Ethical considerations in health technology assessment

Nursing is a Large Field


Nursing is a large field, both philosophically and practically. A nurse must constantly resort to the respective theoretical framework while making any ethical judgment in the practice of nursing. As a result, this paper will examine Jeremy's case study in all eventualities. According to the case study, Jeremy is a patient who is exposed to several scenarios in the hospital, each of which presents an ethical quandary. In all four scenarios, Jeremy suffers additional injury not from the stroke itself, but from the settings to which the nurses subject him. This paper shall apply various theories to inform the right cause of action that as a Nurse would have taken to prevent further injuries in Jeremy's case study as per the particular scenario. From the respective theories, the paper shall also try to extrapolate the best intervention practice possible that nurses can apply in various situations. The stipulated ethics informs most of the nursing practices and the professional values instigated by evidence-based practice.


Nursing Care


Two fundamental concepts define the practice of nursing care, and that is Dignity and comfort while handling a patient. Dubois, D'amour, Tchouaket, Clarke, Rivard, and Blais (2013, pp.110-117) write that dignity exists when an individual has the capacity of exerting control over his behaviour, the environment and the way he or she wishes to be treated by others. The patient should have the capability of understanding the situation. According to this definition, an individual needs to have some competencies to be dignified. For instance, people suffering from intellectual disabilities may not have the capability to understand the situation and cannot exert control over their behaviours (Nettina, Msn, and Nettina, 2013). However, in the Nursing practice dignity involves compassionate care to a patient by virtue of him or her being human (Leuter, Petrucci, Mattei, Tabassi, and Lancia, 2013, pp. 348-358).


Badzek, Henaghan, Turner, and Monsen, (2013, pp. 15-24), points out that comfort exists in three forms and that is a relief, transcendence, and ease. If the needs of a patient are met, for instance in the perspective of relief, by administering the recommended analgesia, this will help the individual to experience some sense of reparation. If a patient is in a state of contentment, then he or she could be said to be in a state of comfort (You, Aiken, L, Sloane, Liu, He, Hu, Jiang, Li, Liu and Shang 2013, pp. 154-161). For instance, a depressed patient feels ease after the issues that were causing anxiety have been resolved. Gjerberg, Lillemoen, Førde, and Pedersen (2015, p.103) describes transcendence as a feeling of relief in which a patient can rise beyond their illness or whatever challenge posed by their respective health conditions.


In Jeremy’s case study (scenario 1) presents a challenge to the nursing practise; the patient is sick and requires care to help in prolonging his health. The problem arises from the fact that ten years ago when the patient was able to make correct and autonomous decisions, he made it clear that he did not want any measures that would prolong his life when he is helpless. This statement ought to be considered and respected (to show dignity to the patient), and at the same time this statement, jeopardizes the primary goal of healthcare itself. As much as the patient cannot talk in his state, his actions such as pulling out his nasogastric tubes is already a sign that the patient is against the treatment he was getting.


As stipulated by the nursing codes of ethics, nurses should respect the dignity of their respective patients. According to the definition above, the dignity of Jeremy lay in not prolonging his life when he is helpless. Therefore, as a nurse one is obliged to respect this wish. However, respecting this particular wish would mean to jeopardize the existence of nursing both as a study and as a practice (Wong, Cummings, and Ducharme 2013, 709-724).


