This essay will consider ethics in nursing, discuss values and morals and how dignity and respect in patient care is influenced; considering the importance of reflection and the implications it has on effective practice from the perspective of a student nurse.
The scenario “Call Me Joe” provided by Nursing and Midwifery Council (NMC) (2010a) highlights concerning issues and bad practice that are happening in modern day nursing practice, and using the Driscoll and Teh (2001) reflective model: What, Now What and So What, to consider the care that Joe is receiving; considering how the nursing practice affects him directly and the implications of the nature of knowledge in nursing practice.
Part of the way in which nursing practice is developed is through evidence based practice. Evidence based practice informs modern practice by using reliable, valid and relevant research and clinical experts to inform and improve nursing practice and patient care, enabling care that improves and makes a positive difference (Malloch & Porter-O’Grady 2010). It is through evidence based practice that pre-registration nurses are informed and trained and how professional development is maintained (Adams 2009).
Nurses must use evidence to improve the standards of care to achieve higher standards in the nursing profession; evidence based practice improves the quality of nursing care guiding practice to ensure best practice is attained and is supported by literature and evidence (Brooker & Nicol 2003). It is evidence based practice that healthcare practitioners often draw upon to support clinically based reflections. Reflection is a process which enables healthcare professionals to improve practice through continuous monitoring (Daly et el 2010).
Throughout the pre-registration nursing programme, the importance of reflection in practice is taught and is developed throughout, extending into post-registration to become a vital part of a nursing career and portfolio development. Reflection involves breaking down individual processes, considering what was successful, how practice can be enhanced and how this can be achieved; this also includes situations involving patient interaction and communication, enabling a greater understanding and an increase in self-awareness (Lundy & Janes 2009).
By evaluating and reflecting, the practitioner is self-educating, improving clinical practice as well as their personal approach to nursing care that they provide; the main outcome of reflection in nursing is to improve and encourage best practice (Bulman & Schutz 2004). The Driscoll and Teh’s (2001) reflective model is made up of three parts, What, Now What and So What, and this model is appropriate to reflect upon the care that Joe is receiving as it enables the scenario to be deconstructed and analysed in detail to recognise and understand: What is wrong?
So what are the implications? Now what can be done to resolve the situation? Using the model as an aid, the implications of unsatisfactory care and poor practice in the scenario can be explored and exploited to recognise that although there is a code of conduct produced by the NMC (2010b) that governs nurses, in some instances the care that is delivered fails to meet the expectations of the NMC, the patient and other professionals.
WHAT? From the scenario provided by the NMC (2010a) it is apparent that Joe lives in residential care, he is no longer able to care for himself so the decision for him to reside in the home was made; he is not unhappy about it, and feels lucky to live in there. Joe is a very proud man and until recent years was very able and self-caring. Since moving into the care home; Joe has begun to notice things about his environment, his carers and himself.
Initially when Joe moved into the care home, he was mobile with a frame, as time has passed in the home Joe is no longer mobile and unable to get to toilet, reduced mobility can effect personal hygiene and toileting, but also social interactions and daily living (Brooker & Nicol 2003). Joe seems to accept his loss of mobility as part of the normal aging process; however from the scenario it is apparent that Joe now has a catheter, from which the bag does not get emptied regularly as Joe explains that it “pulls”.
Joe does not complain and states “it’s just the way things are”; Joe has not recognised that he is suffering at the lack of competency of the care provider and that his needs are not being tended to and he is being neglected (Department of Health 2000). Joe then reminisces about his life before the care home; it becomes apparent that since moving into the home, Joe’s life has changed drastically; the things he used to enjoy prior to his admission are no longer considered or even talked about.
He explains that when he first moved he filled in a form on which he stated his meal preferences; nevertheless this has not been acknowledged and each day Joe has porridge to eat and “lukewarm tea” to drink. This is not the only preference of Joe’s that is being overlooked. Joe explains that although his name is Joseph, he prefers to be called Joe; however it appears that the care providers do not recognise this and do not accommodate Joe’s choice, despite him requesting that they call him Joe on numerous occasions.
Joe is being disrespected and his choices are not being honoured or considered; nurses should consider each patient as an individual and empathetically deliver the appropriate care (Lipe & Beasley 2004). Joe also remembers how he used to dress in his youth and through his life before entering the home. He implies he was a smart dresser and a well-kept man; even combing his hair. From Joe’s expression whilst sat, unshaven wearing his pyjamas which he implies are unclean and unchanged, it is clear that he does not feel that way anymore, he has accepted his life as it is now.
He is unable to dress himself; he spends his time in his pyjamas and explains how the staff are always busy with the other residents. Joe has low self-esteem after losing his mobility and his independence, dignity and self-worth. Social role valorisation is where somebody is perceived by their role in society, a person may be deemed of value or devalue dependant on their role in society and this influences the way in which others behave towards them (Wolfensberger 2000).
In social role valorisation Joe is considered to be of a lesser value, as he is elderly and can no longer care for himself, he has a low social status; this is reflected with in the scenario (NMC 2010a), Joes behaviour reflects that of little self-worth or respect, mirroring the way in which he has been treated. Through a lack of communication, it is clear that Joe feels lonely, he does not verbally communicate this but it is apparent that he feels this way: his facial expressions suggest he is unhappy, he frequently loses eye contact and sighs; frowning a lot.
