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Subject Area - NursingLegal, Ethical, Professional Issues in Nursing
Critically analyse how ethical, professional and legal issues underpin nursingpractice.
Nurses are subject to a plethora of ethical, legal and professional duties whichare too numerous to discuss within this thesis. Therefore the main professional,ethical and legal duties will be discussed. These three main duties are generally considered to be to respect a patient’s condentiality and autonomy and torecognise the duty of care that is owed to all patients.These three main duties are professional duties, however there are legalimplications if they are breached, therefore they are also legal duties; ethicalconsiderations arise in contemplation of these duties, such as consideration of when they can be breached and they are therefore ethical duties as well. Beforeconsidering the main duties, consideration will be given to the regulatory body of nursing, the GMC.
2. The Nursing and Midwifery Council
The medical and nursing professions are bound by their own code of ethics whichis enforced by disciplinary procedures. The professional governing body has forthe most part a more immediate inuence over the conduct of its members thandoes the law, which is invoked relatively rarely in medical matters.The NMC is a regulator of professional standards. Central to its regulatory function is the Register of Medical Practitioners. The register operates as aregulatory tool in two ways; rst of all, by operating the register the GMC isthe profession’s gatekeeper, allowing entry only to those who have achieved therequired standards for a ‘registered medical practitioner’ (‘RMP’).Secondly, ‘tness to practise’ proceedings against RMPs may result in their being suspended or erased from the register. As a means of pre-empting thenecessity for disciplinary proceedings, the NMC issues guidance on aspects of apractitioner’s duties and responsibilities in areas such as consent, condentiality and medical research, to prevent poor practice at source. The translation of NMCguidance into conduct rests primarily, of course, on the individual conscience of members of the profession whom, it is hoped, adhere to the guidance on a day
Although the survey was administered in 2004, the data remain relevant to contemporary thought about the study topic. First, nurses continue to face challenging ethical issues in clinical practice and this will only increase with an aging, chronically-ill society. Second, these issues or problems are stressful and influence whether nurses want to remain in their positions. Third, given the current nursing shortage and the need for qualified, caring providers, understanding the ethical problems and how they influence the provision of beneficent care and the health and well-being of nurses is urgently needed. This is a concern for nurses everywhere
Ethical issues for nurses
Our findings underscore the importance of ethical issues that nurses frequently experience across a range of clinical practice settings and the amount of stress these issues engender in the nurses. Several important conclusions can be drawn from our findings. First, although more than two-thirds of our respondents cited protection of patient rights as their most frequent ethical issue, they identified staffing inadequacies as the most stressful issue. Without sufficient staffing it is difficult to meet the ethical standards of professional practice. Understaffing and other organizational and systematic barriers could preclude nurses from meeting many of their primary responsibilities, including protecting the rights of individual patients and families, alleviation of suffering, and preserving their own integrity. Today's healthcare environment is driven by discordant demands to provide high quality care and to manage costs with diminishing resources. Nurses seem to be doing more and more with these limited resources, but “Even when the provider does the best he or she can, it may not feel good enough” (Ulrich & Grady, 2009, p.5).
Nurses in each of the four regions cited frequent problems with staffing and resultant stress. In fact, more than twice as many respondents reported high or very high stress associated with staffing difficulties than with any other item. In 1999, the California legislature passed the first comprehensive minimum nurse staffing ratios for acute hospitals, yet 32% of California nurses in our sample reported regular occurrences of staffing patterns that negatively affected their work. Advancements in medical technology and research have made ordinary what was once considered extraordinary, making the needs of today's patients vastly more complex. Although California's nurse staffing ratios were meant to be protective for both patients and nurses, perhaps nurses perceive little qualitative differences. One patient with multifaceted needs could consume a large amount of a nurse's time and possibly exceed the demands of their skill set—for example, a patient with diabetes and a psychiatric illness who also has aggressive behavioral problems and emotional outbursts needs a great deal of attention. More research is needed to determine how staffing patterns negatively affect the ability of nurses to do their work. Research is also needed to tease out other important components that affect nursing care, such as patient acuity levels and treatment complexities, as well as the skill mix and educational needs of the professional staff on any given unit.
