Care study
Care of a child with hypospadias: ethical issues in practice Pat Rose, N ightingale and G uy’s C ollege o f Health, London
Care study ohn, a 6-year old, was undergoing his sixth hospital admis sion ( Table 1). He had been born with hypospadias, a congeni tal malformation of the genitalia resulting in the urethral orifice being found on the ventral surface of the penile shaft. In John's case it was at the base of the penis. With this condition, chordee (ventral curvature of the penis) often occurs due to the presence of fibrous tissue (Fig. 1). Surgery may be performed in stages to release the chordee and progressively extend the length of the urethra (Waley and Wong, 1991). The purpose of the surgery is threefold: to enable the child to void urine in the standing position; to improve the cosmetic appearance of the genitalia; and to produce an adequate organ for sexual activity.
J
t the age of 18 months John had the first of a planned three-stage repair of his abnormality. This involved release of the chordee and was performed success fully. The second stage took place when John was three and a half years old. The urethra was extended to half-way along the penis and a temporary urethral orifice con structed. Initially, the operation appeared success ful; however, 1 year after surgery a fistula appeared at the original urethral orifice. It was decided to repair the fistula and carry out the third stage of surgery when John had reached 5 years of age and could co operate with his care. Despite the apparent set back there was still no reason to predict anything other than a successful outcome. When John was 5 years, old stage three of the surgery was carried out and a urinary catheter was to stay in situ for 10 days to ensure patency of the new urethra. John fiddled with the catheter which began to leak before falling out. A new catheter could not be passed for fear of damaging the healing tissue. John was discharged, able to pass urine through the new orifice. At the outpatient clinic John was found to have a very fine urethral opening and because of the risk of fistula formation it was decided that dilatation was necessary. % '*ie c'mc J°lln was admitted a fistula had developed, again at the site of the original
A
Pat Rose is Lecturer in
Gu/in^lle^eKoftlifeaieth,nd Guy's Hospital, London
British Journal of Nursing. 1992, Vol l,N o 8
urethral orifice. However, he had to be sent home because he developed chickenpox on the ward. John was readmitted 4 months later, and surgery was carried out to dilate the urethra and close the fistula. A urinary catheter was again to be left in situ for 10 days. On the fifth day John pulled it out; within days the fistula had reopened. After a further 8 months, John, now aged 6 years, was admitted for his sixth visit to hospital. Before discussing the ethical prob lems that arise out of this hospital admis sion there is one important issue that should be considered: is this type of sur gery justified in the first place? Hypospadias is not a life-threatening condition. However, there are three argu ments used to support early surgery. First, the urethral orifice is in an abnormal place, near the anus, thus increasing the risk of urinary tract infection. This was not a strong argument in John’s case as surgery to move the urethral orifice was not com menced until he was in his third year and out of nappies. Second, repair is necessary because when the child reaches adulthood and wishes to engage in sexual activity he will be unable to ejaculate sperm effectively into his part ner’s vagina. However, this hardly warrants surgery in a child of his age. The third reason for operating on this condition at an early age is to avoid the psychological problems that may arise for the child from the stigma of being different from other boys — John would have to sit to void urine. However, this should be weighed against the trauma of frequent hos pital admissions and constant attention to the genital area. There is no guarantee that after surgery the child would look like other boys. It should also be remembered that the genital area is not a part of the body that is often exposed to the public’s gaze. In every other way John was a perfectly normal child. It is easy for doctors using these argu ments to persuade parents, already distress ed and feeling guilty that their child has an
