Law and Ethics in Health and Social Care - Essay Example

Law and Ethics in Health and Social Care Ethics is all about doing the right thing. It is about arriving at the most honourable decision given a difficult situation in hand. The dilemmas pertaining to this very topic in the sphere of medicine, treatment, medical care or science is all pervasive in the world today. Ethical dilemmas are universal in health care as the technological and scientific advances improving patient care are often accompanied by tough ethical questions. They are a challenge since one has to come up with a decision regarding two contrasting decisions most of the time, both of which contain ethical worth. The National Health Service in the UK employs 300,000 nurses approximately, making them the largest group of health professionals (Department of Health 2000).Ethics is an important feature in nurse education in the UK with ethical and professional practice being established by the regulatory body namely the Nursing and Midwifery Council (NMC) which is an organization set up by the Parliament; their sole aim is to protect the public by ensuring that they provide high standards of care to their clients and patients. Hence it is a requirement that nurses need to ensure effective participation in ethical decision making arising from their practice. The advantage of learning and teaching ethics is the basic question in an underlying discussion of whether there is a separate subject in nursing ethics. For example, Milton (2004) describes nursing ethics as a theme that has "has philosophical underpinnings embedded within the discipline's nursing theoretical perspectives" (p309) Fry and Veach (2000) regard it to be part of a larger general system of bioethics.Allmark suggests that the various uncertainties which lie in the areas of nursing and education determine the manner in which ethics is taught. "In nursing there are uncertainties about whether we are teaching ethics to professionalise, or because we are a profession. Also about whether there is something which is uniquely nursing ethics. In ethics there are competing paradigms of ethical theory and competing theories of moral development. In education there are competing epistemologies, theories of learning and models of curriculum planning." (Allmark 1995 p377) According to Yumiko (2005), ethical dilemmas are "situations where moral requirements conflict, and neither requirement is overridden." The population of Scotland sees a decline of 5.11 million to fewer than 5 million (GROS 2002) announcing significant challenges for the National Health Service Scotland. The reasons range from an aging population to a shrinking tax fund as well as increasing workloads for the working age population (Duncan 2002).The NHS already experiences staff shortages which is significantly acute in nursing, a work force which is itself "graying" (Buchan 1998; 1999).The year 2000 saw almost 21,000 nurses leaving the nursing register. It left a huge vacancy of 9,200 in number (Watson et al, 2003).The NHS Improving Working Lives (DoH 2000) investigates the cause behind this predicament which is widespread in all of UK,in an effort to tackle this recruitment and retention crisis. This initiative aims at increasing labour market competitiveness, increased productivity, retention rates, improved morale and reduced absences. It looks at flexible working arrangements such as part time working and annualized hours. Meadows et al (2000) points out that "In terms of pay and career structure, the current grading clinical grading system is instrumental in nurses' dissatisfaction with skills, workloads and responsibilities often going unrecognized." But the evident and the ever-expanding responsibilities of the ones on the higher rungs should also not go unnoticed. It is important to understand the changing role of Senior Nurses and Ward Managers and their ability or inability to come to a rational decision while faced with an ethical dilemma under such circumstances. They are responsible for the day to day running of the ward which comprises staffing issues such as discipline, development and recruitment, clinical protocols and leadership, budget and store management as well as covering for junior doctor's reduced working hours. In addition, they are faced with dealing with the investigation of poor practice and cases of negligence and incompetence concerning the junior nurses; and this is where they come face to face with an ethical dilemma. The senior nurses see and understand the causes for their errors which are a result of poor and stressful working conditions of the hospitals as well as an understaffing crisis. They deem it too harsh sometimes to reprimand the junior nurses for their errors. Sometimes they are forced to evaluate one nurse's level of competence against the other which again, seems unfair to them. Nursing being a 24/7 job, this is a source of constant stress for Senior Nurses or Matrons. They also have to balance this with aiding the staff reconcile their home and work life, face customer situations, handle