Accountable_Practitioner

Nursing is an incredibly demanding and evolving sector. Not only are nurses required to deliver care, based on the best available evidence, they are also expected to be fully knowledgeable regarding professional, ethical and legal issues which may relate to their practice and for which they may at some point be held accountable. For this essay I will discuss the theme of communication as this plays an important role in all aspects of nursing care, whether verbal, non-verbal or written. I will then consider professional, legal and ethical issues surrounding communication and relate them back, where possible, to the Eddie scenario that we looked at in our group sessions. I will also look back reflectively and discuss how I believe I have personally developed as an accountable practitioner throughout the module. Accountability, according to Savage and Moore (2004) is an ambiguous, ever-changing term which often cannot be defined. The Oxford English Dictionary, (2006) describe it as being responsible for ones actions and being able to explain them. The NMC, (2008) develop this further by stating that nurses are personably accountable for their own practice which means that they are answerable for all their actions and omissions, regardless of advice from other professionals. A further conjecture to this point is that registered practitioners are accountable for their actions as professionals at all times, whether on or off duty (Martin, 2004). They are also accountable to the public, the profession, their colleagues and their employers (Dimond, 2008). Professional accountability is the standards and frameworks which are set by governing bodies such as the Nursing and Midwifery Council’s Code of Professional Conduct (2009). This states that nurses hold a position of responsibility and other people rely on them. Caulfield, (2005), asserts that standards and frameworks enable the public to trust nursing staff as they feel that they are adhering to a strict code. We discussed in week one (appendix I) the importance of documenting everything that is done in the health care records. If it is not documented then there is no proof that it was done. The health care records are a tool of communication utilised within the team and it is therefore imperative that, in accordance with the NMC Code of Conduct (2009) that an accurate account of every observation and intervention is clearly documented here. In the Eddie scenario, although the nurses stated that four hourly observations had been carried out, it had not been documented. As stated in the scenario, better record-keeping would have made Eddie’s deterioration more apparent much earlier. The nurses were therefore in breach of the Code of Conduct (2009) as they could not provide proof and their omissions could have contributed to Eddie’s death. The NMC published ‘The NMC Record Keeping Guide, (2007)’ in order to provide advice and standards of practice to nurses. The Code of Conduct (2008) states that consent must always be gained before undergoing treatment or care. It goes on to say that appropriate arrangements should be made for those with language or communication difficulties (NMC, 2008) and (Rumbold, 2002). It is unclear in the scenario, if Eddie had the mental capacity to consent to his treatment, however, the Mental Capacity Act (2005), states that a person must be presumed to have capacity unless otherwise established and all practical steps must be taken in aiding someone to make a decision. Throughout the scenario it appears that no-one actually spoke to Eddie or even addressed the issue of consent. Valid consent can be obtained in a number of different ways; verbal is just one method. Voluntary actions such as raising an arm for blood pressure to be taken or holding out a hand to accept medication are both methods of communicating consent (Young, 1994). Gaining consent from a patient is ethical, respectful and part of the process of treatment (DoH, 2001a). The National Service Framework (2001) for Diabetes states that the NHS need to ensure that all health professionals involved in the diagnosis and care of people with diabetes should receive continuing training to ensure that they are appropriately skilled in the treatment and management of the illness. It is apparent that Eddie did not receive care from nurses that were skilled in the treatment of diabetes and therefore, as we discussed in week 2 (appendix II), they were breaching their duty of care by practicing outside of their limits (NMC, 2009). Nurses are accountable for their own actions and they must have the skills, values and knowledge in order to perform competently (Savage and Moore, 2004). As discussed in week 2 (appendix II) medical professionals should seek assistance if they have uncertainties (Caulfield, 2005). Edwards, (1996) asserts that nurses face more ethical problems and moral dilemmas than most ordinary members of the community. Decisions made by nurses affect both the quality and quantity of the lives of others and therefore nurses have an ethical responsibility to their patients (Savage and Moore, 2004). Hendrick, (2004), describe it as a person doing what they believe is morally right so that they can justify their actions. Everyone has strong beliefs about what is right and wrong