Professional, Moral and Legal Issues in Nursing - Essay Example

Professional, Moral and Legal Issues in Nursing Contents Introduction . . . . . . . 2 Main text . . . . . . . . 3 Conclusion . . . . . . . . 14 Glossary . . . . . . . . 15 . References . . . . . . . . 16 Bibliography . . . . . . . . 17 Introduction Nurses have struggled hard to gain the respect of society. Part of this newfound respect for the profession stems from the increasing emphasis on continual education and efforts to improve nursing care through review and reflection of practice and the use of theory to guide practice; it is with this spirit of reflection in mind that this report focuses on a critical incident involving a 55-year old man who was admitted to the emergency section of a hospital for Acute Pancreatitism at 17:00 hours. The Consultant Surgeon requested that a nasogastric tube (Ryle’s tube (be passed through the left nostril and put on free drainage. By the following day the patient’s condition was not very good. Pulmonary Oedema and respiratory failure were diagnosed following chest x-ray. On the fourth day, with the patient appearing to have improved the consulting surgeon requested the initiation of enteral feeding for the patient. This was done by means of a fine bore nasogastric tube through the right nostril. Clearly, the patient now had two nasograstric tubes. The Ryles nasogastric tube, which remained in place became spigotted. Nurse A made an attempt to find out if there was any gastric aspirate emerging from the fine bore tube. The junior doctor on duty asked for another chest x-ray in order to find out the exact place where the fine bore tube was prior to feeding the patient. The junior doctor (Pre-Registration House Officer) could not make the proper determination regarding the location of the fine bore tube. The Senior House Doctor (SHO) determined following examination of the x-ray that the tube was in the patient’s stomach. Central feed was ordered. Feeding began but by midnight patient’s condition had become worse. A junior doctor on call checked up on the patient from time to time. Yet another chest x-ray was done. On the 6th day, the junior doctor asked for the enteral feeding to be stopped. The Ryle’s tube was ordered removed by the SHO but it was not because of the belief that tampering with the fine bore tube might actually get it displaced, thus creating even more problems. Main text Nurses work in high pressure situations and under conditions where quick thinking and planning are essential. Even so, the reality is that nurses are human beings subject to all the weaknesses of humankind. Training, of course, can help nurses to go about their duties with more deliberation and thus minimize the potential for error. Considering, however, that nurses often have to take care of a multiplicity of elements during any given shift, it is not surprising though not necessarily welcome that errors are common. Pretending that nurses are perfect will not be a good approach to helping deal with the problem because the consequences of error are real and can sometimes be fatal. The use of critical incidence reports, though hardly perfect, goes a long way towards helping nurses to make use of the benefit of hindsight so that they can avoid making the same or similar errors in the future. Also, nurses who keep up their knowledge can gain access to reports stemming from errors made by other nurses and thus learn from such experiences. In focusing on a critical incident, it is always recommended that the nurses in question try to get to the root cause of the problem. As experience has revealed, however, often, it is not just one major problem that leads to danger for a patient but possibly a chain of interaction events, including omissions and commissions. As C.E. Meurier rites in the article, “Understanding the nature of errors in nursing,” “Human errors are common in clinical practice, but they are under-reported. As a result, very little is known of the types, antecedents and consequences of errors in nursing practice. This limits the potential to learn from errors and to make improvement in the quality and safety of nursing care” (Meurier 2000). When nurses have the chance to reflect on their work, a key component of critical incidence reporting, they prepare themselves for more effective and efficient action in the future. Presenting a critical incidence report is not an occasion for blame but one for learning. When more nurses come to appreciate that such reports are not meant for castigating them or putting their careers in danger but rather ones that would help them to get more closer to their own ideals of a nursing career, they are more likely to feel comfortable reporting their mistakes or those of their colleagues. It must be acknowledged that nurses form only one leg that holds the table of medical care in place. In addition to doctors, there is the patient herself, and of course, family members. This report, therefore, looks at the role of the patient, the doctors, family members, and nurses, in order to