specialist jobs with staff shortages; all of which make flextime impossible. Such are the realities working in this demanding role along with comes a high level of responsibility to create an atmosphere where everyone excels as well as effectively manage a multi-professional team. Therefore, the Principle Nurses understand and sympathise with the current state of affairs and avoid putting unnecessary pressure on the staff but on the flip side, they are bound by the NMC guidelines. In accordance to the Nursing and Midwifery Order 2001 in article 22 to 24, the Investigating Committee has the right and the power to investigate any allegation pointing towards registered nurses in manner of any misconduct or incompetence. The Order states that every time an allegation is brought to the Committee, it shall notify the person concerned without any delay and also invite him/her to submit representations within a prescribed period of time. Also if the Committee finds it fit for the allegations made to be true and not fraudulent, it shall undertake mediation or refer the case to: The Screeners The Health Committee The Conduct and Competence Committee; all depending on the type of allegation made and the article it falls under. The methods of disciplinary action are also similarly carried out depending on the seriousness of the offence. For example, the Norfolk and Norwich University Hospital, Human Resources Department (NHS Trust) follows a Disciplinary Policy that ensures and recognizes the need for managers to manage their staff in a consistently supportive and fair manner. It is designed to maintain acceptable standards of conduct, attendance and performance from all employees including the safeguard of their interests as well as of the patients, clients and the Trust. Their main intention is to deal with potential disciplinary cases at an early stage which will eventually result in the quick and fair rectifying of problems and also the improvement of the employee's standard of performance and conduct. The procedure has also kept in mind the duties and guidelines imposed by the legislation and recognized good practice. In the case of an Investigating Officer finding an employee guilty of the charges made, he or she is liable to: Formal written warnings Suspension, sometimes on full pay under certain circumstances Transfer/Demotion Or, Dismissal But considering the situation in hand, it is only fair to give the health professionals e.g. nurses, the benefit of the doubt before coming to the expected conclusion in such matters. It is wise to carry out an investigation in case of an allegation but it is also called for to probe into the causes which has led to those cases of misconduct, which can vary from an occurrence of medical negligence to ethical issues pertaining to law and the Trust guidelines. The most common factor in relevance to the causes is the reduced staffing levels in the hospitals. This vital reason for worry is immediately followed by lack of good supervision and checking procedures, high workload, poor communication and lack of competent guidance which under these circumstances is almost impossible. The understaffed dilemma of the hospitals is a source of great worry and risk and something which the Trust should not overlook. Decision making under these difficult circumstances as well as pinning disciplinary action against the alleged incompetence of nurses is no less than a Catch 22.Even the ones with the strongest of leadership skills find it a demanding role to keep up with. From this origin has sprung a wide variety of misconduct and lack of high standard performance in nurses and hospitals alike. The NHS utilizes suspension as a means to get rid of the staff who have left sick because of harassment, bullying or false allegations against them. Some of them are so traumatized by these incidents that they don't return to work at all. The UK National Workplace Bullying Advice Line states that healthcare employees and nurses account for around 12% of the 1000 cases reported. Working under such extreme conditions as well as trying to meet with the NMC guidelines simultaneously, have resulted in nurses: Failing to implement suitable checking actions Failing to provide sufficient documentation Lacking in confidence and attentiveness Lacking in training Giving to mechanical and inconsiderate performances Communicating poorly Hesitating to ask when unsure Lacking in training and guidance Disobeying verbal orders It is also wrong to omit the evident and potential system failures which most of the hospitals and health professionals face. It is no secret matter that most of the clinics are in total disarray and disorder. Information systems also fail to deliver and the stocks are sometimes insufficient, borrowed or are excessive on the other hand. Such events can lead to major mishaps in medical circumstances like a wrong dose or medicine, incorrect prescription, crushing of pills as a time management measure etc and the ones to be suffering are the patients leading to the loss of a life or many for that matter. But to