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The purpose of this assessment is to identify and discuss the vulnerability issues arising from the scenario. Peter is a vulnerable adult and inclined to be forgetful therefore, reference will be made to the nursing and Midwifery Council’s code of professional conduct in respect of duty of care, safety, respecting client’s dignity, confidentiality, and consent to accept or refuse treatment. This case scenario is not a real client, therefore no consent was needed and no breach of confidence was made. An attempt will be made to explore whether Peter has the mental capacity to consent to the treatment himself. Guidelines on The Mental Health Act 2005 and the legislation will be included to support this. A discussion will be outlined to the nurse’s role in safeguarding vulnerable patients and their families, which will include the government’s policies and procedures, and the Nursing and Midwifery’s Council guidelines. The discussion will also include the consequences of the policies not being followed correctly and the outcome that would have on the nurse. The key vulnerability issues relating to Peter and his daughter within the scenario will be identified such as Peter’s age and his forgetfulness.
This assignment will contain the major role and responsibilities of a nurse in terms of ensuring that the rights of Peter are promoted and maintained and will be specifically around him not to be treated in a degrading manner. Autonomy and advocacy, and the interventions which are available to support Peter for his security to be assured and him needing confidence to increase his mobility. The Human Rights Act (2008) refers to individual’s rights to make decisions for himself and not to be discriminated against. Peter has a specific right of expression of thought and conscience to accept or refuse care. The assignment criteria require students to explain how Peter’s autonomy may be promoted by the nurse to gain the ability to make his own decision, including patient-centred care and acting as an advocate. A final requirement of students is to specify and justify appropriate professional behaviour and interventions for Peter. Reference will be made to therapeutic relationships between the nurse and Peter, highlighting the support the nurse should give to the patient and his family, and to discuss the importance of maintaining professional boundaries. The multi-disciplinary team will also have to assess Peter’s home to see if there were any adjustments needed to support him further with his mobility. Peter would also need further extensive health services if he agrees to go ahead with the surgery.
The paper is presented in accordance in line with the University’s academic guidelines presented as appendix 7 in the Student Handbook 2010. References will also be citied in line with the University’s own version of the Harvard referencing system.
Vulnerability – Section 1
According to Rogers 1997, vulnerability is “Liable to damage or harm, especially from aggression or attack”.
Vulnerability is when a person is put into a situation where they are not familiar with, which makes them feel uncomfortable. A vulnerable adult is anyone over the age of 18 who is unable to protect themselves against harm or exploitation. The types of people who may be particularly vulnerable are children, the elderly, adults with visual, hearing or speech impairment. Other types of vulnerable adults include those with learning disabilities, mental health problems or a severe physical illness.
People who require care services may have an increase in their vulnerability as they are entering a new environment with unfamiliar surroundings. Another factor could be their age and if they are unable to take care of themselves. Therefore, they are not in control of the situation and could become fully dependant on a nurse to care for them which to the patient increases their risk of becoming vulnerable. Peter is particularly vulnerable due to him being 85 years old and inclined to be forgetful, also the fact his daughter is trying to force Peter’s decision in going ahead with the surgery yet he is no longer certain he wants too.
“Abuse is a violation of an individual’s human and civil rights by any other person or persons” (Department of Health, Pg 9).
Abuse can consist of a single act or repeated acts. It may be verbal, physical or psychological; it may be an act of neglect or an omission to act. It may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of the person subjected to it.
A nurse’s most important responsibility is to the client first. The NMC (2008), states that “Nurses have an absolute duty to safeguard and protect vulnerable adults from harm.”
The responsibility of a nurse is to promote health, prevent illness, restore health and alleviate suffering. A nurse should take appropriate action to safeguard the individual when their care is endangered by a co-worker or anyone else. Nurses have a right but also a responsibility to act on behalf of the client if they feel he or she is being mistreated.
Registered nurses hold a position of trust to the client and this must never be breached, they should also maintain professional relationships with vulnerable clients at all times. A nurse not only has a professional duty to protect vulnerable clients, but also a legal responsibility. If a nurse failed to comply with legal obligations they could be struck off the NMC register, but also it could be classed as a criminal offence.
