Law and Ethics in Nursing Argumentative
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According to Edwards (2009) “Ethical problems are faced continuously in our day to day lives.” He then goes on to discuss various examples of the types of ethical issues many individuals can face during a typical day, such as a homeless person asking for money for food and explains how this common dilemma has an ethical dimension to it that most ordinary people may not be aware of. When defining an ethical dilemma, the Royal College of Nursing (RCN) (1997) bring a human element to the definition and explain how choices are made with the consideration personal feelings, principles, beliefs and personal opinion of what is good or bad within a situation (Jones, 2007). Nurses are faced with many more ethical problems on a day to day basis within health care environments than ordinary members of the community and the increasing variety of ethical issues that arise within modern nursing practice is why it is essential that nurses study law and ethics (Edwards, 2009).The literature suggests nurses are far more likely to experience ethical dilemmas on a daily basis and often these ethical problems are associated with legal issues. Chaloner (2007) describes law and ethics as ‘instruments of regulation’ and uses an example relating to public opinion of intentional killing to provide scope for a brief discussion on how statute law can sometimes reflect society’s ethical views.
It is also imperative that registered nurses have a sound legal knowledge and understand the legal consequences of their actions (Dingwall, 2007) Chaloner (2007) believes that understanding ethics within nursing is essential to providing skilled nursing care in practice. The advances in modern medicine have directly affected the role of nurses and as a result nurses are now faced with decision making that may conflict their own moral values (Edwards, 2009). The study of ethics can enhance nursing practice by ensuring that nurses have the skills and knowledge to tackle ethical dilemmas and the study of ethics also helps to develop nurses own personal moral values and beliefs, ensuring that they are able to make ethical decisions with a higher quality of reasoning (Allmark, 2005). This assignment aims to explore the legal and ethical implications of covert medication administration based on an incident witnessed in practice and will conduct a critical analysis using Gibbs’ (1988) reflective cycle. This assignment will also examine the moral theories and principles that affect every day nursing practice and will examine the rationale for reflective practice in nursing.
For the purpose of this assignment and to maintain confidentiality in accordance with the NMC’s Code of Professional Conduct (2008) the patient’s name within the critical incident has been changed. Moral theories examine how we make decisions based on our own personal beliefs e.g. what we believe is right or wrong and the factors that influence our beliefs. Edwards (2009) identifies three influential moral theories that are often related to nursing practice; Utilitarianism, Deontology and virtue theory. Utilitarianism theories were originally devised by J. Bentham [1748-1832] and J.S. Mill [1808-73]. Beauchamp & Childress (2008) describe utilitarianism as a consequence based theory and identify the main principle of this theory as utility, stating “This principle asserts that we ought always to produce the maximal balance of positive value over disvalue (or the least possible disvalue if only undesirable results can be achieved).”(P.341). The authors then explain how the Utilitarian approach to ethics is one that believes that negative actions can be justified as long as the outcome was positive. Edwards (2009) gives an example of how the Utilitarian theory relates to ethical decision making in nursing by describing a terminally ill patient in constant pain.
Edwards (2009) then continues to discuss how the Utilitarian approach with regards to care for this patient would be based upon opting for the course of treatment that would result in the least amount of pain, regardless of other consequences. Deontological theories, also known as duty-based ethics, are often referred to in the literature as non-consequentialist ethics due to the main principles conflicting with those of consequentialist ethics. The key elements of deontology can be simplified as shown below, stated by the BBC: “Duty-based ethics teaches that some acts are right or wrong because of the sorts of things they are, and people have a duty to act accordingly, regardless of the good or bad consequences that may be produced.” “Duty-based Ethics” from BBC Ethics Guide http://www.bbc.co.uk/ethics Noble-Adams (1999) describes the Utilitarianism and deontological theories as the two dominant theories of ethics although notes that each of these theories have their limitations. Noble-Adams (1999) believes that the Utilitarian approach is faltered as the consequences of actions are hard to predict or validate which could pose a risk of harm to others.
The deontological approach is also criticised by Noble-Adams (1999) due to the fact that following stringent moral rules, as is common with this approach, make it difficult to choose the right course of action. Edwards (2009) agrees with the criticisms made by Noble-Adams (1999) and believes that it is extremely difficult to foresee the consequences of particular acts and also notes how Utilitarianism can often lead to a lack of truth telling (p.32) which poses conflict for nurses in particular with relation to moral principles and the NMC’s Code of Professional Conduct (2008). Edwards (2009) explores the limitations of the deontologist theory in more detail than Noble-Adams (1999) by firstly discussing the difficulties in understanding the work of philosopher Kant (p.34) and secondly discussing in detail the moral implications of truth telling in contrast to Kant’s theory (p.39-41). Edwards (2009) gives an example of how lying could be ethically justified within the text by using a hypothetical situation where an innocent relative or friend could be at risk and the only way to protect them would be to tell a lie. The author then states how “…lying is never justified for Kant.” (p.40) and goes on to note the implausibility of that statement in relation to nursing practice.