393 Downloaded from magonlinelibrary.com by 129.215.017.188 on January 19, 2019.
Care of a child with hypospadias: ethical issues in practice
Table 1. Summary of hospital admissions Age
Purpose
1 year 6 months
Release of penile chordee
3 years 6 months
2nd stage hypospadias repair
5 years
Closure of fistula and 3rd stage hypospadias repair
5 years 5 months
Dilatation of urethra (not performed due to chickenpox)
5 years 9 months
Closure of fistula and dilatation of urethra
6 years 5 months
Closure of fistula and dilatation of urethra
1
1
Fig. 1. Diagram showing hypospadias and ventral curvature of the penis
abnormality, that all will be made well by surgery. If informed consent for surgery is to be obtained the parents must be made aware of the risks, benefits and alternatives. Dimond (1990) suggests that the nurse has a clear duty to inform the doctor if it is discovered that the individual giving con sent does not have all the information re garding the case. Would it be ethical for a nurse, in cases such as this, to suggest that there is an alternative point of view regarding the need for this surgery at all, or must the nurse confine the discussion to clarifying the information given by a doctor? By the time of John’s sixth admittance to hospital there were many attendant problems. He had been missing school fre quently and was becoming increasingly dis trustful of hospital staff, while his parents -were worried about the failure of previous operations. Added to this, the repeated sur gery meant an increase in scar tissue and the risk that the fistula may never heal; it was also unlikely that John’s penis would
394
ever look normal. In view of these prob lems it seemed imperative that surgery was successful this time. Following routine preparation, John was taken to theatre, a standard consent form having been signed. He returned to the ward having had the fistula repaired and with instructions that the urinary catheter remain in situ for 10 days. He was also to be on strict bedrest for a week so as not to put any strain on the repair. John appeared in the ward with his fore arms encased together across his chest in a cylinder of plaster of Paris. This was a complete surprise to him, his parents and the nursing staff. The surgeon had done it to ensure that John did not pull out his catheter. The ethical issues that arise from this have implications for both medical and nursing practice. In the delivery of care nurses have certain codes and rules which must guide their de cision-making. For example, there are Acts of Parliament to which nurses must adhere — Dimond (1990) lists more than five pages of acts and statutes that regulate the practice of nursing. There is also a Code of Profes sional Conduct (UKCC, 1992) which nurses agree to conform to when joining the profession. However, these rules and codes can only act as a guide and even in the most ordinary of cases, nurses may be faced with ethical dilemmas which they need to be capable of addressing. There are many standpoints from which ethical judgments can be made. These in clude law, social etiquette, professional codes, religious beliefs and practicality (Rowson, 1990). There are also various ethical positions from which an individual makes decisions regarding right and wrong {Table 2). It is useful to have these stand points and positions in mind when examin ing the issues arising from the case reviewed here.
Consent Was it ethically right for the surgeon to de cide to encase John’s arms in plaster with out any prior discussion? It could be argued that the parents gave consent for any addi tional procedures found necessary. This clause on the consent form is, however, usually taken to mean that unless the addi tional procedures ‘are related to the oper ation for which consent has been given, or can be justified out of necessity, they will not be covered by this consent’ (Dimond, 1990). Thus, it is questionable whether the surgeon acted ethically. British Journal of Nursing, 1992,Vol l, N o 8
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Care of a child with hypospadias: ethical issues in practice
probably decided during the operation to plaster the arms together so did not raise it with the nursing staff beforehand.
Table 2. Summary of ethical positions
Position
Characteristics
Egoism
Promotion of personal good
Deontology
Right and wrong guided by an outside in fluence, e.g. a deity or political belief
Utilitarianism
Actions based on a balance between the greatest possible good and the least poss ible harm
Obligation
Doing good and avoiding harm (benefi cence) while giving equality to all (justice)
Ideal observer
Acting from a disinterested, dispassionate, all-knowing, consistent point of view
Justice as fairness
Actions guided by the point of view of the least advantaged in society
Cost-effective provision of care
Adapted from David and Aroska (1983)
Cooperation between healthcare professionals By doing what he did, it is clear that the surgeon felt solely responsible for ensuring that John did not pull out the catheter; the nursing staff were also aware of John’s his tory and the need for successful surgery. Neither the surgeon nor the nursing staff discussed how they planned to manage the catheter problem postoperativcly. The Code of Professional Conduct requires the nurse both to safeguard the interests of the patient, and to work in cooperation with other healthcare professionals (UKCC, 1992). Does their apparent failure to raise the issue of the postoperative management of John to prevent him pulling out his catheter constitute a breach of the Code or were the medical staff responsible for raising this issue? If it was a nursing responsibility does this failure warrant disciplinary action or are some breaches of the Code less serious than others? Dimond (1990) claims that if communi cation with other professionals ‘falls short of the required professional standard, it can be regarded as negligent and is actionable’ in law. The difficulties in respect of com munication between the professions of medicine and nursing provide considerable fuel for debate (Duncan and McLachlan, 1984) but in this case the nursing staff can not have imagined that the surgeon would do as he did, so perhaps saw no special rea son for raising postoperative nursing man agement with him. Likewise the surgeon British Journal of Nursing, 1992, Vol l.N o H
Because John was immobilized in plaster he needed constant attention when awake. Sometimes the playleader was available and in the evenings John’s parents visited (they had other children so chose not to be resi dent) but apart from this it was the nursing staff who had to stay with him. It is accept ed practice in paediatric nursing that if a child is adjudged to be in danger when left alone, then a ‘special’ nurse is allocated to stay with him. John needed this level of care because he was on bedrest and immobilized in such a way that he was unable to do any of the normal activities of a child of his age. This gives rise to a second ethical issue. In times of financial constraint, is it costeffective to use scarce resources to provide a special nurse for a patient whose condi tion was never life threatening and whose need for surgery could be questioned? Even if John’s arms had not been plastered he would have needed someone with him all the time to ensure that he did not pull out the catheter. Could it have been made a condition of surgery that a parent fulfil this function? The benefits of parental presence for any child have long been recognized (DHSS 1959, 1979; Department of Health, 1991), but a requirement that parents stay is never suggested. Is it ethical, however, that public money be used to pay for a special nurse in a non life-threatening situ ation?