The Independent Safeguarding Authority is a government policy which helps to prevent unsuitable people from working with vulnerable adults. They assess those individuals working or wishing to work in regulated activity that are referred to them on the grounds that they pose a possible risk of harm to vulnerable groups. The Government ensures the safety of vulnerable adults by integrating strategies, policies and services relevant to abuse within the framework of the NHS and Community Care Act 1990, and the Mental Health Act 1983.
The Mental Capacity Act 2005 and Code of Practice is another vitally important piece of legislation setup by the government. The Code of Practice provides guidance and support to anyone who is working with or caring for adults who may lack a decision making capacity. This includes professionals, carers and families who know the person best. It focuses on those who have a duty of care to someone who may lack the capacity to agree to the care that is being provided.
As the NMC (2008) states, “You must disclose information if you believe someone may be at risk of harm, in line with the law of the country in which you are practising.”
The key vulnerability issues relating to Peter is that he is an elderly client of 85 years. He has not yet consented to the treatment as he is feeling apprehensive as there are major risks associated with the procedure. His daughter is very keen for the surgery to go ahead and Peter is seeking help from the nurse as he obviously feels he cannot discuss his fears with his daughter.
Article 3 in the Human Rights Act states no one shall be tortured, or suffer inhuman or degrading treating or punishment.
Although there is no absolute right to receive care in the UK, all patients have certain rights in their dealings with health care professionals. In 1995, the government issued the patients charter to inform clients of their rights, it is designed to improve the services people receive and it lays down the level of care that people can expect from the National Health Service. The charter was made public so that clients know the standards they should expect, they can take steps to complain and have things put right if the standards are not met.
Client’s rights include the right to make their own decisions about their own lives and the right to be given appropriate information to make informed decisions. The right to privacy and confidentiality and to be given appropriate assistance in exercising their rights, when they are unable to themselves, such as having an advocate available. Clients also have the right to freedom from exploitative and abusive practice, and the right to have personal beliefs, preferences and choices including religion, culture and political beliefs.
Peter should expect the nurse to maintain his right’s by having his dignity and privacy maintained while care is being given. The right to be included when making his care plan, the right to accept or refuse treatment, and for his patient information to be kept confidential. Also as Peter asked the nurse to help him make the decision and due to him being vulnerable and inclined to be forgetful, the nurse should act as Peter’s advocate for him if needed.
As the NMC (2008) states: “You must uphold people’s rights to be fully involved in decisions about their care.”
Accountability is based on three conditions including ability, responsibility and authority. Nurses hold a position of responsibility and to promote efficiency and safety as other people rely on them. They are professionally accountable to the NMC and to the law for their actions. Nurses use their professional judgement, knowledge and skills to make a decision based on evidence for best practice and for the client’s best interests. Nurses need to be able to justify the decisions they make. If you are a professional in charge of a task you can be called by law to account what happened, especially if something goes wrong. This is because if a nurse performs a task, they immediately take responsibility for that task and its outcomes
“As a professional, you are personally accountable for actions and omissions in your practice, and must always be able to justify your decisions” (NMC, 2008).
Duty of care
Any health care professional who undertakes the care of a client owes them a duty of care. A nurse’s duty of care includes managing risk appropriately, work effectively as part of a team, share information with colleagues and delegate effectively. Treat people as individuals and respect their dignity and confidentiality. Nurses should also need to ensure they gain consent, maintain clear professional boundaries, and collaborate with those in your care.
The most essential element to confidentiality is it must be built on trust. The nurse’s need to know that the client trusts them but also that they trust the nurse’s professional judgement, knowledge and skills. It is also essential that the nurse feels the client will inform the nurse all that is necessary to deliver the most appropriate care. Confidentiality is an integral component of the nurse-patient relationship and a fundamental element of professional conduct and ethical practice. Sharing information with other professionals can only be done on a strict “need to know basis”, and patient confidentiality can only be breached in exceptional circumstances. Nurses must maintain confidence and respect the privacy of a patient’s health information at all times. Professionals must only disclose confidential information with consent from the client, if they are required to by the court of law or where they can justify that it was in the public’s interest.
Section 4 – Autonomy
Autonomy is about independence and the freedom to choose, and about not being coerced into doing something one would not otherwise choose to do. Autonomy has been defined as “the power of self-determination and freedom from alien domination and constraint” (Smith, 1967).