Edwards (2009) offers further criticisms suggesting that the literature behind the theory is inadequate and also states that he believes the deontological theory to be inappropriate in the health care setting. Conversely, Forschler (2013) introduces a new dimension to the arguments for and against each theory by comparing the arguments of two authors with conflicting views as to whether Kant’s views could have led him to Utilitarianism had his own bias not affected his approach. Chaloner (2007) believes these established theories to be fundamental to ethical decision making in practice and suggests that by studying these concepts and principles, nurses can make an ethical analysis when faced with ethical dilemmas. Edwards (2009) writes of the principle-based approach to ethics in which nurses are encouraged to focus on the four moral principles identified by Beauchamp and Childress (2008) (p.12). They offer a set of moral principles that they believe should function as a basis for ethics within nursing as follows; respect for autonomy, non-maleficence, beneficence and justice.
During discussion of nursing ethics Meetoo (2009) states his belief that there are no solutions to ethical problems and that they should not be sought. However, Meetoo (2009) relates the principled approach to the topic within his article addressing each of the four principles in detail, yet he is reluctant to promote the use of one ethical framework. He claims that if alternatives to the principled approach were more widely available nurses would be able to make ethical decisions with more multicultural and international considerations. The four moral principles within the principled approach are defined as autonomy, non-maleficence, beneficence and justice. Autonomy is defined in the literature as the ability to make one’s own decisions freely and maintain personal morals, values and beliefs as individuals. Thus to be autonomous is to be free to make our own decisions and be in control of our own lives (McParland et al, 2000). Non-maleficence relates to the moral obligation not to inflict harm on others physically or mentally and beneficence describes the obligation to ‘do good’, prevent/remove harm and act in ways that promote well-being in others (Edwards, 2009).
The principle of justice in relation to nursing requires being just and fair to all patients and respecting their human rights and dignity (Hussey, 2011). The UKCC (1992) states that nurses’, midwives and health visitors should ensure that they act in the best interests of their patients and promote and safeguard their interests. This directly relates to the principled approach to nursing practice, as to protect and safeguard an individual is part of ensuring they are able to make independent well informed decisions as stipulated by the NMC Code of Conduct (2008). McParland et al (2000) suggest that one of the ways in which nurses can ensure they respect autonomy in practice is by ensuring patients and their families are given relevant information relating to their care and encouraged to make their own decisions, regardless of the potential outcomes or the moral values the nurse may have. Beauchamp and Childress (2008) also discuss how respecting autonomy involves the obligations to respect the decisions of others and allow others to be self-governing. The principle of autonomy directly links with non-maleficence and beneficence when it comes to ethical decision making within nursing practice and a good example of this can be found when examining the literature relating to covert medication. Tweddle (2009) explains how the principles of beneficence and non-maleficence can conflict when making ethical decisions relating to health care.
When discussing whether to conceal medication in food is in the best interests of the patient, Tweddle (2009) states “The underlying question is whether the harm caused by giving the medication covertly is greater than the harm the patient may sustain if they do not receive the medication at all.” (p.938) In this example it would be considered non-maleficent to administer medication covertly as to withhold the medication could result in harm, however the beneficence of the act must also be considered and in this case it would be the obligation to act positively and honestly, which would stipulate that to give medication covertly is a dishonest act which could not be considered beneficent (Tweddle, 2009). Another notable example of how the four principles conflict in nursing practice is that of nurses being advocates for patients and McParland et al (2000) gives the example of how a nurse may explain a procedure to a patient that they may not have understood when explained by another healthcare professional.
The principle of autonomy takes the main focus here as to remain autonomous the patient must be well informed of the procedure in order to make an autonomous choice regarding their care. Advocating for the patient in this way is beneficent and non-maleficent as explaining the procedure fully to the patient is ensuring that no harm is caused (non-maleficent) and giving the patient an honest, clear description of the procedure is to benefit the patient and ensure the situation is improved (beneficent). The principle of justice is maintained in this example as the nurse is ensuring the patient is well informed which would suggest that the nurse is mindful and respectful of the human rights of the patient. However this kind of advocacy is highly likely to cause conflict within the care team and the nurse advocating could find themselves in a difficult position between the duty to the patient and the duty to work as part of a team (McParland et al, 2000). Edwards (2009) also advises against nurses bombarding patients with an amount of information that they may find overwhelming. Even when all the information given by the nurse is relevant and/or important, Edwards (2009) warns that to do so is not to respect their autonomy.