Interests of the patient A third ethical issue involves the psycho logical effects on John. Would the benefit of passing urine normally outweigh the ef fect of this type of immobilization and the possible resultant excessive fear of hospital ization in the future? Did the surgeon act ethically in choosing to make this decision alone? He did not consult a child psychol ogist, John’s parents, paediatric nurses, or indeed, John himself. At the age of 6 years John may have been able to make some contribution to the planning of his care and, according to Government recommenda tions (Department of Health, 1991), is en titled to be consulted. The nursing staff, who are directed to ‘safeguard and promote the interests of in dividual patients and clients’ at all times (UKCC, 1992), argued that it would be in
395 Downloaded from magonlinelibrary.com by 129.215.017.188 on January 19, 2019.
Care of a child with hypospadias: ethical issues in practice
John’s interest to have the plaster removed. They would ensure that he did not pull out his catheter; he would be ‘specialled’ as be fore but able to engage in appropriate activ ities for a 6-year old on bedrest. Under this pressure the surgeon reluctantly agreed that the plaster could be removed on the fourth day.
Student nurse supervision Part of John’s care was to have a daily blad der washout with antiseptic solution. On the seventh day after surgery a student nurse was specialling John. She said she could do the washout and was subsequently left unsupervised. However, she injected the washout fluid into the balloon used to retain the catheter in the bladder rather than into the bladder itself. The balloon there fore burst and the catheter fell out. The par ents were told that the catheter had come out but were not informed how it happen ed. They may have assumed that John had been responsible. This raises the issue of what learners should be allowed to do unsupervised. It would be easy to say that they should al ways be supervised; however, this is just not possible while learners still constitute a part of the workforce of a ward. Until students are supernumerary throughout their course — and this will not happen even for Project 2000 students (ENB, 1990) — they cannot be supervised at all times by a qualified nurse. Should students therefore be supervised until they gain competence in an activity?
KEY POINTS • Nurses are faced with ethical dilemmas on a day-to-day basis and in seemingly ordinary cases. • Decision-making in nursing is guided by various rules and codes. • Different ethical positions can be used to justify decisions and actions. • Some of the rules and codes governing the nursing profession may appear to give contradictory guidance. • The decisions and actions of other healthcare professionals create ethical dilemmas for nursing staff.
British Journal of Nursing, li)92,Vol l, N o 8
This system would be difficult to carry out since learners move constantly from ward to ward. They do not carry a schedule of skills in which they have been assessed as competent so the nursing team must rely on the student’s word regarding compet ence. The Code of Conduct (UKCC, 1992) requires a trained nurse to acknowledge his/her limitations in knowledge and com petence but a student may not be able to do this safely. Indeed, Burnard and Chap man (1988) describe the complex process of development of self-awareness which they suggest is necessary in order to be able to identify successfully one’s limitations. Who is responsible if a student makes a mistake of this nature? In a system that does not allow for total supervision of stu dents, can the trained staff be held account able? Perhaps the responsibility lies with the UKCC and the Government for allow ing a situation to persist where students are part of the nursing establishment of a ward. Whoever is responsible it seems grossly un ethical to allow the blame to fall on a 6year-old boy by failing to inform the par ents fully of the cause of the incident, and thus risk him suffering similar immobil ization if more surgery is necessary.
