‘Nobody is infallible; and for that reason many different points of view are needed’ (Midgley 1991)
Cameron, a nursing student develops an unprofessional relationship with a patient whilst on clinical placement. As the relationship develops Cameron breaches several ethical principles and legal responsibilities, first by allowing said patient a cigarette and second by using Facebook® to post the patients story. As a student nurse Cameron must maintain a duty of care respect confidentiality (Levett-Jones & Bourgeois 2011, p.36).
Insight into the qualities and ideals the nursing profession embodies can be reach applying Barbara Carper’s fundamental patterns of knowing and bioethical principles to examine Cameron’s actions. This examination will also provide guidance for ethical and legal conduct within said profession (Johnstone 2009, p.23). Health legislation enforces obligations to maintain and protect said responsibilities. Such legislation facilitates an understanding of legal responsibilities defines said responsibilities in relation to nursing students and espouses appropriate behaviours (Johnstone 2009, p.167).
WAYS OF KNOWING
Barbara Carper’s analysis of the structure of knowledge surrounding the nursing profession allowed for the identification of a ‘framework of knowing’ (Kingsley 2002, p.136). Carper identified four patterns of knowledge that are of great significance in nursing practice; emprics, aesthetics, personal and ethics. Each of these patterns are unique, however, there interplay provides a framework for the composition, guidance and implementation of knowledge in nursing practice (Kingsley 2002, p.136). When applied to Cameron’s situation Carper’s fundamental patterns of knowing provide insight into suitable nursing behaviours and actions.
Empircs provides logical understanding of the scientific knowledge supporting nursing actions; therefore it is recognised as the science of nursing. Empiric data is verifiable, replicable and most importantly evidence based (Kingsley 2002, p.136 and Hillard 2006, p.38). Empirical knowing allows for the recognition of symptoms, explains disease states and employs evidence-based nursing interventions; hence emprics is the data underpinning nursing actions (Hillard 2006, p.38). Empirical data offers evidence regarding the negative impacts of smoking on a person’s health.
Research proves that cigarette smoke causes a myriad of diseases for the smoker and any passive smokers, long-term smokers risk severe damage to the lungs and heart disease (NSW Department of Health 2005a, p.46). Research has found that short term and passive smokers, attentiveness and ability to problem solve were reduced and levels of agitation increased. In Cameron’s situation inhalation of passive smoke can be seen as counterproductive to his learning and behaviours on clinical placement (NSW Department of Health 2005a, p.45). Employing empirical knowledge Cameron should have offered Darcey education programs and promoted cessation interventions. Evidence suggests that combining patient education programs, nicotine replacement therapy products and counselling services augments the chances of successfully quitting (NSW Department of Health 2005a, p.12).
Aesthetics employs a conceptual approach to nursing care, referring to the ‘expressive or perceptive aspect of caregiving’ (Kingsley 2002, p.138). Hence aesthetics is considered to be the art of nursing, involving particular skills such as empathy. Empathy or ‘the capacity for participating in or vicariously experiencing another’s feelings’, allows for an understanding of patients experiences. Exploration of aesthetics has indicated that patients value a nurse who adopts empathy when communicating or caring for them (Levett-Jones & Bourgeois 2011, p.30).
Hence the specialised skills of aesthetical knowing allow for the development of therapeutic relationships in health care settings. Cameron used aesthetical knowing to build a rapport and establish a relationship with Darcey, however, also allowed this relationship to overstep professional boundaries. Therefore Cameron should have combined aesthetical knowing with his understanding of smoking to respond effectively regarding the hazards of smoking and advocate for a healthier alternative (Hillard 2006, p.37).
Cameron could have also used his understanding of aesthetical knowing to construct a relationship that allowed for better communication between himself and his clinical teacher. This would have allowed Cameron to gain the perspective of a more experienced nurse and enable a discussion of a suitable resolution to Darcey’s problem (Hillard 2006, p.37). By creating said relationship Cameron would have also been provided with an avenue for communicating Darcey’s story without breaching confidentiality.
Personal knowledge stems both from interpersonal exchanges or relationships and from the awareness of one’s own beliefs, values and prejudices. Forethought of said factors allows a health professional to eliminate any biases which may have a significant influence on their perception and interactions with a patient (Kingsley 2002, p.139 and Hillard 2006, p.37). Hillard (2006, p.38) recognises that individuals are predisposed to view themselves and their actions in a favourable manner, hence argues personal knowing is the for the most part complicated.
