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Ethical

Ethical, Legal and

Professional Issues in Nursing

The area of work I have decided to reflect on in my clinical practice is advocacy. I will use the Gibbs (1988) cycle of reflection to draw on my recent experience on an Oncology ward whilst on placement as a student nurse. I will evaluate advocacy within an ethical, legal and professional framework of nursing. In order to evaluate advocacy it is important to define what it means within the context of a health environment, the following are two definitions that enable a clear understanding. Teasdale (1998) suggests that advocacy is about power and ‘influencing those who have power on behalf of those who do not’. An expansion of this definition is considered by Cahill (1994) ‘as the act of informing the patient of his/her rights in a particular situation, making sure that he/she has all the necessary information to make an informed decision, supporting him/her in the decision he/she makes and protecting and safeguarding interests’...advocacy can be viewed as a necessary part of a therapeutic relationship.

The following therapeutic relationship will be used as my brief reflective account of an incident that occurred on placement, in which I will explore the role of advocacy and its implications on practice.

Whilst on practice a young practising Muslim boy was admitted to the hospital accompanied by both his parents. I will refer to the adolescent in question as ‘Adie’ to maintain and protect patient confidentiality in accordance with the Nursing and Midwifery Council’s Code of Professional Conduct (NMC) (2004). Adie was a 15 year old boy who was admitted to hospital with a severe asthma attack. During his stay on another ward, blood samples were routinely taken and they identified Adie was suffering with Acute Lymphoblastic Leukaemia. The National Health Cancer Plan (2001) lays out clear guidelines for supporting patients and their parents/carers at each stage of the patient’s illness which includes diagnosis. These guidelines where adhered to throughout Adie’s treatment and care. Adie’s parents were informed of the diagnosis and they were devastated. They requested their son was not told about the diagnosis, as they did not want him to know, as they thought he would not be able to cope and they believed ‘Allah’ would decide his fate. The Doctor explained to both parents that in his opinion Adie was a competent Adolescent that he had assessed using the Fraser guidelines of competency (Gillick Competent, 1985) and should be informed of the diagnosis, and that they should reconsider their request as survival rates of childhood cancers with the various treatments available made the prognosis very optimistic. The advocacy role involves protecting the child’s rights, enabling them to participate in the decisions and having their goals and views considered (Doyle & Maslin-Prothero, 1999). The Nurse advocated on behalf of Adie to his parents and advised them that it was within Adie’s best interests to be informed of the diagnosis, as this would enable him to participate in his care. The National Institute for Health and Clinical Excellence (NICE 2005) set national guidelines to improve the services for young people with cancer and they recommended that all children and young people should be offered the opportunity to take part in research trials that are appropriate for them. With this stipulation is the requirement to provide accurate information in order for an informed choice to be made. The nurse also advocated on behalf of the parents, to address concerns they had raised that needed to be addressed with the Doctor, so they felt more informed about the outcomes of childhood treatments for cancer. The nurse was also able to look at the practical implications of withholding the truth from Adie as she advised Adie’s parents that it would be very apparent to Adie when he was transferred to the oncology ward, that all the children on the ward had some form of cancer, as the majority had hair loss and spoke openly of their condition. The parents asked the nurse to speak to Adie’s eldest brother and together they helped his family to work through how they would break the news to Adie about his condition. On commencement of the news of his diagnosis Adie looked as if he could not comprehend the news, and that he was in total shock and disbelief. Initially he kept repeating over and over again that he thought it was a mistake. Eventually he asked to speak with the Doctor and along with his family he discussed the diagnosis and the treatment options available to him. The role of advocacy in nursing is entwined with professional, ethical and legal considerations that could be viewed as encapsulating the following within the duty of care; protecting the patient’s rights and confidentiality; the protection of the patient’s autonomy; in actively seeking to do good for the patient (Beneficence) and in protecting the patient from harm (Non-Malefience). I will consider each of these points and how they impacted on the role of advocacy for Adie in my clinical example along with the ethical considerations of religion and culture.

