Art & science tissue viability supplement
Ethical issues and accountability in pressure ulcer prevention Welsh L (2014) Ethical issues and accountability in pressure ulcer prevention. Nursing Standard. 29, 8, 56-63. Date of submission: June 25 2014; date of acceptance: August 18 2014.
Abstract Pressure ulcers represent a considerable cost, both in terms of healthcare spending and quality of life. They are increasingly viewed in terms of patient harm. For clinicians involved in pressure ulcer prevention, ethical issues surrounding accountability may arise from both policy and practice perspectives. It may be useful for clinicians to refer to ethical theories and principles to create frameworks when addressing ethical dilemmas. However, such theories and principles have been criticised for their simplicity and over-generalisation. Alternative theories, for example, virtue ethics and experiential learning, can provide more comprehensive guidance and promote a pluralistic approach to tackling ethical dilemmas.
Author Lynn Welsh Community vascular specialist nurse, NHS Greater Glasgow and Clyde, Glasgow. Correspondence to: [email protected]
statements outline comprehensive prevention strategies, which reflect the notion of employees’ duty of care and prevention of patient harm (NHS Quality Improvement Scotland (NHS QIS) 2009). For nurses, this notion is linked to one of intrinsic duty underpinning The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (Nursing and Midwifery Council (NMC) 2008). Concerns have been raised about lack of evidence for the claim that 95% of pressure ulcers are preventable, but this continues to be cited in several NHS policies and in the literature (Downie et al 2013). If prevention of 95% of pressure ulcers is found to be unachievable in practice, this raises potential legal and clinical anomalies that could affect clinician accountability. Ethical dilemmas may also arise around aspects of individual organisation’s pressure ulcer prevention policies and guidelines, and their application in the clinical setting.
Keywords Accountability, duty of care, ethics, policy, pressure ulcers, pressure ulcer prevention, quality of life, wound care, wound management
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: http://rcnpublishing.com/page/ns/about/author-guidelines PRESSURE ULCERS REPRESENT two considerable burdens: financial and quality of life (Posnett and Franks 2008). One in five patients in the acute health sector in the UK will develop a pressure ulcer. This represents 4% of NHS spending at an annual cost of £2 billion (National Education for Scotland (NES) 2009). With ever-increasing healthcare litigation and pressure ulcers being increasingly viewed in terms of patient harm, pressure ulcer prevention has become a national priority. NHS policy initiatives and best practice
Ethics Ethics has been defined as the philosophical consideration of right and wrong and the consequences of human actions (Taylor 2005). Medical ethics underpin the fundamental values system of most healthcare professions (Lugton and Kindlen 2002). There has been a notable division in the literature pertaining to medical and nursing ethics since the 1980s, when nurses in the US sought to establish an independent professional ethical code (Lugton and Kindlen 2002). No distinction between medical and nursing ethics will be made in this article. Ethical issues are relevant to all disciplines and a collaborative, patient-centred approach might be argued to reflect the ethos of nursing. Aroskar (1989) identified ethical issues in health care as those in which the duties and obligations of the clinician lack clarity. Ethical issues become dilemmas when the different values of those involved come into conflict (Lawton and Cyster 2002). Many nurses continue to regard ethics as a theoretical subject, remote from practice, despite growing public interest in ethical and legal issues,
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more frequent dilemmas occurring in practice and a climate that seems to foster litigation (Chippendale 2006). Formal ethical requirements are outlined by the NMC, but ethics as taught in nurse education can lack coherence (McKie et al 2012).
Ethical theories To avoid ethical dilemmas, it is suggested that potential ethical issues should be considered in advance (Lugton and Kindlen 2002). The most widely accepted approach for undertaking ethical analysis – and assisting clinicians to address issues that arise in practice – is referral to ethical theories (Beauchamp and Childress 2012). There are numerous theoretical frameworks to support clinicians, which can be grouped into two broad categories: deontology and utilitarianism (Beauchamp and Childress 2012).
Deontology
Deontology dictates that a notion of intrinsic duty should be adhered to consistently and absolutely. Its origins lie in the writings of the philosopher Emmanuel Kant, who maintained that humans must always act in accordance with universal law (Snelling 2004, Beauchamp and Childress 2012). Universal law may arise from sources such as religion, legal and political systems, or institutional and professional governing bodies (Taylor 2005). The Code (NMC 2008), for example, outlines the nurse’s duty of care to the patient, imposing strict deontological principles that govern all aspects of practice and an ultimate goal of safeguarding patient and public wellbeing. The notion of duty is linked intrinsically to professional accountability. As members of a recognised profession, nurses providing pressure ulcer prevention are accountable in four domains (Dimond 2005): 1. To the public under criminal law. 2. To the patient under civil law. 3. To their governing body. 4. To their employer under contractual law. Thus, in the case of a potential omission in practice, a nurse could be legally called to account in all four domains with four different outcomes (Dimond 2005). If a patient were to develop pressure damage while under the care of a nurse, for example, the nurse may be in breach of standards of the NMC code, as well as in breach of contract to his or her employer. Criminal proceedings would be unlikely, but the healthcare provider – which is ultimately responsible for ensuring the provision of safe care in its facility, and is the nurse’s employer, may also be accountable under breach of civil law (Dimond 2005).
