Ethics of Advocacy in Nursing Practice - Essay Example

 SECTION 1. INTRODUCTION TO THE PORTFOLIO. The nursing professional performs many roles in the care of patients. Advocacy is one such role. Advocacy is the term used to describe the relationship between the nursing professional and the patient. Advocacy in nursing is founded in one of the many philosophies of nursing, according to which, nursing practice consists of support to individuals in their efforts to promote their own well-being, in their own perspective, and therefore by itself forms an ethic nursing practice (Gaylord & Grace, 1995). This ethic of advocacy in nursing practice calls for acknowledgement of professional responsibility as an active functional involvement in supporting the needs and wishes of the patient. (Vaartio, Leino-Kilpi, Salantera & Suominen, 2006). SECTION 2. EXEMPLAR 1. A nineteen year old was presented in a dazed and confused state to the emergency ward, as a result of an automobile accident. Physical and radiological examination suggested that there was internal abdominal haemorrhage that would require immediate surgical intervention. The teenager refused treatment and wanted to go home. The emergency physician instructed the emergency nurse to get the boy readied for surgery and the formality of the consent form could be dealt with later.. The emergency nurse refused saying that there were legal and ethical issues involved. The consent form was not a formality, but reflected the dignity of the patient. Present an Exemplar from practice which focuses on an ethical dilemma whereby the nurse spoke on behalf of a patient. ANALYSIS. The emergency nurse did act as an advocate for the young boy. Patient advocacy by nursing professionals has the tendency to enhance inter-professional conflicts in healthcare and yet, as advocacy is an integral part of nursing, the nursing professional has to stand up for these rights of the patient and expect support from the healthcare system (Mallik, 1998). Medical ethics are steeped in the concepts of non-malfeasance, beneficence, autonomy and justice (Silva & Ludwick, 1999). The medical professional went by the concept of beneficence and his perspective of what needed to be done to provide the best outcome to the patient, while the nursing professional stood by the ethical concept of autonomy. From an administrative and legal perspective beneficence is subject to autonomy in other words the patient needs to be convinced that the treatment procedures are in the individuals best interests and be a part of the decision making process and hence the need for informed consent. The Nursing and Midwifery Council (NMC) code is evolving, with the NMC code 2006 expected in 2008. Till then the NMC code of 2004 continues to be effective. According to the NMC code of professional conduct: standards for conduct, performance and ethics, 2004, nursing and midwife professionals are required to uphold the dignity of the patient by respecting the patient as an individual. It also requires that due recognition and respect is given to the role of patients in their care and the contributions that they could provide. This means that their consent is required before any kind of treatment is provided. The NMC Position Statement on The Covert Administration of Medicines, 2001, provides the guide lines for informed consent from patients. According to these guidelines every adult needs to be considered as having the mental capacity to consent or refuse to treatment including medication, unless the individual is not capable of absorbing and retaining the information by the treating staff, particularly when there are severe consequences due to refusal or is not able to understand the information being provided and unable to take a coherent decision. Should the individual be capable of giving consent then the individual has the legal right for the same and on the individual withholding the same no treatment or medication is to be started. When the patient is unable to provide consent the same should be sought from the attending relatives or carers. The National Institute for Health and Clinical Excellence (NICE), UK, is in the process of developing guidelines to prevent any harm to the patient as a result of the processes of the healthcare system. When these guidelines are readied additional guidance on patient consent and safety are expected. To improve the quality and stands of National Health Service (NHS) trust hospitals, the Health Commission of UK has created performance ratings for these trust hospitals. Through these performance ratings healthcare professionals in these trust hospitals and the public in general will have information in the key areas of performance, including upholding of patient dignity and autonomy (Performance ratings). Taking into consideration the legal and guidance from the administrative authorities the emergency nurse was right in advocating for getting the informed consent in a proper manner, as otherwise there would be contraventions and legal issues arising from the denial of patient autonomy. Lindahl & Sandman, 1998, point out that “Advocacy rests on the patient-nurse relationship and occurs as an outspoken demand of another human being whose autonomy is threatened”. The Sphere of Nursing Advocacy (SNA) model provides a theoretical framework for the concept of advocacy on the nursing profession. According to the SNA model the patient is always protected from the external environment by a semi-permeable sphere of nursing advocacy that permits the patient to self advocate when emotionally and physically capable and for the