Not surprisingly, for the majority of nurses in our study the most frequent ethical concerns centered on protecting patients' rights as this is one of the basic tenets of the profession. Both national and international nursing codes of ethical conduct stress the importance of beneficence, professional advocacy, and serving patients' best interests. Unfortunately, anecdotal evidence suggests that when nurses attempt to advocate for patients they are often discouraged from doing so to the degree that some now say, “It's simply not worth it.” More research could elucidate which patients' rights are at stake and what helps nurses to feel successful in protecting them, as well as the factors that influence nurses' ability to act on their reasoned moral judgments. Qualitative interviews with nurses on the frontlines would provide us with more nuanced data about the process of and problems associated with advocating for patients' rights in different practice settings.
Our data also show that nurses identify concerns with informed consent, advance care planning, surrogate decision-making and end-of-life care. These concerns could possibly reflect the acute, chronic, and life-sustaining direct care needs of vulnerable populations, such as older people and those with Alzheimer disease and other cognitive ailments. Nurses need to engage in difficult ethical conversations, yet those with less experience reported greater stress and possibly were more uncomfortable and/or had received little training in broaching these subjects. Harrington and Smith (2008) note that “even clinicians who are well trained and skilled at giving bad news can find it burdensome and emotionally difficult” (p 2674). Indeed, although a quarter of our cohort reported no ethics education (Ulrich et al. 2007), those who had in-house and educational ethics training reported higher levels of stress associated with allocating resources. The majority of respondents cited confidence in justifying their decisions about ethical issues and felt prepared to address them. Yet, paradoxically, many also reported a sense of powerlessness and little influence in dealing with others about ethical issues. This sense of powerlessness “fits” the classic definition of moral distress, where one knows the morally correct course of action but cannot carry it out due to situational and/or other internal and external constraints (Corley 2002; Corley et al. 2005). Moral distress can leave a person emotionally scarred and often hesitant to speak out against what is perceived as an impenetrable hierarchical system of care.
Rheaume (2009) noted that “The nursing profession offers innumerable rewards, but the work is demanding” (p. 1). Indeed, many of our respondents reported fatigue, feeling powerless, and frustration when dealing with ethical issues, and more than three-quarters felt that there were some ethical issues they can do nothing about. Levi and colleagues (2004) describe an occupational hazard known as “jading” that occurs in the clinical context of healthcare delivery when a person is basically “worn out” and exhausted from labor intensive work that is embroiled with the social dynamics associated with complex human caring relationships. Moral apathy can occur because the drive to make a difference and to care is compromised by repeated interactions that remain unresolved. For example, some nurses in our survey responded that it is often difficult to know what the options are when faced with an ethical dilemma, and that nurses are inadequately prepared to address them.
Interestingly, nurses with less experience encountered end-of-life and surrogate decision-making issues more frequently than those with more experience. Some research suggests that less experienced physicians and nurses are reluctant to withdraw life-sustaining treatments for critically ill patients, and have more difficulties associated with providing analgesic or sedative relief during treatment withdrawal (Burns et al. 2001). Additionally, end-of-life concerns were more prevalent for Californian nurses than for those in other regions. In fact, 1 in 5 Californians will be 60 years of age or older by 2010, and the state has also seen a rapid rise in the oldest old population (California Department of Aging, 2009). Older populations tend to suffer from multiple chronic diseases and disabilities, and their growing numbers in all U.S. states will require well-prepared practitioners to address the unprecedented ethical concerns related to their care needs.
More than one third of the nurses indicated that advanced care planning issues occurred frequently, and this was equally reflected in both for-profit and not-for-profit organizations. In a study of nurses' knowledge of advance directives at a large acute care hospital in the Midwest of the USA, Crego and Lipp (1998) found that a large majority of respondents thought that neither nurses nor patients had a good understanding of advance directives and that both needed more education. Although these conversations can be difficult, sensitive, and contentious, respect for persons is a cornerstone of the patient-provider relationship and allows individuals the right to determine their course of care. Further work is needed to understand how nurses, patients and families can best engage in advance care planning, the level of preparation that is needed to have these conversations, how well advance directives are honored by families and healthcare professionals and, finally, the factors that contribute to quality end-of-life care.
More than a decade ago, Scanlon (1994) identified important ethical problems in nursing practice that included issues of cost containment, futility, and informed consent. Our data show that these and other issues remain concerns for nurses in today's environment. “Acting for the good of the patient is the most ancient and universally acknowledged principle in medical ethics” (Pellegrino & Thomasma, 1988, p. 73), but about a quarter of our respondents said that to some extent ethics stress influenced their current thinking about remaining in active practice.