Introduction
In this essay the author will discuss the legal, ethical and therapeutic issues raised in the incident that has been reflected upon, (appendix 1).
There are many issues raised in this incident like empowerment, assertiveness, patient privacy, accountability, trust, decision making and disability discrimination, however the author will be focusing on assertive communication, patient empowerment, disability discrimination and accountability. The author feels that these are some of the most important legal, ethical and therapeutic areas in nursing, particularly patient empowerment and accountability.
Assertive Communication
Communication can be a continuum of behaviour, with aggression at one end and passivity at the opposite end. Assertive communication is a balance in the middle, this means being able to communicate in a direct and honest way which meets the needs of others and also the needs of self, (Wondrak, 1998).
Wondrak (1998) describes the passive person as ‘the person who consistently subordinates their own rights to their perception of the rights of others’. This passive type of behaviour may bring feelings or actions of helplessness, submission and indecision, (Wondrak, 1998, p96).
However people move up and down the continuum with different situations that they face. A person who is passive in one situation may be aggressive with the next situation. Wondrak (1998) describes aggressive behaviour as behaviour that ‘frequently camouflages a basic lack of self-confidence, which leads to attempts to overpower others to prove superiority’, (Wondrak, 1998, p96).
Quite often a person who is passive or submissive by nature may find that they too often agree to things that they do not want to do or do not agree with, this is known as non-assertiveness. Non-assertive interactions may lead to angry internal feelings or a build up of stress and irritability. Eventually these feelings are let out in an aggressive manner.
Assertiveness is a skill that needs practice to develop; the essential skills of assertiveness are self-awareness, negotiation, compromise and calm insistence, (Wondrak, 1998).
Self-awareness is the continual process of noticing and exploring aspects of the self with the intention of developing personal and interpersonal understanding, (Burnard, 1985). Negotiation is a skill that recognises the value of personal needs and the needs of others. Compromise is necessary when it is difficult to reach an agreement; both parties need to be prepared to give up certain ground in order for both to be content with the result. Calm insistence is a technique in which a person states their position clearly and calmly then sticks to it, repeating their point as necessary, (Wondrak, 1998).
In this particular incident the student nurse used assertive communication with the staff nurse. On arrival at the scene the student was uncertain about how to deal with what she was witnessing. However the patient’s obvious distress and the staff nurses’ attitude raised feelings of anger. Initially the student nurse could be placed at the passive end of the continuum as she felt helpless and indecisive. However the feelings of anger that she experienced could have taken her to the opposite end and led her to respond with aggression. In this instance the student was neither passive nor aggressive but assertive which had the desired effect and ended the incident. However later that day when approached by the patient’s parents the student nurse showed signs of passive communication by apologising although she had no need to. She also behaved passively by not having the confidence and being afraid to report the staff nurse to her manager.
Empowerment
Traditionally the patient has always been perceived as the weaker party in the care equation, now moves are being made to change this.
The NHS National Plan, the Health and Social Care Act 2001 and the Government’s Health Service Policy Agenda have all built in the concept of patient empowerment, (Tingle and Cribb, 2002).
The Nursing and Midwifery Councils Code of Professional Conduct 2002, section 2.1, states that ‘you must recognise and respect the role of patients and clients as partners in their care and the contribution they can make to it. This involves identifying their preferences regarding care and respecting these within the limits of professional practice, existing legislation, resources and the goals of the therapeutic relationship’, (Nursing and Midwifery Council, 2002, p3).
A patient’s ability to chose for themselves and determine their own lifestyle is an important aspect of physical and psychological wellbeing. Empowerment aims to encourage personal growth by developing assertiveness and self-esteem. People who feel they have little or no control over their circumstances or events in their lives have higher rates of illness and mortality, (Kenworthy, Snowley and Gilling, 2002).
This emphasises the responsibility on nurses to promote and encourage patient independence by recognising and respecting their involvement in the planning and delivery of care. It is important that nurses also recognise that empowering care optimises patient independence and disempowering care leads to increased patient dependence, (Faulkner, 2001).
