Nurses are faced with many legal or ethical dilemmas, the Nurse’s Handbook of Law & Ethics (1992) states that nurses should “integrate knowledge of ethical and legal aspects of health care and professional values into nursing practice”. It is important to know what types of dilemmas nurses may face during their careers and how they may have been dealt with in the past. In this paper I will address one of these dilemmas in the form of a critical incidence and outline the legal and ethical problems, I will also give my personal reflective thoughts to show learning and understanding.
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As a student nurse I have encountered a number of critical incidents that I have wanted to reflect on to improve my practice. The critical incident that I am focusing on in this essay deals with issues of neglect, duty of care and a lack of communication and awareness between professionals and patients. Through this critical incident, I will explore the issues from a professional, legal and ethical perspective. Showing how through reflection, I can learn both personally and professionally how to become a better nurse. In this essay I will discuss my understanding of reflection using a reflective model. This will be followed by an analysis of the incident and what ethical and legal borders were crossed. In accordance with the Nursing and Midwifery Code of Conduct (NMC 2008) all names and placement details will be concealed, and I will refer to the patient as Mrs. A at all times.
Refection is an important tool for a nurse, it offers a ‘vehicle through which we can communicate and justify the importance of practice and practice knowledge’ Bulman and Schtuz (2004, p1) .
There are two forms of reflection, refection-in-action and reflection-on-action. Reflection in action is ‘to think about what one is doing whilst one is doing it; it is typically stimulated by surprise, by something which puzzled the practitioner concerned”(Greenwood, 1993). Schon (1987, p26) believes that the individual will ‘Stop and think’ and ‘pause in the midst of action’. I do believe that this happens in practice and a benefit of this type of reflection is it shows more intelligent thinking however a disadvantage is it would take up valuable time when stopping to think about all your action.
Reflection on action is defined as “The retrospective contemplation of practice undertaken in order to uncover the knowledge used in practical situations, by analysing and interpreting the information recalled” (Fitzgerald, 1994pp67). Reflection on action involves looking back in hindsight and turning the information from the incident into knowledge to use in the future.
Alternatively Boyd & Fales suggest reflection on action is “The process of creating and clarifying the meanings of experiences in terms of self in relation to both self and world. The outcome of this process is changed conceptual perspectives” (Boyd & Fales, 1983pp113). None of these views however take into consideration reflection before action, as we plan out our acts before we do them.
There are many reflective models that show how to reflect on situations properly and learn from them, the one I have chosen for the purpose of my essay is Gibbs model of Reflection (1998).
Gibbs model Confronts practitioners to consider their normal way of thinking and responding within the situation towards gaining insight into self and practice (Johns
2005 p18). It is a simple model and encourages a clear description of the situation, it analyses the practioners’ feelings, gives you help to evaluate the experience and maybe make sense of it all and it examines what you would do if the situation arose again. Gibbs model incorporates all the core skills of reflection. It is focused more on reflection on action, but with practice it could be used to focus on reflection in and before action.
Gibbs Model consists of 6 stages: Stage 1: Description of the event, Stage 2: Feelings and Thoughts (Self awareness), Stage 3: Evaluation, Stage 4: Analysis, Stage 5: Conclusion (Synthesis), Stage 6: Action Plan. I will go through each stage in relation to my critical incident. The first stage is describing the event, my placement was on a busy community hospital that dealt with a variety of elderly patients who were there for rest and rehabilitation or re-housing. Mrs A was a 70 year old patient on the ward who was suffering with orthopaedic problems. She had bone deterioration and had broken her leg badly from a fall in her home, it was such a bad break that she had to have her right leg in a full cast from hip to toe. She had good use of her other limbs and was taught by the physiotherapists to use a special stick and strap on shoe when trying to walk. Mrs A found this extremely hard to do and over time she stopped trying or even wanting to try and eventually stopped wanting to do anything for herself. Mrs A gradually started pressing the call bell more and more to get the nurses to help her with trivial things that often she could do or get for herself. The nurses who were at times very busy felt this was of great annoyance, they would tell Mrs A that ‘they had other patients to help, not just her’ and that she ‘had to stop pressing the bell so much’. Mrs A was obviously scared about falling again and wanted a bit if attention which was overlooked by the nurses and I witnessed a number of times, that the call bell would be moved out of Mrs A’s reach or wrapped around a peg behind her where she again could not reach it. This was a great worry to me as what would happen if she did have a genuine emergency?
