NURBN1012 Professional Legal And Ethical Decision Making In Person Centered Care

Clinical Scenario: Jade’s Dilemma?

The lift doors open and Jade rushes into the lift. Jade is a newly graduated RN and she is running late for a shift at the start of her second week of her new graduate program. Inside the lift are two, night duty nurses on their way home after finishing their night shift. As they share the lift Jade over hears them discussing a patient.

“She should be made to take the drugs,” one of the night nurses said. “Yes,” agreed the second. “That mother is condemning Bethany to a death sentence.”  The lift doors open onto Jades floor, she quickly rushes to start her shift.

The shift coordinator reminds Jade about the importance of being on time to start her shift, but adds that she is lucky, as the night staff had left their handover information on a tape for her to listen to. Jade listened to the handover tape and discovered that she would be working with the shift coordinator as they are short staffed. She and the shift coordinator have six patients to care for in their patient load.

One of her patients is an 11-year-old girl, called Bethany and Jade wondered if this was the same child she had heard the two, night duty nurses discussing in the lift. The tape covered much of the essential care for all six patients, but additional information had been handed over verbally that Jade had missed. The coordinator (Lisa) failed to pass on the additional information. Primarily, it related to Bethany’s mother’s religious beliefs and a discrete move by the medical team to make Bethany a “ward of the state.”

Jade decided to check on the welfare of all six patients. Eventually, she met Bethany an 11 year old child, newly diagnosed with Acute Lymphocytic Leukaemia (ALL) and she had recently developed a serious chest infection. To Jade’s surprise Bethany was not receiving any medications and had no IV line. She also found Bethany in her mother’s arms as she sat in a chair at the bed side being gently rocked. Jade noticed that on Bethany’s medication chart she was written up for IV antibiotics.

“Has Bethany had these medications yet?” Jade asked Bethany’s mother.

“Oh no, our religious beliefs don’t agree with the administration of drugs of any kind and I have not allowed it,” Bethanie’s mother replied politely.

Jade thought Bethany looked flushed.

“Can I take her temperature?” Jade asked. It was 38.9 degrees.

“Can I give her some paracetamol for her high temperature?” Jade asked.

“No,” said Bethany’s mother, “as I explained, in our religion the use of medications of any kind is forbidden.”  Jade asked if Bethany’s mother would sponge Bethany with a cool sponge cloth. Her mother agreed and took the cloth.

Jade wasn’t sure what else to do about the pyrexia and spoke to the doctor at the nurses’ station about the situation. The doctor explained that they were quite concerned about Bethany, but that as a new registered nurse Jade would not understand their responsibilities as doctors and that the medical team were aware of the situation and had sought a court order to force the mother to release Bethany to the care of the hospital and ban the mother and close family from contact with Bethany while they aggressively treated the chest infection and underlying ALL. The doctor said, “we have tried to reason with the mother and now we have no choice but to secretly plan to treat the child without the mother’s consent.”

Shortly after, Lisa took Jade aside and suggested that when Bethany’s mother went to the toilet she should give Bethany some paracetamol for her high temperature. Jade refused. The doctor, who was nearby, suggested that Jade hide the paracetamol solution in some ice cream and give this to Bethany. Again, Jade refused. Bethany’s mother suspected the staff were planning to tamper with the ice cream and refused to allow Bethany to take it, even though it had not been tampered with.

Hoping to help reassure Bethany’s mother Jade spoke with her about the situation. During the conversation Jade disclosed the medical team’s plans to gain legal custody of Bethany. Shortly after the conversation Bethany and her mother left the hospital, suspending the medical treatment for either the chest infection or underlying ALL.

Lisa questioned Jade about her conversation with Bethany’s mother at the end of the shift. When Jade mentioned her conversation with Bethany’s mother Lisa became very angry with Jade and at one point said, “you have helped kill this child.” Jade left the shift at the start of her second week as an RN in tears.

A report on ethical and legal issues, clinical decision making, scope of practice, professional nursing standards and leadership roles in a newly graduated registered nurse.

Introduction

Ethical principles are appropriate in guiding the acts of nurses and other health professionals within the sphere of nursing and health in general. Working within the scope of nursing is also crucial for success within the medical filed (Bijani et al., 2017; Campo et al., 2016)..

