Paternalism in Nursing, Core Values, and Code of Ethics - Essay Example

Introduction Despite noble intentions, nurses face ethical dilemmas arising from various circumstances. For one, nurses are made to strike the balance between the equally significant values of individual autonomy and beneficence especially when their patients have limited or diminished faculty for decision making. Fortunately, the global nursing profession has its codified ethic serving the purpose of directing the nurses’ thinking and guiding the actions they take. This paper tries to understand paternalism in nursing and its ethical color through the prism of Code of Ethics for Nurses in Australia. Likewise, this paper tries to sift through organizational considerations as it shows how an instance of paternalism in health care context may be addressed. Paternalism in nursing Lexically, paternalism involves one person caring for and guiding another in fatherly way (Group & Roberts, pp. 111-112). Associated always with benign motive, “fatherly way” involves taking steps to restrict people’s choices for their own good or preventing them from making unwise choices that may harm them – such as restricting what television programs children may watch, or what books they are allowed to read, or what friends they are allowed to associate with (Jackson, pp. 67)? Particularly in medical practice, paternalism refers to conferment of treatment or service on person or persons without their consent, ostensibly because of their limited autonomy or diminished capacity (Cody). As such, it has two central features: it involves substitution of one’s decisions for the patient’s decisions, which is tantamount to not respecting the latter’s autonomy; and the patient’s decision is ignored or overridden because in doing so the same person benefits or is prevented from being harmed. And there are two main ways by which a medical behavior may be paternalistic: by preventing people from acting, or by forcing them to act, or by doing something to them, without their consent but for their own good; and, by interfering with people’s decision-making process – such as lying to them – for their own good (confer Moral and Ethical Principles in the End of Life Care; see also Marchewka). While paternalism is widespread in healthcare and in societies (see Cody), its ethical standing is actually far from being settled. For Western philosophical tradition which gives emphasis on individual rights – especially the right to be informed and to make decisions – paternalistic medical actions are unacceptable (see Marchewka’s position that paternalism is unacceptable). For the Eastern cultures, however, where traditional social norms and values of group of group behavior and harmony, mutual dependency, and protecting others from harm supersede the self-regulating individuals with rights, medical paternalism is not only allowed but may even be required from physicians (see Konishi & Davies). With paternalistic behavior by medical practitioners neither simplistically ethically black-and-white, the nurses – in so far as they fulfill a middle role between the doctors and the patients – are very often faced with dilemma. For one, usually with patients who lack self-determination as a result of their terminal health status, nurses need to square off with such questions as, among others, can they be caring and dishonest at the same time? It pays that in Australia there is some basic understanding of what constitutes nursing values and ethics – a helpful backdrop, as it were, that would help the nurses in dealing with ethical conflicts. Core Values and Code of Ethics It is deemed helpful that we start off this section by pointing out the relevant information about the given scenario upon which relevant elements of Code of Ethics for Nurses (by Australian Nursing and Midwifery Council) are going to be applied. There’s a young adult paraplegic patient who does not lose his optimism that he would return the soonest to independent living and whom several members of the health team treat paternalistically. The head nurse notices such paternalistic treatment, and she’s resolve to deal with it. As said in the preceding, Western culture does not accept paternalism. At the outset of dealing with the scenario, it would help to paint in broad strokes the nature of nursing work and the context within which nurses do their work. Nursing care is actually a therapeutic relationship with patients as a whole person. Nursing approach, then, is expectedly patient-centered. But, more than their proximity to the patients, nurses also serve among others as information broker (see the value of holism in Core Values). Fast paced and turbulent the nurses’ working environment may be, they are not supposed to lose cognizance of the defining ethic of their practice – which is caring (for patients). As such, caring work is complex, demanding, multi-dimensional, and not easily quantified or inadequately valued (see Core Values). Notwithstanding, they are equally expected to be professional in their conduct and practice of their craft. Professionalism, in nursing practice, is not only about following the regulations of the profession, but more importantly is about