Introduction
Ethical considerations are crucial values in nursing practice where honesty, integrity and advocating for patients, families and communities are upheld. Nurses are required by law to provide safe and quality healthcare by using their knowledge and skills as well as ethically protecting the public. Many ethical issues arise from work and can be considered ethical if safe, affordable and quality care is delivered through appropriately informed decision making (Monroe, Herr, Mion, & Cowan, 2013).
The case scenario provided shows with the legal and ethical concerns from the actions and inactions of the RN on duty providing care to Mrs Ramirez (Pseudonym). These include professional negligence, failure to uphold the duty of care, failure to respect patient’s decision by ensuring that all the care provided is documented accordingly and failure to escalate the matter to Nurse in charge as well as to the Doctor responsible to the patient as detailed from the scope of practice.
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On the other hand, best nursing practices are evident from the case scenario by ensuring that practices performed are recorded and acting within the scope as well as by involving other care providers. This essay, therefore, will focus on ethical issues emanating from the case scenario with the help of code of ethics, standard practices approach, code of conducts, ethical concepts and principles, theoretical approach, legal consequences/implications and a summary is drawn.
Code of Ethics and Standard of Practice
NMBA, (2005) highlights the code of ethics that nurses are obliged to provide quality and safe care for all, respect choice of care by preserving their dignity, recognizing and managing of information in a professional way to ease easy and effective communication hence positive patient outcome. Taking into account the case scenario, even though Mrs Ramirez had the right to make her own decision to refuse medication, the RN had a duty of care to provide the patient with adequate information regarding the available treatment options by critically assessing the risks associated with refusal of medication. As bound by the code of ethics, RN should have acted for the best interest of the patient to provide beneficent care. However, the RN did not involve the patient in decision making, withheld her medication and failed to comply with mandatory documentation. On the patient-centred care approach, Akkafi, Sadat, Zainab, Sajadi and Krupat (2019) denotes that a patient and family should always be involved in decision making about their health where values and preferences are respected and individual care needs are met.
Foster and Nurse (2019) echoed that nurses are responsible for ensuring patient safety is prioritized to reduce related risks to patients by comprehensively assessing and recognizing potential outcomes, by adhering to best evidenced-based practices and being competent with sufficient knowledge and skills to support and safeguard patient’s health and wellbeing. Reflecting on the case scenario, duty of care was breached and it was morally wrong for the competent RN to handle Mrs Ramirez case in an unprofessional manner. First by not safeguarding Mrs Ramirez wellbeing considering health condition status, failing to adequately assess the patient’s potential adverse effects associated with the medication missed for three consecutive days and failing to comply with documentation protocol.
Saunders (2017) emphasized on the principle of non-maleficence or rather “do not harm” as a duty of care for all health care providers and should be focused on while providing safe and quality care to all patients to improve their health conditions. On Mrs Ramirez situation, RN did not comply with “do not harm” approach by ensuring that the patient was free from any harm associated with missed medications.
In the view of the above arguments, it is crystal clear that the RN did not work in accordance with six standards of practice as outlined by NMBA (2016) which states that RNs are required to use their “critical thinking and analyzing” techniques, to “conduct a comprehensive assessment”, and to “develop a plan” that “provide safe, appropriate and responsive quality nursing practice” as well as “evaluate the outcomes” which is achieved by “engaging in a therapeutic and professional relationship”. Failure to comply with the above standards of practice, the RN endangered Mrs Ramirez life by compromising her health condition by not sorting out for alternative treatment intervention and advocating for her which in returned increased the cost of care as well as a long hospital stay.
Safety and Quality Health Service Standards
According to Griffith (2014), patients have the right to refuse treatment and their choice should be respected whereas the health care providers are obliged to make an informed decision, to weigh the benefits of the treatment and risks associated with it and act immediately on the best interest of the patient by escalating the matter. In the case scenario, there are actions and inactions of the RN that displays health safety concerns. RN appeared to be medically incompetent with the inability to recognize the use of every medication before withholding it. Patient’s refusal of medication was respected; however, the RN did not consider safety reasons and the benefits of medication prescribed by trying to discuss the patient’s concerns, to explore her fears and to negotiate an acceptable solution before withholding the medication. This is a medication error that RN was aware which resulted in adverse effects and lead to worsening health conditions as seen on Mrs Ramirez situation. Tzeng, Yin and Schneider (2013) argued that medication errors occur with the awareness of the person administering it by either omitting or refusal by the patient and the adverse effects are harmful to the patient.