The nurse is accountable in a fifth dimension: the moral sense. A breach of morality – while not always legally enforceable – is the basis of ethical accountability. The duty not to breach morality therefore, is arguably the duty that carries the most weight (Dimond 2005). The example of a breach of morality illustrates the fine, and often blurred, distinction between ethics and the law. While the two share a commitment to a notion of duty, the law determines legal, but not always moral, rightness or wrongness (Chippendale 2006). An example in pressure ulcer prevention practice would be the nurse who – while not breaching laws of accountability in any of the four domains – holds the belief that he or she failed to provide a standard of care that was personally acceptable, thereby breaching personal codes of conduct and morality. Feminist theorists have criticised the deontological approach for being paternalistic and authoritarian. This, it could be argued, undermines the notion of caring that is inherent to nursing (Criggar 1994). Gray (2010) proposes that feminist ethical theory, in contrast, is less concerned with duty and rules and has an all-encompassing view of morality. It could be argued that nursing itself has roots in regimental systems, but the evolution of the profession, to one that favours holism, has led to a general consensus that the traditional deontological approach is outdated (Polvsen and Borup 2011). Several deontological factors govern pressure ulcer prevention. In the UK, pressure ulcers continue to be regarded as patient harm and clinicians are increasingly accountable for ensuring their prevention. There is ambiguity, however, surrounding the definition of accountability and what it actually means in practice (Thompson 2006). Savage and Moore (2004) argue that while accountability should assume a responsibility of personal judgement on the part of the clinician, it is more often associated with rules and criteria imposed from external sources. This has led to a theoretical conflict of interest between the concept of clinician accountability and the organisations and agencies that govern professions. Clinicians may feel that certain mechanisms of formalised pressure ulcer prevention reporting are indicative of a growing culture of policing health care. For example, the NHS Scotland Pressure Area Safety Cross publicly displays visual data relating to pressure ulcer incidence in individual clinical areas (NHS QIS 2011), although this was devised to provide reflective learning opportunities. In response to such claims, Thompson (2006) defends formal codes of conduct, suggesting that they provide a baseline for ethical permissibility,
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Art & science tissue viability supplement which supports rather than conflicts with clinician autonomy. Pressure ulcer prevention policy, guidelines and best practice statements may differ across NHS organisations, but their commitment to the reduction of patient harm is consistent. For example, The Dudley Group NHS Foundation Trust in England, the Abertawe Bro Morgannwg University Health Board in Wales, and NHS Greater Glasgow and Clyde in Scotland have all developed pressure ulcer prevention policies that include the establishment of a zero-tolerance agenda for avoidable damage, and an overall reduction of healthcare-acquired pressure ulcers (NHS Wales 2012, Wounds International 2013). Clinical governance arose as a system to ensure quality and accountability, in response to several public incidents in the 1990s that highlighted poor standards of health care in the UK. It is a further example of a deontological framework to which clinicians are obligated (Scally and Donaldson 1998). Nurses are expected to adhere to principles of clinical governance (Donaldson 2001), which form the basis of national guidance, such as the Pressure Ulcers: Prevention and Management guideline (National Institute for Health and Care Excellence 2014). The Scottish Intercollegiate Guidelines Network (SIGN) does not have a guideline specific to pressure ulcer prevention, but considers it in guidelines such as Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning (SIGN 2010). As evidence-based protocols for practice, national guidelines are designed to safeguard quality of care and accountability and provide standardised care pathways. However, clinical governance has also been criticised for masking underlying managerial and political agendas regarding resource control (Parsky and Corrigan 2002). Such hidden agendas, it has also been argued, undermine clinician autonomy (Baker and Roland 1999) by changing the climate of healthcare provision from one of trust in professionalism to one of blame and surveillance. Although clinical guidelines were intended to contribute to the overall effectiveness of the NHS, evidence to support a direct improvement on patient care outcomes remains mixed (Checkland et al 2004). The main basis of several NHS policies is the claim that 95% of pressure ulcers are avoidable (Bader et al 2010). The data that supported this 95% figure originated from a report produced by Hibbs (1988). No claim of research evidence was made to support the figure at the time of publication, but it has been widely cited and adopted by NHS organisations across the UK (Waterlow 1988, Stanzak 2006, Bader et al 2010, Anderson and
Fletcher 2013). After consistent data collation – which repeatedly demonstrated a failure to meet the 95% figure – a study within five acute NHS trusts in England found the figure relating to avoidable pressure ulcers to be 43%, less than half that frequently cited (Downie et al 2013). The results of this study were limited to the NHS trusts in which they were carried out and, therefore, cannot be assumed to reflect the national context, however limitations in data collection and reporting on pressure ulcer prevalence continue to be recognised (Fletcher et al 2013). The political drive to reduce pressure ulcer incidence is understandably high. However, potential inaccuracies inherent to reporting frameworks raise worrying questions about the proposed accountability of those involved directly in patient care. For example, what would happen if a clinician were to document evidence to support the implementation of comprehensive pressure ulcer prevention interventions for a patient who subsequently developed what is considered to be avoidable pressure damage? If the clinician is found to be in breach of one or more areas of accountability – and as the 95% claim has been subsequently discovered to be inaccurate – can such a breach be upheld? While application of investigation tools and root cause analyses may be crucial for investigation and support of the clinician at the individual level (National Pressure Ulcer Advisory Panel (NPUAP) 2014), a sustained and collective inability to achieve specified outcome goals in preventing pressure ulcers may have detrimental effects for clinicians and healthcare providers. The rise in healthcare litigation crucially dictates the correct application of evidence, to safeguard the interests of patients and healthcare providers.
