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Accountable Practitioner- Consent
Caulfield’s (2005) Four Pillars of Accountability provides a good overview of the elements that need to be addressed in relation to the professional role. This assignment will look at three of the pillars: relevant legal, ethical and professional issues that impact on the role of a nurse. Other areas that can inform professional judgement and decision-making practice include clinical guidance from the Department of Health (DoH), the National Institute for Clinical Excellence (NICE), alongside information from the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC). All of these have been looked at by my group throughout the module and will be considered when forming this essay.
This assignment will discuss my leaning throughout the module and analyse my development as an accountable practitioner. I will also discuss the accountability of student nurses and reflect on my branch of nursing which is Mental Health. Towards the end of my assignment I will write a critical incident report which will reflect on an event which happened on a past placement regarding my chosen topic.
Hendrick (2004) interprets accountability to be about justifying your actions, omissions and decisions. And in order to be accountable you must have the necessary knowledge to explain the motives behind your action (Dimond, 2005).
In the School of Nursing, this module has looked at the scenarios of Pamela and Eddie. From the Pamela scenario our group queried her ability to give consent when she was in a confused and agitated state. Even though consent may have been gained prior to the original operation date some changes were discussed in the scenario and therefore I believe these changes should have been discussed with Pamela and further consent should have been gained. So the concern that I have raised I have decided to base my assignment on the subject matter of consent.
CONSENT
It is a general legal, ethical and professional principle that valid consent must be obtained before starting any treatment or physical investigation, or providing personal care for a patient. This principle reflects the right of patients to determine what happens to their own bodies, and is a fundamental part of good professional practice (Department of Health, 2001). Expressed consent can be given in writing or verbally. Dimond (1995) suggests that, written consent is by far the best form of consent.
The Department of Health (2001) declares that for consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. Acquiescence where the person agrees but does not know what the intervention entails is not consent.
ETHICAL ISSUES
Ethics is defined as the knowledge of the principles of good and evil. Sensitivity to ethical issues should be prerequisite for any profession that holds public trust. Nursing holds a public trust and therefore we must be aware of ethical concerns when dealing with patients (Barry, 2002). Ethical dilemmas such as consent force nurses to decide on possible actions to take. By discussing the ethical principles of autonomy, beneficence and non-maleficence and applying the ethical theories I hope to make it clear how nurses justify their actions.
My understanding of ethical accountability is that I am answerable to myself; I must always be truthful, fair and respectful and I believe I must treat others as I would like to be treated. Nurses faced with an ethical dilemma have to decide which possible action is the right action to take and how choice of this action over others is justified (Singleton and McLaren, 1995). During the module we have looked at various ethical models including Seedhouse’s Ethical Grid (1998) and Curtin’s Ethical Decision Making Model (1982) which provide guidance toward the resolution of clinical dilemmas; some of the aspects of these models will be evolved in the next section of this assignment.
Rumbold (1999) insists that respect for a person’s autonomy is one of the crucial principles in nursing ethics and ethical models. Gillon (1986, pp.56) defines autonomy as “the capacity to think, decide, and act on the basis of such thought and decision, freely and independently and without let or hindrance”. Therefore, it can be said that patients can expect to be fully informed of any methods of treatment available to them, in order to exercise their rights to consent to or refuse such treatment. In order for a nurse to fully respect patients autonomy, she must respect whatever decision the patient makes, and to act otherwise is to disregard the patient as an autonomous being (Fletcher et al., 1995).
Fletcher, Holt, Brazier et al. (1995) discuss that when considering patient well-being, nurses may demonstrate paternalism towards their patients. Paternalism is to believe that it is right to make a decision for someone without taking into consideration those persons wishes, or even to override their wishes; therefore overriding autonomy. This happens all the more in Mental Health and Learning Disability services because people assume that they may not have capacity to make decisions for themselves.