The primary aim of nursing is to provide care that is aimed at prolonging life. Therefore, it is important to come up with an intervention strategy that would balance both the dignity of the patient and the fundamental ethics of nursing (Rehnsfeldt, Lindwall, Lohne, Lillestø, Slettebø, Heggestad, Aasgaard, Råholm, Caspari, Høy, and Sæteren 2014, pp.507-517). First as a nurse, one should determine the level of family involvement and support. One should ask for support from relevant mechanisms such as friends, family and the respective religious leader of the patient (if applicable) (Johnstone and Turale 2014, pp. 67-77). Before resolving to strictly following the patient’s wishes, the nurse should seek the legal status that involves the authority to give consent for treatment and life prolonging procedures. As much as Jeremy cannot talk, he still can act (that is why he is always removing his nasogastric tubes), this means that some form of communication with the patient is still possible. Therefore, it would be important for the nurse to develop a visiting schedule and ensure that there is a desirable level of privacy (Jong, Schout, and Abma 2014, pp. 2651-2662). In these visits, the nurse should try to ask the patient the reasons behind his decision and the role that the medical practitioners can play to help him. Due to his impaired speech, the nurse should to be careful to any gesture the patient gives. Kangasniemi, Pakkanen, and Korhonen (2015, pp. 17744-1757) posit that to ensure that the nurse can communicate with such a patient easily, the nurse should try to keep the questions open –ended. Avoids using words such as; “why,” when asking questions, rather use terms such as "what," "could," and "how." Since the patient is still able to hear, provide a brief education on the legal rights of the patient to have his dignity respected as well as the hospital's policies on respecting the rights of patients (Sanjari, Bahramnezhad, Fomani, Shoghi, and Cheraghi 2014). As a nurse, one should avoid showing any signs of negative attitude and always ask for feedback from the patient (Ramezani, Ahmadi, Mohammadi and Kazemnejad 2014, pp. 211-219).


This intervention would be helpful when balancing, the interests of the patient and the underlying principles of nursing. However, the state of mind of the patient is not at its best and therefore the patient can be compelled by external forces to make decisions, which he would later regret, especially, now that the intervention involves various stakeholders, who have different interests and all these stakeholders would be pursuing the patient to buy into their idea.


Empowerment


Empowerment is a multi-disciplinary subject, and its definition varies from one subject to another. For this case, the paper shall define empowerment as utilized in the practice of nursing. The goal of empowerment in nursing is to ensure the well-being of a patient (Lake, Hallowell, Kutney-Lee, Hatfield, Del Guidice, Boxer, Ellis, Verica and Aiken 2016, p. 24). Empowerment involves around valuing patient predilections in refining or developing health amenities. Empowered patients can make various verdicts on the conducts of their caregivers (Assasi, Schwartz, Tarride, Campbell, and Goeree 2014, pp. 203-220).


Nurses experience various challenges while trying to empower patients. Some patients came to a healthcare with a fixed mind, thinking that they are already empowered and whatever the nurses are recommending is not the best remedy (Papastavrou, Andreou, and Efstathiou 2014, pp. 3-25). For instance, in the case of Jeremy (scenario 3), after the SALT assessment, Jeremy was advised to consume soft diet only yet he felt like he wanted bread for breakfast. According to the empowerment theory, one way of empowering a patient is through listening and respecting his views. When the caregiver decided to abide by the desires of the patient and gave him a toast of bread for breakfast, it chocked him and led to his death.


Such cases present dilemmas for nurses. Among the fundamental questions that could arise from such a situation are; was it wrong for the caregiver to give Jeremy bread for breakfast, yet he insisted on it despite prior advice? Should the nurse be accused of negligence that caused the death of Jeremy? Due to the fact that the nurse knew that Jeremy was supposed to be on a soft diet yet they decided to give him bread. Should this act be considered as an ethical or unethical? Ethical, because the nurse adhered to the nursing codes of conducts and empowered the patient and immoral in the sense that the nurse ignored the dietetic recommendations of Jeremy and gave him a loaf of bread.


Nurses can carry out various interventions to improve patient’s engagement in their treatment plan; however, the best response plan should be to incorporate cultural awareness strategies as an essential component in the intervention process (Jameton 2013, pp. 297-308). The reason behind using cultural sensitive activities is because patient empowerment varies from culture to culture. Secondly, shared decision-making among the relevant stakeholders can promote patient empowerment (Peter and Watt-Watson 2016). Shared decision-making can be introduced by healthcare professionals through; first presenting the agreed choice to the patient, secondly, provide the options to the initial decision decided (this can be done with the help of tools that support decision-making) (Roberts 2015, pp. 314-325). Lastly, helping the patient to discover the impacts of his choices and help him make a decision as professionals (Kalisch, Xie, and Ronis 2013, pp. 405-413).