Utilitarianism
Utilitarianism is at the opposite end of the philosophical spectrum to deontology, and states that actions of right or wrong are determined by their consequences rather than notions of duty (Chippendale 2006). In utilitarianism, the result of the action, rather than the action itself, determines morality (Lugton and Kindlen 2002). Utilitarians would argue that it is morally acceptable to break rules of duty provided the outcome is positive (Chippendale 2006). Utilitarianism stems from the works of philosophers Jeremy Bentham and John Stuart Mill, who advocated the greatest good for the greatest number. Utilitarianism can be further divided into ‘act’ utilitarianism, which judges the consequences of each individual action; and ‘rule’ utilitarianism, which devises rules based on
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Art & science tissue viability supplement probable outcomes, predicted from past actions (Beauchamp and Childress 2012). Since the prediction of individual actions can be complex, rule utilitarianism, which recognises general patterns, is the dominant perspective applied within the healthcare setting (Taylor 2005). Where the deontological approach guides the standards imposed by regulatory and institutional bodies, such as employers and the NMC, utilitarianism is usually associated with the personal perspectives of patients, families and individual clinicians (Chippendale 2006). While deontologists maintain that rules must apply in all situations, utilitarians would argue that each individual context is unique. From a utilitarian perspective, a clinician involved in pressure ulcer prevention may propose that non-adherence to certain elements of policy would be ethically acceptable if outcomes were positive and the patient came to no harm. An example may be the patient who refuses recommended preventive measures, for example specialist pressure-redistributing equipment, and proceeds to develop pressure damage. If the patient has mental capacity and a belief that pressure damage is preferable to the discomfort and upheaval of using the equipment, it might be argued that outcomes were positive, even if damage could have been avoided by policy adherence. Another example may be patients at the end of life, for whom comfort and simplicity are likely to take precedence over disruptive interventions such as re-positioning protocols. These scenarios illustrate potential ethical anomalies that can arise between the deontological approach advocated by bodies of authority and the utilitarian views of the patients. Moral theory is often considered to be the highest level of reasoning available to assist nurses in tackling ethical problems (Beauchamp and Childress 2012), but it is not without criticism. Lamb (1995) argued that theoretical analysis ignores the effect of the wider social context in ethical decision making. Additionally, some feminists argue that, despite female domination of the caring professions, medical ethics excludes women from moral equality (Tulloch 2005) and that the historic elitism and male domination of the medical professions deny recognition of their moral claim to be treated equally (McInnes and Lawson-Brown 2007). Nurses often find it difficult to determine exactly what constitutes good or harm, since they are highly value-laden concepts (Chippendale 2006). Beauchamp and Childress (2012) maintain that failure to use moral theory does not necessarily affect the quality of ethical decision making.
While ethical theories provide general guidance, they do not provide clear-cut right or wrong answers and individual reasoning is often argued to be the ultimate determinant in the provision of good care (Chippendale 2006).
Ethical principles The principle-based approach to ethical reasoning derives from both deontological and utilitarian theories and forms the basis of The Code (NMC 2008). The four widely accepted ethical principles are (Beauchamp and Childress 2012): 1. Autonomy. 2. Beneficence. 3. Non-maleficence. 4. Justice.
Autonomy
Autonomy is the right of self-determination (Beauchamp and Childress 2012). It is the principle that guides many issues in the clinical setting, and is one that may only be overridden in exceptional circumstances (Cahill 2004). From the legal perspective, a person’s right to autonomy is based on his or her competence or capacity to make a particular decision; however, determining competence can be problematic (Dimond 2005). Several factors can affect autonomy, either temporarily or permanently, including (McParland et al 2000): Physical or mental illness. Culture. Education. Stress. Age. For the clinician involved in pressure ulcer prevention, issues of autonomy are similar to those in the wider healthcare setting, and can pertain to consent. Some NHS pressure ulcer prevention policies dictate that clinicians, including those from professions such as physiotherapy and speech and language therapy, should perform regular skin checks to determine risk as part of their initial assessments. In the author’s professional experience, many clinicians express concerns about the appropriateness of such invasive practice, which may compromise dignity among older and more vulnerable patient groups (Baillie 2009). When a patient refuses to consent to a skin check, the legal implications and potential consequences that may result from this are additional issues. The law states that all competent adults have the right to refuse treatment (Cahill 2004), however the clinician who supports such a refusal may also feel that, in doing so, they are failing in their duty of care to protect and promote patient health,
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particularly if the patient goes on to develop pressure area damage (NMC 2008). A further concern is the difficulty in determining mental capacity for consent or refusal of treatment. In Scotland, all persons are considered competent unless incapacity has been legally determined by medical assessment and subsequent completion of a Certificate of Incapacity under section 47 of the Adults with Incapacity (Scotland) Act 2000, which remains a component of their medical records. In England and Wales, the equivalent legislation is the Mental Capacity Act (2005), which has a supplementary code of practice to guide practitioners with its implementation. In Northern Ireland, recommendations from The Bamford Review of Mental Health and Learning Disability (2007) are being considered to shape future legislation in this area. Despite the existence of legal frameworks, a clinician who is the first to make professional contact with an individual could detect early signs of cognitive impairment that, although not yet legally recognised, may make mental capacity difficult to assess. Cahill (2004) adds that incapacity may not be all encompassing, suggesting that generalised cognitive impairment cannot be assumed to affect all areas of decision making. This means that a patient with legally confirmed incapacity may still, theoretically, be competent to refuse a skin check. The ability to assess competence is an important clinical skill (Mueller et al 2004). McParland et al (2000) remind clinicians that, even if they have difficulties in actively promoting patient autonomy, they are bound to refrain from interfering with it. Arguably, in determining mental capacity, the role of the patient advocate is crucial in maintaining patient autonomy (NMC 2008). This can include anything from upholding patients’ wishes in their treatment outcomes, to provision of relevant pressure ulcer prevention information leaflets to promote optimum levels of self-care.
