Essay on Nursing Ethics
This essay discusses the ethical issues faced by a nurse in a scenario where a young girl is admitted to a hospital with abdominal pain. The girl discloses to the nurse that she is pregnant, but asks her not to tell her mother. Further, the nurse’s friend, another Registered Nurse, who is familiar with the case, discusses and speculates about it on social media. Based on the details of the case and study of the relevant literature, ethical and legal issues related to disclosure of patient’s confidential and private information are identified. Further, there are ethical issues related to termination of pregnancy. The case is also discussed from the perspective of possible child abuse. The nurse needs to consider the necessity of disclosure and the propriety of the decisions (e.g. termination of pregnancy) at each stage of the decision making process, always keeping the interest of the patient in mind. Physical health, mental state, and cultural background of the patient also need to be factored. In case of suspected child abuse, the nurse is legally obliged to report the matter to the authorities. It is concluded that implementing ethical principles requires high level of professional and communication skills. Importance of regularly updating knowledge related to policy and laws on ethics is also evident.
Ethics is a concept about right and wrong in the context of the decisions and actions of people. Consequently, it is vital for nurses to understand the concept of right and wrong so that they can provide professional services to those under their care. Application of the concept requires that nurses should inculcate the underlying principles and develop the reasoning ability so that they can analyse ethical issues better (Chaloner, 2007). Nurses are required to promote personal and organizational ethics, always giving top priority to the interests of the patients. Nursing involves more than physiological care, and can sometimes require the nurse to fight for the patient’s rights (Taylor, 2005). This essay discusses a scenario where a young girl is admitted to the hospital with abdominal pain. Further examination, and consequent unfolding of events give rise to ethical issues in the context of providing treatment and care to the patient. Following paragraphs of the essay briefly describe the situation, identify the main ethical issues involved, and also discuss the issues from the perspective of accepted ethical principles, and existing policies and laws. The situation is viewed from the perspective of all those involved in the situation, and suitable options, in the best interest of the patient, are suggested.
The scenario involves two nurses Kylie (Female) and Claude (Male) who have studied together to become Registered Nurses (RN). They work in the same hospital (Tinytown Hospital) and in the same ward (surgical ward). The hospital is located in a regional community of Smallville. These friends connect with each other on Facebook outside work. RN Claude is required to provide care for a 15 year old girl called Ellen who has been admitted to the hospital with abdominal pain. Ellen’s mother, with whom she stays, is with her while RN Claude goes through the standard process of admission. Claude asks her questions relating to menstruation and the possibility of pregnancy. The mother objects and demands that a female nurse be allocated instead of Claude. Incidentally, RN Kylie is ultimately deployed on the case. When alone with Kylie, Ellen tells her that she may be pregnant, but specifically asks Kylie not to disclose this information to her mother. Based on the diagnosis, preparations are made for appendectomy. After work on the same night, while on Facebook, Kylie sees an update from Claude which mentions about the Ellen’s incident. Claude writes that the girl’s mother wanted a female nurse. Claude goes on to mention that he thought that Ellen was pregnant and the boyfriend of Ellen’s mother was responsible because he did not accompany them.
The important aspects evident from the above scenario include the fact that the hospital is located in a small community, the girl involved is a child or a young person as she is below 18 years (DEECD, 2013), and the mother demands a female nurse. More importantly, Ellen shares personal and confidential information with Kylie, but specifically prohibits disclosure of the information to her mother. Furthermore, Claude shares vital information about the case with Kylie on Facebook. Being a small-town hospital, the details shared may be enough for anyone to identify the patient. In the scenario, the information was shared with Kylie who, incidentally, was actively involved in the case as a nurse. Claude, who may not have got the chance to investigate and examine the girl in detail, goes on to speculate that the girl is pregnant. He further speculates that the boyfriend of Ellen’s mother was responsible for the pregnancy simply because he did not accompany them.
Broadly, the ethical issues which emanate from the scenario include those related to disclosure of private and confidential information about the patient, especially when the patient has prohibited such disclosure. The fact that the patient is living in a small town community makes the issue even more sensitive. Further, Ellen’s pregnancy at a young age may generally pose danger to her health. It may lead to complications or require special considerations while performing the appendectomy, or during post-operative care. Also, more investigation may be required to ascertain whether it is a case of child abuse or it is a case of teenage pregnancy due to a relationship. The requirement and possibility of termination of the pregnancy is also an important ethical issue to be considered. Further, sharing of private information about patients on social media and also speculating about the case by Claude is also against ethics. These issues are discussed further from the ethical and legal perspective next.