For nursing students who have just graduated from institutions of higher learning, such as colleges and universities, it is very difficult to change the culture of negligence and lack of adequate consideration of the guiding principles of nursing. Ethics in nursing describes what is right or wrong in nursing (Richter, Garvare, & Nyström, 2017). Ethics guides what should or should not be done within the scope of nursing. The scope of nursing in itself describes the exact field within which nursing professionals can operate (Chen, & Lou, 2014). In the case scenario presented, with Jade as the new grandaunt, there are many cases in which both ethical practices, professional nursing standards, leadership roles,  legal issues and clinical decision making processes were not followed to the latter- but were rather broken (Chew, Durning  & van Merriënboer, 2016).

Body

There are many scenarios that present themselves throughout the case presented, that show the level  unto which the guiding principles are not being followed. Nursing runs under the ethical principles of autonomy, non-maleficence, veracity, fidelity and justice (Elwyn et al., 2014). It is crucial ,therefore, that this principles are followed throughout nursing practice.

Conversely the principles of augtonomy has been clearly broken in this case. Bethany’s mother has not been involved in the doctor’s plan to add medication in the child’s ice cream. Informed decision making is critical to patient’s care. Patient’ s have a right to identify the particular medication they are put on and the effect that this medication has on their bodies (Numminen, Leino?Kilpi, Isoaho & Meretoja, 2015). Under this scenario, it will not be fair to administer medication to the child under false pretense that it is ice cream.  In cases where one cannot make a decision regarding his or her health, it is legally acceptable for the next of kin or the parents to make the decision for him or her- which is not the case for the above presented scenario (Esmaelzadeh,  Abbaszadeh, Borhani, & Peyrovi, 2017).

Additionally, it is ethically wrong and it goes against professional standards of nursing and medical care in general, for nurses to discuss patients. The nurses in this scenario have gone against the principles of professionalism. Nurses have a duty to uphold professionalism as it is an expectation from fellow nurses and the public. Compounding to that, patient’s right to privacy is recognized both nationally and internationally as one of the human rights. The international human rights conventions agree that the right to privacy is a patient right that needs to be upheld at all times. The dignity of a human being is an important factor to keep in mind when administering care to patients and even afterwards when one is not within the vicinity of the patient in question (Laschinger & Read, 2016). 

It is also clear to see that the there is poor communication practices within the workplace, where Jade is currently working. Communication is essential both for team building and for adequate flow of activities within the workplace. Inconsistent flow of information within the workplace is responsible for inadequate patient care and management. As a result of poor communication, the prognosis of patients along the continuum of health is interfered with and moves towards  a negative direction. Jade had not received conclusive feedback from both the night duty staff who were handing over the patients to them and the shift coordinator whom she was with during the night,  regarding the treatment of Bethany and her nursing care over the period of time (Masters, 2018).

There is  a strain in the collaboration and progress of activities within the workplace. Not only had Jade not received a report of Bethany’s treatment, but also she had not received adequate information regarding the mother’s cultural beliefs and how they affected treatment of the child. This means that the care of Jade was not effective due to the fact that the mother did not support the use of medication. Failure by the shift coordinator to pass such crucial information to Jade, further shows the extent unto which the communication and collaboration process is hampered. Nurses have a duty to share information in a timely manner, to document all the information in a cardex and to work with other team members so as to ensure that the health and wellness of the patient(s) is maintained at optimal levels. As a graduate nurse was in a bit of a tassel owing to the fact that she did not posses adequate information (Parandeh, Khaghanizade,  Mohammadi,  & Nouri,  2015).

Lack of adequate number of staff further worsens the situation for newly graduated student nurses. According to the Institute of Medicine, nursing staffing is important so as to ensure that high-quality and patient centered care is provided for. Nursing in itself is a critical factor in determining the quality of care that patients receive in medical facilities.

 However, the progressive cuts in the number of staffs in hospitals (especially the reduction of nurses) in order to reduce the cost implications by the human resource departments, increases workload for nurses and reduces the quality of care that is accorded to patients. Jade has to work with the  shift coordinator for the whole night despite having six patients to care of. This goes against the ethical principles of beneficence.