Beneficence
Beneficence, the obligation to do good, is a fundamental ethical principle governing health care. It should, therefore, be the ultimate goal of all clinicians (Taylor 2005). Those involved in pressure ulcer prevention are duty bound in the four arenas of accountability to promote the health and wellbeing of those in their care (NMC 2008). Examples of beneficence in pressure ulcer prevention range from respecting individuality and treating patients with dignity, to the correct use of evidence-based tools such as the Waterlow Score to assess the risk of skin damage (Waterlow 2005).
Non-maleficence
Non-maleficence, closely linked to beneficence, is the duty to protect from harm (Beauchamp and Childress 2012). Taylor (2005) maintains that non-maleficence applies to all members of the general public, but has particular implications for healthcare professionals due to their relative position of power over patients. The zero tolerance for avoidable pressure ulcers mandate exemplifies a commitment to the principle of non-maleficence (Scottish Patient Safety Programme 2010).
Justice
Justice is the duty to ensure fairness and equality in the allocation of resources and is considered the most problematic in terms of adherence (Taylor 2005). This is because it relies not only on the actions of individual clinicians, but also on those of society as a whole (Taylor 2005). In pressure ulcer prevention, justice may pertain to the fair distribution of resources, such as high-grade airflow mattresses, which are widely incorporated into pressure ulcer prevention care plans for patients in moderate to high-risk categories. Clinicians involved in pressure ulcer prevention often report practical challenges when making decisions around equality in the distribution of resources, for example the appropriateness of using specialist equipment such as airflow mattresses, which may have implications relating to noise, comfort or convenience of installation for patients at the end of life, for whom comfort may be the primary goal.
Principles in practice Beauchamp and Childress (2012) state that each of the four ethical principles is prima facie binding, which means that no single principle should dominate the others in ethical decision making. When they do come into conflict, the individual circumstances of the situation must be analysed to determine prioritisation (Taylor 2005). In such cases, the most important deciding factors include the subjective priorities and preferences of patients and families (Chippendale 2006). It is important to note that this argument may be subject to cultural interpretation. Autonomy is often viewed as the principle that carries the most weight in Western society, but that view does not necessarily follow internationally (World Medical Association 2009). The clinician should therefore have an awareness of multicultural aspects that increasingly define pressure ulcer prevention care provision, for example, ensuring the provision of culturally relevant and sensitive patient information leaflets. The four-principled approach to ethical reasoning has been criticised for its rigidity
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Art & science tissue viability supplement (Harris 2003), simplicity (Campbell 2003), and over-generalisation of complex issues (Campbell 2003, Gardiner 2003). Although the principles provide a useful framework for ethical decision making, clinicians involved in pressure ulcer prevention should be aware of the potential for cultural and personal interpretation by fellow clinicians, patients and carers. For example, ethical dilemmas that arise from issues including collusion and truth telling, breaking bad news and revelation of diagnosis may vary depending on the culture of the practitioner, the patient, and/or the family involved (Mystakidou et al 2005).
Virtue ethics and experiential knowledge In response to the above criticism of the four-principled approach, advocates of virtue ethics – a framework that places utmost importance on the emotional character and
reactive behaviours of the clinician who has to address ethical issues – argue that a flexible, creative approach is favourable to ensure recognition of the unique needs of any situation. Campbell (2003) attests that virtue ethics are a necessary complement to the four-principled approach towards ethical problem solving. Harris (2003) observes that a pluralistic, unprincipled approach ultimately brings personal objectives and outcomes to fruition. Experiential, practice-based knowledge is an additional source of ethical decision making, which often carries as much weight as that from more formal sources (Kennedy 2004). Carper (1978) cited four fundamentals of nursing knowledge, including empirics, ethics, aesthetics and personal knowledge. This knowledge derives from the expert nurse’s intuition (Benner and Wrubel 1984), personal and professional experience (Kennedy 2004), knowledge shared between
References Anderson I, Fletcher J (2013) Wound management. In Brooker C, Waugh A (Eds) Foundations of Nursing Practice: Fundamentals of Holistic Care. Mosby Elsevier, Oxford, 609-628. Aroskar M (1989) Community health nurses: their most significant ethical decision making problems. Nursing Clinics of North America. 24, 4, 967-975.
Cahill H (2004) Consent. In Holland S (Ed) Introducing Nursing Ethics: Themes in Theory and Practice. APS Publishing, Salisbury, 91-101. Campbell AV (2003) The virtues (and vices) of the four principles. Journal of Medical Ethics. 29, 5, 292-296. Carper B (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science. 1, 1, 13-23.
Bader D, Bouten C, Colin D, Oomens CJ (2010) Pressure Ulcer Research: Current and Future Perspectives. Springer, Heidelberg.
Checkland K, Marshall M, Harrison S (2004) Re-thinking accountability: trust versus confidence in medical practice. Quality Safe Health Care. 13, 2, 130-135.
Baillie L (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies. 46, 1, 23-37.
Chippendale S (2006) Ethical issues in palliative care. In Kinghorn S, Gaines R (Eds) Palliative Nursing: Bringing Comfort and Hope. Baillière Tindall, Edinburgh, 171-190.
