In this current era, nurses are encountering an ample amount of ethical and legal issues in their professional lives. These profuse legal and ethical concerns in nursing practice need to be highlighted as prominent issues that require special attention by healthcare professionals. Nurses are responsible for providing the best quality care, ensuring safe ethical, and legal approaches towards decision making and dealing with the best interest of patients. As a result, a few portions of healthcare professionals pose a serious risk to the public due to several unethical practices which would end up in the loss of their right to practice (National Code of Conduct for health care workers, 2015). This analytical essay deals with the ethical and legal issues that occurred between Ms. Mavis, a post-operative patient after Laparotomy for acute bowel obstruction, and the nurse. The scenario describes that the nurse noticed altered vital signs along with a state of anuria for the last 9 hours and some behavioral changes. So, the nurse left the patient to review the medications she had and report to the shift coordinator. On return she found the patient was not in her room but in the visitors' room with an open gown, an open surgical wound contaminated with feces. The nurse immediately provides the privacy and guides her to the bathroom for her hygienic needs, but Ms. Mavis completely refuses to do it. Based on this given scenario of Ms. Mavis, this essay narrates certain ethical issues such as Negligence, Accountability, and ethical dilemmas within ethical principles like Beneficence vs. autonomy, with the evidence of scientific practice.
Negligence is one’s omission to take rational care to prevent injury or loss to a second person” (Legal Service Commission of South Australia). As a post-operative patient, monitoring of urine output is very important and needs to be checked on an hourly basis. But in the given scenario, a breach of duty to care is observed in terms of “Negligence”. The nurse failed to report to the surgeon that the patient did not pass urine for the last nine hours. Reporting or notifying an abnormal parameter to the concerned person can avoid many serious negative effects on a patient’s health. Here the nurse also failed to possess the first RN standards of practice: To think critically and analyze the nursing practice. The nurse didn’t think critically about anuria in the patient and analyzed the complications that could happen. Rather she could foresee an infection and could have gone for investigations such as urinalysis, blood test, or bladder scan.
For instance, a Retrospective cohort study conducted by Ong M in 2018 states the relation between the length patient’s hospital stay towards the delay in checking the results. This study can be correlated to the case of Ms. Mavis in terms of ‘delay to act’, which can result in a negative impact on a patient's health. WHO, 2019 declared that the occurrence of adverse events due to unsafe care results in the leading cause of death and disability across the world. According to the Australian Commission on Safety and Quality in Healthcare (2010) reports the incidents associated with the knowledge or skill of the practitioners, including missed or delayed diagnosis, wrong treatment, and errors in task execution accounts for 30. 5% of the total incident reports received in that particular time frame.
Maslow’s Hierarchy of needs states that physiological needs are considered primary needs and the next comes safety needs. Correlating to Maslow’s theory, Ms. Mavis’s physiological needs were compromised due to failure to provide proper management for the absence of urine output. Secondly, the nurse left the patient alone or unattended in the room while she noticed changes in his vital parameters as well as his behavior, thereby threatening the safety needs of Ms. Mavis. Reporting to the surgeon managing the physiological changes and seeking help or keeping someone with the patient could fulfill the physiological and safety needs of the patient. Patient safety is embedded in ethical principles which are meant to be care quality indicators (King CA, 2017). And it requires provision as well as implementation of a professional code of ethics.
Accountability is an essential element of professional nursing practice. The American Nurses Association defined Accountability as “to be answerable to oneself and others for one’s action”. Also, responsibility, answerability, trustworthiness, and liability are considered the major pillars of accountability. However, in nursing practice, the nurse is accountable for the medicines he or she administers, and it is the responsibility of the nurse to be knowledgeable regarding the pharmacological actions, interactions, and side effects that can occur in a patient before she administers them.
A cross-sectional descriptive study on the knowledge and attitude of nursing students towards rational drug use concludes that education programs for nursing schools and in-service training for working nurses should include the rationale behind the administration of each medicine. Relating to Ms. Mavis's case, the nurse went to check for the medicine of the patient which caused an alteration in behavior. This indicates that the nurse was unsure about the actions and side effects of the medicines she administered. Similar situations can be rectified in the health care setting by conducting educational services related to pharmacological agents they encounter commonly in their departments which makes the nurse act upon the situation right away and can eradicate the delay in treatment.
In the scenario, the nurse identified bleeding from the pulled-out IV cannula site and the fecal contamination on the surgical wound. So, the nurse took action over that by deciding to meet hygienic needs. This reflects the RN standards of Practice: Provide safe, appropriate, and responsive quality nursing practice.
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Nurses face ethical dilemmas in their everyday professional lives. It can be explained as a decision-making problem between two moral imperialism neither of which resolves the situation in an ethically acceptable fashion. According to Rainer J (2018), an integrated review of the ethical dilemmas in nursing shows an analysis of available evidence in identifying the main areas of moral conflicts, limitations, and gaps. In this scenario, the nurse guides Ms. Mavis to the bathroom to meet her hygienic needs, but Ms. Mavis refuses the assistance offered and expresses reluctance to cooperate with the nurse. This scene depicts the ethical conflict between the ethical principles of beneficence and autonomy. In Medical ethics, beneficence means a moral requirement to contribute to others’ welfare, and justice, in access to health care and health status whereas autonomy refers to self-rule; the ability and tendency to think for oneself, to make decisions for that thinking, and then to enact those decisions is what makes morality any sort of morality possible (Gillon 2003, p. 310) In the current scenario, even though the nurse works on the principle of beneficence intending to provide hygiene and to prevent further wound contamination were trumped by the principle of autonomy from the patient side. However, the reason behind the patient's sudden behavioral change remains uncertain as it has not been ruled out yet.