Singleton and Mclaren (1995) suggest that justification for nursing interventions rest on the concept that the principle of beneficence and non-maleficence takes precedence over considerations of respect for the patient’s autonomy.
Beneficence means that you must act in ways that benefit others; often summed up as the duty to care. As professionals we have both a moral and legal duty to ‘do good’ (Hendrick, 2004). But the problem is working out precisely how you are supposed to positively benefit others in practice. Rumbold (1996) says that in terms of healthcare beneficence is the idea that one should always do what is best for the patient, and that the good of the patient should be put before ones own needs.
Non-maleficence means that nurses have a duty not to harm patients or subject them to risk of harm (Rumbold, 1999). Hendrick (2004) expresses that harm can be physical and include pain, discomfort and death; but can also be psychological including: mental distress, humiliation and exploitation. Harm can be caused deliberately or without malicious or harmful intent. In healthcare, unintentional harm is likely to be caused by careless or negligent care or treatment (Hendrick, 2004).
In many medical and nursing interventions aimed at doing good, there is an element of doing harm or a degree of risks. Sometimes harm is unavoidable, even intentional, as in surgery; but at other times it can be unintentional and unexpected (Rumbold 1999). Therefore, the benefits and harms need to be balanced against each other; this should materialize the morally ‘right’ thing to do. We must always take into consideration what will cause the least harm and the most good. Pamela’s scenario does not make clear whether the risks of the surgery were explained to her or not.
LEGAL ISSUES
NMC (2008) reports as a professional you are personally accountable for actions and omissions in your practice. We live in a society where demands for accountability and taking responsibility are so common that pinning the blame on someone or something has become an automated response.
NMC (2008) states you must always act lawfully, whether those laws relate to your professional practice or personal life. A nurse could find herself in court under a charge of battery or negligence if a patient makes a complaint that the nurse did not gain consent or that insufficient information was given. The issues surrounding the importance of gaining patients consent I will now discuss together with the implications for the nurse.
Consent has been defined by the Department of Health (2008) as a voluntary and continuing permission to receive a particular treatment by a competent adult, based on an adequate knowledge of the purpose, nature, likely effects and risks of that treatment, including the likelihood of its success and any alternatives to it. This would then allow an individual to make an informed decision about whether or not to have treatment. Equally a patient has the right to withdraw or refuse consent at any time (NMC, 2002). A statement was made in the case of Schloendorff v. Society of New York Hospital (1914) in that “every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without a patient’s consent commits a battery”. I will later discuss capacity to consent in my critical report.
The relevance of battery in nursing is that many forms of treatment, involve direct contact with the body of the patient, therefore a patient can sue in the civil courts for compensation if a valid consent for that contact has not been obtained (Brazier, 1992). In order for a nurse to avoid a charge of battery, Green (1999) states they must have explained in at least broad terms, the intended procedure. When a patient complains about inadequate information, the complainant can only pursue that complaint in negligence. As a nurse you could also be charged with assault by threatening to touch.
Nurses sometimes argue their actions in accordance with duty to care and that their actions were reasonable. The duty of care in legal terms generally arises when a person can see that careless conduct is likely to cause physical injury or damage to another person (Furlong, 1998). But can the nurse always justify their actions?
Within legal issues I still feel I need to expand on my understanding of the consequences of violating laws and not following NMC or Trust guidelines. Although as a group (and class) we had many discussions around the different courts and which cases would be looked at in these courts, I am still not confident in this area and need to continue to educate myself about this.
PROFESSIONAL ISSUES
Hunt (2005) states nurses are downwardly accountable (primarily) to patients and upwardly accountable to management, the National Health Service (NHS) and the NMC.
Doctors are responsible for prescribing treatments and medication and are answerable to the patient, the General Medical Council (GMC) and the NHS. But nurses are responsible for providing the treatments and are answerable to the patient, the NMC, the employer and the NHS.
The NMC (2008) Code of Professional Conduct gives advice on standards of practice and gives ethical guidance to nurses. Secondly, it is the body, which can punish a nurse for professional misconduct.
