Question:
Discuss about the Ethical Dilemma for Ethical Principles and Ethical Theories.
Ethical dilemma is common occurrence in present day health care. Nurses need to be knowledgeable about the ethical principles, ethical theories, professional codes of conducts, codes of ethics and others to ensure safe practice and save themselves form legal obligation (Preshaw et al., 2016). A case study is chosen where the nurses had provided restraints in the aggressive patient leading to clashes between beneficence, non-maleficence. Theory of utilitarianism was also not followed. Several codes of ethics and professional conducts were also breached. The present assignments will gradually unfold how such occurrences had taken place and what a nurse in such situation should have done.
In the case study 2, the nurse named Camilla was assigned to care for a patient named Sam who was suffering from acute abdominal pain. When she was trying to measure his vital signs, she was prevented by the patient who was quite agitated. He violently pushed the nurse away and was not cooperating with her. He was answering irrationally and was continuously calling out. When the team arrived and witnessed his aggressive behaviour and verbal abuses along with his trying to pull his cannula out, they decided to restrain him. Although Camilla was apprehensive of the negative outcome that would result from the restraints, yet the nurse in charge Julia insisted to follow her orders as there was no workforce on the shift to handle the patient effectively.
The case represented a scenario where the nurse was torn between two ethical situations. On one hand, she had the duty to maintain the safe practice of the patient to ensure that he gets well and her interventions have positive outcome on his health. On the other hand, she had to maintain the orders of her senior to restrain the patient as he was being a threat to the safety of the staffs on the ward and also to himself. To prevent any adverse events to occur on the ward, he was restrained so that his treatment could be continued without any interruption from him. However to do that, the nurses had to breach the ethical principles of autonomy and dignity as informed consents were not taken from the patient and his rights and human dignity was not paid importance to. Hence, here rises an ethical dilemma. The nurse named Camilla was facing dilemma where she was torn apart between her duties to maintain safe and effective practice for the patient to make him get well but at the same time was not being able to take informed consent of the patient for maintaining his dignity and autonomy (due to his aggressive behaviour and violence exhibited by him).
While working with the patient, there arose many situations for which the nurse was not being able to initiate her treatments effectively. Measuring the vital signs of the patient was very important in order to understand the physiological condition of the body (Mertz & Stretch, 2014). Following the vital signs and then determining the treatment requirements were extremely important to tackle his abdominal pain. The responsibility of the nurse is to provide the safest, evidence based and person centered care to the patient so that his symptoms are overcome. The ethical principles of beneficence and non maleficence always guide the nurse to provide the safest care to patients. The theory of Utilitarianism states that those care practices will be considered right which has the best outcome on the patient health (Eren, 2014). However, in order to do so, an uninterrupted care was very important which would ensure quality life. However, it was not possible as the patient was violent and aggressive and was not allowing the nurse to actively conduct her assessment which was delaying his process of treatment. Therefore the nurses decided to restrain him and contribute his treatment. However, this was an unethical approach as present healthcare system guidelines instructs the importance of the maintenance of the principle of autonomy and dignity and asking for the patients’ permission before applying any interventions or restrains on him (Sinclair, Papps & Maeshall, 2016). This should be kept in mind also that the patient was not in a stable state of mental health for which he was not being able to answer rationally and did not understand the negative aspect of his aggression. Still, by the rulebook, asking for dignity and informed consent are important which were breached by the Camilla and her senior nurse. Therefore this led to an ethical situation where Camilla was not being able to understand what actions to take as he was aware that restraints may also have physical harm to the patient and his aggression could increase. However providing effective care by restraining was also important.