Some health professionals however may feel that empowering patients constitutes a threat to their professional role and many dislike relinquishing any amount of control in a care situation, but empowerment is essentially about the process of enabling the patients’ personal control, (Alexander, Fawcett and Runciman, 2002).
With any patient it is important to empower them to be part of their own care and to make decisions about what happens to them. With the patient in question being disabled it is important to help her feel in control of her life and the things happening to her, for example, although she cannot dress herself she can be given the choice of what she wants to wear. This would promote feelings of self-worth and control therefore empowering the patient. If these types of decisions are continually taken away from the patient they will feel they have no control and that they are unimportant and worthless.
In 1967 Seligman put forward his theory of Learned Helplessness which was based on animal experiments. His theory was that if placed in an unpleasant situation from which there is no escape we would soon become resigned and never try to escape the situation in the future. This is a learned state, in which we believe in our own powerlessness which then makes any attempts to learn futile, (Atherton, 2002).
In relation to the incident reflected upon the nurse in question completely disempowered her patient. Although the situation was not directly related to practical nursing care it was still affecting the patient’s emotional wellbeing. By not listening to the patient’s protests the nurse had implied to the patient that she was unimportant and inferior. This risks the effect of feelings of worthlessness and inequality. The situation was extremely undignified for the patient. Section 2.2 of the NMC Code of Professional Conduct states that ‘you are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs, (Nursing and Midwifery Council, 2002, p3).
This also leads us to the question of whether such an incident would have occurred if the patient had not been physically disabled and unable to stop the situation.
Disability Discrimination
Discrimination against others is a widespread problem, however in recent decades there have been laws and acts passed to help prevent discrimination. Discrimination can occur in several ways, for example, Direct Discrimination which is where one person treats another person less favourably on the grounds of sex, race, religion, etc. Also there is Indirect Discrimination which is where a condition is applied to a situation so that the proportion of people of one sex, race, religion, etc who can comply with it is considerably smaller than the proportion of another. There are also discrimination acts such as Victimisation and segregation, (Dimond, 1995).
The Disability Discriminations Act came into force in 1995. The Disability Discriminations Act part 3 is concerned with access to goods and services. The act makes it unlawful for a service provider to discriminate against a disabled person in the standard of service which it provides to the disabled person or in the manner in which it provides a service to a disabled person. Under the list of service providers mentioned in the Disability Discriminations Act are emergency services, hospitals and clinics.
The act says one of the ways discrimination occurs is ‘when a service provider treats the disabled person less favourably for a reason relating to the disabled person’s disability than it treats or would treat others and when the service provider cannot show that the treatment is justified’, (Disability Rights Commission, 1998).
Under the act adults and children have protection from discrimination if they are disabled. A disabled person is defined as someone who has a physical or mental impairment which affects their ability to carry out normal day-to-day activities, the effects must be substantial, adverse or long term.
This means that the way in which a disabled person is treated is compared with how the service provider would treat or does treat others. If a disabled person were to take a service provider to court they would not have to show that they were treated less favourably than others if other people would have been treated better. It is unlawful for a service provider to offer a lower standard of service to disabled people than they would offer to others or to serve a disabled person in a worse manner. A lower standard of service may include such things as harassment or being offhand or rude.
The act also says that service providers are legally responsible for their employee’s actions. If an employee discriminates against a disabled person during the course of their work the service provider is responsible, (Disability Rights Commission, 1998).
The Human Rights Act 1998 also covers discrimination. The Act was designed to give further effect to the rights and freedoms guaranteed under the European Convention on Human Rights.
In Schedule 1, Part 1, Article 3 ‘The Prohibition of Torture’ it states that ‘No one shall be subjected to torture or to inhuman or degrading treatment or punishment’. The way in which the nurse treated her patient was emotionally degrading.