take a neutral stand, it would be foolish to neglect the cause of the error before taking a stand against the alleged or accused individual or health professional. Working under such stressful conditions can manifest into some slips and errors by them since it would be impossible to concentrate on the job at hand. It is only fair to delve into the "root cause" of the mishaps and uproot it, rather than implicate unwisely. Even the disciplinary actions taken against accused individuals should be given a thorough and fair consideration before going ahead with the inevitable lest the punishment prove too harsh for a crime unintentionally committed. This is one major aspect in the nation's Health and Social Care itinerary which has to be seriously reckoned with and rectified. The high expectations imposed by the government in the NHS have led to relatives demanding more, excessive workloads and understaffing are now the norm and the levels of violence that the nurses experience have seen an alarming high. It is not surprising that nurses are seen leaving the profession rather than joining it. The government's response which suggests bringing in nurses from the Philippines, Australia and South Africa does not address nor identify the cause of the problem at hand. Neither the NMC nor the NHS can absolutely negate the current issues or remain oblivious to the genuine cases of misconduct. They are answerable and accountable to the public and hence, they have to take such steps to ensure the safety of the patients and also to uphold the ethical issues in health and social care. What they should not abandon is the fact that these affairs are steering a large number of nurses out of their so-called profession. The Royal Pharmaceutical Society of Great Britain (RPSGB) has launched the 1988 Duthie report in a matter of fact and updated version, providing all health professionals including health visitors and nurses with a more understandable and lucid guide to the safe and secure handling of medicines. It is also designed to serve the purpose of developing guidelines for competent practice in handling medicines in community health care settings and NHS hospitals. It also takes into account the many changes in legislation and practice since the original report. The measures taken by the government and the agencies towards a more safe and secure environment for patients in the hospitals are quite evident. The eight billion pounds which the UK government has put aside for the next ten years for the NHS to deal with the soaring cost of medical negligence cases is an alarming figure. This shocking figure will cover compensation losses and legal bills which has reached an all time high since the 1990's. Liberal democrat Steve Webb has pointed out: "The provision for clinical negligence claims is rocketing. It is about time that the system for settling claims was streamlined." A BBC report also has him observing: "Much more needs to be done to prevent these sorts of incidents happening in the first place." One would also like to be witness to similar steps taken in improving the working conditions of these hospitals vis a vis the staff and professionals involved. It would definitely act as a preventive action against the alarming cases of uncountable nurses abandoning their vocations at a shocking rate and the cut costs in the area of clinical negligence claims. If a nurse fails to follow the NMC guidelines for professional accountability, the committee may take disciplinary action but it should also take the utmost care to determine the difference between those cases where the error was the result of an incompetent practice or was hidden, and those that resulted from other causes such as a situation where there was an instant and sincere disclosure in the patient's best interests and serious pressure of work and stressful working conditions. The examination of liability and accountability is then conducted for prescribing under different prescribing models, which is committing a criminal offence if the drug prescribed is not on the formulary. They are the uncertainties of ethics which one faces in nursing practices. In a report by Sarah Wise, Reconciling Career and Family Life in NHS Nursing and Midwifery: Dilemmas in Ward Management, she points out that "senior nursing jobs are more than unsustainable or inaccessible for people with care responsibilities, they are undesirable to all". Of course, disciplinary action should not be forsaken if it is a serious matter of probably life and death. On similar grounds, the Human Rights Act of 1998 reinforces a persons Right to Life as a measure of safeguarding existing human rights. Like wise, it states: 1) Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution in the sentence of a court following his conviction of a crime for which the penalty is provided by law. 2) Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary- (a) in defence of any person from unlawful violence; (b) in order to effect a lawful arrest or to prevent the escape of a person lawfully detained; (c) in action lawfully taken