Critical thinking and proper decision making are two important characters which need to be possessed by every nurse in her professional practice to ensure that she is providing the best care to the patient with the best approach that would ensure patient satisfaction. It was indeed true that the nurse was facing issues in carrying out her assessments of the vital signs. The patient was aggressive and violent which proposed a threat to the patient and also to the healthcare professionals. It was very indeed important for the nurse to carry on with the treatment just for the patient benefits. The principles of beneficence and non maleficence ensure the proper caring of the patient by the best service (Park et al., 2016). However, it does not necessarily mean that in order to maintain the two principles, another principle of autonomy and dignity needs to be avoided. Providing the right to the patient to allow the nurses to carry on the treatment is very important (Margettic et al., 2014). If a more skilled nurse would have been present in the ward, with proper experiences and skill, she should have found out other ways to handle the situation and thereby take an effective decision rather than deciding for restraining on the patient. Over the years, various evidence based journals have been published may procedures which help in handling aggressive patient thereby making their conditions stable (Hughes & Lane, 2016). Researchers convey that restraints should be the last resort only when the other techniques for managing aggression fail. Ensuring open communication, developing a culture of positive attitudes, giving the scope to the patient to express his anger, refraining from having judgmental attitudes, smoothing the situation without pressuring the patient for proper behavior and many others help in such situation. Establishing decision-making protocol and acknowledging and dealing with conflicts quickly help in tackling the situation (Mohler & Meyer, 2014). The rationale provide by the nurses for applying restraints cannot be held valid. If the nurses really are following the principle of beneficence as well as non maleficence for the patient along with following the ethical theory of utilitarianism, still their activity for not asking for consent cannot be justified as restraints as rightly said by Camilla will cause physical harm and will increase his aggression. Therefore if another nurse would have been in the area, she would have applied the human factor for situation awareness and correct decision-making and apply evidence based strategies by which he could be stabilized following which consent would have been taken.
Human dignity can be defined as the sense of self worth and self respect which includes the right to fill basic needs of food, safety and shelter. In the healthcare environment, human dignity mainly remains focused on the importance of privacy, respect and autonomy. Care should be always taken by healthcare professionals that their practices should never erode the human dignity. Modesty is one of the traits of human dignity and simple activities like lowering of voice when talking, helping them to walk, educating them about their health and the interventions, asking for their permission before applying interventions, before feeding, bathing and others increase patient satisfaction (Luo, 2014). Over the years, social activist researchers have found out through researches that every human being recognizes the need to have some measure of control over their bodies or what happens to their bodies and even over how their destinies unfold. Therefore, healthcare professionals do not keep any human beings restrained to bed. This not only affects their mental health like creating depression, anxiety, frustration and others and even exacerbates aggression in case of psychotic patients. Besides, it also leads to physical harm, bruises, fractures and others. Just like the case study, researchers have also found out that less time and inadequate staffing act as some of the biggest barriers which nurses face when the condition of preserving patient dignity arises. In rush hours, nurses do not get time for address each patient as individual. Stress, fatigue, lack of concentration and also burnout may hamper the patient’s dignity (Eclock & Lewis, 2016). In this case as well, Julie advised Camilla to apply restraints without trying her best to calm down the situations as staffs were less in number. Therefore, it is extremely important for every nurse to develop professional knowledge, dedication as well as clear vision to see every patient as another human being and thereby try to keep the dignity intact by proper critical thinking and decision making skills.
A debate can be established on the use of the ethical theory of utilitarianism. This theory states that an intervention or care can be termed as sufficient and proper only when the outcomes of the interventions has the best impact on the patient making the patient happy and live proper quality life. This theory mainly instructs to implement strategies which bring happiness for the people (Luo, 2016). Nurses treat patients with the goal that their intervention would help them overcome their phase of ailment and distress and give them a healthy life to make them happy. While Camilla was trying to provide the best care plan, she could not do so because of the violence she faced. In order to forcefully apply interventions and make him safe from threats, the patient was restrained. Applying restraints is a breach of the ethical theory of utilitarianism as making the patient feels bondage can never make him happy and in turn gave negative impacts on him. With the long term goal of the patient’s happy and healthy life, the nurses beached the short term goal of maintaining immediate happiness of the patient by applying restraints as they never thought about how the patients self image and self respect can be hampered making him unhappy (Chehab, 2017). Consequentialism which is the theory of ensuring interventions with the best outcomes to be the appropriate one is also not followed here. Julie never thought of the physical and mental impacts that would result from restraints and hence her activity also beached theory of consequentialism.
Beneficence states that nurses should provide interventions which ensure safety of the patients and should have the best outcome (in comparison to other options). Non maleficence ensures interventions which would give no suffering to the patient. It is seen that both the principles clashed among themselves. In order to develop the health of the patient and to keep him safe from any self harm, restraints were put. Providing restraints helped them to conduct assessments of the patient and thereby develop an understanding of his condition to develop care plan with the bets interventions (Bollig, Gjengaegdal & Rosland, 2016). However to do so, non maleficence was not maintained. The application of medical restraints harmed the patient more causing him mental as well as physical suffering which is strictly against the principle of non-maleficence. Hence, nurses should be more concerned and develop critical thinking ability to ensure proper decision making in stressful situations.