determine if any of the legs of the table were too weak to help support the level of care needed for the patient. The role of family members In the investigative report there is no mention of family members. Whether it is a child who has been admitted or an adult, family members can help provide a sense of comfort for the patient. As Mitchell (2005) writes in “Family-centered care – are we ready for it?” “having…family there is viewed as an asset by the health care team. They recognize that it is those closest to the patient who can help the nurses and doctors better understand the patient’s response to treatment” (Mitchell 2005). It is curious, therefore, that there was no family member present for the patient. Did the hospital staff seek information regarding possible family members – a wife, mother, father, cousins, or other relatives or did they consider this irrelevant? Family members often know more about the patient than health care workers who have only a short term appraisal of the patient and can, notwithstanding their professional training, not hope to know more than family members who have had the opportunity to be acquainted with the individual for years or decades. Such family members can be enlisted in the care of the patient as their insights can help health care workers make more insightful decisions. Family members may also have served as advocates for the patient where the hospital staff may themselves have become lax. Family members, however, need not be viewed as hostile to the healthcare system but as co-workers in seeking health solutions and the well-being of a patient. The fact that there were no efforts made by doctors or nurses to seek out family members is a big problem because these family members might have provided information that might have helped if not eliminate all problems entirely. Mitchell (2005) wonders if health care workers are threatened by having family members around the bedside more? And some of the poignant questions she asks include whether health care workers should expect family members to leave when health care workers perform procedures that family members are expected to take care of once the patient is discharged? “Should we promote family presence and involvement in ward rounds? Are families ‘visitors’? Are we being fair and reasonable in access and involvement?...For changes to occur we need to genuinely believe that having families involved more with their relative in ICU produces better patient outcomes” (Mitchell 2005 54). If family members had been apprised of the care that was being given to the patient it was possible that one or more of them might have asked a question, raised a point that might have helped the health care team to avoid making some of the errors that they made. This is not to suggest that health care workers have to cede their place in the care of a patient to family members but family members should not be seen as a deficit in the care of patients. If the health care network that was responsible for the care of the patient profiled in this critical incident had a family nursing orientation they would have gone beyond the care of the patient to considering the well-being of the patient’s family as a whole, an orientation that would also certainly have revealed that there were no family members in the wings to help the patient. As Astedt-Kurki et al write in “Family members’ experiences of their role in a hospital: a pilot study,” notes, “Keeping family members informed is widely recognized as an important source of support. Information should be provided spontaneously, without waiting for relatives to ask for it; it should be honest, comprehensive and easy to understand; and it should be continuously available, although timing is important” (Hentinen 1982, 1984, Lauri 1984, Voutilanen 1989…cited in Astedt-Kurki et al. 1997). When family members are absent and they are not missed by health care workers there is something terribly wrong with the hospital setting in the first place. The role of the doctors The doctors in charge of the 55-year-old gentleman with Acute Pancreatitis understood the importance of their duty of care as physicians, to some extent. Doctors understand that they ought to be careful not to do any harm to their patients. This often means that doctors want to take active steps to alleviate the pain of a suffering patient or to initiate a series of steps that can help put the patient on the road to healing. In fact, the legal obligation on the part of doctors with regard to duty of care has been well established in the law and requires not superior ability on the part of a professional but “the standard of the ordinary skilled man exercising and professing to have that special skill” (cited in “The duty of care: an update” 2005). This raises the question of whether the junior doctor was in a position to exercise the proper care with regards to the needs of the patient. In fairness, the issue is not whether the doctor in question is a senior one or not. In this particular case, it seems that the junior doctor