Public trust and confidence The problem of covering up mistakes is not as straightforward as it at first appears. The public need absolute trust in those people whose hands they put themselves in when undergoing hospital treatment. Indeed, the Code of Conduct requires nurses to act ‘in such a manner as to . . . justify public trust and confidence’ (UKCC, 1992). It can be argued that it is ethical to cover up mistakes if, in making them known, the public as a whole would lose trust and con fidence in the profession. The ethical justifi cation would be the utilitarian one of seek ing the greatest good for the greatest num ber and the least harm possible. This posi tion contradicts that of the best interests of John who may be subject to further im mobilization if it was believed that he him self had pulled out the catheter.
Conclusion John was discharged on the tenth day after surgery and was to be followed up in the outpatient clinic. The ethical issues arising out of his care during this admission are those which nurses may encounter, often to a lesser extent, on a day-to-day basis: the question of nurses imparting informa tion that doctors have omitted to give the
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Care of a child with hypospadias: ethical issues in practice
patient; issues of consent and communica tion between healthcare professionals; the ethics surrounding cost-effective care and possible use of family in carrying out nor mal daily care; the supervision of students and responsibility for their mistakes; and the issues concerning the balance between the interests of the individual patient and public trust in the profession. Law and codes of conduct can only provide guide lines regarding ethical decisions and acts. Ultimately nurses are responsible for, and must be able to justify, their actions and the decisions underlying them. U p Burnard P, Chapman CM (1988) Professional and Ethical Issues in Nursing. John Wiley, Chichester David AJ, Aroska MA (1983) Ethical Dilemmas in
Nursing Practice. Appleton-Century-Crofts, Con necticut, USA DHSS (1959) The Welfare o f Children in Hospital: Report of the Platt Committee. HMSO, London DHSS (1979) Fit for the Future: Report o f the Court Committee on Child Health Services. HMSO, London Department of Health (1991) Welfare o f Children and Young People in Hospital. HMSO, London Dimond B (1990) Legal Aspects o f Nursing. Prentice Hall, London Duncan A, McLachlan G, eds (1984) Hospital Medi cine and Nursing in the 1980s: Interaction Between the Professions o f Medicine and Nursing. Nuffield Provincial Hospitals Trust, London English National Board (1990) Regulations and Guidelines for the Approval o f Institutions and Courses. ENB, London Rowson RH (1990) An Introduction to Ethics for Nurses. Scutari Press, Harrow UKCC (1992) Code o f Professional Conduct for the Nurse, Midwife and Health Visitor. UKCC, Lon don Waley LF, Wong DL (1991) Nursing Care o f Infants and Children. 4th edn. CV Mosby, St Louis
Instructions to authors for care studies All care studies submitted for publication should be sent to Joy Notter/Paula McGee, Nursing Research Unit, University of Central England in Birmingham, Perry Barr, Birming ham B42 2SU. Studies should be typewritten on A4 paper, double spaced with reasonable margins on one side of the paper only. Please send three copies.
a critical evaluation of the effectiveness of the care given and recommendations for future care (where appropriate). Other disciplines, e.g. psychology, should be included if perti nent as should any specific physiological de tails. Where a specific model of nursing is used, a brief outline of the model should be included (a diagrammatic representation may be help ful) together with a short evaluation including its advantages/disadvantages.
Short Introduction/Abstract
Confidentiality
This should be approximately 50-100 words and should give a precis of the background to the study, the patient’s history, family sup port and the clinical setting in which the study occurred.
Main text The main emphasis should be on the nursing care of the patient(s) and not on the disease process, the surgery carried out, the investiga tions conducted and/or the drugs used. These should be mentioned where appropriate but should not dominate the study. The study should present a comprehensive account of each stage of care: a clear assess ment of the patient; the aims and plan of care;
398
You must ensure that whatever other informa tion is included you do not identify the pa tients), his/her family, home or place of work.
Overall presentation Headings should be used where appropriate, and the study should be approximately 2000 words in length. Photographs, charts, tables and/or diagrams should be used to illustrate the main points. Clear indication of where these fit into the text is essential.
Reproduction permissions You must gain the necessary permission to re produce figures/tables/artwork from other journals or books before submitting your care study.