for the purpose of quelling a riot or insurrection. It is plain that other than the above mentioned clauses or conditions as stated and signed by the United Kingdom at the European Convention on Human Rights, any other case of losing a life or even harming one, be it by medical negligence or any other, is punishable by law. It is understood and also difficult in a health care context to ascertain the sufficient amount of information or a person's ability to evaluate it, which can also make way for the nature of the health care setting and relationship to use tacit pressure on the patient. Such problems surrounding the matter of consent can lead to various ethical dilemmas which can be presented to a clinical ethical committee. The principle of high regard for autonomy in the Act as well as every human right convention underpins the need for valid consent to treatment. This criterion acknowledges the most fundamental of rights of a person i.e. to establish how his or her life is to be lived by his or her own make and choice and also those that lead to the consistencies of the life plan in question. Such esteem for autonomy is often associated in relation with deontological theories and utilitarian philosophers like John Stuart Mill also emphasise the importance of the right to live one's life, free of any kind of coercion. In quoting the philosopher: "..the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinion of others to do so would be wise, or even right" (Mill JS, On Liberty, 1982, Harmondsworth: Penguin, p 68). The government is also encouraging nurses to take on new roles and responsibilities to aid in meeting targets for the reduction of waiting lists for treatments and consultations. The primary concern of all nurses is patient safety and all the more so when they have to cover 24 hour work-shifts. The other important dimension to this is clinical risk management. What needs to be considered are decision making of staffing levels and skill sets which have to be approached in a more systematic manner, rather than blindly blaming the negligence and poor practice skills of the few nurses in hand. More emphasis has to be laid on safety and constant quality improvement. Universal staffing norms need to be avoided since that might not meet with general acceptance. According to a document issued by the British Association of Medical Managers, British Medical Association, Institute of Health Services Management and the Royal College of Nursing (1993), Revised (1994), the key principles to implement the involvement of staff from all disciplines in the management of NHS trusts are: decentralised management: directorates or their equivalent with decision-making responsibility and devolved budgetary responsibility flexible, adaptive management arrangements, changing over time the multidisciplinary team as a core concept; the concerns of all professionals represented at trust management group level the development of shared views of clinical services between clinical staff in provider and purchaser organisations Ethical theories are the basis of all ethical analysis since they are the ideas from which guidance can be obtained to come to the right decision. Ethical dilemmas are real whether by duty, obligation or a specific kind of value. The three types of normative ethical theory are consequentialist, deontological and teleological. Robert Guay (2003) says that "According to consequentialism, the good is specifiable independently from the right, and the right is defined in terms of the good." This divides our ethical judgements into two prominent classes." "The good, first, is characterized non-morally: what counts as important is, roughly, whatever counts as important (or valuable or desirable or whatever). The good is also the only thing that counts as important: nothing matters but the best outcome. Although this does not follow, it is often then argued that, since nothing else matters, the principle of right that is therefore required is that the good must be maximized. The right action is always, that is, the optimific one: the one that produces the best results. Outcomes are usually considered in terms of states of affairs, since that facilitates the counterfactual comparisons that are necessary to make judgments. And to produce a distinctly moral theory, the good is usually characterized in a universalistic way: as the good not of an individual, but as the good of all humanity or an "impartial spectator"; otherwise what is left is rational egoism or something like it". Robert Guay (2003) The combination of a good and maximizing rationality can have an advantageous lead; all dilemmas and conflicts with the proper theory construction and measurement can be solved. Every kind of moral question can be precisely answered without any scope for regret like competing duties if you have executed the optimific action. The most significant form of consequentialism is utilitarianism which has been mostly represented by famous philosophers like Mill, Bentham and Sidgwick. Deontological ethical theories are defined by Guay (2003) as "one in which it is not the case that the good is specifiable independently of the right and the right is defined in terms of the good." It claims two common options; that there are limitations on the right other than optimificity and right is to reject the optimific action. Deontology looks backwards to see how the action was done rather than to the future and at the violation of duties or obligations that the action has done. Kant is a supporter of deontology along with some Christian theology works. Teleological theories are similar to consequentialist theories. It is derived from the Greek word Telos, meaning end. The notion of good is pivotally crucial in both and every other notion is derived from the good. But unlike consequentialism, a teleological theory is not imperative. "It provides an account of what virtues, wants, desires, and satisfactions there are in a genuinely fulfilled life." Robert Guay (2003) Each of these theories has goals which eventually lead to respect for autonomy and justice, beneficence and the least harm caused to the patient. They are all inter-related and though autonomy is the only fair choice, it is difficult for all of us to make autonomous decisions all the time. It solely depends on the complexity of the choice and the ability of the person to evaluate it. These two factors are directly related to respecting autonomy in regard with health care, that too, in consent to treatment specifically. It is the health professional's obligation to essay the enhancement of autonomy in order to make it convenient for a patient to be able to make an autonomous resolution.Also,if the patient is unable to arrive at one, it is again the health professional's duty to act in the patient's best interests. It is also important in such situations to make an attempt at finding out any previous inclinations or current likings of the patient, in order to implement the doctrine of autonomy as far as possible. From the utilitarian perspective of John Stuart Mill (Norman 1983), "the main beneficiary is not the subject" in medical treatments. Mill's principle provides an ethical reason for clinical trials and reinstates that in doing so, duty is also being done. It is a co-relating fact with the theories explained above that a patient is not to be deemed incompetent if he or she does not heed the health professional's advice or suggested treatment. Even though it is normal to view this decision as irrational from a health professional's point of view. It is the internal rationality that is vital here. The Jehovah's Witness case is a fair example of someone who refuses a blood transfusion which would have saved his life. Though it might appear irrational to the health professional, it is internally consistent with the principles and beliefs of the patient. The highlight of beneficence is the importance of doing well to others. It is the health professional's duty to aid the patient who cannot make an autonomous decision, with regard to his best interests at heart. Beneficence is what would be best for the patient and autonomy is what the patient considers to in his or her best interests. Even though there are no legal requirements for written consent, a consent form provides the evidence and is essential when in cases like major interventions such as the likes of surgery. Theorists Virginia Held Held presents the definition of care ethics as a prominent theoretical approach in complete contrast to the moral Kantian or utilitarian views. She maintains that care ethics relies on communal ties and personal relations. Even though she accepts the feminist roots of care ethics, she still supports it as an independent moral structure whose wider agenda is different from the feminist agenda as well as from virtue ethics. The meaning of this view on political and social matters is most important. Care ethics is viewed by her to be more promising than the Kantian and utilitarian philosophies when in consideration of its central values and market constraints. She also raises some worries about the restrictions about rights-based political discourse and suggests more focus on care in order to overcome those limits. She also proposes care ethics as an optional characterization of international development since it offers a larger magnitude for global issues. She also does not will to let care take the place of justice, in opposition to some of the other care ethics supporters. The integration of both however, remains complicated. There are times when she suggests that they relate to contrasting areas and that they should be permitted priority in their respective domains of competence. She also claims that "care may provide the wider and deeper ethics within which justice should be sought" Held (2006), Ethics of Care: Personal, Political, Global. She argues for the priority of care and also questions the priority of justice. Held looks at care as both a value and a practice which is characterized by values such as trust and mutual consideration; acknowledging at the same time that the ethics of care may not suffice