This type of framework could have helped in identifying the possible alternatives for Jeremy apart from sticking to bread only. By any chance, if Jeremy stacked to his bread after undergoing such an intervention, then he would have been given the potential consequences of his decisions. The health care practitioners, on the other hand, would have helped Jeremy in making the right choices in his diet. However, one major challenge to this framework would be the mental state of Jeremy; due to the effects of the stroke Jeremy might not be able to comprehend the right choices to make, which would be beneficial to him.


Law and Ethics


There are various issues that when practicing nursing can present both ethical and legal implication in relations to the care of patients. In this case, Scenario 4 of Jeremy’s case study is a relevant situation that can present both legal and ethical issues. Dehghani, Mosalanejad and Dehghan-Nayeri (2015, p. 61) outline four ethical practices that nurses should adhere to, they include, Beneficence, Justice, Autonomy, and non-maleficence. For the case study of Jeremy (scenario 4), the paper shall cover Beneficence as an ethical practice in nursing


Beneficence


Edvardsson, Watt, and Pearce (2017, pp. 217-227), defines beneficence as an action carried out for the benefit of others. These particular activities can be carried out as a positive step towards preventing or eliminating harm to improve the situations of patients. Nurses are expected not to engage in any situation that may cause harm, but instead, have the mandate to help their patients in the best way possible. Fowler and Davis (2013, pp.126-141) classifies the principle of beneficence into two as, requisite and ultimate beneficence. Ultimate beneficence encompasses of acts of kindness or the efforts to benefit people in any probable opportunity presenting itself. While requisite beneficence is showing acts of charity within the line of duty (Griffiths, Dall’Ora, Simon, Ball, Lindqvist, Rafferty, Schoonhoven, Tishelman and Aiken 2014, p.975). The fundamental goal of medicine is to support the well-being of patients, and health practitioners should have abilities that are helpful in promoting patient welfare (Taylor, Fraser, Signal, and Prentice 2014, pp. 135-152). The kind of the association between caregivers and patients, mandate the nurses to; avert and eradicate any potential harm from the patient and balance the likely benefits against possible threats in any action (Kangasniemi, Vaismoradi, Jasper, and Turunen 2013, 904-916). Beneficence acts do not only involve the named practices. However, it also includes protecting the human rights of others, saving individuals who are exposed to dangerous situations and also helping physically challenged patients (Jones, Hamilton, and Murry 2015, pp.1121-1137).


In this case, it is evident that the employees of the hospital (ward hostess, cleaner, and the respective nurse) are not practicing the principle of beneficence. As a professional nurse, once you see a patient exhibiting signs of malnutrition and there are no signs of improvement then the first thing to do is to monitor the Dietetic consumption of the patient. Unfortunately, the nurse ignores this and continues to update her charts among other records to show that the patient is feeding properly. The ward hostess and the cleaner also do not seem to care whether Jeremy is eating or not, and both are carrying out their duties generally as if there is Jeremy is on the right path of recovery. In this case, the ward hostess can show beneficence by helping Jeremy in the feeding process. Apart from the ward hostess, the cleaner has the objective of reporting to the relevant authorities that Jeremy is not feeding. On the same note, the nurse a professional should be able to detect that Jeremy is not improving from malnutrition and find the cause of the reason behind it. That way they would have expressed beneficence to Jeremy.


Conclusion


In conclusion; the practice of nursing involves around ethical codes of conduct, without these codes then the medical field would lose it meaning, and patient care would be void. The importance of using ethics in the practice of nursing is that it improves the trust of the patient in the healthcare system and improves service delivery in a health facility. Even so, as much as nurses exercise their duties with all the ethical considerations, some situations crop up within the hospitals that sometimes are tricky, and if not addressed carefully, they might lead to unethical practices. In cases, nurses are recommended to consult with the relevant stakeholders (these include, the patient, the family members of the patient, and the hospital authorities) on the way forward and the best course of action to take in this situation.


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