Patients have an ethical right to receive maximum and timely care at all times from the nursing staff. However, it will be very difficult to conclusively achieve this as the number of nurses available are very few. It is only possible to achieve this goal when the number of nurses are enough to meet the individualized needs of the patients appropriately.

Veracity, the act of being truthful in all acts performed by a nurse and other team members of the medical profession, is highly crucial. The nurses and doctors in this case scenario involving Jade and Bethany have not been truthful in their acts. They have a plan to administer medication to Bethany through her ice-cream once her mother has left. This act also goes against principle of justice. It is not only unprofessional to perform such an act but also unjust for both the mother and the child.  

Justice in itself is an ethical value. It is defined by the traits that not only consider the value of human dignity and respect but also have a focus on the equal and appropriate access to health services and the right of being fairly treated and care for. Care of a patient by considering justice is one which is free from the consideration of social, economic and cultural status. It is the right of individuals to receive equal care. Nurses have a duty of offering care to patients in spite of their cultural beliefs or attributes, nursing care should not be limited by any factor.

There is also poor interdisciplinary  collaboration. This is evidenced by the fact that the nurses in question do not collaborate effectively with the doctors in the case scenario. Jade is found to communicate with the patient regarding the plans that the doctors and other nurses have. She has broken the ethical boundaries by revealing the plans that the doctors had to put a restraining order on Bethany’s mother so that they can easily rid her of her illness. The principle of privacy has been drastically broken. It is the doctor’s who should have provided this information to the mother. The use of this should have been after all the avenues of care had failed. Not only does her act (Jade) of speaking to the mother about the doctor’s plans show a lack of teamwork but also it shows a lack of interdisciplinary collaboration between the doctors and the nurses on the shift.

The poor communication process between the student nurses and the other medical professional affects their performance drastically. Most of the student nurses may be unaware of institutional policies, just like Jade and end up receiving blame for activities they were not responsible for. Poor communication decreases cross-collaboration, reduces the productivity and increase employee Grambling such as displayed in Jade’s case. Jade ended up receiving an unneeded comment that severely affected her emotional well-being. (Purpora & Blegen, 2015). However, she was not to be blamed for what happened as she did not receive appropriate information on the subject matter- this further highlights the effects of poor teamwork and lack of interdisciplinary practice.

Key responsibilities of a newly graduated registered nurse in the case scenario.

Jade, or any other nursing student, has many duties. Nurses need to communicate with doctors and collaborate with other health care professionals. Nurses need to ensure that information is adequately shared. As a graduate student, it is crucial to communicate with other nurses who have worked longer in the institution so as to manage the patient effectively (Schuler, 2016).

Additionally, it is crucial for the nurse in this case to update all the records and monitor the patient for changes in vital signs. Any fluctuation in the vital signs should be reported to other medical personnel and appropriately dealt with (Vryonides et al., 2015).

Compounding to this it is the duty of the nurse to ensure that health education is administered (Reem, Kitsantas & Maddox, 2014; Reuber, Toerien, Shaw & Duncan, 2015). It is crucial to educate the mother on the importance and mechanisms of action of medication, since this will aid in changing her mind and helping her see the importance of modern medicine. She should see why it is crucial to take medication (Richter, Garvare,  & Nyström, 2017).

While administering health education to the mother it is critical to be mindful of her culture and beliefs so as to avoid offending her in any way. Culture plays a key role in the life of the client (Reuber, Toerien, Shaw,  & Duncan, 2015).

It is also the nurses to act as the patient’s advocate. It is her duty to ensure that all the needs of the patient are met in spite of her mother’s negating attributes. It is her duty to find a way to agree to the use medication in the management of the child’s condition.

Conclusion

In conclusion it is highly crucial for the graduate nursing student to ensure that she is able to offer the right information to the right people at the right time to so that the patient receives timely and adequate patient centered care. The lack of teamwork and collaboration among team members of the health profession is responsible for poor patient prognosis. The use of a patient centered approach in the care of patients is appropriate to ensure improved patient prognosis.

Recommendations

In order for better patient prognosis under the care of newly graduate nurses such as Jade, it is highly recommended that:

References

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