and naturally these beliefs will sometimes be misguided or misinformed when decision making (Johnstone and Kanitsaki, 2006). Fulford, Dickenson and Murray (2002) highlight that what is seen as good practice by one person may differ greatly from that of another. They go on to say that neither may be right or wrong, they just have different values. Although it may not always be apparent what the right decision is, good decision making requires strong moral justification and moral reasoning (Beaucham and Childress, 1994) and (Yeo and Moorhouse, 2005) Nurses work with a number of ethical frameworks. We discussed in week 3 (appendix III) decision making and looked at deontological and utilitarianism ethical principals. Utilitarianism is associated with the writings of Jeremy Bentham, a Philosopher. It is the theory that the rightness of an action is determined by its consequence (Fletcher, Holt, Brazier and Harris, 2001). If, Eddie had not suffered any harm, then a utilitarian would have deemed all decision making and actions as good even though there were obvious errors and omissions. Deontologists would disagree with this as they believe that duty is the foundation of morality and that an act can be independently judged as right or wrong irrespective of whether the outcome is good or bad (Fletcher et al 2001). Thinking about these theories has made me realise that I should always be consciously aware of the potential outcomes of my actions. In week 4 (appendix IV) we discussed ethical issues and the components of an ethical framework by Beauchamp and Childress (1994). This framework is based on four basic moral commitments; autonomy, beneficence, non-maleficence and justice (Gillon, 1994). Although these are not considered as rules, they can aid health care professionals to make decisions when reflecting on moral issues that may arise at work. Autonomy is the right to freedom of choice and action, which means that care providers should respect the choices people make regarding their own lives and put aside their own personal beliefs (Beauchamp and Childress, 1994). Beneficence and non-maleficence are closely linked together in that all actions must be beneficial for the patient (beneficence) and must not cause any harm (non-maleficence) (Husted and Husted, 2008). It was not beneficial for Eddie, as a vulnerable patient to be selected to be lodged on a ward in which he was unfamiliar. The nursing staff were not skilled in the care of diabetes and as there were communication difficulties, could not even discuss it with Eddie. The scenario indicates that Eddie may have been a ‘difficult’ patient which is why he may have been selected. Arguably, the nurses on the renal unit may have been considering the benefits of the other patients on the ward when choosing Eddie. Nurses are required to take numerous factors into account and have to consider the beneficence of everybody in their care, not just individual patients (Code of Ethics, 2006). Yeo and Moorhouse (2005), state that the nurse’s commitment to individual clients will often come into conflict with their commitment to the rest of their clients. Justice is a duty to treat people fairly and ensure they get the treatment they deserve. Unfortunately the nurses did not act in a non-maleficence manner with regards to Eddie and although no-one intentionally set out to harm him, ultimately he died due to a series of errors and omissions. There were many health care professionals involved in the care of Eddie. Although the nurses had concerns and communicated them to the doctors, there were many misunderstandings. It is possible that each of them may have been trying to pass the responsibility to the other. As the communication between them was so inefficient and it appears that no clarification took place then it could be assumed that the nurses were not acting in a virtuous manner and were therefore morally accountable for their actions. In week 3 (appendix III) we also discussed the reality that legal issues can often override ethical issues and that sometimes due to the fear of being legally accountable, a nurse may choose not to act in a way that they believe to be morally right. Fletcher et al. (2001) assert that the law acts as a deterrent for bad practice but does little to promote good practice. Yarling and Elmurry (1986), add that, under the existing, constricting, legal and institutional arrangements, many nurses do not have the freedom to practice in an ethical manner. The law affects everybody and in particular nurses who are deemed personally accountable for their errors or omissions through the law (Tilley and Watson, 2004). Ignorance of the law will not excuse legal action and therefore it is a necessity that nurses are aware of the legal aspects of their role (Dimond, (2008). Thompson, Melia, Boyd and Horsborough, (2006) state that as student nurses are not considered to be employees they cannot be held legally accountable. They are however, accountable to their University and the law can be called in by them (Thompson et al. 2006). There are two main branches of the law; criminal and civil. Criminal law is punishment from the state and can result in a crown court prosecution. Civil law deals with cases of negligence where a person has suffered some form of harm or loss (McHale