British Journal of Nursing, 1992,Voi l,N o 8
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Care of a child with hypospadias: ethical issues in practice Pat Rose, N ightingale and G uy’s C ollege o f Health, London
Care study ohn, a 6-year old, was undergoing his sixth hospital admis sion ( Table 1). He had been born with hypospadias, a congeni tal malformation of the genitalia resulting in the urethral orifice being found on the ventral surface of the penile shaft. In John's case it was at the base of the penis. With this condition, chordee (ventral curvature of the penis) often occurs due to the presence of fibrous tissue (Fig. 1). Surgery may be performed in stages to release the chordee and progressively extend the length of the urethra (Waley and Wong, 1991). The purpose of the surgery is threefold: to enable the child to void urine in the standing position; to improve the cosmetic appearance of the genitalia; and to produce an adequate organ for sexual activity.
J
t the age of 18 months John had the first of a planned three-stage repair of his abnormality. This involved release of the chordee and was performed success fully. The second stage took place when John was three and a half years old. The urethra was extended to half-way along the penis and a temporary urethral orifice con structed. Initially, the operation appeared success ful; however, 1 year after surgery a fistula appeared at the original urethral orifice. It was decided to repair the fistula and carry out the third stage of surgery when John had reached 5 years of age and could co operate with his care. Despite the apparent set back there was still no reason to predict anything other than a successful outcome. When John was 5 years, old stage three of the surgery was carried out and a urinary catheter was to stay in situ for 10 days to ensure patency of the new urethra. John fiddled with the catheter which began to leak before falling out. A new catheter could not be passed for fear of damaging the healing tissue. John was discharged, able to pass urine through the new orifice. At the outpatient clinic John was found to have a very fine urethral opening and because of the risk of fistula formation it was decided that dilatation was necessary. % '*ie c'mc J°lln was admitted a fistula had developed, again at the site of the original
A
Pat Rose is Lecturer in
Gu/in^lle^eKoftlifeaieth,nd Guy's Hospital, London
British Journal of Nursing. 1992, Vol l,N o 8
urethral orifice. However, he had to be sent home because he developed chickenpox on the ward. John was readmitted 4 months later, and surgery was carried out to dilate the urethra and close the fistula. A urinary catheter was again to be left in situ for 10 days. On the fifth day John pulled it out; within days the fistula had reopened. After a further 8 months, John, now aged 6 years, was admitted for his sixth visit to hospital. Before discussing the ethical prob lems that arise out of this hospital admis sion there is one important issue that should be considered: is this type of sur gery justified in the first place? Hypospadias is not a life-threatening condition. However, there are three argu ments used to support early surgery. First, the urethral orifice is in an abnormal place, near the anus, thus increasing the risk of urinary tract infection. This was not a strong argument in John’s case as surgery to move the urethral orifice was not com menced until he was in his third year and out of nappies. Second, repair is necessary because when the child reaches adulthood and wishes to engage in sexual activity he will be unable to ejaculate sperm effectively into his part ner’s vagina. However, this hardly warrants surgery in a child of his age. The third reason for operating on this condition at an early age is to avoid the psychological problems that may arise for the child from the stigma of being different from other boys — John would have to sit to void urine. However, this should be weighed against the trauma of frequent hos pital admissions and constant attention to the genital area. There is no guarantee that after surgery the child would look like other boys. It should also be remembered that the genital area is not a part of the body that is often exposed to the public’s gaze. In every other way John was a perfectly normal child. It is easy for doctors using these argu ments to persuade parents, already distress ed and feeling guilty that their child has an