As a Nurse you have a professional ‘duty of care’ to your patients and you must promote the interests of the patients to gain access to health and social care information. A nurse has the legal responsibility and will be drawn into account by the law of the land, as there is an expectation of the role of the nurse to provide a ‘duty of care’. The NMC sets out clear guidelines for a professional code of conduct, performance and ethics and a nurse can be disciplined by the NMC if these are not upheld. If a nurse is found to be in breach of their duty of care the nurse risks losing his/her registration number, which could result in not being able to practice, or to practice with certain limitations being imposed. A nurse is also personally accountable and responsible for ensuring they promote and protect the interests and the dignity of patients in an equitable and just manner (NMC 2004). Adie’s parents needed more information and further clarification about their child’s diagnosis, the nurse was able to advocate for them and refer them back to the Doctor to ensure they felt fully informed about their child’s illness. The initial shock of a hearing the word ‘cancer’ seemed to negate any other information that followed. This has been widely researched that parents who have been given a diagnosis of cancer, have indicated they are unable to absorb any further information that follows the nurse was able to use this evidence base to inform her practice and advocate on behalf of the family and child (Forsyth 1992). The nurse has a professional code of standards that acts as guidance for her role and responsibilities. The nurse is expected to always place the patient needs as her primary concern, this is in accordance with the Children’s Act (2004) in which the child’s needs are paramount and the importance of children participating in making decisions about their own welfare must be upheld. The European Convention on the rights of the child (1992) also highlights the importance of the child’s needs being the primary consideration and Article 10 outlines the rights of a hospitalised child and emphasises the importance of the child’s participation in their care, and the provision of the right information being provided in accordance with the child’s age and maturity. By law the Doctor may withhold information from a patient as long as it is deemed to be in the best interests of the patient, this is considered to be the Doctor’s ‘therapeutic privilege’. In law the concept of nurse advocacy is not recognised and the courts are reluctant to acknowledge the nurse as an autonomous professional (Mallik and McHale 1995). Although it should be considered that the changing roles of nurses as nurse pre-scribers and specialist nurses along with multi-disciplinary working enables a more visible autonomy professionally. The parents of Adie in the clinical example were initially hoping they could insist on the ‘Doctors therapeutic privilege’ to protect their child from knowledge of the cancer diagnosis, as they considered this to be in his best interests. Whereas the Doctor considered the prognosis to be optimistic and because of the advances in childhood cancer treatments could not justify withholding information about the diagnosis from Adie. Apart from the ethical considerations of withholding information there are also the legal considerations of confidentiality. The Department of Health (DHS) sets out quite clear guidelines for the National Health Service on confidentiality and what a parent, child and professional person should expect (DHS 2003).

A nurse has a professional and legal responsibility to gain consent before giving any treatment or care (NMC 2004). An adult has the right to give or withhold consent, but a child must be consented by their parents or legal guardian, if there is a dispute about the child’s best interests then the health professional will have to apply to the court to make the child a ward of court (Dimond 1995).

Tuxhill (1994) suggest that patient advocacy is one of the roles that separates nursing ethics from medical ethics. The nurse is considered to look to engage in ethical reasoning, patient autonomy and patient empowerment. This is evident in the clinical example where the nurse explores the ‘truth telling’ component of the diagnosis and supports the parents in a reasoned, informed dialogue as to what is in the best interests of Adie. The ethical issues that arose out of the clinical example are characterised by attempting to make the right decision for the patient with the justification that it is the right choice for the patient. Deontological ethics is an ethical theory holding that decisions should be made solely or primarily by considering one's duties and the rights of others. Ethically the importance of including children in the decision making helps them to find a voice in which they can find a sense of themselves and feel apart of a ‘team care effort’ instead of feelings of vunerability in which care is percieved as being ‘done to them’ (Casey 2000). Within the context of the clinical example the parent’s decision to withhold information from Adie needed to be explored and informed to ensure they were looking at the best interests of the child. Parents are usually capable of making reasoned judgements for their children, but when a child is ill most parents are ill equipped with the knowledge of the illness to make reasoned decisions. This is where information and advocacy on their behalf of the patient encourages and facilitates their decision making. Eventually the parents were able to address their concerns and questions as a family with the nurse, and re-evaluated what was best for Adie. Through out the communication there was a respectful acknowledgement of the family’s religious and ethical beliefs by the multi-disciplinary team. This is an important ethical consideration as Western cultures and religions concur that the individual is always the ‘first’ consideration, were as in other more traditional cultures the well being of the ‘family’ is given first priority as in Korean and Japanese families. After being informed of the options for Adie and deciding to inform Adie, his parents then refocused their thoughts to their religious beliefs, believing that regardless of what interventions and treatments the medical world could offer Adie’s fate lay in the hands of Allah. The cultural impact of breaking bad news needs to be addressed ethically to ensure health workers have an understanding of where the family’s beliefs and values originate in order to demonstrate respect and cultural awareness (Charles Kemp 2005) the nurse’s approach demonstrated good cultural awareness in the clinical example. Ethically it is important to preserve patient autonomy and ensure it complies with the principle of beneficence, as this includes both information giving and patients giving informed consent. The nurse is duty bound to beneficence which can be interpreted to mean the nurse always does what is good for the patient, with their patients needs paramount over the nurses. It is important when a nurse is carrying out the duty of beneficence that they ensure it is equitable for all patients and is not done to the detriment of others. It is the nurses duty to provide information on health and social care issues, the nurse in the clinical example was a good advocate as she was empowering and enabled Adie’s parents to explore decisions that would be for the ‘good’ of Adie to give him autonomy over his treatment and care. Research has shown that by empowering parents with information regarding the child’s illness and treatment, the child’s compliance with treatment is also increased. I found the sensitive communication strategies employed by the nurse to be very effective tools in a very fraught time. She was able to adopt an open body posture with a calm quite quiet voice, whilst demonstrating active listening to both parents. Initially I felt uncomfortable as an observer in the situation as I found it very hard to give the parents eye contact when they were upset. I also felt I had little to offer in the way of comfort due to the lack of my nursing experience in these type of situations and had to remind myself that both parents had given their consent to my presence (NMC 2004). Whilst I felt quite inadequate during the initial interview with the parents I did not appreciate the foundations of a therapeutic relationship had already been initiated. I was allocated this family to care for as a student on several occasions and I do feel the positive professional relationship was built on my presence of sharing the initial diagnosis on reflection. As a registered Nurse it is also important that no action or omission causes harm to a patient and this is referred to as Non-maleficence. It is not always possible to view these two principles separately as in Adie’s case it could be argued that the chemotherapy treatment would in fact cause him ‘harm’ as it would make him feel very ill, it would reduce his ability to fight infection due to his reduction in white cells and he most probably would experience hair loss and sickness. Yet from a therapeutic view there is also a good chance that it will do him ‘good’ by eradicating the cancer cells and enabling him to survive his cancer. When assessing what is good for a patient and not doing them harm it is important that their autonomy is considered.