did take positive steps but maybe because of the doctor’s status the nurses did not feel compelled to follow the orders given. This was particularly the case when the junior doctor asked for the removal of Ryle’s tube. Perhaps, if this request had been made by the senior doctor compliance would have been forthcoming thus helping to eliminate the problem of having two tubes in situ. Though there was some communication such as the report from the physiotherapist it does not seem as though such reports are given the level of attention that they deserve. It is almost as if the reports are routine and that they need not be given a high level of attention. While in some cases, such reports led to positive action on the part of health care workers, there also seemed to be some overreaction, leading to the feeling that hospital staff either under-reacted or over-reacted to events and reports. The role of the patient In this case it seems that the patient did not have much to do except to follow instructions and open himself up to whatever the doctors and nurses thought was proper. There is no indication that the patient was informed about the insertion of the nasogastric tubes or that any consent was sought. There is no indication if the patient had been asked to sign any documents or that the health care workers had ascertained that the patient understood the kind of care that was being offered him. The role of the nurses It is a problem when nurses cannot recall whether they had been asked to use a fine bore tube or not. This actually should not be a matter of how good the memory of the nurses might be. Such a request should have been documented in order to allow other doctors or nurses to understand exactly what was being used to take care of the problems facing the patient. It seems that the nurses did not take much care to establish whether there was another nasogastric tube in the patient before inserting another one. This lack of documentation is clearly antithetical to the requirements and guidelines of the NMC code, which explicitly states to nurses and other health care workers that “You must ensure that all your discussions and associated decisions regarding to obtaining consent are documented in the patient’s or client’s health care records” (NMC code 2004). It seems that nursing staff were acquainted with some of the protocols surrounding the use of nasogastric tubes. The nursing staff appears to have understood that “A combination of pH measurement and assessment of gastric secretions is a simple, accurate, and economical bedside method to evaluate correct gastric placement. Normal gastric aspirate colour is clear to slightly yellow, but may be altered in patients with gastrointestinal bleeding or bowel obstruction” (Weinberg & Skewes 2006 276). Not relying on just this method, the nurses and doctors requested an X-ray. This was in line with approved practice since, after all, the pH method is not always accurate. Though there are other methods such as “endoscopy, fluoroscopy, bedside videoscopic placement, electrocardiogram guided placement, end-tidal capnography and capnometry…These methods can be expensive and time consuming, difficult to interpret, and may also be associated with significant complications” (Weinberg & Skewes 2006 276). The gold standard in checking for correct placement is considered to be the plain chest x-ray. In this particular case, however, it seems that one x-ray is not enough. Numerous x-rays are taken without regard to any possible long-term effect on the patient. If the x-ray that was taken in the first place had been properly examined, that is, by a competent person, then it might not have become necessary to take x-rays again and again. As the NMC code of professional code makes patently clear with regard to registered nurses, midwives, and specialty community public health care nurses, “You must keep your knowledge and skills up-to-date throughout your working life. In particular, you should take part regularly in learning activities that develop your competence and performance” (NMC code 2004). This means that the issue of misinterpretation of the x-ray is totally unacceptable. In any hospital, while each individual nurse is responsible for his or her own educational development, administrators can also facilitate the process by giving nurses time off or giving nurses some financial breaks to ensure that they are fulfilling this aspect of their responsibility. If nurses do not update their knowledge, this could come back to haunt the hospital as a whole so the matter of professional development should not be seen as being the sole responsibility of a nurse the NMC code notwithstanding. Though nurses seemed to be generally familiar with the use of the nasogastric tube it seems that there were gaps in their knowledge. For example, it is recommended that “If placement of the NG tube cannot be confirmed it should be removed and repositioned” (Wilkes-Holmes 2006). If such a recommendation had been followed there would not have been a problem of having two NG tubes in a