393 Downloaded from magonlinelibrary.com by 129.215.017.188 on January 19, 2019.
Care of a child with hypospadias: ethical issues in practice
Table 1. Summary of hospital admissions Age
Purpose
1 year 6 months
Release of penile chordee
3 years 6 months
2nd stage hypospadias repair
5 years
Closure of fistula and 3rd stage hypospadias repair
5 years 5 months
Dilatation of urethra (not performed due to chickenpox)
5 years 9 months
Closure of fistula and dilatation of urethra
6 years 5 months
Closure of fistula and dilatation of urethra
1
1
Fig. 1. Diagram showing hypospadias and ventral curvature of the penis
abnormality, that all will be made well by surgery. If informed consent for surgery is to be obtained the parents must be made aware of the risks, benefits and alternatives. Dimond (1990) suggests that the nurse has a clear duty to inform the doctor if it is discovered that the individual giving con sent does not have all the information re garding the case. Would it be ethical for a nurse, in cases such as this, to suggest that there is an alternative point of view regarding the need for this surgery at all, or must the nurse confine the discussion to clarifying the information given by a doctor? By the time of John’s sixth admittance to hospital there were many attendant problems. He had been missing school fre quently and was becoming increasingly dis trustful of hospital staff, while his parents -were worried about the failure of previous operations. Added to this, the repeated sur gery meant an increase in scar tissue and the risk that the fistula may never heal; it was also unlikely that John’s penis would
394
ever look normal. In view of these prob lems it seemed imperative that surgery was successful this time. Following routine preparation, John was taken to theatre, a standard consent form having been signed. He returned to the ward having had the fistula repaired and with instructions that the urinary catheter remain in situ for 10 days. He was also to be on strict bedrest for a week so as not to put any strain on the repair. John appeared in the ward with his fore arms encased together across his chest in a cylinder of plaster of Paris. This was a complete surprise to him, his parents and the nursing staff. The surgeon had done it to ensure that John did not pull out his catheter. The ethical issues that arise from this have implications for both medical and nursing practice. In the delivery of care nurses have certain codes and rules which must guide their de cision-making. For example, there are Acts of Parliament to which nurses must adhere — Dimond (1990) lists more than five pages of acts and statutes that regulate the practice of nursing. There is also a Code of Profes sional Conduct (UKCC, 1992) which nurses agree to conform to when joining the profession. However, these rules and codes can only act as a guide and even in the most ordinary of cases, nurses may be faced with ethical dilemmas which they need to be capable of addressing. There are many standpoints from which ethical judgments can be made. These in clude law, social etiquette, professional codes, religious beliefs and practicality (Rowson, 1990). There are also various ethical positions from which an individual makes decisions regarding right and wrong {Table 2). It is useful to have these stand points and positions in mind when examin ing the issues arising from the case reviewed here.
Consent Was it ethically right for the surgeon to de cide to encase John’s arms in plaster with out any prior discussion? It could be argued that the parents gave consent for any addi tional procedures found necessary. This clause on the consent form is, however, usually taken to mean that unless the addi tional procedures ‘are related to the oper ation for which consent has been given, or can be justified out of necessity, they will not be covered by this consent’ (Dimond, 1990). Thus, it is questionable whether the surgeon acted ethically. British Journal of Nursing, 1992,Vol l, N o 8
Downloaded from magonlinelibrary.com by 129.215.017.188 on January 19, 2019.
Care of a child with hypospadias: ethical issues in practice
probably decided during the operation to plaster the arms together so did not raise it with the nursing staff beforehand.
Table 2. Summary of ethical positions
Position
Characteristics
Egoism
Promotion of personal good
Deontology
Right and wrong guided by an outside in fluence, e.g. a deity or political belief
Utilitarianism
Actions based on a balance between the greatest possible good and the least poss ible harm
Obligation
Doing good and avoiding harm (benefi cence) while giving equality to all (justice)
Ideal observer
Acting from a disinterested, dispassionate, all-knowing, consistent point of view
Justice as fairness
Actions guided by the point of view of the least advantaged in society
Cost-effective provision of care
Adapted from David and Aroska (1983)
Cooperation between healthcare professionals By doing what he did, it is clear that the surgeon felt solely responsible for ensuring that John did not pull out the catheter; the nursing staff were also aware of John’s his tory and the need for successful surgery. Neither the surgeon nor the nursing staff discussed how they planned to manage the catheter problem postoperativcly. The Code of Professional Conduct requires the nurse both to safeguard the interests of the patient, and to work in cooperation with other healthcare professionals (UKCC, 1992). Does their apparent failure to raise the issue of the postoperative management of John to prevent him pulling out his catheter constitute a breach of the Code or were the medical staff responsible for raising this issue? If it was a nursing responsibility does this failure warrant disciplinary action or are some breaches of the Code less serious than others? Dimond (1990) claims that if communi cation with other professionals ‘falls short of the required professional standard, it can be regarded as negligent and is actionable’ in law. The difficulties in respect of com munication between the professions of medicine and nursing provide considerable fuel for debate (Duncan and McLachlan, 1984) but in this case the nursing staff can not have imagined that the surgeon would do as he did, so perhaps saw no special rea son for raising postoperative nursing man agement with him. Likewise the surgeon British Journal of Nursing, 1992, Vol l.N o H
Because John was immobilized in plaster he needed constant attention when awake. Sometimes the playleader was available and in the evenings John’s parents visited (they had other children so chose not to be resi dent) but apart from this it was the nursing staff who had to stay with him. It is accept ed practice in paediatric nursing that if a child is adjudged to be in danger when left alone, then a ‘special’ nurse is allocated to stay with him. John needed this level of care because he was on bedrest and immobilized in such a way that he was unable to do any of the normal activities of a child of his age. This gives rise to a second ethical issue. In times of financial constraint, is it costeffective to use scarce resources to provide a special nurse for a patient whose condi tion was never life threatening and whose need for surgery could be questioned? Even if John’s arms had not been plastered he would have needed someone with him all the time to ensure that he did not pull out the catheter. Could it have been made a condition of surgery that a parent fulfil this function? The benefits of parental presence for any child have long been recognized (DHSS 1959, 1979; Department of Health, 1991), but a requirement that parents stay is never suggested. Is it ethical, however, that public money be used to pay for a special nurse in a non life-threatening situ ation?