Article 14 of the Human Rights Act is the ‘Prohibition of Discrimination’. It states that ‘The enjoyment of the rights and freedoms set forth in this convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status’, (Her Majesty’s Stationary Office,1998, p16, 19).
In the health care profession it is not just the avoidance of discrimination that is important but also the recognition of any prejudice that we may have. It is only by recognising this that we will come to honour a patient’s uniqueness. Once a prejudice free nurse/patient relationship is formed the patient will be free to communicate openly and this will help them to make informed choices about their care, (Young, 1994).
Accountability
The Nursing and Midwifery Council’s (NMC) Code of Professional Conduct states in section 1.3 that ‘You are personally accountable for your practice. This means that you are answerable for you actions and omissions, regardless of advice or directions from another professional’. Section 4.5 also states that ‘When working as a member of a team, you remain accountable for you professional conduct, any care you provide and any omission on your part’, (Nursing and Midwifery Council, 2002, p3, 7).
Accountability is defined by responsibility therefore any one who is responsible for someone or something can be held accountable. If someone is accountable they must be prepared to give an explanation or justification to relevant others for their judgements, intensions, acts and omissions if called upon to do so. Accountability is an essential dimension of professionalism that must be accepted by all professionals.
There are three aspects to accountability, moral, ethical and legal. In many day-to-day events we have a moral right to expect an explanation from someone we feel has caused an injustice towards us just as that person has a moral duty to provide an explanation to us. The extent and degree of moral accountability we have towards others depends on the relationship we have with them, (Hunt, 2003).
Professional accountability is about answering to clients, professional colleagues and other relevant professionals. The demand to give an account of our judgements, acts and omissions arises from the nature of the professional relationship. In professional ethics accountability has a central place. Here the readiness to explain ourselves applies only to those acts and omissions which attach to our professional role. Professional accountability does not exclude moral accountability but simply builds upon it. Breaking a patient’s confidence is a different matter to breaking a friend’s confidence. Even though a patient may be a complete stranger we have an ethical obligation to them as our patient and breaking a patient’s confidence is professionally wrong, this is what is meant by professional ethics.
In some areas of our lives, like our employment, we may be held accountable by the law; there are many ways in which our responsibilities are reinforced by legal means. Some areas of legal regulation are delegated out to professional regulatory bodies such as the Nursing and Midwifery Council or the General Medical Council (for Doctors). This legal delegation gives these regulatory bodies the power to strike a professional person from its register so that it would then be illegal for that person to practice in their profession, (Hunt, 2003).
If a nurse is found to have behaved in such a manner as to constitute ‘misconduct’ then he or she can be held liable to disciplinary action from the NMC (formally the UKCC). Failing to care for patients properly can be classed as misconduct. If a nurse was reported to the NMC the allegations would be investigated by an NMC officer and the nurse may then be asked to justify their actions and they will be held accountable for them, (McHale and Tingle, 2001).
In the incident being discussed the nurse in question could have been held professionally accountable for her actions by the hospital and by the NMC. However as she was not reported by the student nurse, the patient or the patients family she was not held professionally accountable and appropriately disciplined. She was however held morally accountable by the patient’s parent when they questioned her about the incident. Hopefully for the good of all her future patients she will never repeat such an act.
Appendix
Gibbs (1998) Reflective Cycle
• Description: What happened?
• Feelings: What were you thinking and feeling?
• Evaluation: What was good and bad about the experience?
• Analysis: What sense can you make of the situation?
• Conclusion: What else could you have done?
• Action Plan: If it arose again what would you do?
Description
I was a student on my first placement in a large surgical ward. There was a sixteen year old female patient who was severely disabled on the ward. I had built a good rapport with this patient as I found her funny and intelligent and also felt that she was isolated from the other patients on the ward as they were unsure of how to deal with her disability. The patient (who I will call Jill) had shown me in confidence a personal folder she kept about all her hospital visits which was in essence a diary of her thought and feelings, her carers at home helped her to type this on a special computer.
