Introduction
Nurses and nursing staff face numerous legal, ethical, and professional issues in caring for and providing treatment to patients, their carers, and families (Edwards, 2009). These issues are crucial in establishing standards of professional conduct and moral judgment in nursing practice. Nurses are accountable not only to their patients but also to their profession, employers, and the public at large. Therefore, it is essential for nurses to have a sound understanding of the different legal, ethical, and professional issues they may encounter in their line of work. The three main duties of nurses involve ensuring patient confidentiality, autonomy, and duty of care (Gordon, Rauprich, and Vollmann, 2009). Additionally, the principles of non-maleficence and beneficence supplement these nursing duties. Nurses are expected to adhere to these duties to avoid breaching any policies or legislation, as this could result in legal ramifications. The Nursing and Midwifery Council (NMC) has developed minimum requirements and standards for ethical and professional practice to guide their members and avoid unwarranted legal, ethical, and professional problems. This essay examines the legal, ethical, and professional issues involved in the case study of Sara, a 34-year-old female diagnosed with borderline personality disorder by her community psychiatrist. The essay will reference guidelines from the Mental Health Act, NICE guidelines, and the Nurse Code of Conduct, among other relevant professional guidelines.
Legal Issues
Evaluating whether a patient is legally competent to make sound decisions about their treatment requires healthcare professionals to assess the patient’s mental capacity (Buchanan, 2004). The capacity being evaluated, which is vital for legal competence, increases based on the gravity of the issue at hand. This balance between a patient's best interests and their autonomy is crucial. The 2005 Mental Health Act (MHA) is a statutory framework that protects and empowers vulnerable individuals who lack the capacity to make personal decisions. The Act applies to individuals aged 16 and above and outlines who qualifies to make decisions and in what situations.
The 2005 MHA is underpinned by five basic principles. The first principle involves the presumption of capacity, assuming that every adult has the right to make their own decisions unless proven otherwise. Healthcare professionals attending to Sara should not assume she lacks the capacity to make decisions unless there is a reason to doubt her capacity. Distress and anxiety should not be taken as indicators of incapacity.
The second principle states that people must be given the necessary support to enable them to make their own decisions (Department for Constitutional Affairs, 2007). Sara should be assisted in all appropriate ways before concluding that she lacks the capacity to make her own decisions. This includes giving Sara sufficient time for evaluations and repeating evaluations if her capacity fluctuates. The clinical team needs to optimize the decision not to increase her leave to 3 hours at any given period by explaining the risks and benefits to Sara relative to other management alternatives.
The third principle indicates that patients have a right to make unwise decisions (Brown, Barber, and Martin, 2009). If the clinical team cannot prove Sara's incapacity, her decision for extended leave should be respected, even if it seems risky or “unwise.” The process of arriving at a decision, rather than the decision itself, is crucial. Sara should be informed of the best route to re-accessing treatment if she changes her mind. Given the high risks associated with her decision, seeking a psychiatry opinion may be necessary if the initial evaluation of Sara's capacity is unclear.
The fourth principle of the MHA states that decisions and associated actions taken on behalf of individuals who lack capacity should be made in the patient's best interests (Mental Health Act 2005). If Sara is assessed and determined to lack the capacity to make decisions, healthcare professionals must make decisions on her behalf with her best interests in mind. The fifth principle states that decisions made on behalf of such individuals should be the least restrictive alternatives regarding basic freedoms and rights.
Section 5(4) of the 1983 MHA authorizes mental health nurses to detain an informal in-patient receiving treatment for a diagnosed mental disorder for a maximum of 6 hours (Ashmore, 2015) or until a doctor decides to hold the patient in line with s5(2), or if an MHA evaluation determines if the patient can be detained under sections 2 or 3 of the Act. Before invoking section 5(4) of the Act, the mental health nurse must establish that the mental disorder is of such a degree that prompt action is needed to ensure the patient's health and the protection or safety of other patients. Sara meets the criteria of section 5(4) of the MHA because she is an informal patient. In this case, section 5 defines an informal patient as '... any person receiving in-patient treatment in a hospital, except a patient already liable to be detained under sections 2, 3, or 4 of the Act...' (Department of Health, 2008, p. 96). The definition also includes patients admitted to the hospital due to a deprivation of their liberty in line with the 2005 MHA. Sara is also extremely distressed and agitated, causing her to be verbally aggressive to staff members and overturning chairs in the ward day room, posing a safety risk for other patients.
On the other hand, section 5(2) of the MHA relates to doctors' holding powers. The doctor in charge of Sara's care or an approved clinician can authorize her detention for up to 72 hours by explaining why the patient needs to be held or why informal treatment is not suitable (Brindle et al., 2013). As an informal patient, Sara has a right to be involved in all stages of her care, therapy, or treatment. She should also have access to all relevant information about her treatment to make an informed decision. Furthermore, Sara should be allocated a nurse during her hospital stay who will coordinate her care. Although Sara is an informal patient, she should not be detained against her will unless sections 5(2) and 5(4) of the MHA have been revoked by relevant health professionals. Additionally, Sara has the right to access her mental health record, whether electronically or on paper.
Ethical Aspects
Nurses frequently encounter ethical dilemmas in their everyday patient care, including communication, confidentiality, and fulfilling patients' needs (Ulrich et al., 2010). At the same time, nurses are expected to maintain fundamental duties, principles, and moral virtues crucial to the nursing profession (Ulrich et al., 2010). However, nurses find it increasingly difficult to undertake their professional duties with integrity when faced with daily pressures and compelling moral choices (Burns et al., 2001). Fortunately, nurses are guided by the ethical principles of beneficence, justice, non-maleficence, autonomy, and confidentiality/privacy in assessing the ethical pros and cons they may encounter in their professional practice and ensuring they uphold the highest standards of practice (Aston, Wakefield, and McGown, 2010).