If Cameron employed personal knowledge, his actions would not have been guided by his emotions, rather unbiased thought processes and evidence-based practices. Personal knowing would have allowed Cameron to maintain professional boundaries and act in an unbiased manner. Consequently Cameron would have been able to refuse Darcey’s pleas for a cigarette and think critically in regards to Facebook® postings (Hillard 2006, p.37 & Kingsley 2002, 139). Personal knowing also involves reflecting on actions and thoughts in a given situation. Hence if Cameron applied personal knowing, reflection on each situation would provide insight into his emotions and actions, prompting solutions or providing experience to base his behaviours on in future (Kingsley 2002, 139).
Ethical knowing entails ‘what professionals ought or ought not to do, how they ought to comport themselves, what they, or the profession as whole, ought to aim at’ (Johnstone 2009, p.21). Ethical knowing is the moral component of Carper’s patterns of knowledge concerning moral responsibilities and decisions, regarding what is good and what is right. These obligations may encompass the quality of health care, the respect for a patient, advocacy for patient welfare and accountability (Kingsley 2002, p.140). Ethical knowing is used by a health professional when managing complex situations or situations with unpredictable outcomes.
If subscribing to ethical knowing Cameron would have discouraged Darcey from smoking because it is proven to be hazardous to the an individual’s health (NSW Department of Health 2005a, p.46-45). As previously espoused Cameron should have offered Darcey cessation interventions because those actions reflect the ethical principles contained within ethical knowing (NSW Department of Health 2005a, p.12 and Johnstone 2009, 39). Ethical knowing also details that it is wrong to breach patient confidentiality therefore if Cameron was using ethical knowledge he should not have posted Darcey’s story on Facebook® (Johnstone 2009, 14). Hence perspicacity of various ethical foundations and professional codes is required to fully understand and abide by ethical knowing (Kingsley 2002, p.140).
Ethics are ‘designed to illuminate what we ought to do by asking us to consider and reconsider our ordinary actions, judgments and justifications’ (Johnstone 2009, 13-14). Ethics function as a systematic framework of superseding principles detailing a manner of conduct as either admissible or inadmissible (Johnstone 2009, p.19). Hence ethical codes express the qualities and ideals a profession should embody and provide guidance for ethical conduct within said profession (Johnstone 2009, p.23). The Australian Nursing and Midwifery Council (2008a, p.3) espouses,
The nursing profession recognises the universal human rights of people, and the moral responsibility to safeguard the inherent dignity and equal worth of everyone. This includes recognising, respecting and, where able, protecting the wide range of civil, cultural, economic, political and social rights that apply to all human beings.
As a result of Cameron’s actions, there are several ethical standards stated in the Code of Ethics for Nurses in Australia (Australian Nursing & Midwifery Council 2008a), which have been violated. These issues revolve around the concepts of confidentiality, duty of care, professional boundaries and practicing within your scope of competence (Bendow & Jordan 2009, p.52-71). Cameron’s breach of confidentiality is the key ethical issue, due to its various implications.
Confidentiality occurs within a patient-professional relationship when a patient entrusts information to a professional with the understanding that it will not be disclosed (Ngwena & Chadwick 1994, p.139). Confidentiality is an important concept, appearing in both the Code of Professional Conduct for Nurses in Australia (Australian Nursing & Midwifery Council 2008b), and Code of Ethics for Nurses in Australia (Australian Nursing & Midwifery Council 2008a). Cameron’s Facebook® posting details confidential patient information and although Cameron does not name Darcey, previously posted information enables any member of the public to identify Darcey. Thus Cameron’s actions endanger Darcey’s safety and mental welfare (Wallace 2011).
A breach of confidentiality on a public forum reflects negatively on the hospital where Cameron completed his clinical placement and on the community expectations of the nursing profession. This is concerning because Cameron’s breach may have negative impacts on the patient-professional relationship in regards to the willingness of patients to disclose information in future, (Australian Nursing & Midwifery Council 2008a, p.10) A breach of confidentiality will also reflect badly on Cameron’s university as students are ‘obliged to protect and maintain personal information about your patients during clinical placements’ (Levett-Jones & Bourgeois 2011, p.37)
Hence it is Cameron’s duty, as a student health carer to abide by statements contained within Code of Professional Conduct for Nurses in Australia (Australian Nursing & Midwifery Council 2008b), Code of Ethics for Nurses in Australia (Australian Nursing & Midwifery Council 2008a) and other relevant legislation to ensure the patient safety and uphold a community and university expectations (Wallace 2011). The bioethical principles of autonomy, beneficence, non-maleficence, justice enable comprehension of the multiple ethical issues which arise from Cameron’s situation (Johnstone 2009, 39).