Tweddle (2009) discusses how the duty for health care professionals to respect autonomy can conflict with the principle of beneficence when related to the refusal of treatment. The author describes how beneficent acts aim to promote physical wellbeing and reduce suffering yet acknowledges that it is not possible to define what beneficent acts are specifically as individuals have different ideas and definitions of illness and pain (p.936). Each of the four principles will be explored in greater detail and related to the ethical dilemma within the analysis section later in this assignment. The use of the principled approach to ethical decision making interlinks with the use of reflective practice within nursing in the sense that the four principles can be reflected upon and explored further using reflection. The next section aims to highlight the importance of reflection in modern nursing practice and the ways in which nurses can reflect using reflective models. Reflection is a necessary part of nursing practice as it can facilitate the understanding of actions carried out and the consequences that follow, and is a way of learning from experience (McSherry et al, 2002). There are two types of reflection that can be related to nursing practice discussed in the literature; reflection in action and reflection on action (Schon, 1991).
Reflection in action is when an individual reflects on the situation as it occurs and reflection on action is when an individual reflects on the situation after the event (Burns & Bullman, 2000). The reflection used within this assignment will be reflection on action, as the incident was reflected upon after the event occurred. Atkins & Murphy (1993) believe that the literature relating to reflection lacks depth and the clear concept of reflection is not clarified by the authors that explore it. This view is echoed by Andrews, Gidman & Humphreys (1998) who also detail how reflection is more than just recollection and go on to discuss how reflection can be used as an educational tool for nurses if the process of reflection is taught correctly. Taylor (2000) believes that there is a great deal of importance in nurses aspiring to be reflective practitioners and discusses how describing, analysing and evaluating care provided to patients could be imperative to the improvement of future nursing care.
The literature relating to reflection and reflective practice highlights the importance of analysing critical incidents in order to fully understand the concept of reflection and use it to enhance nursing practice. However Andrews et al (1998) dispute the fact that reflection can immediately benefit and improve nursing practice by noting how there is little evidence in the literature to prove this theory and that often it is presumed that reflection will lead to better nursing practice with no theoretical proof. Andrews et al (1998) examine the literature and conclude that the process of reflection bares more importance to the content of the reflection, noting also how there is a need for more research and clarification on this topic There are several processes for reflection defined in the literature. Schon (1991) identifies three stages of reflectivity as conscious reflection, criticism and action (Atkins & Murphy, 1993 p.1189). Atkins & Murphy (1993) interpret the first stage as an awareness of uncomfortable thoughts and feelings, the second involving a critical analysis of the situation and the third stage being the development of a new perspective following the use of stages one and two, concluding that the overall outcome of reflection is learning.
Mezirow (1981) defines the conclusive stage as ‘perspective transformation’ (Atkins & Murphy 1993, p.1190). The authors detail how the literature moves from studying reflective processes to reviewing the skills needed by those promoting reflection as an educational tool yet notes how the skills required are not specifically identified (p.1190). Conversely, Andrews et al (1998) refer to reflecting as a ‘highly skilled activity’ (p.414) although the authors argue that the skills required for reflection are taken for granted in many cases and discuss how assumptions are often made that reflection in nursing practice does not require much effort, suggesting that nurses have always done it. The literature offers a multitude of ideas and opinions on why nurses should reflect and the key aspects have been developed into numerous frameworks available to assist nurses with the reflective process (Barnett, 2005). Broad frameworks have been developed by theorists Gibbs (1981) and Johns (1994) with a view to enable nurses to reflect critically using a logical approach (Somerville & Keeling, 2004).
Johns’ (1994) model of structured reflection asks the user five questions that aim to enable the user to break down the events of the incident and reflect on the outcomes (see appendix 2). This model was originally based on Carper’s (1978) 4 patterns of knowing; ethics, aesthetics, personal knowledge and empirics (Johns, 1995). Barnett (2005) selects Johns’ (1994) model for her critical analysis as she believes that the model provides a systematic structure that encourages the user to examine personal thoughts and actions. Barnett (2005) also suggests that this model is suitable for practitioners who are new to reflection due to the simplicity of the framework and the ability to adapt the model to most situations. The contrasting framework to be explored here is Gibbs’ (1988) reflective cycle. Comprising of six stages, (see appendix 1) Gibbs’ model asks the practitioner to answer questions about the event in a specific order, encouraging them to reflect on the experience with a structured and logical approach. Jones (2007) writes a reflective account using Gibbs’ (1988) model and explains that her reasons for doing so are due to ways in which the model encourages personal development and the simplicity of the framework overall.