patient’s body. The nurses in this case are certainly not the only ones with minimal knowledge of the correct use and procedures surrounding the placement of NG tubes. As Wilkes-Holmes writes, “NG tubes can easily be displaced on insertion or after placement has been confirmed and often with no accompanying clinical signs…Although displaced NG tubes carry associated morbidity and mortality, many nurses continue to be unaware of the potential risks associated with their insertion and subsequent management” (Cannaby et al 2002 cited in Wilkes-Holmes 2006 14). Clearly the nurses and doctors missed an opportunity to link the respiratory problems to the possibility of the misplaced NG tube. There are many methods besides radiography, including the practice of auscultation, which includes listening for a whooshing sound. Though this method is unreliable, if the health care workers had been properly attuned to the problems that NG tubes can cause they would have sought various ways to confirm proper placement and not have made the error of inserting another tube while the other one was still embedded in the patient. Where the hospital staff really botched their handling of the case were with regards to the x-rays. The first x-ray had stated that there was a naso-gastric tube with its tip below the diaphragm. Efforts should have been made to remove this or to ensure that it was positioned where it ought to be. This was not done. In the second x-ray report it was noted that two naso-gastric tubes were in situ, with clear descriptions of their positions. And yet, a third x-ray had to be taken, meaning that hospital personnel were not taking the time to review reports and to think about how to handle them. Discussion Nurses have fought very hard to be recognized as professionals in their own right. With recognition, however, comes responsibility. Nurses, in recent years, cannot simply say that they are waiting for instructions from doctors or act as passive beings in the hospital setting. Rather, nurses have to take responsibility for their practice and be willing to take decisions that can have major repercussions for the patient and for themselves. This, however, should not incite fear among nurses but rather be considered an opportunity by individual nurses to do what it takes to take their professional expertise to an even higher level. The truth of the matter is that nurses have to work under a very complex set of circumstances in which they have to exercise not just technical expertise in the handling of problems but also make decisions that have a moral, financial, physical, and even spiritual dimensions. Most nurses, at heart, might declare that they want to do what is right. What is right, however, may depend on the upbringing of a particular nurse and the beliefs that the family might have implanted in him or her at an early age. If nurses have to operate from such a hodge-podge set of standards there is no question that matters could be hard for them and for their patients as well who may come from a completely different base of morality and ethics. Of course, it is with this in mind that the NMC presents a uniform code of guidelines for health practitioners, one that takes into consideration not only the needs of patients but also those of nurses and other health care workers. Of paramount importance in the health care environment is the issue of communication. In Meurier’s article regarding errors in the hospital setting, communication was a major component. As Meurier writes, “The communication between the senior clinical nurse and the ward was perceived to be inadequate. For instance, the ward staff did not feel able to ask the senior clinical nurse for help on the day of the incident” (Meurier 2000). Likewise, in the incident under review in this paper, the communication between doctors and nurses and with other ancillary staff did not appear effective and well-coordinated. The importance of physician-nurse communication, however, cannot be overemphasized. As Arford (2005) aptly notes, “The importance of nurse-physician communication has been demonstrated in terms of patient safety and outcomes as well as nurse burnout and turnover” (Arford 2005 72). In this regard, the organization, that is, the hospital management has a responsibility to ensure that there are policies in place to ensure that relevant communication is happening. As Arford (2005) further notes, it is the organization that offers the context within which nurses and doctors interact. This includes the power dynamics as well as the cultural norms that determine how professionals from different settings relate to one another. While communication might seem to be a very simple matter, research indicates that this is not necessarily the case. For example, “The more specialized the work of nursing (for example, the more distinct roles there are involved in delivering care) the more complex the communication lines. Registered nurses often prefer to deliver total care to a group of patients rather than function as a team leader of ancillary