He is slumped in chair, his body language suggesting he lacks confidence and self-esteem. Communication is a means for a practitioner to build security and trust with a patient, begin to establish a therapeutic relationship in which important information is shared (Lloyd et al 2009), however the communication process has been ignored, Joe is uncertain of any boundaries devised, and does not want to appear as a nuisance and as a result of this he does not ask for things, voice his opinion or disclose his discomfort.
Joe’s individual needs are not considered as he has minimal support in the home from staff and independence is not encouraged. Through the lack of assistance and promotion Joe has minimal mobility and is no longer able to maintain his lifestyle in a manner he deems appropriate. Nonetheless Joe is accepting of his new life; and is oblivious to the bad practice he is subjected to and the neglect he is incurring as a result. SO WHAT Ethics in nursing are centred on individual worth, respect for patients and autonomy.
Individual morals impact upon ethics in nursing, considering what is right, wrong, good or bad. Morals are personal, so each individual has their own interpretation of what it right, wrong or acceptable (Rumbold 1999). The care that Joe is receiving is unacceptable, it is clear that the practitioners who provide the care either failed to consider the principles of ethics in nursing, or are influenced by ruthless morals. In nursing practice, what the nurse must and ought to do are defined by morals; the duties of a nurse involve moral and legal dimensions (Young et el 2009).
Joe lacks independence, and the practitioners offer little support or opportunity to encourage and enable independence: promoting independence is an essential part of nursing practice (Alexander et el 2006); it enables the patient to feel of use and can build self-esteem, encouraging a patient to be actively involved in a task and enabling them to carry it out or assist the practitioner enables both physical and physiological independence to be achieved (Acello 2005). As a result of a lack of stimulation and social interaction, Joe has low self-esteem and little self-worth.
All patients are individual and will have individual care needs. Care needs are patient specific, when providing care respect for the patient’s dignity should be anticipated, providing the patient information can help to relieve anxiety or confusion and honouring patients preferences can assist in delivering comfortable care (Gerdin et el 1997). Joe’s care is not specific to him, the care he is receiving is generalised, it is essential that the care provided is on an individual base: personalised to each patient’s specific needs (Kneedler & Dodge 1994).
As a result of reduced mobility, Joe has a catheter in situ. Due to poor catheter care Joe is left in discomfort and at a higher risk of infection, all catheter bags should be emptied regularly to maintain infection control (Royal College of Nursing 2008). Joe is not considered as an individual person and his needs are not being tended to: nursing philosophy advocates patient centred care whereby the nurse establishes a rofessional relationship with the patient, treating them with dignity and respect, involving and empowering the patient allowing them to convey their needs and preferences, actively engaging the patient within their care and the decisions surrounding their care (Falvo 2011). Joe is not actively involved in his own care, he is tolerant of the care as he is lacking in dignity (NMC 2010a). It is apparent that within the home that there are issues of neglect and that Joe is the victim of neglect and possible abuse.
The Department of Health (2000) describes abuse as “a violation of an individual’s human and civil rights by any other person or persons”. Joe’s individual needs are being neglected, he is suffering institutional abuse meaning that the care he is receiving is of a poor standard, and the practitioners lack in positive response to his complex needs, in the home there are rigid routines where individual needs are left unconsidered, and the practitioners with in the establishment lack knowledge (Department of Health 2000).
NOW WHAT Joe is a vulnerable adult; he is unable to take care of himself and is unable to protect himself against significant harm or exploitation (Department of Health 2000) and safeguards are necessary. Safeguarding consists of protecting and supporting vulnerable people and adults; the successful prevention of adult abuse and neglect depends on the service providers identifying and approaching the factors which contribute to the issues and result in neglect and abuse occurring, and tackling and dealing with these situations appropriately (The Association of Directors of Social Services 2005).
Therefore to begin to tackle the issues raised in the scenario by the NMC (2010a) immediate positive action must be taken to assess the risks and increase the safety for the service users (The Association of Directors of Social Services 2005). Best practice as outlined by the NMC (2007) emphasises the importance of anti-discriminatory practice in promoting parity in patient care acknowledging the difference and the beliefs people have. Implementing this in the home would enable Joe to be treated as an individual and his needs and preferences accommodated.
It is suggested that promoting independence in the elderly improves quality of life, and emotional wellbeing (Fisk 1986); if Joe’s independence was supported and encouraged he would become happier stable and able to continue with some level of independence and control over his life. Dignity is a human right protected by international law, all individuals are entitled to the right to life, free from torture and degrading treatment (Human Rights Act 1998) therefore Joe’s human rights, dignity and safety have been compromised. On entering the care home to protect Joe’s dignity, a care plan should have been put into place.
A care plan outlines the care an individual needs; it identifies the actions the nurse must implement as per the nursing assessment (Carpetnito-Moyet 2009). Documentation should be clear and up to date (Department of Health 2010). Also a risk assessment should have been carried out to ensure Joe’s safety; recognising his mobility needs and if he is at risks of falls, reviewed and amended as necessary. Joe also needs a catheter care plan to monitor the progress of his catheter to ensure that is maintained correctly, changed regularly and to ensure that Joe is aware of personal hygiene and cleaning his catheter (Royal College of Nursing 2008).
Joe’s food and fluid intake should also have been recorded to monitor his input, output and his weight, ensuring he was maintaining a healthy balance (Brooker & Nicol 2003). Having investigated, researched and reflected upon the scenario using the available material, the above should be the minimum requirement; Joe should be treated with respect, honouring his choice whilst maintaining dignity and encouraging independence for a better quality of life; whilst supporting him in establishing friendships and outside interests.
Courtney from Study Moose
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