Studies have reported that nurses consider protecting patients’ rights, human dignity and informed consent amongst the most important ethical issues which they encounter while providing care (Johnstone, Costa, & Turale 2004). The basic concepts in nursing ethics involve truthfulness, rights of the patients, confidentiality and autonomy. For example, it is important to consider whether the disclosure of any information is morally correct or allowed (Chaloner, 2007). Nursing knowledge, skills, knowledge of ethics and related principles, relationship with patients, and proper communication skills can make the task of the nurse easier in situations where ethical dilemma is involved. The ethical principles are to be used with care, respect, transparency and veracity. It is imperative that the nurse follows the principles of autonomy and beneficence. The principle of autonomy considers that the patient has the right to take decisions about the treatment and care being provided to him (Parker, 2007). However, it is important for the patient to have appropriate information so that the autonomy serves his interests. A nurse also needs to make sure that the patient is exercising his autonomy based on relevant information. The patient and family should be in the frame of mind to accept the education which helps them take informed decisions about patient care (Heiskell, 2010). Even those whose autonomy is diminished are entitled to protection. Beneficence implies increasing the benefits and reducing risks (Judkins-Cohn, Kielwasser-Withrow, Owen, & Ward, 2014). It is the principle of helping, causing and supporting the welfare of the patients (Johnstone, as cited in Heiskell, 2010). Also, the principle of beneficence is more relevant than autonomy in certain situations as many patients do not want the autonomy. Furthermore, the principle of multi-culturalism helps take into consideration the culture of the patient while following the ethical principles (Heiskell, 2010). Culture of the patient is an important consideration as the notion of confidentiality may be different in different ethnic groups (Johnstone & Kanitsaki, 2009).
The Code of Ethics for Nurses in Australia requires that Nurses value ethical management of information. It is required that nurses maintain utmost professionalism and integrity while recording information. The information has to be correct, without any judgmental bias, and relevant in the context of the healthcare and treatment of a person. It is important to take care while adding any information in health records of a patient as the impact can be profound and long lasting. Patients’ privacy and confidentiality have to be respected, though it is important that it is not at the cost of his health and safety. Importantly, personal information can be shared after consent of the patient or after obtaining legal authorization. Notably, nurses should not disseminate such information to anyone not authorised to receive it (NMBA, 2008a). Code of Professional Conduct for Nurses in Australia also requires that nurses should treat personal information about patients as private and confidential. Nurses are legally and ethically obliged to take care of the privacy of patients under their care. If a nurse cannot obtain consent of the person for disclosing information, he needs to exercise his professional judgment on the need for such disclosure. Again, the interests, health and safety of the patient have to be paramount. The code also emphasizes that nurses have to fulfil their legal obligations to disclose information in certain circumstances. Protection of the persons, especially children, from sexual abuse is specifically mentioned (NMBA, 2008b).
In Queensland, health professionals, including nurses, may disclose confidential information to a person outside the Department only if it is required for the care and treatment of the patient. The disclosure has to be with consent of the patient, even if the person is a child, and even when the disclosure is to be made to the parents of the child. The nurse may need to consider whether the child has sufficient capacity to consent. However, if the child has the capacity to consent and has specifically refused to disclose the information, and even the parents have refused to disclose, the nurse can still disclose the information provided it is in the interest of the child’s health and safety (Queensland Health, 2012b). Further, the guidelines of Royal College of Nursing, Australia about use of social media require that discussions about a patient should be done in confidence and his identity should be protected. Further, it should not be possible for anyone to somehow identify the patient through the cues and clues in the messages being posted online. Any breach of this requirement, can be reported to the Nursing and Midwifery Board of Australia (NMBA), and the Privacy Commissioner may be involved in the proceedings. Legal action can also be taken against the nurse (Cerasa, 2011). Registered health practitioners are allowed to post only that information on the social media which is in compliance with their professional obligations, and confidentiality and privacy obligations. They are not allowed to discuss about their patients or share sensitive information which may lead to identification of the patient without his consent (AHPRA, 2014)
Under sections 11(1) and (2) of the Children’s Protection Act 1993, a registered or an enrolled nurse is mandated by law to notify the concerned authority via the Child Abuse Report Line if he has reasonable grounds to believe that a person under 18 years of age is a victim of abuse. Section 6(1) of the Act includes sexual abuse as a form of abuse. Importantly, it is not necessary that the child or his family member reports the abuse (DEECD, 2013). However, reasons, such as limited knowledge about the signs and symptoms of abuse, lack of experience, bad experience with those providing child protection services, fear for their families, and absence of a proper environment to support the nurses to report deter nurses from reporting (Piltz & Wachtel, 2010).