Bioethics is a comparatively new concept; having emerged in the early 1970’s, it may be defined as ‘the systematic study of the moral dimensions … of the life sciences and health care’, concerning ‘the rights and duties of patients and health care professionals’ (Johnstone 2009, 13-14). Bioethics uses the principles of autonomy, beneficence, non-maleficence and justice to enable understanding of and guide actions and judgements (Bendow & Jordan 2009, p.86).
The principle of autonomy is defined as ‘the capacity to think, decide and act on the basis of such thought and decision…freely and independently without let or hindrance’ (Gillon 1985, p.6). Hence autonomy is the ability to self-govern (Johnstone 2009, p.40). It is evident that Cameron was coerced by Darcey to leave the hospital for a cigarette therefore Darcey was not acting autonomously (Gillon 1985, p.6). Cameron’s ability to be influenced highlights the unprofessional relationship between himself and Darcey and his actions demonstrate that he was working outside his scope of practice. This may cause a breakdown in therapeutic relationships and inefficient nursing practice (Levett-Jones & Bourgeois 2011, p.112).
Autonomy and confidentiality are closely intertwined; a competent individual will autonomously choose to divulge information of a confidential nature to a health professional and therefore is required to autonomously choose if that information is to be divulged to others (Ngwena & Chadwick 1994, p.139). Cameron’s decision to post patient information on Facebook® without the consent of the patient consequently breached confidentiality and patient autonomy (Johnstone 2009, p.40).
The principle of beneficence necessitates that an individual act for the benefit of others; augmenting the health and safety of said individual whilst avoiding any physical or psychological harm (Johnstone 2009, p.42 and Bendow & Jordan 2009, p.88). On the contrary non-maleficence entails the ‘stringent obligation not to injure or harm others’ (Johnstone 2009, p.40). While beneficence and non-maleficence are distinct ethical principles their application in this case leads to similar issues arising (Johnstone 2009, p.41).
As previously discussed smoking causes a myriad of health issues (NSW Department of Health 2005a, p.45-46) therefore Cameron did not act with either beneficence or non-maleficence, as it is reasonable that he could have anticipated harm coming to either Darcey or himself as a result of smoking. The Department of Health notes (2005a, p.45) that passive smoking causes problems with attentiveness and ability to problem solve, therefore it is possible that Cameron may be endangering other patients when caring for them.
The principles of beneficence and non-maleficence are also lacking in Cameron’s actions surrounding the posting of confidential information on Facebook®. A breach of confidentiality such as Cameron’s, which allows a patient to be identified is likely to cause psychological harm and may endanger patient safety (Ngwena & Chadwick 1994, p.139). On assessment it is evident that Cameron failed to apply either ethical principle of beneficence or non-maleficence and this is reflected in his actions. Furthermore any action which disregards an ‘imbalance of harms over benefits where this can be [repaired] without sacrificing a benefactors own significant moral interests, warrants judgement as being morally unacceptable’ (Johnstone 2009, p.43).
Unlike the above bioethical principles, justice has eluded a harmonised definition or quantification due to differing perceptions of both its nature and its constitution. For this reason many different and competing theories endure (Johnstone 2009, p43). Few theories of justice are truly relevant to the ethical issues raised in this report; these consist of ‘justice as fairness and impartiality’ (Johnstone 2009, p.44) and justice in regards to respect for the law and the rights of individuals (Benbow & Jordan 2009, p.90).
Cameron’s actions also highlight that the ethical principle of justice was not used to guide his behaviours. Cameron’s display of bias emphasizes the breakdown of therapeutic relationships and effective nursing care due to distorted professional boundaries (Levett-Jones & Bourgeois 2011, p.112). Cameron’s actions also show that he had no respect for patient rights in regards to confidentiality and no respect for hospital policies or procedures concerning smoking which should have governed his actions (Benbow & Jordan 2009, p.67 and NSW Department of Health 2005a).
