All health care professionals are responsible for delivering safe, effective and ethical care to their clients. They must deal every day with the situations in which they have to resolve dilemmas caused by conflicting obligations. Resolving dilemmas require thoughtful consideration of all relevant factors, awareness of the relevant standards and legislation and use of ethical decision-making process to ensure that the best decision is made. Communication is essential aspects of issue resolution and practicing effective communicating before a situation develops will prevent or minimize the risks to clients. The below mentioned scenarios are the examples of ethical dilemmas.
VOILATED HUMAN RIGHTS
According to the first scenario the following human rights of Mrs Adam has been violated:
Often wearing the same clothing, bruises observed (Right to Adequate Living Standard, right to be treated with dignity and respect, the right to life, liberty, and security of the person, Freedom from Torture and Degrading Treatment, Assault), Son reads all her mail (Invasion of privacy, intentional tort), Pressuring to sign over the house to him (Right of autonomy, Right to Own Property), She appears anxious with her son (Freedom of Opinion and Information).
INDICATOR AND TYPE OF ABUSE
- Mrs Adam poor hygiene, often wearing the same soiled clothing, bruises above left eye exhibit (physical indicator, physical abuse and neglect).
- Losing weight, fear, seems withdrawn, sad and anxious show (psychological indicator and psychological abuse).
- Controlling behavior such as isolation from friends, harassment by reading all her mails exhibit (domestic violence and abuse).
Being an ideal health care assistant following steps can be taken to deal with the situation
- Listen attentively and reassure her that you trust her about what she has said you. Assure her that you will do whatever you can to help her.
- Ensure client safety by removing her from potentially dangerous situation, explain her all possible options available including to get into long term care facility but if she decides to stay home even though it will increase intentional harm to her but still we respect her decision and wishes and provide her with emotional support. We will explain Mrs Adam about the consequences of her decisions and then involve supervisor for finding the best solution.
- Document findings such as victims and abuser name, age, contact number, description of abuse and neglect and then report to supervisor.
- Inform her about the emergency helpline number and make her aware about the availability of support services whenever needed.
- If possible then taking tours of assisted living or other facilities is helpful in eradicating seniors fear about institutionalization as it is a barrier to reporting abuse.
- Home support worker is a good source in resolving the problem as she can work especially hard to maintain good relationship with her son to rule out the cause of his bad behavior with Mrs Adam. She can be able to monitor what is positive and negative changes going on inside home during her visit and if Mrs Adam decide to leave the house she can contact the supervisor about her decision.
- Many seniors don’t report abuse because they are fearful from the abuser and think that if they report then no one else will take care of them or they don’t want their children to get into trouble with the law. Support worker taught Mrs Adam that According to Ontario’s residents bill of right it’s her legal right to be protected from abuse so, she can speak up to at least one person a friend or another family member whom she can trust to report about abuse and neglect she is receiving from her son.
- Identify about caregiver stress and burnouts. Caregiving can be extremely demanding with physical impairment elder and if caregiver have disturbed sleep, can’t take a break, substance abuse, unemployment or experiencing health problems then there is a greater risk of increase elder abuse.
- HCA collaborate with Mrs Adam’s doctor to make sure that the elderly is connected with medical services to prevent her end up in depression, grief, dementia, or other medical problems.
- HCA respect Mrs Adam right of autonomy while at the same time he/she look for legal guardianship appointed by court if no appropriate family member is available to make sure that the care should not be compromised.
- To effectively deal with ethical situation support workers keep their skills and knowledge updated by participating in educational programs.
Communication with confused client hold specific challenge for all health care professionals in delivering care. Identifying and learning essential communication skills in caring elderly may help provider to develop more sustaining relationships with elderly and they become even more skilled at managing their care.