For example, a qualitative study on ethical challenges experienced by clinical research nurses in 2017 by Larkin M E, reveals that nurses are exposed to dual obligations at the same time and those ethical issues are central to the nurse-patient relationship, patient advocacy, nurses' responsibility in implementing the hospital and organizational policy, which is reflecting in the case of Ms. Mavis and her nurse.
To preside over these ethical dilemmas and issues, certain strategies of action can be applied such as (a) approaching the patient in a polite acceptable manner. (b) Family involvement: Participating the family members in the planning and implementation of care. (c) educating the patients regarding the benefits. (d) Discovering the patient’s reason for refusal of care helps to tackle the situation ethically. (e) Imposing sanctions will deter the health care professionals from acting unethically. (f) Adhering to a Decision- Support- Framework can support people who must make difficult decisions which in turn reduces the chance of professionals making inappropriate or inconsistent decisions. For instance, if such a situation arises approach a decision support framework. Following such a framework or guideline can avoid favoritism and unfairness in dealing with ethical conflicts.
Informed consent is a person’s elective contract to health care, which is carried out after knowledge acquiring and understanding of the possible advantages and risks involved. In the case of Ms. Mavis, when the nurse found the patient in the visitors' room in such a manner that her wound dressing was contaminated with feces, she told the patient that she needed help with her hygiene needs, but Ms. Mavis refused it. Here, the nurse did not ask a consent from the patient to aid in her hygienic activities and also did not explain the need for it. Rather she directly gets involved in it. Even though the nurse’s intention was good, this is a typical case that violates the code of conduct of Informed consent.
Nurses and Midwifery Board of Australia in the code of conduct describes Professional boundaries for nurses through A continuum of Professional Behaviour. It provides a picture of Therapeutic Vs Non- therapeutic behavior in the relationship between the nurse and the persons in their care which involves three zones of practices: Involved (disinterested- neglectful), Zone of helpfulness (therapeutic relationship), and over-involvement (boundary violations). In the given scenario, the nurse went into the zone of over-involvement by invading the patient’s privacy and independence to meet her hygienic needs on her own. Besides she failed to take an informed consent.
Apart from the ethical issues in Ms. Mavis's case, the nurse followed certain ethical principles such as reporting the variations in vital parameters as well as behaviour to the shift IN Charge which reflects her accountability. Besides, when the nurse found Ms. Mavis with the exposed body in the visitors' room, she immediately closed the door to provide privacy to the patient, this shows her Respect for Privacy. Moreover, the intention of the nurse to provide hygienic needs to prevent infection of the surgical wound, which is contaminated conveys the Principle of Non-Maleficence. Still, a single violation of the ethical principle can ruin the trusty relationship between the caregiver and the caretaker.
Conclusion
This analytical essay has discussed various ethical and legal issues that a nurse possesses in the daily nursing practice, thus emphasizing the need for in-depth exploration into the code of ethics, code of conduct, and RN standards of nursing practice. The discussion mainly focused on the breeching of ethical principles like Beneficence, Autonomy, and Accountability, as well as ethical issues such as Negligence, invasion of privacy, independence, and contravention of certain nursing standards of practice. Also, it projects some ethical dilemmas like Beneficence vs. autonomy. All these point out the need for distinctive implications regarding the knowledge and practice of ethical principles and nursing standards in the day-to-day professional life. Hence, this has implications for the areas where the care is served, specifically in clinics, hospitals, community health settings, homes, etc. Due to the hike in the number of ethical issues in everyday nursing practice, the need for more research studies based on this topic is in high demand. Therefore, special attention should be given from the very beginning to the nursing students regarding how to approach these legal and ethical principles as well as to motivate and insist the high-level nursing authorities to promote the research recommended.
References
- Coaghealthcouncil.gov.au. (20115). National Code of Conduct for health care workers. [online] Availableat:https://www.coaghealthcouncil.gov.au/NationalCodeOfConductForHealthCareWorkers [Accessed 17 Nov. 2019].
- King, C. (2017). Clinical Ethics: Patient and Provider Safety. AORN Journal, 106(6), pp.548-551.
- Ong, M., Magrabi, F. and Coiera, E. (2018). Delay in reviewing test results prolongs hospital length of stay: a retrospective cohort study. BMC Health Services Research, 18(1).
- Özatik, F., Babaoğlu, Ü., Özkaraman, A., Yiğitaslan, S. and Erol, K. (2018). The Knowledge and Attitude of Nursing Students TowardsRational Drug Use. Osmangazi Journal of Medicine, pp.315-325.
- Rainer, J., Schneider, J. and Lorenz, R. (2018). Ethical dilemmas in nursing: An integrative review. Journal of Clinical Nursing, 27(19-20), pp.3446-3461.
- Larkin, M., Beardslee, B., Cagliero, E., Griffith, C., Milaszewski, K., & Mugford, M. et al. (2017). Ethical challenges experienced by clinical research nurses: A qualitative study. Nursing Ethics, 26(1), 172-184. doi: 10.1177/0969733017693441
- Nursing and Midwifery Board of Australia - Professional standards. (2018). Retrieved March 2018, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx
- Nursing and Midwifery Board of Australia - Search. (2010). Retrieved from https://www.nursingmidwiferyboard.gov.au/search.aspx?q=professional%20boundaries
- Gillon, R. (2003). Ethics needs principles--four can encompass the rest--and respect for autonomy should be 'first among equals'. Journal of Medical Ethics, 29(5), 307-312. doi: 10.1136/jme.29.5.307
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