One afternoon I heard Jill shouting and crying so I went to see what was wrong. When I entered the room I saw a staff nurse standing reading Jill’s diary, Jill was extremely agitated and was crying and telling the nurse to put down her diary as it was private. The nurse was ignoring Jill and continued to read. I approached Jill’s bed unsure of what I should do but when the nurse saw me approaching she called to me and showed me the diary and started to laugh at it. I told the nurse that I didn’t think she should be reading it and that as Jill was asking her to leave it alone perhaps she should do as she was being asked. The nurse looked at me for a moment with a look of uncertainty then put the diary down and walked off. I pulled the screens around the bed and spent some considerable time with Jill trying to calm her down and reassuring her that no one else would touch it. Later that evening Jill’s parents arrived to visit and Jill told them what had happened, they were extremely shocked and angry, however when they told me they knew what had happened they said they would speak to the nurse involved but they would take the matter no further. The nurse never mentioned this matter again as far as I am aware however she also completely ignored me and refused to speak to me for my remaining time on the ward.
Feelings
My initial thoughts upon entering the ward were ones of shock, horror, disbelief and anger. I could not take in what I was seeing, the nurse so blatantly ignoring the protests of her patient. As I approached the bed I faltered, wondering what I should do or say, however, when the nurse called me over and started laughing I felt very uncomfortable with the situation and angry that she seemed to think what she was doing was an acceptable way to behave. This anger gave me the confidence I needed to be able to tell her that what she was doing was unacceptable. In the time I spent afterwards reassuring Jill I felt embarrassed that this had happened and I was embarrassed to be associated with any of it although I had done nothing wrong. When talking to Jill’s parents that evening I felt my anger and embarrassment again resurfacing, it was difficult to know what to say to them other than to apologise for the behaviour of the nurse but I felt that I shouldn’t be apologising for her and that it should have been her doing so. As it turned out they also felt this way and told me I had no need to apologise and they thanked me for comforting Jill.
Evaluation
I feel the only good thing about this situation was that I heard Jill’s outcry and went to investigate therefore managing to put a stop to it. What the nurse had done was awful, she had looked through the personal property of a patient, and she had upset a patient, ignored a patient and tried to bring me down to her level then ignored me afterwards for not going along with her. She had broken the trust of the patient and invaded her privacy. As Jill was physically unable to stop the situation it was as though the nurse took advantage of her disability.
Analysis
To analyse a situation you need to break it down and look at each part then ask yourself ‘why?’ Why did you do the things you did? Why did you do them the way you did?
It would be hard to say why the nurse did what she did as I don’t know what she was thinking; perhaps her curiosity got the better of her. However this is no excuse for her behaviour. When I ask myself why I reacted as I did the answer to that is simple. I knew what was happening was wrong and it was seeing Jill’s anguish that gave me the conviction and courage to speak out even though I knew this would make my relationship with the nurse difficult for the rest of my placement.
Conclusion
I feel that in this instance I acted appropriately and put an end to a very distressing situation. Now that I look back I wish I had reported the nurse to my supervisor as in effect the nurse got away with misconduct. I also regret not having broached the subject with the nurse and asking her to apologise to Jill and her parents for breaching her privacy. I feel also that it would have been appropriate for the nurse to have apologised to me for putting me in a difficult situation and trying to make me a party to her misconduct.
Action Plan
If this type of situation ever arose again (although I would like to think that it would not) I would have no qualms about reporting the nurse to the ward manager. I would explain to Jill and her parents that although they had no intentions of taking the matter further that the nurse had broken her professional duty and that it would be my duty to report it. I would also advise them of the appropriate way for them to go about making an official complaint.
Reference Page
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Dimond, B. (1995). Legal Aspects of Nursing. 2nd ed. Essex: Prentice Hall Europe. pp162, 169.
Disability Rights Commission, 1998. Disability Discrimination Act. [Online]. Available from: [Accessed 3rd June 2003]
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Her Majesty’s Stationary Office. (1998). Human Rights Act 1998. London: The Stationary Office Limited. pp16, 19.
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