Baker R, Roland M (1999) Clinical Governance: A Practical Guide for Primary Care Teams. University of Manchester, Manchester. Beauchamp TL, Childress JF (2012) Principles of Biomedical Ethics. Seventh edition. Oxford University Press, New York NY. Benner P, Wrubel J (1984) The Primacy of Caring: Stress and Coping with Health and Illness. Addison-Wesley, Menlo Park CA.
Criggar N (1994) Universal prescriptivism: traditional moral decision making theory revisited. Journal of Advanced Nursing. 20, 3, 538-543. Dimond B (2005) Legal Aspects of Nursing. Fifth edition. Churchill Livingstone, Edinburgh. Donaldson L (2001) Professional accountability in a changing world.
Postgraduate Medical Journal. 77, 904, 65-67. Downie F, Guy H, Gilroy P, Royall D, Davies S (2013) Are 95% of hospital acquired pressure ulcers avoidable? Wounds UK. 9, 3, 16-22. Fletcher J, Crook H, Harris C (2013) Monitoring pressure ulcer prevalence: a precise methodology. Wounds UK. 9, 4, 48-53. Gardiner P (2003) A virtue ethics approach to moral dilemmas in medicine. Journal of Medical Ethics. 29, 5, 297-302. Gray M (2010) Moral sources and emergent ethical theories in social work. British Journal of Social Work. 40, 6, 1794-1811. Hare RM (1981) Moral Thinking: Its Levels, Method and Point. Clarendon Press, Oxford. Harris J (2003) In praise of unprincipled ethics. Journal of Medical Ethics. 29, 5, 303-306. Hibbs PJ (1988) Pressure Area Care Policy. City of Hackney Health Authority, London. Kennedy J (2004) A typology of knowledge for district nursing assessment practice. Journal of Advanced Nursing. 45, 4, 401-409.
Lamb D (1995) Therapy Abatement, Autonomy and Futility. Avebury, Aldershot. Lawton S, Cyster D (2002) Ethical Issues. In Lugton J, Kindlen M (Eds) Palliative Care: the Nursing Role. Churchill Livingstone, Edinburgh, 249-270. Lugton J, Kindlen M (Eds) (2002) Palliative Care: The Nursing Role. Churchill Livingstone, Edinburgh. McInnes A, Lawson-Brown V (2007) ‘God’ and other ‘do-gooders’: a comparison of the regulation of services provided by GPs and social work in England. Journal of Social Work. 7, 3, 341-354. McKie A, Baguley F, Guthrie C et al (2012) Exploring clinical wisdom in nursing education. Nursing Ethics. 19, 2, 252-267. McParland J, Scott PA, Dassen T, Gasell C, Lemonidou M, Leino-Kilpi H (2000) Autonomy and clinical practice. 1: identifying areas of concern. British Journal of Nursing. 9, 8, 507-513. Mueller PS, Hook CC, Fleming KC (2004) Ethical issues in geriatrics: a guide for clinicians. Mayo Clinic Proceedings. 79, 4, 554-562.
62 october 22 ::from vol 29 no 8 :: by 2014 NURSING STANDARD / RCN Downloaded RCNi.com ${individualUser.displayName} on Nov 16, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
colleagues (Kennedy 2004), and individual moral reasoning (Hare 1981). For the clinician involved in pressure ulcer prevention, practice-based knowledge may involve the recognition that non-adherence to treatment may be a significant factor in the failure to achieve policy outcomes. This is particularly so in community settings where clinicians are not physically present for extended periods and, therefore, cannot accurately monitor patient activity. In the clinical setting, a pluralistic approach to ethical problem solving is often adopted, meaning that in addition to referring to deontology, utilitarianism and ethical principles, the clinician’s individual body of knowledge and intuition are employed, achieving a less absolute middle ground (Snelling 2004). In accordance with the principles of evidence-based practice, clinicians should demonstrate awareness of the importance of patient preference in the implementation
Mystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L (2005) Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society. European Journal of Cancer Care. 14, 2, 175-181. National Education for Scotland (2009) Creating Viable Options. www.nes.scot.nhs.uk/ media/148790/creating_viable_ options_04_08_09.pdf (Last accessed: September 18 2014.) National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management. Clinical guideline No. 179. NICE, London. National Pressure Ulcer Advisory Panel (2014) NPUAP Pressure Ulcer Root Cause Analysis (RCA) Template. NPUAP, Washington DC. NHS Quality Improvement Scotland (2009) Best Practice Statement: Prevention and Management of Pressure Ulcers. NHS QIS, Edinburgh. NHS Quality Improvement Scotland (2011) Pressure Area Safety Cross. NHS QIS, Edinburgh. NHS Wales (2012) Pressure Ulcer Prevention: SKIN Bundle. Abertawe
of ethically sound pressure ulcer prevention (Sackett et al 2000).