Each ethical principle provides diverse insights into nursing decisions and actions (Johnstone 2009, 13-14). The principle of autonomy highlights each individual’s capacity to self-govern, if acting autonomously Cameron would have sought advice from senior nursing staff, to prevent a breach of multiple ethical issues occurring. Both beneficence and non-maleficence guide nursing actions to prevent harm from befalling an individual (Johnstone 2009, p.40-43). These principles prompt consideration of improved alternatives such as nicotine replacement therapy or communicating with a clinical teacher (NSW Department of Health 2005a, p.46-45 and Hillard 2006, p.37). The principle of justice advocates impartiality and respect for the rights of patients. Hence justice provides guidance in decisions regarding professional relationship and patient rights concerning confidentiality (Johnstone 2009, p.44 and Benbow & Jordan 2009, p.90). Collectively ethical principles provide guidelines and boundaries to nursing practice (Johnstone 2009, p.23).
DUTY OF CARE
Duty of care is based on ‘the principle that a person must take reasonable care to avoid acts or omissions which would be likely to harm any person they ought to reasonably foresee as being harmed’ (McIlwraith & Madden, 2010, p.178). Hence a duty of care is said to emerge when the possibility of harm befalling another is perceived or should be perceived by an individual. Conversely a duty of care also transpires when one accepts the care of another; hence all health professionals owe a duty of care to their patients (McIlwraith & Madden, 2010, p.185).
Following from the ideas of McIlwraith and Madden (2010, p.185) it is evident that Cameron owed a duty of care to Darcey. Interestingly a duty of care was owed both because Cameron should have perceived the possibility of harm befalling Darcey and because Cameron accepted the care of Darcey (McIlwraith & Madden, 2010, p.185). Nonetheless Cameron failed in his duty of care to Darcey by enabling her to have a cigarette and hence cause more damage to her health and by permitting the possibility of mental harm arising from the breach of confidentiality (NSW Department of Health 2005a, p.45-46 and Ngwena & Chadwick 1994, p.139).
Once more following from the ideas of McIlwraith and Madden (2010, p.185) it is apparent that a duty of care was also owed to several other parties. A purpose of the Code of Ethics for Nurses in Australia (Australian Nursing & Midwifery Council 2008a) is to ‘indicate to the community the human rights standards and ethical values it can expect nurses to uphold’. Hence it is realistic to foresee that by posting confidential information on Facebook®, Cameron would damage the public image of the nursing profession and hospital where his placement occurred. It is also reasonable to anticipate that Cameron’s behaviour in regards to the smoking incident, coupled with his breach of confidentiality would reflects poorly on Flame Tree University, damaging the reputation of the university and calling into question it’s teaching standards and ethics. Thus Cameron owed and breached his duty of care to the nursing profession, the hospital and Flame Tree University (McIlwraith and Madden 2010, p.178).
As a student nurse Cameron has several legal responsibilities outlined within the Code of Professional Conduct for Nurses in Australia (Australian Nursing & Midwifery Council 2008b) and Code of Ethics for Nurses in Australia (Australian Nursing & Midwifery Council 2008a). These responsibilities include maintaining a duty of care through competence and safety in practice and respecting confidentiality to promote patient and community trust in the nursing profession (Levett-Jones & Bourgeois 2011, p.36). Health legislation at Commonwealth, state and territory levels enforces multiple obligations to maintain and protect said legal responsibilities (Johnstone 2009, p.167).
The Commonwealth government established the Privacy Act 1988 to provide privacy standards for all occupations in relation to the communication of personal information (Wallace 2011 and Office of the Australian Commissioner 2010). The New South Wales Privacy and Personal Information Protection Act 1998, also details how to handle personal information, providing guidelines for the sharing of patient information in health care settings. The Privacy and Personal Information Protection Act 1998 also gives the New South Wales Privacy Commissioner authority to scrutinise and reconcile breaches of privacy (Wallace 2011 and Office of the Australian Commissioner 2010).
The Health Records and Information Privacy Act 2002, similar to the above Act’s details the management of personal health information. The Health Records and Information Privacy Act 2002 also contains ‘four statutory guidelines … [that] are legally binding documents that define the scope of particular exemptions in health privacy principles’ (Office of the Australian Commissioner 2010). The New South Wales Government has also published the Occupational Safety Act 2000, to necessitate safety in the workplace (NSW Department of Health 2005a, p.4).
Another New South Wales government policy demanding safety in the workplace is the Department of Health Smoke Free Workplace Policy 1999 (NSW Department of Health 2005a, p.4). The Australian Nursing and Midwifery Council (2008a and 2008b) released the Code of Professional Conduct for Nurses in Australia and Code of Ethics for Nurses in Australia which govern the conduct and ethical standards of the nursing profession. Each of these codes outlines the responsibilities of maintaining a duty of care through competence and safety in practice and respecting confidentiality to promote patient and community trust (Levett-Jones & Bourgeois 2011, p.36).