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When I was a student nurse doing, my clinical I have encounter many situations in which I witness nurses ignoring or not noticing confused clients, especially with cognitive impaired clients. They considered these clients as a “difficult patients” they did not make any effort to show support or understanding towards them. Stockwell (1972) wrote in the book “The Unpopular Patient” Nurse patient interaction with cognitive impaired client is not always satisfactory especially dealing with unpopular patient. Support workers and nurses might become ignorant towards the fact that ageing or cognitive impairment cause deficit in cognitive functioning and cause behavioral changes for instance irritability, anger, frustration, tired, loss of interest and become insensitive. Mr Bains has moderately severe dementia and unable to speak clearly So, nursing team were ignorant towards his speaking difficulty and consider it irritating for staff to keep repeating themselves. In this way, they might have considered Mr Bains and other clients like him as an unpopular patient. This kind of health professional’s behavior is unethical and unjust, they should be concerned for the client regardless of their condition. Furthermore, the behavior exists because when confused client call for help and then not able to tell why they called out can be tiring and lead to frustration for health workers. They thought that if they went or listen to the client every time when behave inappropriately to get attention then they wouldn’t be able to get anything else done. Most of the staff pretend not to notice confused clients because they have made presumption about client’s behavior that they are irritable because of their diseases, they have an issue that may not be known, some become irritable because they don’t want to be there. Thus, when they know that the client repeat the behavior all the time staff simply thought there is nothing to do about it and in this way, they are not giving equal care and attention that every client deserves from their support worker. According to Davis, C. (2008) studies show that staff are less likely to interact with confused client and their interaction solely task oriented.
LACK OF COMMUNICATION AND MENTAL HEALTH
Communication with someone having mental illness is the key factor in interaction. Support worker need to be mindful so that they won’t lack empathy and sensitivity during interaction otherwise they can unknowingly hurt the feelings of individual having mental illness. The NMC Code (2008) clearly states that health personals should be sensitive towards clients having distress and must listen, respond them to their concerns and preferences because this can have a cumulative effect on their wellbeing. According to Heyward and Ramsdale, (2008) If nurse is not listening to her patient then the patient lose faith in the services nurse provide. Reflecting to the scenario Mr Bains frustration and grabbing arm as someone go by to get attention is his nonverbal communication and indicator of emotional abuse. MR Bains behavior clearly shows that he was distrustful and aggressive towards staff member as they are constantly rejecting him and fail to listen and respond to his concerns. Moreover, when resident voice is not heard by doctors, psychiatrist and authorities then they are not upholding resident’s principle of justice and this has a very real effect on their lives and mental health. Client may feel depressed, rejected, likely to have low self-esteem, low confidence level, they likely to feel unsecure, unsafe from their surroundings, being aggressive or violent or displaying inappropriate actions. Besides, continuous confusion, frustration, unable to cope with stressful situation leads to catastrophic reactions.
HUMAN RIGHTS VIOLATED
According to human right acts article 14(Every person should be treated equally without any discrimination)I believed that section of act broken when Mr Bain was discriminated because of her condition and illness as he was not given the same time and energy that was given to other patients. Not treating Mr Bains same way as to others and hurting his feelings(Freedom from Torture and Degrading Treatment, We Are All Born Free & Equal). By ignoring Mr Bains we are not giving him chance to say or share ideas (Freedom of Expression).
The following interventions might improve Mr Bains quality of life in facility
- Give him time to make him feel special, valued, relax and safe as well as providing him opportunity to ask questions and voice his concerns.
- Support worker demonstrating nonverbal communication such as proper body posture, head nodding to show interest, smiles, touch and making eye contact to show empathy and respect for Mr bains help in developing trusting relationship. Always approach the client from front, moving slowly and gently without startling him.
- Treat the client with dignity and respect, while responding to his feelings
- While interacting speak soft and in low pitched voice, always introduce yourself and explain what you are doing while approaching the client.
- Be constant with gestures. It only adds to the client’s confusion if you use a gesture to mean one thing one time and something else at a different time.
- The best way to deal with a catastrophic reaction is to try to prevent it from happening, speak to the client calmly, using short direct statements, never argue them and repeat key words to promote understanding.
- Often times cognitive impairment clients just need a caring hand to hold so, just try to give him a calming presence, and do your best to meet his needs.
- When residents call for help without any reason there is actually feeling of loneliness, fear, internal, external stimuli frightening them in their mind due to decreasing cognitive ability. Help them deal with these feelings by simply being present, talking, giving company for a while and reassuring them that they are safe.
- Attend them when they call to make sure they are not in any immediate danger, ask them what was wrong, talk to them about it.
- Ensure that basic physical needs are meet like toileting, food, assess for pain, maintain safety of patient, prevent from fall and physical injury.