accountability – that is, nurses are accountable for their practice (see professionalism in Core Values). And, all of these are meant to ensure the delivery of quality nursing service, which is robustly linked to quality patient outcomes (see Core Values on advocacy). Having broadly painted the bigger context of the scenario, a way forward is to, first, place the head nurse in his/her rightful organizational place as the one to deal with the issue and, second, to bring to the fore the elements of the Code of Ethics that may be helpful for the head nurse as he/she deals with other nurses in his/her team who paternalistically care for the paraplegic patient. Especially when the institution – which, as in this case, the head nurse represents, being the leader of particular group of nurses – has a clear stand on paternalism, the head nurse indeed is expected to rise to the occasion for the interest of all concerned bearing in mind the dynamics and idiosyncrasies of formal and informal organizations (see Hein) where they are in. In more concrete way, that the head nurse would deal with paternalistically-treating subordinates is accounted for by his/her difference of tasks from the latter insofar as affirming values are concerned. The latter is expected to assist the patients and their family members to sort out and articulate personal values related to health problems and the effects of these problems on their general way of life, while the head nurse is expected to assist the staff in the interpretation of organizational values and strengthening of their personal values in alignment to those of the organization (see Bleich, pp. 16). This is an important point to make especially when the individual and the institutional views on whether paternalistic care may be extended to patients differ. In more ways than one, when the head nurse meets his/her subordinate on the said issue, he/she exercises leadership ethics – which is held by Johnstone (see pp. 91-92) as related to effective leadership. Leadership ethics is part and parcel of nursing management, specifically when by management we mean development of people through work (see Huber, pp. 33). For, checking on the nurses’ work conduct is one concrete way of setting up direction and influencing others to follow that direction in health care (Huber, pp. 40). An attempt to discuss the matter of concern by the head nurse with the rest of the team may take the concrete form of values clarification. To a certain extent, values are practically biases. Based on our value system, we view the world and interact with people around us, or – in the case of nurses – treatment and care are extended to the patients. Thus, one may justifiably hold that all other skills are subjugated and the quality and integrity of nursing service is compromised unless both individual and institutional values are clarified (Meleis & Lipson, pp. 77). Too, there’s a need to emphasis here that should values clarification be done it’s more apparent goal should be towards formation of effective teams (for difference between teams and groups, see Kowalski) – which is going to be achieved especially through appropriate communication process. We say it is a more apparent goal because an effective management is a result of and at the same time manifesting itself through a smoothly functioning team. Now, there are at least four talking points when the head nurse meets the other nurses. Firstly, nurses are accountable to raise the standard or quality of nursing care for all people (see Code of Ethics for Nurses in Australia, pp. 4). From this, one may deduce that the head nurse particularly is responsible to clarify or even question what he/she considers to be unethical behavior treatment by his/her nursing team members. Even from ethical point of view (and not just from managerial or administrative viewpoint), the head nurse has the reason to confront the paternalistically treating nurses. Actually, while this ethical element is not categorically dwelling on the nature, as it were, of what would constitute a breach of ethical standard, it is quite clear on requiring every member -- and not just the leaders – of medical or nursing unit to report to the proper authorities whatever malpractice that they come to see or observe. While the head nurse may report the matter to his/her “higher-ups” (which he/she is expected to do so in later times) in response to the same ethical requirement, it may similarly serve him/her a purpose should he/she meets with the issue first and foremost on their lowly level. In such case, the minimum of ethical demand is satisfied: the standard of nursing care is raised by not tolerating an unethical practice. On similar score, the head nurse may remind the other nurses of the consideration that they should afford to everyone’s moral worth and dignity as he/she too practices the same towards his/her subordinates (see Code of Ethics for Nurses in Australia, pp. 5). Towards his/her colleague, the head nurse exhibits acknowledgement and respect of their knowledge, experience, expertise and insights. This is why he/she calls for a meeting and seeks for clarification of values. This is also why the head nurse is arranging for a civil and polite