It is outlined in the Code of Professional Conduct (NMC, 2008) that one of the overriding responsibilities of nurses is that they must obtain patients consent before treatment is given. The NMC (2004) guidelines state that the information must be given in a sensitive and understanding way, and that enough time should be given for the patient to consider the proposed treatment and be able to ask questions. It is not safe to assume that the patient has enough knowledge for them to make an informed choice without explanation. The code outlines that the nurse must respect and support people’s rights to accept or decline treatment and care (NMC, 2008). Patients may well be vulnerable and unable to protect their own interests, so by providing information and making the patient feel confident to make their own decisions will guarantee the professional role.
The nurse must be able to account for any decisions made. Accountability is concerned with weighing up the interests of patients in complex situations by using professional knowledge, judgment and skills to make that decision. A nurse is professionally accountable to the NMC, the employer and to the law. A student nurse is professionally accountable to their mentor, the school of nursing and the NMC.
The NMC, your team leader and management should provide important sources of consultation and support for nurses facing difficult situations (Jasper and Jumaa, 2005).
Consent is very much tied up with the law surrounding it to the extent that consent must be obtained before treating a patient. Also patients are to be made aware of all the risks in order to make a fully informed decision. Otherwise a nurse could find herself in court or being struck off the nurse’s register.
Nurses are constrained by their role as patient advocate and are bound by their duties to their patients. However they may feel that they know what is best for their patient and thus limit the amount of information they give. Nonetheless the courts require a patient to be informed of any risks in at least broad terms.
Employing bodies may also be liable for the actions of their staff (Department of Health, 2001).
So in the case of Pamela, after she was given analgesia the doctor then suggested that skin traction should be applied; this was an action that was not discussed with Pamela beforehand and therefore consent for this action had not been gained. Because she is now medicated gaining consent at this point would make it invalid. Although, the skin traction did not go ahead because staff did not feel that it would assist with pain relief they do not have the authority to make decisions over the doctor. The scenario also states that “Pamela became confused and agitated making traction unsuitable in any event” but if the treatment had been thoroughly explained to the patient maybe she might have been more relaxed because she would have a better understanding of what to expect. The Department of Health (2001) acknowledged that during an operation it may become evident that a patient would benefit from an additional procedure that was not within the original consent. If it is in the patient’s best interest and there is a threat to the patient’s life it may go ahead, otherwise the procedure should not be performed merely because it is convenient.
To recap, a dilemma or ethical issue often involves being caught between multiple decisions which all can pose risks. Some situations may seem unsolvable, but can be resolved if ethical principles and approaches are used. Nurses need to take steps to minimize risk and improve quality of care. Following nursing standards and codes of ethics, in conjunction with communication with colleagues and patients we can protect patient’s rights for choice and advocate their desires of care. We must remember to take professional responsibility for all of our actions and autonomous judgement and that we are accountable to numerous people including: the patient and their family, fellow staff, your employer, the NHS, the NMC and society as a whole.
Application to practice
Reflecting on a past placement, the critical account I am going to write regarding consent involves an elderly lady with dementia, for the sake of confidentiality the patients name in the case experienced by the author has been changed and she will therefore be referred to as Sally.
Sally is a lady in her seventies who has been diagnosed with vascular dementia. Since her dementia has deteriorated she now speaks very few short words to express her needs and she also can become very violent, typically for no perceptible reason.
Dementia is a condition of impaired memory and cognition. Early in the course of vascular dementia, competence and capacity may be relatively intact. Patients may be able to manage their own affairs, provide consent for medical treatments, execute living wills, or nominate a durable power of attorney for health care and finances. As the dementia progresses, competency and capacity are impaired. Sometimes, severe incapacitating dementia can occur before protective legal decisions are made (Alagiakrishnan and Masaki, 2007). It has been known that Sally’s Dementia has deteriorated over the past year and a half and she incapable of making most decisions.