- Redirection, reorientation to time place and person and diversional activities can be helpful in dealing with simple confusion.
- Don’t be judgmental about resident behavior, accept it and don’t forced them to change their behavior.
- Validation and rephrasing therapy help residents to regain dignity, reduce anxiety, and prevent withdrawal.
As a health care personals, we are taught and accountable to do everything necessary to save a life as well as trained to respect the patient’s wishes. Sometimes, when these two beliefs conflict, this leaves the ethical dilemma for health care personnel’s.
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After analyzing the scenario, two strong but conflicting principles are recognized the autonomy and beneficence. According to Lunda, M, (1991) Autonomy refers to the capability of individual to make competent decisions about their own lives Whereas beneficence refers to do good for client and not harm them. The situation provokes inconsistency between my belief and resident action and thus, creates moral distress because I strongly believe that patient right to refuse should be respected and if I provide care against client wishes it constitute intentional tort (battery). In addition, it is unethical if I ignore her choice and it shows lack of respect towards client. I feel constrained to follow that course of action.
After analyzing each alternate, respecting the autonomy of resident outweighs all other ethical decisions relating to this dilemma. By giving bowel care I am doing beneficence with the resident but as she is cognitively alert to make right decision related to her health and care I will priority to Mrs Clark decision for right of refusing for bowel care. Furthermore, by Respecting the autonomy of Mrs Clark I am not forcing her against her wishes into making a choice thus, allowing her to become more active participant in making health care decision.
Being a HCA, by respecting Mrs clark autonomy I am protecting her the following human rights Right of autonomy, the right of the individual to self-determination over what is done to one’s body, the right to privacy, the right to be left alone, right to refuse, freedom of thought, freedom of expression, right to born free, right to life,
ROLES AND RESPONSIBILITIES
- HCA will ensure that Mrs Clark decision was not improperly forced in expression of her autonomy and client was aware of the reasons for her treatment, risks, benefits, alternatives and the consequences of refusal.
- Respecting client autonomy means do not judge client choices if she has refuse for any care, set aside your biases because your residents values and standards are different from yours.
- HCA will not give Mrs Clark their advice, opinion nor express their disapproval about her decision.
- Heyward and Ramsdale (2008) explain that sympathizing with a patient displays support worker’s readiness to recognize resident’s anxieties and make them feel more comfortable. In the context of a therapeutic relationship HCA understand Mrs Clark view point about why she is making the decision because sometime it is due to the communication issue that the residents don’t understand what is being done and reason behind it.
- Discuss the concern might be she has a fear of the procedure so, speak to her rationally and calmly to ensure that her decision is informed.
- Educating resident about their condition and how the bowel care procedure will help her in her present condition.
- Negotiate to make acceptable solution ask the resident how she would prefer to be helped, listen her carefully and respectfully in addition proposes her other treatment possibilities.
- Always observe, notified and document (for example, in professional responsibility forms, incident reports) even slight changes in client behavior observed related to their care.
- Give oral report about any events for which the next shift will need to be prepared for e.g. if a client refuses care.
- Experience of helplessness and moral distress can be cope up by respecting resident refusal as one’s principal obligation.
- Always consult supervisor if have concern about client wellbeing due to her refusal.
If Mrs Clark continue to refuse care on subsequent days then I will arrange for more information for the resident and will go one step beyond by involving physician or supervisor, ask them to talk with resident explaining how procedure goes about to decrease her fear and anxiety. Besides, discuss the issue with other co-workers and find their approach to solve the problem. This can help me reflecting upon my way of approach so that I will gain self-knowledge and insight as well as plan better in future if such kind of dilemma occur again. In addition, treatment decision making is an ongoing process so giving adequate support, encouragement, information and time necessary to make decision from health care professionals help residents who initially refuse care may later accept the care.
According to Heyward and Ramsdale (2008) Maintaining people’s privacy is essential to maintaining dignity. Privacy refers to treating an individual in a manner which safeguards their dignity, do not expose unnecessary which embarrass, humiliate them or cause emotional discomfort. Whereas dignity refers to appearing and behaving that portrays that the individual is valued and respected.