and Tingle, 2007). The outcome of this type of proceeding usually results in compensation being paid out by the hospital or an injunction could be ordered against the nurse to stop practicing (Fletcher et al. 2001). Much legal argument surrounds the definition of a breach of duty. Essentially the standard of care has to have fallen below what is considered to be acceptable. The landmark case was that of Bolam (Bolam v Friern Hospital, 1957), when the so-called Bolam test was established (NMC, 2004). This was a Tort law case that lays down the rules for assessing the appropriate standard of reasonable care. Once the duty of care has been established it must then be proven that this duty was breached. The Tort of Negligence law states someone can be deemed as negligent if their duty falls below the standard of a person expected at that level (Fullbrook, 2005). The claimant would be expected to show that there was a breach of duty, causation and injury (Tingle and Cribb, 2002). Communication between doctors and nurses was negligible and data was not recorded in Eddies Health Care Records which are a communication tool. Dimond (2008), states that inadequate communication between staff and with patients can be regarded as negligent and is actionable if it causes reasonable foreseeable harm to the patient. As Eddie died due to this negligence the staff would have been legally accountable. Dimond, (2008), states that most nurses, during their career, will be involved in a complaint of some sort. In our group session (appendix V) we discussed that the majority of complaints are issued by the relatives of the patient and not the patient themselves. This is true of the Eddie scenario where the complaint was issued by his parents and was based around lack of communication and information. Brooker and Nicol, (2003), state that the relationship between nursing staff and relatives is vital, and they too will sometimes require support from staff. Brooker and Nicol, (2003), go on to highlight the importance that patients and relatives are given clear communications in order to make informed decisions. In our final week of the module (appendix V) we discussed vicarious liability. Vicarious liability means that a superior has a responsibility over the actions of a subordinate. In the Eddie scenario there were communication misunderstandings between the doctors and nurses. Dimond (2008) explains how the failure to communicate properly with the appropriate person at the appropriate time may be deemed as negligence. Although the doctor did not personally remove the ‘sliding scale’ or change Eddie’s insulin dosage, he/she delegated this task to the nurses and so could therefore be held vicariously liable. The NHS, as the employer, can also be held vicariously liable for the actions of their staff. The trust has to accept responsibility when there are staff shortages or lack of training courses available. Throughout the module I have developed an awareness of the professional, legal and ethical issues surrounding health care (Siviter, 2004). Prior to this I believe I was quite naïve to these issues and unaware of the importance of having this knowledge for when I become qualified. I found the group sessions to be very useful. Working on the case study of Eddie enabled analysis of the situation by using the different tools and frameworks that we had discussed (Yeo and Moorhouse, 2005). Each week we were required to select a topic, go away and research it and then present our findings to the rest of the group in order to share our knowledge. According to Wood, (2004) working in this active, rather that passive way enables students to learn mush more effectively. To conclude, nurses face professional, ethical and legal dilemmas on a daily basis. They will face conflicting responsibilities and loyalties and find themselves in stressful situations which will involve complex decision making (Cameron, Schaffer and Park, 2001). Although there a number of frameworks and tools to assist decision-making it is natural that making mistakes is reasonable within the limits of safe and acceptable practice. Not all decisions will be correct and nor will all judgements. They will however, allow reflection and enhance learning in this a dynamic, ever-changing sector. Care deliverers all have a moral responsibility to understand what being accountable means to them so that they are always able to act in the best interest of the patients. As Fry (2008) states, accountability itself is a basic moral value and foundation for nursing practice. References Beauchamp, T.L. and Childress , J.F. (1994). Principles of Biomedical Ethics. 4th ed. Oxford: Oxford University Press. Bolam v Friern Hospital Management Committee (1957) 1 W LR 582. [online]. Available at: http://www.kevinboone.com/lawglos_BolamVFriernHospitalManagementCommittee1957.html [Accessed 29 August 2010] Brooker, M. and Nicol, M. (Eds) (2003) Nursing Adults: The Practice of Caring. China: Elsevier Limited Cameron, M. E., Schaffer, M. and Park, H. (2001). Nursing Students’ Experience of Ethical Problems and Use of Ethical Decision-Making Models. Nursing Ethics. 8(5): pp.432-447 Caulfield, H. (2005) Vital Notes for Nurses: Accountability. Oxford: Blackwell Publishing. 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