Interests of the patient A third ethical issue involves the psycho logical effects on John. Would the benefit of passing urine normally outweigh the ef fect of this type of immobilization and the possible resultant excessive fear of hospital ization in the future? Did the surgeon act ethically in choosing to make this decision alone? He did not consult a child psychol ogist, John’s parents, paediatric nurses, or indeed, John himself. At the age of 6 years John may have been able to make some contribution to the planning of his care and, according to Government recommenda tions (Department of Health, 1991), is en titled to be consulted. The nursing staff, who are directed to ‘safeguard and promote the interests of in dividual patients and clients’ at all times (UKCC, 1992), argued that it would be in
395 Downloaded from magonlinelibrary.com by 129.215.017.188 on January 19, 2019.
Care of a child with hypospadias: ethical issues in practice
John’s interest to have the plaster removed. They would ensure that he did not pull out his catheter; he would be ‘specialled’ as be fore but able to engage in appropriate activ ities for a 6-year old on bedrest. Under this pressure the surgeon reluctantly agreed that the plaster could be removed on the fourth day.
Student nurse supervision Part of John’s care was to have a daily blad der washout with antiseptic solution. On the seventh day after surgery a student nurse was specialling John. She said she could do the washout and was subsequently left unsupervised. However, she injected the washout fluid into the balloon used to retain the catheter in the bladder rather than into the bladder itself. The balloon there fore burst and the catheter fell out. The par ents were told that the catheter had come out but were not informed how it happen ed. They may have assumed that John had been responsible. This raises the issue of what learners should be allowed to do unsupervised. It would be easy to say that they should al ways be supervised; however, this is just not possible while learners still constitute a part of the workforce of a ward. Until students are supernumerary throughout their course — and this will not happen even for Project 2000 students (ENB, 1990) — they cannot be supervised at all times by a qualified nurse. Should students therefore be supervised until they gain competence in an activity?
KEY POINTS • Nurses are faced with ethical dilemmas on a day-to-day basis and in seemingly ordinary cases. • Decision-making in nursing is guided by various rules and codes. • Different ethical positions can be used to justify decisions and actions. • Some of the rules and codes governing the nursing profession may appear to give contradictory guidance. • The decisions and actions of other healthcare professionals create ethical dilemmas for nursing staff.
British Journal of Nursing, li)92,Vol l, N o 8
This system would be difficult to carry out since learners move constantly from ward to ward. They do not carry a schedule of skills in which they have been assessed as competent so the nursing team must rely on the student’s word regarding compet ence. The Code of Conduct (UKCC, 1992) requires a trained nurse to acknowledge his/her limitations in knowledge and com petence but a student may not be able to do this safely. Indeed, Burnard and Chap man (1988) describe the complex process of development of self-awareness which they suggest is necessary in order to be able to identify successfully one’s limitations. Who is responsible if a student makes a mistake of this nature? In a system that does not allow for total supervision of stu dents, can the trained staff be held account able? Perhaps the responsibility lies with the UKCC and the Government for allow ing a situation to persist where students are part of the nursing establishment of a ward. Whoever is responsible it seems grossly un ethical to allow the blame to fall on a 6year-old boy by failing to inform the par ents fully of the cause of the incident, and thus risk him suffering similar immobil ization if more surgery is necessary.
