Ethical Dilemma In Nursing

One of the most challenging moral/ethical dilemmas to resolve occurs when the patient’s autonomous choices conflict with the nurse’s duty to look out for the patient’s best interests. The scenario presented to me describes a conflict between a patient who refuses to bathe and a nurse whose duty is to provide the patient’s care. Because of the patient’s physical condition and inability to get out of bed, they require a two-person bath involving lifts. The patient refuses to bathe at the time scheduled putting the nurse in a difficult position, as the equipment and personnel are only available at a certain times. The nurse is unable to postpone the time resulting in the patient’s upset and ultimately refusal to bathe. In my paper, I will discuss
the moral/ethical dilemma presented in this scenario, analysis of the ethical dilemma, values clarification for the nurse, analysis of choices the nurse and the patient in this position could make, and provide a plan with rationale for resolving the dilemma. As I stated previously, the moral/ethical dilemma I believe presented is the conflict between the patient’s right of choice and autonomy and the nurses duty to provide beneficent care.
Those involved with the discussion of the issue include: the patient; as it is their right to decline treatment and right to autonomy, the nurse providing the care, the charge nurse on duty, and legal guardians if the patient is of youth status. I believe this situation has occurred due to a significant gap in the care process, where a breakdown in communication has ultimately led to the problem. It is the responsibility of the nurse to establish a therapeutic relationship with the client from the beginning of patient care. This will establish a basis of trust between the client and the nurse and will open the lines of communication and hopefully avoid dilemmas such as this one. Along with communication barriers between the client and the nurse, there also appears to be a conflict in communication within the care team as well. Ultimately, it is the patient’s right of choice as long as they have proper decision-making capacity. It would be considered inhumane if the patient were physically and forcefully treated against their will. It is undefined whether the patient is competent or not. A competent individual possesses proper decision-making capacity to understand the consequences of refusal, and can make a decision without manipulation or coercion by outsider. If the patient is deemed incompetent, the nurse must then consult a substitute decision-maker (CNO, 2009). The moral/ethical dilemma at hand, is the nurse’s decision to by pass the patients bath for the day, respecting the patients right of choice and autonomy even though it goes against the nurses duty to provide integral care for the patient. If the nurse decides forgo the patient’s bath, it may result in detrimental repercussions. Some of the consequences may include; endangering the patient of potential risk for skin breakdown, infection due to inadequate hygiene, and potential destruction to the patients self esteem and self worth. The nurse may also face punitive actions for not following through on her duties and fail as an effective communicator and problem solver. If the nurse decides to go through with the bath, though it means following through on the patients care, establishing good hygiene for the patient, and preventing risk for skin breakdown, it also risks the cessation of patient trust and communication, and goes against the patient’s right to refuse and autonomy. Essentially, by going through with the bathing schedule, the nurse is faced with the possibility of the patient refusing to cooperate with any future treatments and/or care. Though “pros” for ceasing the patient’s bath are few, they are imperatively significant. To not go through with the bath means to keep the patients autonomy in tact and builds trust in the patient-nurse relationship. If the patient does not wish to bathe that particular day or time, it is the nurse’s duty to uncover the reasons behind the refusal as well as other options available to the client. In this situation, I would practice therapeutic communication techniques to uncover why the patient is refusing to bathe and based on what I found out I would try to reschedule the bath that day, or skip the bath and offer other options to the patient to maintain good hygiene. After I made the decision I would notify the nurse manager on duty of the situation, as well as any other colleges that might be affected by my decision. After the situation has been dealt with, I would schedule a meeting with a superior to review what went well and what could have been done differently. This would allow the opportunity to determine what can be done in the future if this situation were to arise again.
In order to resolve ethical conflicts between a nurse and their patient, it is essential that the values of both parties be established (CNO, 2009). Nurses must first be aware of their own ethical values. As a nursing student I value providing safe, compassionate, ethical care, promoting health and well being, promoting informed decision making, preserving dignity and maintaining professional accountability. The patient in this scenario, would value their right of choice, preservation of dignity, and the ability to reject care if desired. This would create a conflict within values, hindering the nurse from her professional accountability. It also creates conflict with the nurse whose value is to promote health and well-being. This ethical dilemma is difficult, as you cannot force care on your patient. Although I do value professional accountability, I believe the main goal in this situation is to provide patient-centered care. This includes establishing a therapeutic relationship to avoid barriers of communication with your patient enabling the nurse to work through problems that may arise.
As indicated earlier, patient-centered care is the main goal of this ethical dilemma.
I believe this situation could and should have been avoided. If the nurse had established a therapeutic relationship with the patient from the beginning of care, the issue could have been identified before the dilemma was presented. In the event that a nurse’s personal value system conflicts with the professional (CNO/CNA) value system, guidelines can be implicated to help nurses work through ethical dilemmas. One guideline presented by CNO provides the following steps: the first is to identify issues at hand, conflicting values, and resources available. The second step is to identify options and develop a plan of approach. The third step is to implement the plan and then the fourth step is to review, discuss, and evaluate the process often with a fellow college or nurse manager (CNO, 2009). When the patient, nurse and ethical standards do not match, a breakdown in the therapeutic relationship between the nurse and patient occurs. In order to resolve the differences between the nurse’s value framework and those of the patient, the nurse must meet the needs of the patient even if it goes against their personal values. The nurse must consider client well-being and client choice in the situation. According to CNO, client well being involves listening to, respecting and understanding the patient, supporting your patient to find the best possible outcome, minimizing risks and maximizing the
benefits of the client. The client also has the right of choice, which involves the nurse providing all the necessary information for the patient to make an informed decision about their care. There are many resources available to provide guidance in ethical decision-making.
When recourses are not available to provide ideal care for the patient, nurses can collaborate with fellow colleges and nurse managers to adjust priorities and minimize harm and maximize care (CNA, 2008). As I stated previously, there are Nursing Care Guidelines available provided by CNO to aid nurses to work through ethical situations. The best resource for the patient is his/her nurse. That is why it is of the utmost importance to provide the client with as much information about their care as possible. This will allow the patient to make an informed decision regarding their care. One possible solution to this situation could be rescheduling the patient’s bath for a different time or a different day. Because there are only a certain amount of staff and lifts available, this would undoubtedly inconvenience other colleagues as well as other patients scheduled for baths. This solution would be beneficial in maintaining client autonomy and maintaining their heath care needs. Another solution would be to accept the client’s decision to not bathe. This would also preserve client’s autonomy but ultimately could cause potential health concerns for the patient and communication breakdown within the patient-nurse
relationship.
Following the CNO practice guidelines are essential in working through ethical dilemmas. “Identifying and solving ethical problems requires sensitivity, intellectual curiosity and commitment” (CNO, 2009). Along with these key elements, it is crucial for nurses to develop therapeutic relationships with their patients and be willing to consult with fellow colleagues and other members of the team, as they may have experienced a similar situation in the past and aid in addressing and solving the problem (CNA, 2008). Finally, it is the nurse’s beneficent duty to provide safe, ethical, patient-centered care and is what I will place my focus on in my last two years of nursing school and in my future nursing career.

References:

Canadian Nurses Association. (2008, June). Nursing Ethics: Code of Ethics for Registered Nurses. Retrieved from http://www.cna-aiic.ca/en/on-the-issues/best-nursing/nursing-ethics/

College of Nurses of Ontario. (2009, June). Standards and guidelines: Ethics. Retrieved from http://www.cno.org/Global/docs/prac/41034_Ethics.pdf