NSQHS (2012) standard four on medication safety focuses on the safe use of medication and its quality by minimizing the medication errors/incidences which is achieved by correct standard practices exhibited by all healthcare providers during administration and proper information management through correct and proper documentation guideline which in the case scenario, RN failed to comply with this standard by not being able to safely use the medications as prescribed to reduce risks linked to medication errors. Also, RN’s inability to document in detail the reasons for not giving medication and actions taken as well as escalating the matter to the other health care providers did not meet the standards required.
Ethical Concepts and Principles
Even though Mrs Ramirez’s autonomy was respected, RN failed to comply with the duty of care and had moral obligation to consider other treatment options, seeking advice as well as establishing a win-win situation and to advocate for patient’s safety. Patient’s autonomy and beneficence should be balance by respecting patient’s decision by providing informed consent and the outcome in regards to their choice of care and the health care providers must abide by the code of ethics to provide beneficent care in ensuring that the benefits outweigh the risks (Braun, Patel, Jr, & Rosen, 2019).
Furthermore, the principle of non-maleficence was not evident from the RN’s actions by withholding the medications even though the benefits outweighed the risks, as well as the principle of justice, was violated as RN did not provide any information in relations to actions taken. Byrd and Winkelstein (2014) argued that non-maleficence is a way of alleviating actions that will create harm to others as well as justice is ensuring that “information management is consistent with applicable law”.
Ethical Theoretical Approach
Consequential, deontological and virtue ethical theories will be focused on the actions and inactions of RN during care provision to Mrs Ramirez. Pieper (2008) indicated that consequential theory is the “doctrine” that is morally correct and the course of action taken will have positive benefits to the person receiving care. Relating to the scenario, RN’s course actions were morally incorrect and the outcome was unpleasant as the patient’s condition continue to deteriorate requiring further medical attention and hospitalization.
The deontological theory according to Pieper (2008) is based on the “act and the intention” to be of more importance than the outcome of the actions. RN’s actions and inactions, therefore, were not beneficent rather were maleficent. RN’s negligence and lack of duty of care in failing to administer medication and failure to comply with communication protocol are well explained in the deontological theory.
On the other hand, virtue ethical theory as explained by Ulrik Kihlbom (2000) emphasizes the moral character of a person doing the right thing more than the consequences or outcome of an action performed. The RN was morally incompetent and the virtue of being caring did not show up while providing care to the patient. Also, the inability to assess the situation, show empathy, communicate effectively with both the patient and the healthcare team as well as seeing the patient as a person indicates that the RN was inconsiderate to patient’s condition.
Legal Consequences/Implications
Reflecting on the scenario, RN breached the duty of care by not providing quality and safe care to Mrs Ramirez in accordance to the standard of practice bound to nurses and this kind of inaction caused harm to the patient as a result of incompetency to administer medication, failure in communication, lack of knowledge about medication and failure to recognize the potential risks hence extended hospitalization and poor health outcome. Hammett (2012) indicated that all healthcare providers who breach a duty of care can face legal consequences and disciplinary action as well as losing registration when quality and standard of care provided is jeopardized.
According to Griffith (2019), negligence is “actionable harm” by a healthcare provider to a patient under their care. Taking into account RN’s actions to the patient’s refusal of medication and failure to communicate was unethical behaviour which is unacceptable and punishable by law. NMBA (2018) denotes that all nurses must abide by mandatory reporting and provision of safe and quality care as underpinned by the use of patient-centred care approach in accordance to professional standards of practice, ensuring informed consent is reached and taking responsibility of any actions by openly and honestly communicating the inactions or any risks involved and in which failure to uphold and adhere to these best standard nursing practices results to professional misconduct and can lead to termination of employment or further actions being taken by the regulatory body.