Case law has established a contemporary definition of duty of care – note the results of reputable Donoghue v Stevenson case in 1932 (McIlwraith & Madden, 2010, p.179). Hence a duty of care transpires when one accepts the care of another (McIlwraith & Madden, 2010, p.185). The Code of Professional Conduct for Nurses in Australia explains duty of care is upheld as a result of the personal responsibility of nurses to provide secure and competent care, ‘within their scope of practice’ (Australian Nursing and Midwifery Council 2008b, p.2). The Occupational Safety Act 2000 and Department of Health Smoke Free Workplace Policy 1999 (NSW Department of Health 2005a, p.4), defines the standards expected to uphold a duty of care in the health environment to assure ‘the health, safety and welfare of all persons utilising [health] facilities and services’ (NSW Department of Health 2005a, p.21)
Case law is also applicable to facilitate understanding of legal responsibilities surrounding confidentiality and define said responsibilities in relation to nursing students. Lord Denning ascertained in the 1967 Seagar v Copydex case that,
‘[a person who] has received information in confidence shall not take unfair advantage of it. He must not make use of it to the prejudice of him who gave it without obtaining his consent’ (McIlwraith & Madden 2010, p.277).
Thus the nursing profession is tasked with the ethical and legal obligation to respect and maintain the confidentiality of patient information (Australian Nursing and Midwifery Council 2008a, p.10).
The Code of Professional Conduct for Nurses in Australia provides guidelines justifying nursing ideals and actions and expresses that the conduct of nurses is in accord with legislation relevant to the profession (Australian Nursing & Midwifery Council 2008b, p.3). Through the discussion of these guidelines and ethical and legal responsibilities it has become evident that Cameron should not have breached hospital smoking policies or violated confidentiality.
If familiar with relevant legislation and hospital policies Cameron would note, ‘staff members must not facilitate patients to smoke’ (NSW Department of Health 2005a, p.S-11). Hence Cameron should have offered education programs and promoted a range of cessation interventions such as nicotine replacement therapy products or counselling services (NSW Department of Health 2005a, p.12). By offering said interventions, Cameron’s approach to nursing practice would have been safe, impartial and ethically correct. These actions reflect the qualities found in Conduct Statement 1 and Conduct Statement 6, of the Code of Professional Conduct for Nurses in Australia (Australian Nursing & Midwifery Council 2008b, p.1).
It is expected that if a student is unsure they ‘know when to ask for help’; hence Cameron should have sought guidance from his clinical teacher in regards to policies surrounding confidentiality (Levett-Jones & Bourgeois 2011, p.32). By creating an avenue for communication between himself and his clinical teacher Cameron would have enabled discussion of Darcey’s situation without a breach of confidentiality occurring. Should Cameron have chosen to act in this manner his behaviours would have been reflective of Conduct Statement 5 and Conduct Statement 8. These statements justify the importance of confidentiality in health care relationships and highlight the implications of Cameron’s actions (Australian Nursing & Midwifery Council 2008b, p.1).
Hence Cameron’s unprofessional conduct requires implementation of corrective actions. Although Cameron breached legal and ethical responsibilities, his actions and consequences of those actions did not constitute professional misconduct; thus Cameron should be offered mandatory counselling and re-education and clinical placement supervision increased (Department of Health 2005b, p.3, 9). These recommendations will enable Cameron to fulfil the ethical and legal responsibilities of the nursing profession outlined by the Code of Professional Conduct for Nurses in Australia for future placements (Australian Nursing & Midwifery Council 2008b, p.7).
In summation Carper’s fundamental patterns of knowing may be applied to Cameron’s situation to understand the composition, guidance and implementation of knowledge in nursing practice (Kingsley 2002, p.136). Bioethical principles express the qualities a profession should embody and provide guidance for ethical conduct within said profession (Johnstone 2009, p.23). Hence bioethics can be used to explore Cameron’s violation of confidentiality and duty of care. As a student nurse Cameron’s legal responsibilities, including maintaining a duty of care and respecting confidentiality (Levett-Jones & Bourgeois 2011, p.36). Health legislation enforces obligations to maintain and protect these responsibilities (Johnstone 2009, p.167). Such legislation facilitates an understanding of legal responsibilities, defines responsibilities in relation to nursing students and espouses appropriate behaviours.
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