staff members; one reason they cite is the inefficient use of time spent communicating with team members” (Arford 2005 72). In this particular case, while the nurses were diligent in their handling of matters, it seems that there was not much in the way of leadership, in terms of a senior nurse who would have been able to connect the dots and ensure that proper protocols were being followed in the interests of the patient. The level of staffing also left something to be desired. There was no extra staff because one of the staff members had phoned in sick. Once again, if proper administrative protocols were in place, it might have been possible for management to call in another staff member to ensure that there was appropriate level of staffing. It is not enough, however, for nurses to have just the right technical expertise. Nursing, after all, involves more than just knowing when to administer medicine or insert a nasogastric tube. This is not to say that these technical skills are not necessary; they certainly are but if nurses have enough caring and enough of a sense of morality and respect for the other they might be able to avoid making some of the more common mistakes that appear to result from perhaps not caring enough or knowing enough upon what moral ground they stand. There are various frames by which nurses can draw strength in their decision making beyond the confidence that their training imparts. In his study of doctors and nurses in a hospital setting, researcher Robertson (1996) observed that utility was very important to both nurses and doctors. This meant not simply looking at the greatest good for the greatest number but often “weighing benefits of two or more possible outcomes. The most common example was the weighing of risks and benefits of over- and under-medicating patients in the pursuit of an ideal mean” (Robertson 1996 295). As Robertson observed, such a utilitarian perspective, however, was not always adequate. For some health care workers, beneficence was much more important. As one nurse explained to Robertson, “Somebody with a bright kind of attitude with regard to other human beings could become a good nurse, no matter how unacademically developed. If you don’t care, if you don’t struggle…you won’t be very much use and won’t be a comfort to suffering people” (Robertson 1996 295). If such a caring attitude, which presupposes an element of empathy were involved in the care of the patient for whom this report is about it is unlikely that the patient would have ended up with two nasogastric tubes inside of him. That utilitarianism alone is not enough for nurses and nursing is brilliantly discussed by Tuckett (1998) in the article “An ethic of the fitting: a conceptual framework for nursing practice.” As explained by Tucket, utilitarianism at the core focuses on maximizing pleasure and minimizing pain. Utilitarianism comes across as a practical grounding for behaviour because it seeks to consider outcomes and is not so much bound by rules as by the facts of the case at the moment and what the nurse can do about it, taking into consideration, of course, what the consequences would be for the patient and for others that are likely to be affected by the decision. In effect, “the nurse guided by utilitarianism acts to maximize the consequences of the act that promote(s) the interests of all those affected by it” (Tuckett 1998 221). Deontology, on the other hand, is less concerned about taking right action that may lead to greater good. Deontology is grounded in perceptions of what is right and what is wrong and is based on pure reason. “In this legalistic framework that rejects the influence of consequences on moral decision making, some acts are considered always impermissible. Such acts are commanded never to be permitted, so that one must refrain from committing such an act even if in so doing ‘the morally admirable is lost’ (Tuckett 1998 221). Deontology treats each individual as an end and not as a means to an end and therefore calls for respect and autonomy of the individual. As Tuckett points out, as admirable as deontology sounds there are times when it does not have a good way to resolve some dilemmas. For example, “how does a nurse act when telling the truth will clearly harm the ill client? Hence, the principle of beneficence is in conflict with the principle of veracity” (Tuckett 1998 222). Those who subscribe to virtue-based conceptions of nursing place more emphasis on the character of a nurse; this means that when there are conflicts or dilemmas that a nurse has to deal with, the character of the nurse and his or her commitment to doing good is likely to affect how the nurse responds. In effect, “the recognition of character traits serves to emphasize the individual as an agent immersed in the moral life rather than acting in some detached way. The application of the utilitarian standard or deontological constraints to a given moral context involves a somewhat reductionist, mechanical problem-solving approach that lacks sensitivity to the very nature of relationships” (Tuckett 