Conclusion Pressure ulcers are increasingly viewed as patient harm and it is vital that healthcare providers and individual clinicians employ standardised, measurable means of ensuring their prevention. Clinicians involved in pressure ulcer prevention may encounter ethical dilemmas relating to policy and practice. They should be aware of personal and professional accountability, as well as ensuring compliance with policy, best-practice statements and formal guidance. The use of a pluralistic, culturally aware approach to ethical dilemmas employing ethical theory, ethical principles, virtue ethics and experiential knowledge is recommended. Patient preference should also be considered, in line with evidence-based practice NS
Bro Morgannwg University Health Board, Wales. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Parsky K, Corrigan P (2002) Quality Improvement in Health Care: Putting Evidence into Practice. Second edition. Nelson, Cheltenham. Polvsen L, Borup IK (2011) Holism in nursing and health promotion: distinct or related perspectives? A literature review. Scandinavian Journal of Caring Sciences. 25, 4, 798-805. Posnett J, Franks PJ (2008) The burden of chronic wounds in the UK. Nursing Times. 104, 3, 44-45. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-based Medicine: How to Practice and Teach EBM. Second edition. Churchill Livingstone, New York NY. Savage J, Moore L (2004) Interpreting Accountability: an Ethnographic Study of Practice Nurses. Accountability and Multidisciplinary Team Decision-Making in the Context of Clinical Governance. Royal College of Nursing, London.
Scally G, Donaldson LJ (1998) Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal. 317, 7150, 61-65. Scottish Intercollegiate Guidelines Network (2010) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. Clinical guideline No. 118. SIGN, Edinburgh. Scottish Patient Safety Programme (2010) What is the Scottish Patient Safety Programme? NHS Scotland, Glasgow. Snelling J (2004) Consequences count: against absolutism at the end of life. Journal of Advanced Nursing. 46, 4, 350-357. Stanzak RK (2006) Medical Malfeasance. In Bottom Line Medicine. A Layman’s Guide to Evidence-Based Practice. Algora, New York NY, 93-123. Taylor R (2005) Ethical aspects of palliative care in neurology. Continuum: Lifelong Learning in Neurology. 11, 6, 78-93. The Bamford Review of Mental Health and Learning Disability (Northern Ireland) (2007) A Comprehensive Legislative
Framework: Consultation Report. The Bamford Review of Mental Health and Learning Disability, Belfast. Thompson I (2006) Professional responsibility and accountability in nursing. In Thompson IE, Melis KM, Boyd KM, Horsburgh D (Eds) Nursing Ethics. Fifth edition. Churchill Livingstone, Edinburgh, 101-115. Tulloch G (2005) A feminist utilitarian perspective on euthanasia: from Nancy Crick to Terri Schiavo. Nursing Inquiry. 12, 2, 155-160. Waterlow J (1988) Prevention is cheaper than cure. Nursing Times. 84, 25, 69-70. Waterlow J (2005) Waterlow Score Card. www.judy-waterlow.co.uk/ the-waterlow-score-card.htm (Last accessed: September 18 2014.) World Medical Association (2009) Medical Ethics Manual. Ferney-Voltaire, France. www.wma. net/en/30publications/30ethicsm anual/index.html (Last accessed: September 18 2014.) Wounds International (2013) Zero Tolerance Approach Results in Reduced Pressure Ulcer Incidence. http://tinyurl. com/ogejz2d (Last accessed: October 2 2014.)
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Ethical issues and accountability in pressure ulcer prevention Welsh L (2014) Ethical issues and accountability in pressure ulcer prevention. Nursing Standard. 29, 8, 56-63. Date of submission: June 25 2014; date of acceptance: August 18 2014.
Abstract Pressure ulcers represent a considerable cost, both in terms of healthcare spending and quality of life. They are increasingly viewed in terms of patient harm. For clinicians involved in pressure ulcer prevention, ethical issues surrounding accountability may arise from both policy and practice perspectives. It may be useful for clinicians to refer to ethical theories and principles to create frameworks when addressing ethical dilemmas. However, such theories and principles have been criticised for their simplicity and over-generalisation. Alternative theories, for example, virtue ethics and experiential learning, can provide more comprehensive guidance and promote a pluralistic approach to tackling ethical dilemmas.
Author Lynn Welsh Community vascular specialist nurse, NHS Greater Glasgow and Clyde, Glasgow. Correspondence to: [email protected]
statements outline comprehensive prevention strategies, which reflect the notion of employees’ duty of care and prevention of patient harm (NHS Quality Improvement Scotland (NHS QIS) 2009). For nurses, this notion is linked to one of intrinsic duty underpinning The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (Nursing and Midwifery Council (NMC) 2008). Concerns have been raised about lack of evidence for the claim that 95% of pressure ulcers are preventable, but this continues to be cited in several NHS policies and in the literature (Downie et al 2013). If prevention of 95% of pressure ulcers is found to be unachievable in practice, this raises potential legal and clinical anomalies that could affect clinician accountability. Ethical dilemmas may also arise around aspects of individual organisation’s pressure ulcer prevention policies and guidelines, and their application in the clinical setting.
Keywords Accountability, duty of care, ethics, policy, pressure ulcers, pressure ulcer prevention, quality of life, wound care, wound management
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: http://rcnpublishing.com/page/ns/about/author-guidelines PRESSURE ULCERS REPRESENT two considerable burdens: financial and quality of life (Posnett and Franks 2008). One in five patients in the acute health sector in the UK will develop a pressure ulcer. This represents 4% of NHS spending at an annual cost of £2 billion (National Education for Scotland (NES) 2009). With ever-increasing healthcare litigation and pressure ulcers being increasingly viewed in terms of patient harm, pressure ulcer prevention has become a national priority. NHS policy initiatives and best practice
Ethics Ethics has been defined as the philosophical consideration of right and wrong and the consequences of human actions (Taylor 2005). Medical ethics underpin the fundamental values system of most healthcare professions (Lugton and Kindlen 2002). There has been a notable division in the literature pertaining to medical and nursing ethics since the 1980s, when nurses in the US sought to establish an independent professional ethical code (Lugton and Kindlen 2002). No distinction between medical and nursing ethics will be made in this article. Ethical issues are relevant to all disciplines and a collaborative, patient-centred approach might be argued to reflect the ethos of nursing. Aroskar (1989) identified ethical issues in health care as those in which the duties and obligations of the clinician lack clarity. Ethical issues become dilemmas when the different values of those involved come into conflict (Lawton and Cyster 2002). Many nurses continue to regard ethics as a theoretical subject, remote from practice, despite growing public interest in ethical and legal issues,
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more frequent dilemmas occurring in practice and a climate that seems to foster litigation (Chippendale 2006). Formal ethical requirements are outlined by the NMC, but ethics as taught in nurse education can lack coherence (McKie et al 2012).