nursing professional to provide advocacy, when the patient is not capable of self advocacy. (Hanks, 2005). Macdonald, 2007, asserts that the importance of advocacy for a nursing professional is due to the universal consideration that advocacy is a moral obligation in nursing practice. Illness and injury infuse in patients a range of negative emotions like anxiety, fear, powerlessness and vulnerability and it is in these circumstances that an interpersonal relationship is created by the nursing professional (Armstrong, 2006). This interpersonal relationship results from the communication between the nursing professional and the patient, which provides an understanding of the needs of the patient and at the same time the treatment issues that confront the nursing professional can be understood by the patient. Through this arises the means to remove of ethical dilemmas (Ward, 2007). . Please see Advocacy Portfolio Guidelines before you commence this section. SECTION 3. EXEMPLAR 2. A seventy-one year old male adult was being discharged from a geriatric ward, after a period of hospitalization for hyperglycaemia. The ward nurse was giving the patient the discharge instructions regarding the medications that needed to be taken, as well as all the other instructions. The patient was hard of hearing. The patient’s wife seemed in awe of the nurse and just kept saying yes to everything. It was obvious that neither was really picking up the information being given by the nurse and the nurse did not seem to be too concerned about that. Present an exemplar from practice which focuses on an ethical dilemma in which a different patient was empowered by the nurse. ANALYSIS. The ward nurse failed in her duty to empower the patient by discussing the condition with patient and providing the information and guidance that was required to improve the quality of life of the patient and make the patient more self-dependant in the perspective of the patient. The NICE clinical guideline 21, 2004, gives the standard that ought to be maintained by nursing professionals at the time of discharging elderly patients. It calls for several sets of information to be provided to the patient or the care provider both in writing, as well as verbally. The nurse ward nurse went through the motions satisfying the mandatory requirements, but not in keeping with the ethical and moral responsibilities of a nursing professional. The conceptual framework of Gramsci, based on hegemony for empowerment of the elderly, calls for maximizing the quality of life of individuals irrespective of their ages. (Hendricks & Leedham, 1992). Social concerns for improving the quality of life of the elderly to make them more self-dependent can be seen and the belief that they have the ability for this can be seen in the Department of Health’s, “Experts Patient Program”, which aims “to support people to increase their confidence, improve their quality of life and better manage their condition”. (THE EXPERT PATIENTS PROGRAM). The onus of this responsibility from the perspective of society falls on the nursing professionals, as it is the nurses, who spend a large amount of time in the care of this vulnerable segment of society. One of the unique functions of a nursing professional to assist individuals, sick or otherwise, to perform those activities that contribute to health, recovery, or peaceful death that the individuals would have performed on their own had the capacity to do so. As such the nursing professionals through their interpersonal relationships with patient have the means of understanding the capacity of the elderly for self-dependence and need to guide them towards it (Wheeler, 2000). All round the world, including the United Kingdom the elderly population is increasing and are quite likely to develop conditions or diseases that cause them to lose their self-dependence capabilities and also spend considerable periods under the care of the nursing professionals. Nurses have a considerable influence on determining the care that is provided and through this and their guidance influence the quality of life that such elderly clients enjoy (Chow, 2003). The word empowerment is bandied about frequently in terms of the role of the nursing professional within the health care delivery system. It is not the frequency with which the term is used, but in the understanding of the concept and what it truly entails that empowerment of the elderly will be realized. Empowerment calls for an understanding of the patients own resources and the limitations that are imposed as a result of the sickness that reduces functionality and self-dependence and then reflecting on the given situation. Such an understanding can come only from dialogue and the interpersonal relation-ship developed with the patient and in it too lies the key to understanding the perspective of the patient to Empowering the patient does not imply imposing the nursing professionals perspective of what is best for the patient as a result of the sickness, but rather the patients own understanding of what it means to be old and frail and through that the best means for the patient to cope and act to become self-dependent. The philosophical roots of empowerment can be traced to Freire and from a Frierian sense the true means to empowerment of the patient lies both in the patient and the nurse reflecting together on the impact of the illness and guiding the patient to a decision on the means to achieve their own perception of self-dependence. It must be remembered that old age does not remove the autonomy enjoyed by patients. (Hage & Lorensen, 