for adequate theoretical resources for dealing with issues of justice. She also tries to attract attention towards personal caring relations. It is an important point to begin with for rethinking the area of justice; however, it is difficult to figure out how it will determine a broader theoretical framework. Also, treating care as a practice could be too demanding since it needs the person to be engaged in an unsustainable network of interactive relations at all times. In her book The Ethics of Care: Personal, Political, Global, she defines the outlines of the moral domain and re-steers some thoughtful attention on abandoned issues and manages to maintain a successful argument in that sphere. Bauman "... the novelty of the postmodern approach to ethics consists first and foremost not in the abandoning of characteristically moral concerns, but in the rejection of the typically modern ways of going about its moral problems (that is, responding to moral challenges with coercive normative regulation in political practice, and the philosophical search for absolutes, universals, and foundations in theory). The great issues of ethics - like human rights, social justice, balance between peaceful co-operation and personal self-assertion, synchronization of individual conduct and collective welfare - have lost none of their topicality. They only need to be seen, and dealt with, in a novel way." (Bauman, Z. (1993) Post Modern Ethics pp. 3-4) According to Bauman, the essence to the approach of post modern ethics lies in not abandoning entirely the characteristic modern moral concerns but in doing away with the quintessential modern ways of going about its problems. He looks at post modern ethics as morality without ethical code. He states that: "Human reality is messy and ambiguous - and so moral decisions, unlike abstract ethical principles, are ambivalent. It is in this sort of world that we must live . Knowing that to be the truth is to be postmodern. Post modernity, one may say, is modernity without illusions (the obverse of which is that modernity is post modernity refusing to accept its own truth). The illusions in question boil down to the belief that the "messiness" of the human world is but a temporary and repairable state, sooner or later to be replaced by the orderly and systematic rule of reason. The truth in question is that the "messiness" will stay whatever we do or know, that the little orders and "systems" we carve out in the world are as arbitrary and in the end contingent as their alternatives." 32-3 Bauman also proposes that it is our moral capacity which eventually defines us as human beings in response to the ambiguity of human reality. He says that it is society, its well being and its continuing existence, which is made competent by the moral abilities of its members. It is not the other way round. "It is the personal morality that makes ethical negotiation and consensus possible, not the other way round."pp. 32, 34 There are new dilemmas manifesting everyday in clinics, wards and hospitals, ones that cannot be ignored or over-ridden. They consist of: Intimacy versus transparency and privacy. The patients' free choice versus working conditions of nurses and care workers. The rights and capabilities of the care workers versus those of the patients Quality of care versus cost efficiency In her more feminist view of ethics, Sevenhuijsen (2000) proposes, that a "philosophical turn from obligations to responsibilities still bares the risk of a renewed appeal on women's caring role." The exact problem is that responsibilities are internally motivated while obligations are not. Women don't even feel it as an obligation while taking on that responsibility when there are no other options left. But professional care is increasingly under duress due to economic pressure and governance processes. Coming back to professional care, "professional expertise as well as professional responsibility demands that a professional be able to cope with client's justified or unjustified claims and their implications".(Lipsky, 1980). These decisions affect a client's life and hence they depend upon the caring skills of the health professional to improve their life's chances. "When applied to care, this professional logic implies that care workers guarantee that quality of care on the basis of educational training, skills, expertise, knowledge and experience. By focusing on improving the condition of their clients, they feel committed to make choices for their clients and, ideal typically, in the client's best interests (Knijn, 2000; Freidson, 2001)."They should go about their duty under any prevailing circumstances is the argument presented here. New trends in professional education are having a crucial impact on nursing work pressure. Student nurses during their under graduate studies need supervision and mentoring during their clinical trainings. Post-registration education is rising in demand as well as regulatory demands for continuing professional development. These are the major factors in decision making in work force management.NHS