Termination of pregnancy is legal in some States in Australia, while in others it is not. It is usually allowed in circumstances where abortion is required for protection of the life of the mother. The physical and mental state of the pregnant person is the most important consideration while taking the decision to go ahead with the abortion. Each case needs to be examined separately. It is important to obtain valid and informed consent prior to abortion. The nurse has to consider whether the patient has the capacity to consent, whether the patient has been informed of all options, and the risks and consequences of each option. In case of a young person or a child, questions of the patient’s capacity to consent is even more pertinent, and the consent of parents / guardians also comes into play. Obtaining an order of the court could be an appropriate course of action, and getting legal advice on the matter is recommended (Queensland Health, 2012a).
As evident from the policies, codes, laws and principles mentioned above, Kylie has to consider various factors in deciding whether she should disclose the information about Ellen’s pregnancy to her mother. This is especially so because Ellen has asked Kylie not to disclose this information. The matter needs to be decided while keeping the interests of Ellen on top. From the perspective of Ellen’s health, it is imperative that the information is disclosed to the doctors. Further, while Ellen is opposed to disclosure of the information to her mother due to fear, it may be important to inform her mother. Intuitively, the mother has the right to know, and a discussion with her can help in understanding the reasons for the pregnancy. However, since the context involves a small town community, the information has to be handled with utmost care. For this, the mother and the daughter need to be assured that the information will be kept confidential. They have to be convinced that it is in the best interests of Ellen that the information is shared with the doctors and relevant health staff. Though Kylie has the discretion to disclose the information in absence of a consent, she should try to obtain the consent of both Ellen and her mother. This is especially important considering the fact that Ellen’s condition may warrant termination of the pregnancy. A disclosure based on consent can facilitate more cooperation for further action related to abortion. Once a relationship has been developed, a collaborative decision can be taken about the abortion after discussions with doctors. At every stage of the decision making process, e.g. decision on the necessity of the disclosure or decision on termination of pregnancy, Ellen’s physical and psychological state, and her cultural background should be the main considerations. This process of decision making will ensure adherence to the principle of autonomy, beneficence and multiculturalism. If a consent for abortion is not obtained, it is advisable to obtain legal opinion on the matter.
Also, if discussions with Ellen or her mother, or by physical examination or any other method, Kylie suspects that this is a case of child abuse, then she is legally required to share the information with the concerned authorities. There is no need for any consent for this. She should obtain more information about various aspects of such disclosure to the authorities so that it serves the intended purpose. While recording any information about Ellen or the cause of the pregnancy, Kylie should remain objective and avoid biases and prejudices. Again, she should keep in mind that all entries may have a long-lasting impact on Ellen’s records and her life. It is important that Kylie does not discuss the case further with Claude, especially on social media. She should advise Claude not to post such messages on Facebook as it may be easy to trace the identity of a patient in a small town hospital. The fact that Claude has speculated about Ellen’s case is also a violation of the ethical principles. In fact, even Kylie should refrain from discussing cases on social media. Since policy and laws may change with time, nurses need to remain updated with relevant policy and laws so that they are on the right side of ethics, all the time.
To conclude, Kylie needs to exercise utmost care and use all the professional skills at her command to handle the situation in the best interests of Ellen. First she has to ascertain whether disclosure of the information is required in the interest of the patient, and then she should attempt to obtain consent of the patient and her mother. The requirement for abortion needs to be discussed with the doctors, and the consent of Ellen and her mother should be obtained. Both the patient and her mother are unlikely to be in a very receptive state. Hence, this will require empathy and exceptional communication skills to explain the need for the disclosure and the abortion. However, if Kylie suspects that child abuse is involved, she should try to find out more about the case and report the matter to appropriate authorities. This is her legal obligation, and no consent is required for this. Further, discussion of such matters on social media is against ethical principles and law. Kylie should refrain from such discussions, and also strongly advise her friend Claude against it. From the above discussion, it is evident that adherence to ethical principles and related policy and laws is a must for nurses. Nurses need to keep themselves abreast with the latest changes in policy and the law. Practically implementing the principles may require knowledge and skills which can be developed with experience.
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