She uses the model to identify the dilemma and then conduct an analysis of the incident in which she examines the legal and ethical perspectives before coming to a conclusion that includes her opinions on what she would do differently if the incident were to arise again. Gibbs’ (1988) model will be used in this assignment due to the simplicity of the questions within the model and the ways that the model encourages the user to explore and reflect on every aspect of the incident. Gibbs’ (1988) reflective cycle has been selected for this assignment after careful consideration and comparison to Johns’ (1994) model on the basis that Gibbs’ (1988) offers a simplistic approach yet allows the user to fully explore each section. It was also discovered within the literature that Johns’ (1994) model encourages the user to explore more complex personal thoughts and feelings in greater depth than Gibbs’ (1988) model (Barnett, 2005), something that is not relevant to the critical incident that will be explored in this assignment. The use of the model by Jones (2007) suggests that Gibbs’ (1988) offers the correct framework to follow when exploring the critical incident below, as Jones (2007) is able to easily identify the legal and ethical implications within the incident in a logical style that is easy for the reader to interpret.
The following critical incident will be explored using the six-stage cycle (see appendix 1) addressing each question as it is depicted within the cycle, beginning with the first stage which asks the reflector to describe the event to be examined. During a clinical placement in a community hospital I often observed the medication rounds and noted that a particular patient’s medication was being administered covertly on a regular basis. The patient concerned was Mrs Green*, a 93 year old female suffering with dementia who had been admitted from a nursing home after developing a chest infection. Mrs Green was reluctant to take any medication when prompted and due to her lack of capacity, the nurses had taken to administering her morning anti-psychotic medication hidden in her porridge. Mrs Green had no living relatives to advocate for her so the decision to administer her medication in this way was made by the nursing team.
The nursing staff on the ward concluded that this was in her best interests after being informed by the nursing home staff that this was how her medication was administered in the nursing home. The ward sister was advised that the decision to hide the medication in food was due to the confusion and agitation Mrs Green experienced when she had not taken her medication and she noted down this conversation into Mrs Green’s nursing notes to inform other staff of the issue. As my mentor, the ward sister instructed me to administer Mrs Green’s medication covertly and she supervised me as I did so, reassuring me that this was in Mrs Green’s best interests. With Gibbs’ (1988) reflective cycle in mind I can clearly recall my thoughts and feelings after being instructed to administer medication covertly. Although it was fully explained to me the reasons why the medication was given in this way and I was also shown the documentation supporting the decision to administer covertly, I could not help but feel as though I was not respecting Mrs Green’s autonomy. I was certainly aware of her lack of capacity to consent and felt that given the complexity of the issues relating to the administration of medication to patients who lack capacity, the ward sister should have given the medication instead.
At the time I was not comfortable in administering the medication in this way as a student nurse, although upon reflection I became aware that the ward sister presented me with a legal and ethical issue that I could learn from and encouraged me to deal with the situation as I would when I become a qualified nurse. The second stage of Gibbs’ (1988) model asks the user to evaluate the incident and decipher what was good and bad about it. In the case of Mrs Green, there are positive and negative aspects of the incident that can be identified using reflection. The decision to administer medication covertly did not seem to have been taken lightly, the liaison between the nursing home staff and the ward sister suggests that staff on the ward did not instantly make this decision due to Mrs Green’s confusion and aggression. The fact that the ward staff contacted the nursing home could suggest that they were indeed trying to act in the best interests of Mrs Green after discovering she suffered from dementia and had no living relatives to act as advocates. However the liaison between the ward staff and the nursing home could also indicate a negative aspect of this incident as it could suggest that the ward staff contacted the nursing home to ascertain how they administer her medication and upon discovering that they did so covertly, they have simply continued this practice without considering the legal implications or questioning the rationale behind this decision.