In this paragraph, I will discuss the second stage; my feelings and thoughts. When I first met Mrs A I introduced myself and sat at eye level with her as to build a good rapport, I could sense she was nervous and so wanted to make her feel comfortable. Each day we would chat and although she was slightly demanding she was a lovely lady who was never nasty or foul mouthed just lonely. The nurses would often complain about her and after voicing my opinion to my mentor of how she just wanted someone to talk to I was told she and the other nurses didn’t have the time and Mrs A was ‘selfish’ for not realising they were busy and tired. I could understand the nurses concerns about seeing all of the patients and having a suitable break but thought the attitude towards Mrs A was unfair. When I saw the nurses remove/move the call bell I asked my mentor again why that was being done and she told me ‘to stop her from having them constantly running around after her ‘ when I asked what if a real emergency arose she did not answer and felt too embarrassed to ask again, this whole situation led me to evaluate my practice and the practice of those around me.
Evaluation is the third stage of Gibbs (1988) model of reflection and the reflector must state what they feel was good and bad about the incident. I understand that fatigue is a common issue with nurses as alot work long hard days sometimes without breaks, Van Dijk & Swaen (2008, p1136) state that, ‘Fatigue is a common complaint in the working population. Approximately 20% of the working population report symptoms that fall under the concept of fatigue.’ and I also recognize that fatigue can contribute toward errors in judgement and practice but I feel fatigue was not a massive factor in Mrs A’s care, it was more laziness on the nurses behalf rather than tiredness.
Stage four of Gibbs (1988) is an analysis. (Will Expand)
In conclusion, stage five of the Gibbs (1988) model, I am aware that all nurses do not hide patients call bells when they are getting tired or annoyed at the patients persistent calling but as I witnessed some nurses do. I will in future try to not let pressure stop me from doing the right thing and speaking up for a patient. I must strive to practice as safely as a can and do so in the patients best interest.
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Within my action plan my aim is to research further into how to help and deal with the ‘patient in need of constant attention’ and find literature to help qualified nurses when dealing with the same problem. In conclusion my reflection skills have developed through the production of this essay. Using Gibbs model of reflection has helped me to structure my thoughts and feelings appropriately. My level of awareness concerning patients needs and feelings has been enhanced with the use of critical reflection. My competence, within this situation, has been further developed and I now feel that my personal and professional development is progressing. Using this reflective model has helped me to realise that my learning is something which I must be proactive in. Furthermore as a student nurse I have recognised that reflection is an important learning tool in practice.
Reflection may help to develop knowledge of law and ethics as when we reflect an incident, legal and ethical issues may arise and be researched thus new knowledge will be learned and then used in relation to practice.
‘Law affects almost everything we do’ Judith Hendrick (2000, p1). Law is either made by judges(common law) or parliament(statute law). Statute law is started as a bill or proposal made by the government, an individual MP or a member of the house of lords, it is debated and then either approved or denied with or without amendments. Statutes have been passed on most topics but some of those relevant to health care are; statutes establishing the NHS and modifying its structure and organisation and acts regulating the health care professions such as the Medical Act 1983 for doctors, nurses, midwifes and health visitors.
This is primary legislation as it sets out basic rules for all in the UK to follow, secondary legislation is law made by an executive authority under powers given to them by primary legislation so for example the welsh assembly have delegated powers to implement requirements set out in primary legislation. Common law is law developed by judges through decisions of cases in court. It is based on precedent (legal principles developed in earlier cases).
Statute law sets out a framework for the NHS and common law sets out the law of the land but nurses are also governed by 3 separate set of legal rules. Legal obligations to patients, Professional obligations to patients (imposed by the UKCC -will explain) and legal employment relationship, this outlines the employers right to have his staff perform at a professional standard and the staff to have the right to be treated properly.
This is what I will include in the rest of my essay.
NHS Trust BREACH OF THE CODE OF PROFESSIONAL CONDUCT: In this incident the following clauses are relevant:
Clause 1. Act always in such a manner as to promote and safeguard the interests and wellbeing of patients and clients
Clause 2. ensure that no action or omission on your par t, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients and clients .
Clause 7. recognize and respect the uniqueness and dignity of each patient and client, and respond to their need of care, irrespective of their ethnic origin, religious beliefs, personal attributes, the nature of their health problems or any other factor
Clause11. report to an appropriate person or authority, having regard to the physical, psychological and social effects on patients and clients, any circumstances in the environment of care which could jeopardize standards of practice
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