The scenario clearly depicts the violation of Miss Davis right to privacy and dignity by the support worker, the facility management, and by Miss jones and her relatives. The support worker leave Miss Davis sitting on commode chair and left the room which is not right practice. The support worker was doing unjust and unethical with the resident she should be responsible and concerned for her resident safety regardless of their condition and should be remain in the immediate area. Additionally, Miss Davis hip fracture was in healing process and leaving her unattended make her prone to fall this shows that the support worker is not performing task correctly and is showing negligence towards the safety of the resident. According to Ontario’s resident bill of rights every resident has a right for privacy in caring his or her personal needs. Miss Davis trust the support worker that she will respect her privacy but the support worker leaving her alone betray her trust and did not meeting her privacy right. The support worker didn’t ask Miss Davis if she want her commode chair to be shifted to washroom so that she will get enough private time for her bowel movement. If in case Miss Davis refuse for moving her commode chair, the support worker should try to approach Miss Jones if it is possible for her to leave the room by the time Miss Davis have her bowel movement. Moreover, if support worker was there in the immediate area, then she will be easily able to know when Miss jones relatives came so, she will direct them to other area for visiting Miss jones. In this way, Miss Davis privacy, will not be disturb. According to Adult care regulation the facility should have dining area, lounges other than residents actual room which can be used during visiting hours so that right for privacy and dignity can be maintained for both the residents sharing the room.
The following interventions I will consider to do to ensure privacy of Miss Davis will be maintained in future:
- First of all, apologize to Miss Davis for what happen as I was not around her and ensure her that such events will not be happened in future. It gives self-confidence feeling to Miss Davis as she thought her privacy and dignity is important for you.
- Residents are protected from unwanted public view by using any label mentioning ‘no entry’ clipped to curtains help to prevent people entering a bay or using curtains, screens, walls etc.
- Try to be around resident during bowel care period to prevent from any disturbance cause by other residents or their family members.
- Providing single sex and age specific toilet and washing facilities.
- Privacy is effectively maintained by covering the legs with sheet and do not expose the body parts unnecessary when residents are in commode chair because they feel embarrassed and lose their dignity.
- Personal care must be carried out immediately as soon as possible so that the residents not be left waiting for long time hence, less chances that their right to privacy will be violated.
- Speak slowly behind the curtain because nobody like others to hear about what is happening to them or what care they are receiving behind curtains.
- Be sensitive and give reassurance to residents during care because using commode beside her bed cause her feel embarrassed especially if she is sharing her room with another resident. Moreover, she also might be worried that she is being a burden on caregiver causing extra work to be done.
- Use of phrases like ‘not to worry’ or ‘no problem’ may indicate to the resident that it’s not her fault to be using commode chair beside her bed and someone is here who is really concern for her. This can help improve self-esteem and dignity.
MAINTAIN PRIVACY IN FUTURE
Following steps will be taken to ensure privacy for miss Davis in future
Give residents time to talk as they are aware of the pressure on staff and about their busy routine which make them reluctant to ask for help. Making time to talk help Miss Davis to share her concern that she wants HCA to be around when she is having her bowel movement so that her privacy and dignity will be maintained from another client. This step help in good relationship building between health care aid and residents.
Giving choice for toileting care help to maintain resident dignity. They feel more control and independence. Asking miss Davis about her preferences if she want to move her commode chair into washroom during her bowel movement so her privacy during that time will not be disturbed.
In conclusion, all health care professionals have ethical obligation to provide ethical and effective nursing care to their clients. Ethical issues arise in health care areas every time and its health care professionals responsibility to deal them by applying their ethical knowledge. They must critically analyze the situation, identify available alternatives and make decision within best interest of clients.
- Wilk, J. M., Newmaster, R., Sorrentino, A.S., & Remmert, L. (2012). Mosby’s Canadian Textbook for the Support Worker (3rd ed.). Canada.
- Stockwell, F. (1972) The Unpopular Patient.Â London: Royal College of Nursing
- Davis, C. (2008) Tea and Empathy: discussing a project focusing on patient centred care. Nursing Standard. Vol 22, no. 32, Â p.18
- Nursing and Midwifery Council (NMC) (2008) Essential Skills Clusters for pre-registration nursing programmes.ÂÂ London: NMC
- Lund, M. (1991). Stopping treatment: Who decides? Geriatric Nursing, 12(3), pp. 147-151.
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