Both deontology and consequentialism are central to decision-making in nursing practice. Decisions based on the utilitarian approach entail making choices based on the greatest benefit for the greatest number of individuals. The outcome of such a decision is at the heart of the morality of intervention (Mandal, Ponnambath, and Parija, 2016). This consequentialist approach might result in harm for some people, even though its net outcome is geared toward maximum benefit. Consequentialism involves confronting every decision/action for an individual patient based on a balance between harms and benefits without evaluating past evidence or experience. Conversely, in deontology, the morality of an action is often determined by the nature of the action. In this case, harm remains unacceptable despite its outcomes. While deontological decisions could suit an individual, they may not yield benefits for society. Although Sara cannot be held by the nurse in charge of the ward against her will, her behavior poses a risk to others. The nurse in charge should weigh the pros and cons of holding Sara before deciding. However, it may be necessary to hold Sara for the benefit of the majority of the people in the healthcare facility.
The principle of beneficence is a basic principle of the nursing code of practice. It states that nurses should always endeavor to do good for their patients. Nurses have a moral obligation to extend acts of kindness, charity, and mercy to patients. This means that whatever the nurse does should favor the patient's interest and well-being (Kinsinger, 2009). Registered nurses working in psychiatric mental health settings are continuously called upon to balance the ethical principles of beneficence (the duty to do good), non-maleficence (doing no harm), and autonomy (the duty to uphold the patient's choices).
Under the principle of beneficence, the nurse is required to undertake positive actions directed toward benefiting the patient. Sara lacks medical expertise and could be vulnerable due to her illness. Accordingly, she has to rely on the nurse to provide her with sound advice geared toward promoting her well-being. Although the nurse attending to Sara is required to desist from causing harm to the patient, they also have a duty to assist the patient (Chiovitti, 2011). The objective is to improve the patient's welfare, and the nurse needs the knowledge and skills to assist the patient. Beneficence also encompasses defending and protecting the rights of others.
Beuchamp and Childress (2008) describe non-maleficence as encompassing a legal and ethical duty not to harm others. Non-maleficence in nursing practice demands that nurses desist from acting with bad intentions or malice toward patients. However, applying utilitarian logic in non-maleficence results in balancing procedures against possible harm. Should the benefits outweigh the harm, the act is considered ethical. Suspending Sara's 3-hour leave should not constitute harm, provided the overall good is achieved.
The ethical principle of autonomy in healthcare suggests that patients have the right to act as independent moral agents (Gallagher, 2004). Patients should have the freedom to determine what they want and the actions they would like to take, including the right to self-determination and informed consent. For patients with the capacity to make their own choices, the health professional is obliged to respect those choices. Thus, Sara has the right to leave the healthcare facility when she deems appropriate and make her own decisions. Conversely, if a patient is deemed incompetent to make decisions, the health professional must act in the patient's best interest. Even when a patient lacks the capacity to make an informed decision, the health professional should continue to respect the patient's autonomy by incorporating their values into the final decision (Sandman and Munthe, 2009). However, the nurse can still suspend Sara's 3-hour leave based on risk management.
Professional Issues
Professional issues related to nursing practice are similar to the ethical principles guiding the profession. These issues aim to prevent and resolve ethical conflicts that may arise in professional practice. The NMC Code of Conduct outlines standards and values that healthcare professionals should embrace to guarantee a consistent quality of care and ensure nurses act in the best interest of their patients (Koprowska, 2010). Healthcare professionals, including nurses, midwives, and caregivers, must comply with the guidelines to guarantee patients' safety.
The NMC Code (2018) provides guidance for professional practice, incorporating four key aspects: prioritizing patients, promoting professionalism and trust, practicing effectively, and preserving safety. Healthcare professionals should adhere to the NMC's four pillars of good professional practice to maintain acceptable standards of practice.
According to the NMC Code, nurses are required to practice effectively by providing individuals with adequate information about their treatment to make informed decisions. Healthcare professionals should also consult patients and listen to their concerns (NMC, 2018). Sara should be given sufficient information about her treatment, including the decision to suspend her 3-hour leave. It is crucial to listen to Sara's concerns to arrive at a decision that respects her views and is consistent with the guidance provided by her physician. Nurses should also demonstrate high standards of professional practice. Sara needs to be confident that the healthcare staff has the required skills and knowledge to manage her mental health issues effectively and keep her safe. Sara should also be assigned a care coordinator to ensure she is continuously engaged and informed throughout her hospital stay. This would help reduce her level of distress.
Nurses have a professional duty to preserve safety by adhering to relevant patient safety guidelines. Healthcare professionals must take necessary steps to manage risk, maintain patient safety, and avoid mistakes. In this case, the healthcare professional is required to suspend Sara's 3-hour leave to avoid harm to other patients. Nurses must prioritize patients and ensure they are safe while receiving treatment. To achieve this, the nurse in charge should undertake a risk assessment to determine whether to suspend Sara's 3-hour leave.
Conclusion
In summary, legal, ethical, and professional issues in nursing are intertwined, and nurses must balance these aspects to provide quality care. Sara's case highlights the importance of understanding the Mental Health Act, ethical principles like beneficence, non-maleficence, and autonomy, and adhering to professional guidelines set by the NMC. Healthcare professionals must navigate these complex issues to ensure patient safety, respect for patient autonomy, and the delivery of compassionate care.
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