way of setting the practice aright. Now, towards the patients who are vulnerable and powerless because of their medical condition or illness, a power differential in the relationship needs to be offset by acts of kindness. Between a person who’s ailing and a nurse who provides the care, it is not difficult to whose side power – as in a fulcrum – is tilted. In this consideration, the patient comes into scene. Will paternalism in this case constitute an act of kindness? Understandably, we cannot provide a straight “Yes” or “No” answer. But the following explanations would at least provide additional considerations to make. The third talking point in the light of the nurses’ paternalistic practice is the ethical requirement for the nurses to consider and appreciate the cultural backgrounds of the patients (Code of Ethics for Nurses in Australia, pp. 6). This is akin to what Meleis and Lipson highlights as a need for culturally competent nurses, who are said to be characterized by sensitivity to issues related to race, gender, social class and economic status (pp. 70). Expectedly, culture (and language) may influence both the provision and receipt of nursing and health care. This ethical element is actually providing a rather effective check on the practice of paternalism. Among the things that it poses is whether or not paternalism is accepted by the patient’s culture. For, when the patient’s culture does not have a space for the practice of medical paternalism, such is going to be considered a cultural transgression in addition to its being an ethical offense. And, even when culturally paternalism sits well with the patient, the paternalistically-caring nurses are still not off the hook especially when the medical institution is very clearly not for it. Finally, in the light of the given scenario for this paper, the most relevant element of the Code of Ethics for Nurses is the order that nurses (should) value informed decision making (pp. 8). In the concrete, this is to ensure people of opportunity to verify the meaning and implication of information being given to them, and to recognize that decision making is sometimes constrained by circumstances beyond individual control, and that there may be circumstances where informed decision making cannot always be fully realized. And this element actually “stabs” the practice of paternalism right at its heart and delivers the last nail to its coffin. For, as explained at the outset of this paper, paternalism is withholding of information and imposition of one’s decision over another. Conclusion (summary of your learning outcomes, 75-100 words) The preceding discussion is very rich in substance. First, it elaborates on paternalism and discusses its ethical color. We’ve highlighted in the preceding that there is yet to have a cross-cultural ethical judgment on this prevalent practice of medical treatment and care. At least, as there are codified ethical rules for, say, nursing profession, the practitioners are never lost in the dark as they do their practice and stumble on ethical conflicts arising from, for example, paternalism. Lastly, we mentioned too in the preceding about leadership ethics among nurses, which accounts for and results to an effective leadership or management. Nursing professionals are regulated by ethics not only in their practice of profession but also in their practice of management and leadership among their own ranks. References: Bleich, Michael. “Managing, Leading and Following.” In Patricia S. Yoder-Wise (ed.), Leading and Managing in Nursing. St. Louis: Mosby, 1999. “Code of Ethics for Nurses in Australia.” 14 September 2009 Cody, William. “Paternalism in Nursing and Healthcare: Central Issues and their Relation to Theory.” Nursing Science Quarterly, 16.4 (2003): 288-294. Johnstone, Megan-Jane, “Leadership Ethics in Nursing and Health Care Domains”. In John Daly, Sandra Speedy, & Debra Jackson, (eds.), Nursing Leadership. Marrickville: Elsevier Australia, 2004. Group, Thetis & Roberts, Joan. Nursing, Physician Control and the Medical Monopoly: Historical Perspectives on Gendered Inequality in Roles, Rights and Range of Practice. Bloomington: Indiana University Press, 2001. Jackson, Jennifer. Ethics in Medicine. Cambridge: Polity Press, 2006. Konishi, Emiko & Davis, Anne. “Physician Non-Disclosure and Paternalism in Terminal Case: Ethical Issues for Japanese Nurses.” Eubios Journal of Asian and International Bioethics 13 (2003): 213-215. Kowalski, Karren. “Building Teams through Communication and Partnership.” In , pp. 341-365. “Management Principles”. In Diane Huber (ed.), Leadership and Nursing Care Management. Philadelphia: Saunders, 2006. Marchewka, Ann. “When is Paternalism Justified?” The American Journal of Nursing 83.7 (1983): 1072-1073. Meleis, Afaf & Lipson, Juliene. “Cross-Cultural Health and Strategies to Lead Development of Nursing Practice.” In John Daly, Sandra Speedy, & Debra Jackson, (eds.), Nursing Leadership. Marrickville: Elsevier Australia, 2004. “Moral and Ethical Principles in the End of Life Care.” Open Learning Space. 13 September 2009 “Sizing Up the System.” In Eleanor Hein, Contemporary Leadership Behavior, 5th ed. 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