employers also claim to become more involved in developing high competency levels in nurses and other staff. But despite the workforce planning, the "right" number of nurses to help the nurse managers is needed to provide the desired amount of safe care. But it does suggest towards a clearer and uniform array of titles, new nursing roles and scope of practice. The nurses are at a risk of losing control without these basic requirements. "65% of NHS trusts relied on professional judgement to determine their staffing levels (Buchan et al 1996)".Many nurse managers argue that senior nurses and ward sisters are familiar with the patterns of dependency levels, patient throughput, ward layout and anticipated nursing activity. They also understand the needs and demands of medical or surgical teams and the strengths and weaknesses of their in-house nursing staff. But to entirely rely on the senior nurse's judgement would also prove fallible as pointed out by Procter in her revealing study on decision making in this area. In summary, professional judgement is a good basis for decisions as long as it is systematically applied and used with the right mix of knowledge and skills. There have been cases where some decisions about the composition and size of the wards have been handed down from the top of the nursing hierarchy without even consulting the ward sisters or ward manager. This kind of mistake has led to certain difficulties in the wards pertaining to the inevitable cases of negligence and incompetence due to the increase in the number of patients allotted to each ward. The most important area in nursing research and development include safety and continuity of care. Research published in this topic and important dimensions of nursing and safety is hard to come across than expected in the UK. Understanding the decision making prospect is another aspect and solving ethical dilemmas when faced with cases of careless conduct and incompetent practice due to the obvious reasons. Nevertheless, the causes of all errors in nursing and ward and staff management cannot always be blamed on the NHS.As they say, it always takes two. Though it is a complex matter, key factors in this calculation to avoid such negligence generated mishaps, are: The direct care workload in a ward pr unit Indirect care and ward overheads The appropriate skill mix to meet patients' needs And the available budget for nurse staffing Dilemma means a difficulty, a problem or an impasse which one faces in all professions. It comes around more often in the professional lives of medical personnel all over the world. The capacity and the ability to make the right decisions and handle such situations in the right way is a very relative consideration, though it is based on many factors. That is why one deems fit to paraphrase the quintessential and omnipresent question from Shakespeare's Hamlet: "To do or not to do - that is the question." References Allmark, P. (1995), Uncertainties in the Teaching of Ethics to Students. Journal of Advanced Nursing 22:374-378 Allmark, P. (2005), Can Ethics Enhance Nursing Practice 51(6):618-624 Article, Ethics and Cross-cultural Nursing, Harvard University Press Bauman, Z. (1993), Postmodern Ethics. Oxford: Blackwell. Buchan, J. (1998), Carrying on nursing The implications of the ageing workforce for employer and employee, London: Royal College of Nursing. Davey B, Popay J. Dilemmas in Health Care Buckingham: Open University Press 1993 Department of Health (1989), Working for Patients Cm 555.London Department of Health. (2000), The NHS Plan. A plan for investment, a plan for reform Freidson, E. (2001), Professionlism.The Third Logic. Cambridge: Polity Press. Guay, R. (2003), Introduction to Ethical Theory. Study Guide. GROS (General Register of Scotland), (2002) Population of Scotland 2000-based Human Rights Act (1998) Klein, R. (1995), The New Politics if the NHS (third edition).London: London Knijn, T. (2000), The Rationalized Marginalization of Social Care: Time is Money isn't it, in: B. Hobson (ed.) Gender and Citizenship in Transition. New York: Macmillan. Pp. 201-219. (Project: ID 49). Lipsky, Michael (1980), Street-level Bureaucracy: Dilemmas of the Individual in Public Services. Meadows, S., Levenson, R. and Beuza, J. (2000) The last straw. Explaining the NHS nursing shortage, London: King's Fund Publishing Mill.S.John, Utilitarianism and Other Essays, Penguin Milton, C.L. (2004), "Ethics Content in nursing education: pondering with the possible." Nursing and Midwifery Order (2001) Pandya, SK. Ethical dilemmas. J Postgrad Med 1997; 43:1-3 Sevenhuijsen, S. (1998), Citizenship and the Ethics of Care Scottish Executive (2001), Caring for Scotland: The Strategy for Nursing and Midwifery in Scotland, Edinburgh: The Stationary Office. Virginia Held, the Ethics of Care: Personal, Political, Global, Oxford University Press, 2006, 211pp. Wilmot, M. (1998), 'The new ward manager: an evaluation of the changing role of the charge nurse', Journal of Advanced Nursing, 28: 419 - 427. 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