An Ethical Issue Of Force Vs. Neglect In Nursing

Force vs. Neglect: An Ethical issue
Ethics encompass every aspect of the world. Each direction a person wishes to take can be directed by their moral compass. However, the complexity of the world requires an analysis of the morals to make certain that everyone follows the same standards in society. There are many jobs that require consistent conversations on ethics. One of these jobs that I was exposed to is nursing and that is the field that I worked in for several years. One of the ethical issues is how to help people with dementia. Throughout my paper I will be discussing the ethical issue of neglect and force in nursing. As a certified nursing assistant (CNA), there is an unwritten rule when dealing with dementia. This rule is
to ask a person three times throughout the shift whether they want to get ready for the day or night, if they do not wish after the three times then it would be written as a refusal.. This allows the CNA to get their work done and allow each resident their rights. Some residents are able to maintain their own hygiene however there are many who need the assistance of a CNA. The constant refusal from residents who need assistance can become an ethical issue. When I was a CNA there was a prideful lady with dementia. She did not like to be told what to do and was adamant about taking care of herself. As her dementia worsened, she became unable to maintain hygiene and she was regularly incontinent. It became a rule to remind her to go to the bathroom every couple of hours throughout the day. Her pride and anger were still profound and she would refuse help on a regular basis by throwing objects at a person, ripping a sink out of the wall, causing people to bleed and other aggression. There were times when she did not respond to people with aggression, and many of those times was with me. I was a person who was more likely to get her into the bathroom or help calm her down. As time progressed she stayed in her room more often. She was unable to live with a roommate for fear of their safety and the nurses realized that she was becoming very incontinent. She would not go to the bathroom on her own and would respond with aggression when someone asked. During the day nurses would try a couple of times but did not go beyond the coaxing her. They appeared to forget to remind her to go to the bathroom. This became evident to the evening shift because of the smell and incontinence on blankets. The evening shift, including me, realized that she was sitting in her filth for a majority of the day. This is unhealthy and a person in their right mind would not want to be in that situation. We decided that we needed to get her washed. This started with one of us, many times me, coaxing her into the bathroom and then getting her into the shower. We would tell her exactly what was happening, however she would fight and scream the entire time. Many times after she was washed and many of the CNAs were covered with water, she appeared happier. She talked to other residents and sometimes played Bingo. This routine became a semi-regular thing that happened in the evening until someone from the day shift heard the screams. It also became a large issue between the evening shift and day shift. The evening shift believed that she was being neglected during the day, and the day shift believed she was being aggressively forced during the evening. There was even a meeting to try and fix this gap between the two shifts. I believe that the right result was to force her to get washed. One of the duties for being a CNA is making sure that each resident is healthy. People are sometimes unable to recognize what they need as dementia worsens. They are unable to remember the steps it take to maintain their own hygiene. The CNA reminds them of each step and what they need in order to live. This is what the evening shift did by forcing her to take a shower. There was nothing I thought was wrong about it throughout the experience because we did not hurt her or hurt others. Throughout the experience I remember thinking that she must have been sexually assaulted when she was younger. Many times people with dementia go back to their childhood and recall the horrible actions that occurred in their past. This was because she was more aggressive when we removed her clothing, however when we cleaned her up she appeared less aggressive. She became easier to hold so another person could get her washed. I was happy that she appeared to have a better demeanor after the shower and that she was able to have a conversation with other residents. I remember feeling glad whenever I was able to get her into the bathroom. It was difficult to hold her because of her screams although I knew that it was good for her. It always took about an hour for us to be able to wash her up but I always believed it was better than neglecting her throughout the day. This ethical issue caused a debate with the staff at the facility and could start an ethical debate with philosophers.
The natural law theory would support my belief that force, in this case, is morally correct. This is because humans share a rational moral nature, and common goals (Boss, 2014 pg. 272). Health is a common goal in human nature and hygiene is essential to health. When a person is unable to take care of their hygiene the natural law would say it is ethically right to step in and help them. Within the natural law theory there is the “Principle of Double Effect”. This principle states that harm is justified when the results are good (2014, pg. 277). We did not physically harm the resident, however her screams would suggest that we did. The principle of double effect supports that our actions were moral because improving her hygiene was the end
result.
Another theory that supports the evening shift’s actions would be Deontology.
Deontology states that duty is the basis of morality. It is a CNA’s duty to prevent illness and optimize health with respect and dignity. Prima facie duty is when one moral action overrides another. In this case the prevention of illness overrides the wishes of the resident (2014, pg. 300). The evening shift practiced the duty of reparation by making up for the day shifts previous actions. The restitution was a meeting with the boss and a rigid schedule during the day (2014 pg. 324).
Neglect and force has been debated throughout the years, and there are ethical concepts that support and critique each of these practices. They can be seen as immoral actions however I believe that neglect is always immoral. In this particular case neglect was unintentional and they believed they were following the wishes of the resident and not ignoring them. This is why there was a discussion of the ethics on the issue. A person with dementia deserves their rights, but when they unable to take care of themselves then they need the helpful force of a certified
nurse.