On one particular date (of which I was not present) Sally injured herself by closing a door on her fingers, which resulted in her loosing the tip of her middle finger. She was taken to hospital, where treatment was given. Since returning to her home (which is a residential unit shared by other people with various mental health problems and learning disabilities) she is repeatedly removing the bandages from her fingers. When the bandages are removed, the wound is at great risk of infection and Sally is time after time opening up the wound and making it bleed, which is preventing it from healing.
In order for staff to treat the wound and re-bandage it, some physical restraint is required. Verbal consent from Sally cannot be gained, although a full explanation of what we were doing is explained every time. From the behaviours of Sally when the treatment is being given, it is obvious that she is not consenting, as she is reacting violently, shouting “no” and refusing to hold out her hand. But have Dementia sufferers got the capacity to consent to treatment anyway? I will now provide information that discusses this issue and also how determining capacity is especially important with mental health patients.
Department of Health (2001) state that for a person to have capacity, he or she must be able to comprehend and retain relevant information material, especially as to the consequences of having or not having the intervention in question, and must be able to use and weigh this information into the decision.
To give valid consent the patient needs to understand the nature and purpose of the procedure, in Sally’s case we believe she is unable to make a rational decision about her care because she is unable to retain the information given to her.
In my understanding, Sally was only refusing the treatment because she was in a lot of pain when the wound was being touched and she has minimal understanding about what the treatment is actually for.
The Mental Capacity Act (2005) states Assessment of Capacity is in two stages: 1. The Diagnostic Threshold – is there an impairment of or a disturbance in the functioning of the mind or brain? 2. The Functional Test – Is the person unable to make a specific decision when they need to (can they understand, retain, weigh-up and communicate)?
If an adult with capacity makes a voluntary and appropriately informed decision to refuse treatment this must be respected (DoH, 2001); but dementia causes you to loose capacity over time so in Sally’s case the Department of Health (2001) goes on to say that where the adult’s incapacity is permanent or likely to be long-standing, it is legitimate to carry out any procedure which is in the ‘best interests’ of the adult. Under English law, no-one is able to give consent to the examination or treatment of an adult unable to give consent for him or herself. Therefore consulting relatives would have been no use.
With relevance to other Mental Health Diagnosis’s it is possible for capacity to fluctuate. In Such cases is it good practice to establish whilst the person has capacity their views about any clinical intervention that may be necessary during a period of incapacity and to record these views (DoH, 2001). With dementia the ability to consent to possible future treatments is likely to deteriorate over time often very quickly, so unless these are discussed at the early stages of the disease then the patients’ wishes would not be known to healthcare professionals.
The Mental Health Act 1983 sets out circumstances in which patients detained under the Act may be treated without consent for their mental disorder, but it has no relevance to treatment for physical disorders (DoH, 2008); which in Sally’s case (although she was not detained anyway) the treatment was physical.
So looking back at what happened, from Sally having a diagnosis of Vascular Dementia in the later stages when rational thinking is not good, imposing physical treatment on her was ‘in her best interest’ so no law breaking was conducted.
Conclusion
There are many different things that must be considered when gaining consent from a patient. Nurses must always remember to give enough information and explain the risks as well as assessing the patient’s ability to give consent. Nurses are obliged to accept patient’s wishes even if we may disagree with their decisions. The main point I have learnt from this module is that whatever decisions are made the nurse must always be able to justify her actions.
I feel my knowledge of being an accountable practitioner and taking responsibility for all of my actions has enhanced dramatically through undertaking this module and this assignment but I still feel that my knowledge needs to continue to expand for the current time as there are still many more things to learn within this area. My diary sheets which were completed each week show some of my learning but most of it was through discussions in my group, which I found difficult to express on paper, but through writing this assignment I hope I have expressed my recent understanding of the subject well. I will ensure that I keep up to date with relevant Accountable Practitioner policies to ensure my professional role as a nurse is never challenged when a complex situation may arise.
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