Best Practices
Apart from the RN actions and inactions to provide safe and quality care, the second nurse actions demonstrate the best practices by recognizing the patient’s deteriorating condition and immediately raising alarm for support. The ability of the second nurse to incorporate a standard of practice in the situation found in needs to be celebrated and acknowledged by putting patient’s safety as a priority as echoed by (NMBA, 2016).
Proper documentation of any action taken by the second nurse shows the level of competency by working within the scope of practice and upholding to the duty of care bestowed unto as well as recognizing the agency to involve another care team who has experience by calling an emergency call. This enhances effective communication between healthcare workers to provide safe and quality care to the patient thus the positive outcome.
Conclusion
The use of ethical theoretical approach help to morally guide nurses towards an objective in a situation where one is undecided to justify why an action is right or wrong and in that case, nurses have the obligation to provide safe and quality care as explained in the standard of practice. RN’s actions and inactions show the level of negligence and failed to uphold the duty of care of Mrs Ramirez. It is crystal clear that the RN did not abide and adhere to the code of ethics, code of conduct as well as the standard of practice as required of all nurses within the law. Given the above, unethical behaviours and professional misconduct are unacceptable in nursing and the legal implications are involved and punishable by law.
References
- Australian Commission on Safety and Quality in Health Care.(2012). Safety and Quality Improvement Guide Standard 4: Medication Safety. Retrieved from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/medication-safety-standard
- Akkafi, M., Sajadi, H. S., Sajadi, Z. S., & Krupat, E. (2019). Attitudes Toward Patient-Centered Care in the Mental Care Services in Isfahan, Iran. Community Mental Health Journal, 55(3), 548–552. https://doi.org/10.1007/s10597-018-0357-2
- Braun, T. L., Patel, V., Dao, H., Jr, & Rosen, T. (2019). What are the ethical and legal considerations when your patient refuses the standard of care? Dermatology Online Journal, 25(8)
- Byrd, G. D., & Winkelstein, P. (2014). A comparative analysis of moral principles and behavioral norms in eight ethical codes relevant to health sciences librarianship, medical informatics, and the health professions. Journal of the Medical Library Association : JMLA, 102(4), 247–256. https://doi.org/10.3163/1536-5050.102.4.006
- Foster, S. (2019). A duty of care to the nurse as well. British Journal of Nursing (Mark Allen Publishing), 28(14), 955. https://doi.org/10.12968/bjon.2019.28.14.955
- Griffith, R. (2014). Respecting a patient’s wish to refuse life-sustaining treatment. British Journal of Nursing (Mark Allen Publishing), 23(6), 332–333.
- Griffith, R. (2019). Negligence and the standard of care in district nursing. British Journal of Community Nursing, 24(1), 35–37. https://doi.org/10.12968/bjcn.2019.24.1.35
- Kihlbom, U. (2000). Guidance and justification in particularistic ethics. Bioethics, 14(4), 287–309.
- Monroe, T. B., Herr, K. A., Mion, L. C., & Cowan, R. L. (2013). Ethical and legal issues in pain research in cognitively impaired older adults. International Journal of Nursing Studies, 50(9), 1283–1287. https://doi.org/10.1016/j.ijnurstu.2012.11.023
- Nursing and Midwifery Board of Australia (2005). Code of Ethics for Nurses in Australia. Retrievedfrom:https://www.ahpra.gov.au/search.aspx?query=%27code%20of%20ethics%20for%20nurses%27
- Nursing and Midwifery Board of Australia (2016). Registered Nurses Standard of Practice. Retrieved from:https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx
- Nursing and Midwifery Board of Australia (2018). Code of Conduct for Nurses. Retrieved from: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
- Pieper, P. (2008). Ethical perspectives of children’s assent for research participation: deontology and on utilitarianism. Pediatric Nursing, 34(4), 319–323.
- Starr, L. (2013). Failure in duty of care. Australian Nursing Journal (July 1993), 20(9), 23.
- Tzeng, H.-M., Yin, C.-Y., & Schneider, T. E. (2013). Medication error-related issues in nursing practice. Medsurg Nursing : Official Journal of the Academy of Medical-Surgical Nurses, 22(1), 13
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