Public trust and confidence The problem of covering up mistakes is not as straightforward as it at first appears. The public need absolute trust in those people whose hands they put themselves in when undergoing hospital treatment. Indeed, the Code of Conduct requires nurses to act ‘in such a manner as to . . . justify public trust and confidence’ (UKCC, 1992). It can be argued that it is ethical to cover up mistakes if, in making them known, the public as a whole would lose trust and con fidence in the profession. The ethical justifi cation would be the utilitarian one of seek ing the greatest good for the greatest num ber and the least harm possible. This posi tion contradicts that of the best interests of John who may be subject to further im mobilization if it was believed that he him self had pulled out the catheter.
Conclusion John was discharged on the tenth day after surgery and was to be followed up in the outpatient clinic. The ethical issues arising out of his care during this admission are those which nurses may encounter, often to a lesser extent, on a day-to-day basis: the question of nurses imparting informa tion that doctors have omitted to give the
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Care of a child with hypospadias: ethical issues in practice
patient; issues of consent and communica tion between healthcare professionals; the ethics surrounding cost-effective care and possible use of family in carrying out nor mal daily care; the supervision of students and responsibility for their mistakes; and the issues concerning the balance between the interests of the individual patient and public trust in the profession. Law and codes of conduct can only provide guide lines regarding ethical decisions and acts. Ultimately nurses are responsible for, and must be able to justify, their actions and the decisions underlying them. U p Burnard P, Chapman CM (1988) Professional and Ethical Issues in Nursing. John Wiley, Chichester David AJ, Aroska MA (1983) Ethical Dilemmas in
Nursing Practice. Appleton-Century-Crofts, Con necticut, USA DHSS (1959) The Welfare o f Children in Hospital: Report of the Platt Committee. HMSO, London DHSS (1979) Fit for the Future: Report o f the Court Committee on Child Health Services. HMSO, London Department of Health (1991) Welfare o f Children and Young People in Hospital. HMSO, London Dimond B (1990) Legal Aspects o f Nursing. Prentice Hall, London Duncan A, McLachlan G, eds (1984) Hospital Medi cine and Nursing in the 1980s: Interaction Between the Professions o f Medicine and Nursing. Nuffield Provincial Hospitals Trust, London English National Board (1990) Regulations and Guidelines for the Approval o f Institutions and Courses. ENB, London Rowson RH (1990) An Introduction to Ethics for Nurses. Scutari Press, Harrow UKCC (1992) Code o f Professional Conduct for the Nurse, Midwife and Health Visitor. UKCC, Lon don Waley LF, Wong DL (1991) Nursing Care o f Infants and Children. 4th edn. CV Mosby, St Louis
Instructions to authors for care studies All care studies submitted for publication should be sent to Joy Notter/Paula McGee, Nursing Research Unit, University of Central England in Birmingham, Perry Barr, Birming ham B42 2SU. Studies should be typewritten on A4 paper, double spaced with reasonable margins on one side of the paper only. Please send three copies.
a critical evaluation of the effectiveness of the care given and recommendations for future care (where appropriate). Other disciplines, e.g. psychology, should be included if perti nent as should any specific physiological de tails. Where a specific model of nursing is used, a brief outline of the model should be included (a diagrammatic representation may be help ful) together with a short evaluation including its advantages/disadvantages.
Short Introduction/Abstract
Confidentiality
This should be approximately 50-100 words and should give a precis of the background to the study, the patient’s history, family sup port and the clinical setting in which the study occurred.
Main text The main emphasis should be on the nursing care of the patient(s) and not on the disease process, the surgery carried out, the investiga tions conducted and/or the drugs used. These should be mentioned where appropriate but should not dominate the study. The study should present a comprehensive account of each stage of care: a clear assess ment of the patient; the aims and plan of care;
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You must ensure that whatever other informa tion is included you do not identify the pa tients), his/her family, home or place of work.
Overall presentation Headings should be used where appropriate, and the study should be approximately 2000 words in length. Photographs, charts, tables and/or diagrams should be used to illustrate the main points. Clear indication of where these fit into the text is essential.
Reproduction permissions You must gain the necessary permission to re produce figures/tables/artwork from other journals or books before submitting your care study.
British Journal of Nursing, 1992,Voi l,N o 8
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