Ethical theories To avoid ethical dilemmas, it is suggested that potential ethical issues should be considered in advance (Lugton and Kindlen 2002). The most widely accepted approach for undertaking ethical analysis – and assisting clinicians to address issues that arise in practice – is referral to ethical theories (Beauchamp and Childress 2012). There are numerous theoretical frameworks to support clinicians, which can be grouped into two broad categories: deontology and utilitarianism (Beauchamp and Childress 2012).
Deontology
Deontology dictates that a notion of intrinsic duty should be adhered to consistently and absolutely. Its origins lie in the writings of the philosopher Emmanuel Kant, who maintained that humans must always act in accordance with universal law (Snelling 2004, Beauchamp and Childress 2012). Universal law may arise from sources such as religion, legal and political systems, or institutional and professional governing bodies (Taylor 2005). The Code (NMC 2008), for example, outlines the nurse’s duty of care to the patient, imposing strict deontological principles that govern all aspects of practice and an ultimate goal of safeguarding patient and public wellbeing. The notion of duty is linked intrinsically to professional accountability. As members of a recognised profession, nurses providing pressure ulcer prevention are accountable in four domains (Dimond 2005): 1. To the public under criminal law. 2. To the patient under civil law. 3. To their governing body. 4. To their employer under contractual law. Thus, in the case of a potential omission in practice, a nurse could be legally called to account in all four domains with four different outcomes (Dimond 2005). If a patient were to develop pressure damage while under the care of a nurse, for example, the nurse may be in breach of standards of the NMC code, as well as in breach of contract to his or her employer. Criminal proceedings would be unlikely, but the healthcare provider – which is ultimately responsible for ensuring the provision of safe care in its facility, and is the nurse’s employer, may also be accountable under breach of civil law (Dimond 2005).
The nurse is accountable in a fifth dimension: the moral sense. A breach of morality – while not always legally enforceable – is the basis of ethical accountability. The duty not to breach morality therefore, is arguably the duty that carries the most weight (Dimond 2005). The example of a breach of morality illustrates the fine, and often blurred, distinction between ethics and the law. While the two share a commitment to a notion of duty, the law determines legal, but not always moral, rightness or wrongness (Chippendale 2006). An example in pressure ulcer prevention practice would be the nurse who – while not breaching laws of accountability in any of the four domains – holds the belief that he or she failed to provide a standard of care that was personally acceptable, thereby breaching personal codes of conduct and morality. Feminist theorists have criticised the deontological approach for being paternalistic and authoritarian. This, it could be argued, undermines the notion of caring that is inherent to nursing (Criggar 1994). Gray (2010) proposes that feminist ethical theory, in contrast, is less concerned with duty and rules and has an all-encompassing view of morality. It could be argued that nursing itself has roots in regimental systems, but the evolution of the profession, to one that favours holism, has led to a general consensus that the traditional deontological approach is outdated (Polvsen and Borup 2011). Several deontological factors govern pressure ulcer prevention. In the UK, pressure ulcers continue to be regarded as patient harm and clinicians are increasingly accountable for ensuring their prevention. There is ambiguity, however, surrounding the definition of accountability and what it actually means in practice (Thompson 2006). Savage and Moore (2004) argue that while accountability should assume a responsibility of personal judgement on the part of the clinician, it is more often associated with rules and criteria imposed from external sources. This has led to a theoretical conflict of interest between the concept of clinician accountability and the organisations and agencies that govern professions. Clinicians may feel that certain mechanisms of formalised pressure ulcer prevention reporting are indicative of a growing culture of policing health care. For example, the NHS Scotland Pressure Area Safety Cross publicly displays visual data relating to pressure ulcer incidence in individual clinical areas (NHS QIS 2011), although this was devised to provide reflective learning opportunities. In response to such claims, Thompson (2006) defends formal codes of conduct, suggesting that they provide a baseline for ethical permissibility,
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Art & science tissue viability supplement which supports rather than conflicts with clinician autonomy. Pressure ulcer prevention policy, guidelines and best practice statements may differ across NHS organisations, but their commitment to the reduction of patient harm is consistent. For example, The Dudley Group NHS Foundation Trust in England, the Abertawe Bro Morgannwg University Health Board in Wales, and NHS Greater Glasgow and Clyde in Scotland have all developed pressure ulcer prevention policies that include the establishment of a zero-tolerance agenda for avoidable damage, and an overall reduction of healthcare-acquired pressure ulcers (NHS Wales 2012, Wounds International 2013). Clinical governance arose as a system to ensure quality and accountability, in response to several public incidents in the 1990s that highlighted poor standards of health care in the UK. It is a further example of a deontological framework to which clinicians are obligated (Scally and Donaldson 1998). Nurses are expected to adhere to principles of clinical governance (Donaldson 2001), which form the basis of national guidance, such as the Pressure Ulcers: Prevention and Management guideline (National Institute for Health and Care Excellence 2014). The Scottish Intercollegiate Guidelines Network (SIGN) does not have a guideline specific to pressure ulcer prevention, but considers it in guidelines such as Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning (SIGN 2010). As evidence-based protocols for practice, national guidelines are designed to safeguard quality of care and accountability and provide