The Nursing and midwifery Board of Australia has provided with a set of codes of ethics which nurses should maintain in their practice to ensure best health of patients without getting engaged in ethical and legal obligations. However among the 8 codes of ethics, code 1, 2, 5 and 6 were not maintained. The nurses did not value quality nursing for the patient and did not exhibit respect and kindness for self as well as others. Nurses also did not value informed decision making as his permission was not taken before restraining him. The code 6 of maintaining a culture while providing care may seem to have been taken care of as they tried to put restraint on him for protecting him form self harm (“Code of Ethics for Nurses in Australia”, 2017). However they missed out the part of the mental and physical harm which the patient may have due to restraints which would hamper his safety.
Professional codes of conduct proposed by NMBA were also not followed. Code 1of maintaining a safe care was not followed (“Standard of practice, Nursing and midwifery board of Australia”, 2017). Code 3 of maintaining laws in profession was not followed as breaching of human rights leads to legal obligations. Code 7 of maintaining informed decision making was also not followed. Hence, it is extremely important for all nurses to abide by the codes to ensure safe practice free from dilemma and legal obligations.
Every nurses when gets tangled in ethical dilemma, should utilize critical thinking skills and decision making skills to ensure that the steps they take are in compliance with the ethical principles and theories. Maintain of the human rights and dignities are important to overcome legal obligations. They should follow the professional codes of conduct and codes of ethics to ensure that their interventions abide by them. Restraints should always be considered as the last resort on different options in interventions. Nurses should follow various evidence based journals so that they can understand the most modern techniques which are applied to handle such patients and treat them effectively (Kusmaul, Bern-King & Bonifas, 2017).
Conclusion:
Due to unavailability of workforce on the ward, Julie’s advice made Camilla apply medical restraints to maintain safety of the patient and also other staff members without his informed consent. This resulted in ethical dilemma as there was a clash between the principles of beneficence and non-maleficence. Moreover, the true sense of utilitarianism was also not followed. Professional codes of conduct and codes of ethics were also breached by the application of restraints on the patients. Nurses in such situations have to develop the human factors of decision making skills, critical reasoning skill and situation awareness so that they can apprehend the situations correctly. Moreover they should go through different evidenced based journals to remain informed about the modern care suggested by researchers in the recent years. This would help them to provide care to patients which would ensure patient satisfaction.
References:
Bollig, G., Gjengedal, E., & Rosland, J. H. (2016). Nothing to complain about? Residents’ and relatives’ views on a “good life” and ethical challenges in nursing homes. Nursing ethics, 23(2), 142-153.
Chehab, M. (2017). Moral Distress: What Is Next?. Pediatric Critical Care Medicine, 18(8), 814-815.
Code of Ethics for Nurses in Australia. (2017). 5_New-Code-of-Ethics-for-Nurses-. Retrieved 23 October 2017, from https://file:///C:/Users/user00/Downloads/5_New-Code-of-Ethics-for-Nurses-August-2008%20(3).PDF
Elcock, S., & Lewis, J. (2016). Mechanical Restraint: Legal, Ethical and Clinical Issues. In The Use of Coercive Measures in Forensic Psychiatric Care (pp. 315-331). Springer International Publishing.
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Margeti?, B., Margeti?, B. A., & Ivanec, D. (2014). Opinions of forensic schizophrenia patients on the use of restraints: Controversial legislative issues. Psychiatric quarterly, 85(4), 405-416.
Mertz, M., & Strech, D. (2014). Systematic and transparent inclusion of ethical issues and recommendations in clinical practice guidelines: a six-step approach. Implementation Science, 9(1), 184.
Möhler, R., & Meyer, G. (2014). Attitudes of nurses towards the use of physical restraints in geriatric care: a systematic review of qualitative and quantitative studies. International journal of nursing studies, 51(2), 274-288.
Park, M., Jeon, S. H., Hong, H. J., & Cho, S. H. (2014). A comparison of ethical issues in nursing practice across nursing units. Nursing ethics, 21(5), 594-607.
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Sinclair, J., Papps, E., & Marshall, B. (2016). Nursing students’ experiences of ethical issues in clinical practice: A New Zealand study. Nurse education in practice, 17, 1-7.
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