Autonomy is based on rational thought and decision making and in order to do this the patient must have enough information to deliberate. Although on some occasions it may be necessary to negotiate some aspects of the patient’s autonomy in their best interests. This was evident in Adie’s case as he did not like to bath everyday, but this was a required by the multi-disciplinary team to bath daily to prevent infection from the MRSA, he had colonised on his skin. It should be noted that Gorovitz et al (1976) states the principle of beneficence is seen as taking over the precedence of respect for autonomy. I found myself modelling the nurse’s style of advocacy. I advocated for Adie to negotiate with Adie and his parents on several aspects of his care. I feel this experience has armed me with enhanced communication and nursing skills for the future. It is suggested that true advocacy can only be fully successful when all those involved in the process work to the core values of valuing choice, justice and empowerment (Henderson and Pochin, 2001).

In conclusion I acknowledge the role of advocacy in nursing is entwined with professional, ethical and legal considerations and the importance of these have been highlighted in research as essential considerations with the context of nursing. It has been argued that in order for a nurse to be a true advocate they must first hold power, to empower their patient, I would argue that the changing roles and multi-disciplinary approach to family centred care is a conduit for this empowerment process. Whilst the nurse may not be considered in law to be an ‘autonomous professional’ it should be considered that the changing role of the nurse practising today is empowered by nurses prescribing and nursing specialists autonomy is much more transparent. The nurse has a clear and undisputed legal, professional and ethical duty of care for their patients to receive competent and safe care. The analysis of advocacy in relation to children’s rights is an area that will continue to develop underpinned by a variety of plans and frameworks such as the NHS plan, European Convention for the rights of children and the National Service Framework that will enable children to become more involved with the implementation of their care and more aware of their rights within the role of advocacy, resulting positively in self advocacy. The cultural diversity of families we care for is also an important consideration when caring for families and is an integral and essential part of all nurse training and practice. When assessing the ethical, professional and legal guidelines and their relevance in nursing they become quite apparent as they are the foundations in which the best interests of the patient remain the focus of the care needs. The professional and legal guidance helps to support nursing to ensure each pre-registration and registered nurse understands their role, responsibility and accountability whilst practising as a nurse. I personally found the experience of working in an oncology ward with children with very complex needs a very inspiring place. I feel I have gained confidence in communicating with families who have children with a poor prognosis, in a way that is supportive, dignified and respectful. I have also acknowledged the empowerment advocacy brings to patients, parents and carers and its importance within the role of the nursing, that will inform my future practice.

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References

BRUARD. P and CHAPMAN, C. M (1992) Professional and Ethical Issues in Nursing. The Code of Professional Conduct, 4th Edition. Chichester: John Wiley.

CAHILL J. (1994) "Are you prepared to be the Advocate?" Professional Nurse 9(6) 371-5.

CASEY, A. (2000) Editorial Paediatric Nursing. 12.3.

DEPARMENT OF HEALTH (2003). Confidentiality. NHS Code of Practice. Doh : London

DIMOND, B. (1995) Legal Aspects of Nursing. London. Prentice Hall.

GIBBS,G (1988) Learning by Doing. A Guide to Teaching and Learning Methods. Further Education Unit: Oxford Brookes University

KEMP, C. (2005) Seminars on Oncology Nursing Vol. 21 pp 44-52.

MALLICK M and MCHALE (1995) Support for Advocacy . Nursing Times. 25, 91. 28-30.

NURSING AND MIDWIFERY COUNCIL (NMC) (2004) The NMC code of professional conduct: standards for conduct, performance and ethics. London. NMC.

TEASDALE K (1998) Advocacy in Health Care. Oxford. Blackwell Science.

TUXHILL, C. (1994) Ethical Aspects of Critical Care. Critical Care Nursing: Tindall. London.

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