Autonomy involves clients making choices for themselves. As a nurse you should actively encourage clients to be involved in the decision making process and ensure that their voice is heard. Respecting client’s autonomy means to treat them as a person with rights and not as objects of care. This mainly involves discussing their care and treatment with them in an open and honest way and allowing them to make their own decision about what care they want to receive. For a nurse to be able to promote client’s autonomy there has to be a relationship and effective communication between them and the client. If their autonomy is to be respected, then nurse’s have to allow client’s to make decisions and then act upon them.
According to (Hendrick, 2004, pg 95) autonomy is defined as “The capacity to make reasoned decisions, the ability to think for oneself, to make decisions for oneself and to act on the basis of such thought.”
Patient-centred care includes all aspects of how services are delivered to our clients. This includes compassion, empathy, values, preferences and responding to all their needs. A nurse should be delivering this care at all times and make sure they are giving the patient all the information available, communicating to them at all times and educating them about their care and how processes and procedures work, using as little jargon as possible. Emotional support should be provided to help relieve client’s fears and anxieties as this can be important to a therapeutic relationship.
“Promoting and protecting the interest of people in your care, many of whom will be vulnerable and incapable of protecting their own interest” (NMC, 2008).
Advocacy is about acting on behalf of the client in a professional capacity who cannot speak themselves. Anyone could potentially need an advocate as any client may feel vulnerable as they are in unfamiliar surroundings. An advocate is acting as an intermediary between clients and family, significant others, and health care providers. It is a role of support for clients, both speaking and emotionally.
As a nurse you have a duty of care to encourage the client to participate or if they cannot speak for themselves then nurses should become that person’s advocate by putting their needs and views forward, and to ensure their rights are promoted.
“You must act as an advocate for those in your care, helping them to access relevant health and social care, information and support” (NMC, 2008).
Valid consent must be given by a competent person and must be given voluntarily. Nurses have three professional responsibilities with regard to obtaining consent. They need to make the care of people their first concern and ensure they gain consent before they begin any treatment or care, ensure that the process of establishing consent is transparent and demonstrate a clear level of professional accountability. After they have obtained consent they need to accurately record all discussions and decisions relating to obtaining consent.
“Every adult must be presumed to have the mental capacity to consent or refuse treatment, unless an assessment reveals they lack the capacity to consent” (NMC, 2008).
When a nurse needs to inform a client about proposed treatment or care it is important that they deliver the information in an understanding and sensitive way. It is essential that they are given sufficient information for them to make a decision whether to accept or refuse the treatment being offered. Nurses should also give the client enough time to consider the information and the opportunity to ask questions if they need too. Nurses should not assume that clients know even basic medical information and should explain every aspect with as little jargon as possible in order for the client to make their choice.
There are three different types of consent including verbally, implied and written. Clients can express their agreement by either of these forms. With Peters surgery includes risks associated his agreement should be made by written consent. Written consent is a document which shows the patient’s choice and that discussions have taken place between them and a professional.
There can sometimes be difficulties with gaining consent. There are particular vulnerable groups such as older people, people with mental health problems, people with learning difficulties and children. Nurses need to keep these vulnerable groups at the centre of the decision making process. As Peter is a vulnerable elderly client he is weaker and inclined to be forgetful, therefore an assessment would need to be carried out by a nurse of doctor to assess his mental capacity; professionals should always presume that older people are able to make decisions.
In the same way a client can accept treatment, they can also make the choice to refuse treatment, even if this may harm them or cause death. Nurses should find out why they are refusing and then the consequences of declining the treatment and what will happen to their health if they don’t go ahead. If this happens it is important that you honour their rights and wishes and document fully any decisions made to refuse, and clearly record that this is the client’s choice.
“You must be aware of the legislation regarding mental capacity, ensuring that people who lack capacity remain at the centre of decision making and are full safeguarded” (NMC, 2008).
The Mental Capacity Act 2005 provides a statutory framework to empower and protect people who may lack the mental capacity to make an informed decision for themselves. The Act is underpinned by five main principles, the first one being that everyone is assumed to have the mental capacity to make a decision until proven otherwise. Every individual needs to be supported to make a decision and if a person makes what seems like an unwise decision, they should not be treated as lacking capacity.
Section 5-last bit
In order for a nurse to develop a therapeutic relationship with a client there must be effective communication involved. The very best of care is only achieved if the nurse is committed to getting to know the client in there care through effective assessment as individuals. This involves finding out how best to care for and communicate with them from their perspective, whilst ensuring respect, dignity and fairness are maintained.
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