From what I witnessed during the incident I feel it was a positive experience overall, as it seemed as though the staff were trying to advocate for Mrs Green and by ensuring she took her prescribed medication they also ensured that she was calm and comfortable throughout her time on the ward. The next stage of Gibbs’ (1988) reflective cycle requires an analysis of the critical incident which will be conducted by examining the literature surrounding the legal and ethical issues of covert medication. Haw & Stubbs (2010) state that the literature relating to covert medication to older adults is ‘sparse’ and conducted a study to review the existing studies of the subject and also reviewed the national guidelines of covert medication along with the legal and ethical implications of such practice. Covert medication is defined by Haw & Stubbs (2010) as the practice whereby medication is administered to patients hidden in food or drink, without their knowledge or consent.
Haw & Stubbs (2010) describe covert medication as unethical when administered to patients who have mental capacity, capacity being defined by the Mental Capacity Act, (2005) however they give examples of when covert medication is considered to be in the patient’s best interests such as when a patient is incapacitated as a result of learning disabilities, schizophrenia and more commonly in older adults diagnosed with dementia. It is widely considered more ethical to administer medication hidden in food and drink as opposed to using forms of restraint or forcible injection (Haw & Stubbs 2010, p.762). The authors also refer to English law by noting the charges that could be brought upon a practitioner that has administered medication covertly, such as charges of assault or battery (p.765). The literature stipulates the importance of adhering to the Mental Capacity Act (2005) when making decisions to administer medication covertly and this is echoed by the requirements of the NMC’s Code of Professional Conduct (2008). Tweddle (2009) describes autonomy as the ethical principle that relates to free choice and explains that all competent adults have the right to refuse treatment or refuse to consent to treatment.
It is important to consider the issue of accountability when administering medication covertly and Tweddle (2009) highlights the importance of the health care professional being able to justify their actions and prove that they were in the best interests of the patient e.g. to prevent suffering or to improve quality of life. Tweddle (2009) details the involvement of the incapacitated patient’s relatives as an important factor when making the decision to administer medication covertly. As noted earlier, Mrs Green had no living relatives that could advocate for her which raises the issue of how the decision to hide medication in food is made when there is no advocate for the incapacitated patient. Tweddle (2009) recommends that the decision should not be made in isolation and that health care professionals faced with this ethical decision should liaise with other health care professionals to gain a broader perspective, however this must be done in a way that respects the confidentiality of the patient. Another notable implication of covert medication raised in the literature is that of the need for nurses to have pharmaceutical knowledge of medications and understand the possible implications of crushing tablets or opening capsules (Honkanen, 2001).
Stages four and five of Gibbs’ (1988) reflective cycle require the user to establish a conclusion and an action plan. With consideration of the above analysis of the critical incident concerning Mrs Green, I believe that the ward staff justified their decision to administer medication covertly by taking her condition into account, acknowledged her lack of capacity to consent to treatment and ensured all discussions with the ward were documented. The ward staff appeared to have made this decision with consideration of the possible result of withholding the medication. This could have resulted in Mrs Greens’ health deteriorating and the decision that was eventually made to administer the medication hidden in food suggests that the principled approach was used here and the principles of beneficence and non-maleficence may have conflicted, as discussed earlier. Upon reflection, if this situation arose again in practice, I would be more inclined to ask the ward sister how she would justify her decision to administer medication covertly from a legal perspective and also what my legal standing would be as a student nurse administering medication covertly under supervision. However I do believe the situation was addressed efficiently and careful ethical decisions were made with Mrs Green’s best interests at the forefront of the decision making at all times.
Exploring the literature relating the critical incident establishes covert medication as a complex issue that should only take place under extreme circumstances and any practitioner who does so must be able to justify their actions, be able to provide proof and in some cases legal evidence that it was the best option for the patient. The literature frequently makes references to moral principles, highlighting the need for nurses to study ethics as an understanding of moral theories and principles is needed in order to make ethical decisions in practice. It is important to note how the four moral principles are challenged in relation to patients who lack capacity, such as in the critical incident, where the patient lacks the ability to be autonomous. The nurse must advocate for the patient in ways that are beneficent, non-maleficent and ethically justified, something that the literature proves can be difficult due to the key principles of beneficence and non-maleficence often conflicting. Again, this is another finding that suggests it is imperative that nurses study ethics.
It is evident from examples within the literature that nurses are frequently required to make ethical decisions instantaneously and that it is only really possible to consider the full legal and ethical implications of our actions upon reflection, which highlights the importance of reflective practice in nursing. Upon further investigation it is clear from the literature that there is a need for more research into the benefits of reflection within nursing practice as the current literature on the subject is quite limited. However the literature that is currently available suggests that reflection has an invaluable effect on nursing practice, something discovered within this assignment as it was only upon reflection of the critical incident that the full legal and ethical implications of covert medication were considered and explored further.
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