjoys the autonomy to give consent to the healthcare team to disclose her HIV status to her partner. However the reason for her denial to consent is more an outcome of fear of isolation and social stigma, and this needs to be addressed by the healthcare team. Disclosure of HIV status can require behaviour modification in people infected with HIV (Norman et al, 2007).

Step 4 Identify Options

The most desired outcome in this situation is to help the patient cope with her emotional response and disclose the HIV status to the partner. It is important to consider the values and goals that motivate the patient so that she can be appropriately counselled. It may not be legally binding to disclose the information, but is still a moral obligation on the part of the healthcare team. The disclosure on the other hand impinges on the rights of the patient if her consent is not obtained.

Step 5 Act on Choice

Counselling the patient and helping her realise the importance of disclosure is the action to be taken. Only after every effort has been made to seek the consent of the patient should the HIV status be disclosed. In case the patient does not give consent despite every effort, the information should still be disclosed in the interest of larger societal good.

Step 6 Evaluate Outcomes of Action

The ethical dilemma will be resolved if patient’s consent is obtained and then HIV status disclosed. If the disclosure occurs against the wishes of the patient it will still be acceptable since it is morally correct and for the larger good to control risk. Mc Manus (2006) suggests that it is acceptable to disclose when the patient poses harm to others. As part of negotiating, the patient could also be asked to seek legal advice.

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