2005). Autnomy of the patients includes the decisions that are taken in the manner in which they cope with their several difficulties in old age. The legal doctrine of informed consent holds good. Derived from the principle of respect for an individual and to preserve the autonomy of the indivdual, informed consent remains a moral duty in the process of ethical decision making with the patient in matters of empowerment. Many a time these ethics and morals are forgotten and empowerment reduced to “a sterile and bureacratic procedure” (Buehler, 1990). The factors that can assist a nursing professional to take up the responsibilities in the manner it is meant ot be are job satisfaction, contiunual learning and commitment (Liisa & Jouko, 2003). Please see Advocacy Portfolio Guidelines before you commence this section. SECTION 4. ACTION PLAN FOR ROLE DEVELOPMENT. Identify one skill you need to develop in relation to your advocacy role. Advocacy calls for the development of interpersonal relationship with patients. The skill that I feel that I lack for this is skill in communication. The communication skills that I will need to develop will be both verbal and nonverbal skills. The need for non-verbal skills arises from several factors. I will definitely come across patients, who cannot communicate in English. Non-verbal communication skills will give me the means to communicate with them. I will also run into situations where patients have hearing disabilities. Finally, non-verbal communication is less formal. A pleasant smile says much more then a host of words. How will you acquire this skill in your next practice area? I will need to develop myself personally and change the attitudes in me that do not allow me to communicate freely. I will need to be happy in what I am doing and my profession. I will need to be dedicated to the acquiring of the communication skills that I need. In case it is necessary I will take a course in verbal and non-verbal communication. I will keep practicing verbal and non-verbal communication, both at work and also when I am with my friends. I will keep updating myself on the knowledge that I need professionally and in communication. REFERENCES. Armstrong, A. E. (2006). Towards a strong virtue ethics for nursing practice. Nursing philosophy: an international journal for healthcare professionals, 7(3), 110-124. Buehler, D. A. (1990). Informed consent and the elderly. An ethical challenge for critical care nursing. Critical care nursing clinics of North America, 2(3), 461-471. Clinical Guideline 21. (2004). Retrieved May 18, 2007, from, Falls. National Institute for Clinical Guidance Excellence. NHS. Web site: http://guidance.nice.org.uk/CG21/niceguidance/word/English Chow, W. (2003). Long-term care: a health promotion challenge. Perspectives (Gerontological Nursing Association (Canada)), 27(2), 16-21. Gaylord, N. & Grace, P. (1995). Nursing advocacy: an ethic of practice. Nursing ethics, 2(1), 11-18. Hage, A. M. & Lorensen, M. (2005). A philosophical analysis of the concept empowerment; the fundament of an education-programme to the frail elderly. Nursing philosophy: an international journal for healthcare professionals, 6(4), 235-246. Hanks, R. G. (2005). Sphere of Nursing Advocacy Model. Nursing forum, 40(3), 75-78. Hendricks, J. & Leedham, C. A. (1992). Toward a political and moral economy of aging: an alternative perspective. International journal of health services: planning, administration, evaluation, 22(1), 125-137. Lindahl, B. & Sandman, P. O. (1998). The role of advocacy in critical care nursing: a caring response to another. Intensive & critical care nursing, 14(4), 179-186. Liisa, K. & Jouko, K. (2003). Promoting or Impeding Empowerment?: Nurses' Assessments of Their Work Environment. Journal of Nursing Administration, 33(4), 209-215. MacDonald, H. (2007). Relational ethics and advocacy in nursing: literature review. Journal of advanced nursing, 57(2), 119-126. Mallik, M. (1998). Advocacy in nursing: perceptions and attitudes of the nursing elite in the United Kingdom. Journal of advanced nursing, 28(5), 1005-1011. NMC (2001). Position Statement on The Covert Administration of Medicines. London NURSING AND MIDWIFE COUNCIL. NMC. (2004). The NMC code of professional conduct: standards for conduct, performance and ethics. 2004. London: NURSING AND MIDWIFE COUNCIL. Performance ratings. (2005). Retrieved May 18, 2007, from, Healthcare Commission. Website: http://ratings2005.healthcarecommission.org.uk/ Silva, C. M. & Ludwick, R. (1999). INTERSTATE NURSING PRACTICE AND REGULATION: Ethical Issues for the 21st Century. Retrieved May 18, 2007, from, Online Journal of Issues in Nursing. Web site: http://www.nursingworld.org/ojin/ethicol/ethics_1.htm TECHNICAL PATIENT SAFETY SOLUTIONS PILOT PROJECT. 2007. Retrieved May 18, 2007, from, NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE and NATIONAL PATIENT SAFETY AGENCY. Web site: http://guidance.nice.org.uk/download.aspx?o=427861 Chief Medical Officer. (2006). THE EXPERT PATIENTS PROGRAM. Retrieved May 18, 2007, from, Department of Health. Web site: http://www.dh.gov.uk/en/AboutUs/ Vaartio, H., Leino-Kilpi, H., Salanterä, S., Suominen, T. (2006). Nursing advocacy: how is it defined by patients and nurses, what does it involve and how is it experienced? Scandinavian journal of caring sciences, 20(3), 282-292. Ward, C. (2007). An Ethical Dilemma Involving a Shy-Drager Patient: A Case Study. The Journal of Neuroscience Nursing, 38(6). 400-402. Wheeler, P. (2000). Is advocacy at the heart of professional practice? Nursing Standard, 14(36), 39-41. BIBLIOGRAPHY. Read More