1998 222). Conclusion Rather than foisting only one worldview on nurses or the nursing profession it is important to understand that each of the ethical frameworks has advantages and disadvantages. This means that clinging wholeheartedly with one while ignoring the others can be counterproductive. Rather, just as the situations nurses face come in varying complexity, human beings are capable of responding to complex situations not just based on one perspective but through a holistic appraisal of the situation. If nurses and health care personnel had kept up their training it is unlikely that there would have been a situation where the results of x-rays could not be properly interpreted; beneficence and compassion would have made nurses consider more carefully the issue of inserting another nasogastric tube into a patient. It is not clear whether the lack of proper documentation was a lapse in the nurses concerned on the basis of character traits or if there were no proper guidelines that would have required them to do so. Issues of communication are very important, whether among doctors, between doctors and nurses, among nurses themselves or indeed between patient and health care personnel, not to speak of family members who may sometimes become a crucial link between health care personnel and the patient but were totally absent from the picture in this instance. Glossary CHAI – Commission for Healthcare Audit and Inspection – soon to take over role from CHI. CHI – Commission for Health Improvement – aims to improve quality of patient care by providing robust and reliable guidance on current best practice DVT – Deep vein thrombosis HDU – High Dependency Unit – staff ratio of 2 patients to 1 nurse NG tube – Naso-Gastric Tube NHS – National Health Service NICE –National Institute for Clinical Excellence NMC – Nursing and Midwifery Council – professional body for nurses NPSA – National Patient Safety Agency – improves safety and quality of care through reporting, analysing and learning from adverse incidents and near misses. RMO – Resident medical officer – equates to senior house officer References Bibliography Arford, P.H. (Mar/Apr 2005) Nurse-Physician Communication: An Organizational Accountability Nursing Economics 23 (2)72. Astedt-Kurki, P. et al. “Family members’ experiences of their role in a hospital: a pilot study.” Journal of Advanced Nursing, (1997):908-914. Barazzetti, Gaia; Radaelii, Stefania & Sala, Roberta. (2007) Autonomy, Responsibility and The Italian Code of Deontology for Nurses. Nursing Ethics 14 (1). Begun, J.W. (Jan/Feb 2006) Opportunities for Improving Patient Care Through Lateral Integration: The Clinical Nurse Leader. Journal of Healthcare Management 51(1) 19. Different skills, different attitudes, same duty of care British Journal of Nursing 15 (10) 537. Drug Delivery; Nasogastric administration of amiodarone results in poor absorption. (Aug 13, 2006) Heart Disease Weekly 142. Dulak, S.B. (Aug 2006) Inserting an NG tube Healthcare Traveler 14 (2) 36. Fluconalzole 1-mg/mL Liquid for Nasogastric Tube Administration (Sep/Oct 2006) International Journal of Pharmaceutical Compounding 10 (5) 383. Fulbrook, S. The duty of care: an update – Current legal principles BJPN 15 (2). Henderson, D. (Nov 11, 2006) Dyslexic nurse may be struck off after drugs mix-up The Herald pg 9. Hospitals must improve workplace communication to help reduce medical errors. (Mar 2005) Hospitals & Health Networks 79 (3) 66. Meurier, C.E. (2000) Understanding the nature of errors in nursing: using a model to analyse critical incident reports of errors which had resulted in adverse or potentially adverse event Journal of Advanced Science 32 (1) 202-207. Stroke; Swallowing function in stoke patients with nasogastric tubes is assessed. (Nov 6, 2006) Gastroenterology Week p 174. Mitchell, Marion (2005). “Family-centred care – are we ready for it? An Australian perspective.” British Association of Critical Care Nurses, Nursing in Critical Care, 10 (2):54-56. Robertson, David W. (Oct 1996). Ethical theory, ethnography, and differences between doctors and nurses in approaches to patient care.” Journal of Medical Ethics, 22 (5):292-299 The NMC code of professional conduct: standards for conduction, performance and ethics. www.nmc-uk.org (December 19, 2006) Tuckett, A G (1998) An ethic of the fitting: a conceptual framework for nursing practice Nursing Inquiry 5 220-227. Trujillo, Maximo H et al. (Jul 2006) “Lariat Loop” Knotting of a nasogastric tube: an ounce of prevention. American Journal of Critical Care 15 (4) 413. Tschudin, V. Editorial Nursing Ethics 13 (6) Webb, John & Warwick, Catherine. (1999) Getting It Right: The Teaching of Philosophical Health Care Ethics. Nursing Ethics 6 (2):150-156. Weinberg, L & Skewes, D. (Apr 2006) Pneumothorax from Intrapleural Placement of a Nasogastric Tube Anaesthesia and Intensive Care 34 (2) 276. Wilkes-Holmes, C. (Nov 2006) Safe placement of nasogastric tubes in children. Paediatric Nursing 18 (9) 14. Williams, F.O. 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