standardised care pathways. However, clinical governance has also been criticised for masking underlying managerial and political agendas regarding resource control (Parsky and Corrigan 2002). Such hidden agendas, it has also been argued, undermine clinician autonomy (Baker and Roland 1999) by changing the climate of healthcare provision from one of trust in professionalism to one of blame and surveillance. Although clinical guidelines were intended to contribute to the overall effectiveness of the NHS, evidence to support a direct improvement on patient care outcomes remains mixed (Checkland et al 2004). The main basis of several NHS policies is the claim that 95% of pressure ulcers are avoidable (Bader et al 2010). The data that supported this 95% figure originated from a report produced by Hibbs (1988). No claim of research evidence was made to support the figure at the time of publication, but it has been widely cited and adopted by NHS organisations across the UK (Waterlow 1988, Stanzak 2006, Bader et al 2010, Anderson and
Fletcher 2013). After consistent data collation – which repeatedly demonstrated a failure to meet the 95% figure – a study within five acute NHS trusts in England found the figure relating to avoidable pressure ulcers to be 43%, less than half that frequently cited (Downie et al 2013). The results of this study were limited to the NHS trusts in which they were carried out and, therefore, cannot be assumed to reflect the national context, however limitations in data collection and reporting on pressure ulcer prevalence continue to be recognised (Fletcher et al 2013). The political drive to reduce pressure ulcer incidence is understandably high. However, potential inaccuracies inherent to reporting frameworks raise worrying questions about the proposed accountability of those involved directly in patient care. For example, what would happen if a clinician were to document evidence to support the implementation of comprehensive pressure ulcer prevention interventions for a patient who subsequently developed what is considered to be avoidable pressure damage? If the clinician is found to be in breach of one or more areas of accountability – and as the 95% claim has been subsequently discovered to be inaccurate – can such a breach be upheld? While application of investigation tools and root cause analyses may be crucial for investigation and support of the clinician at the individual level (National Pressure Ulcer Advisory Panel (NPUAP) 2014), a sustained and collective inability to achieve specified outcome goals in preventing pressure ulcers may have detrimental effects for clinicians and healthcare providers. The rise in healthcare litigation crucially dictates the correct application of evidence, to safeguard the interests of patients and healthcare providers.
Utilitarianism
Utilitarianism is at the opposite end of the philosophical spectrum to deontology, and states that actions of right or wrong are determined by their consequences rather than notions of duty (Chippendale 2006). In utilitarianism, the result of the action, rather than the action itself, determines morality (Lugton and Kindlen 2002). Utilitarians would argue that it is morally acceptable to break rules of duty provided the outcome is positive (Chippendale 2006). Utilitarianism stems from the works of philosophers Jeremy Bentham and John Stuart Mill, who advocated the greatest good for the greatest number. Utilitarianism can be further divided into ‘act’ utilitarianism, which judges the consequences of each individual action; and ‘rule’ utilitarianism, which devises rules based on
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Art & science tissue viability supplement probable outcomes, predicted from past actions (Beauchamp and Childress 2012). Since the prediction of individual actions can be complex, rule utilitarianism, which recognises general patterns, is the dominant perspective applied within the healthcare setting (Taylor 2005). Where the deontological approach guides the standards imposed by regulatory and institutional bodies, such as employers and the NMC, utilitarianism is usually associated with the personal perspectives of patients, families and individual clinicians (Chippendale 2006). While deontologists maintain that rules must apply in all situations, utilitarians would argue that each individual context is unique. From a utilitarian perspective, a clinician involved in pressure ulcer prevention may propose that non-adherence to certain elements of policy would be ethically acceptable if outcomes were positive and the patient came to no harm. An example may be the patient who refuses recommended preventive measures, for example specialist pressure-redistributing equipment, and proceeds to develop pressure damage. If the patient has mental capacity and a belief that pressure damage is preferable to the discomfort and upheaval of using the equipment, it might be argued that outcomes were positive, even if damage could have been avoided by policy adherence. Another example may be patients at the end of life, for whom comfort and simplicity are likely to take precedence over disruptive interventions such as re-positioning protocols. These scenarios illustrate potential ethical anomalies that can arise between the deontological approach advocated by bodies of authority and the utilitarian views of the patients. Moral theory is often considered to be the highest level of reasoning available to assist nurses in tackling ethical problems (Beauchamp and Childress 2012), but it is not without criticism. Lamb (1995) argued that theoretical analysis ignores the effect of the wider social context in ethical decision making. Additionally, some feminists argue that, despite female domination of the caring professions, medical ethics excludes women from moral equality (Tulloch 2005) and that the historic elitism and male domination of the medical professions deny recognition of their moral claim to be treated equally (McInnes and Lawson-Brown 2007). Nurses often find it difficult to determine exactly what constitutes good or harm, since they are highly value-laden concepts (Chippendale 2006). Beauchamp and Childress (2012) maintain that failure to use moral theory does not necessarily affect the quality of ethical decision making.
While ethical theories provide general guidance, they do not provide clear-cut right or wrong answers and individual reasoning is often argued to be the ultimate determinant in the provision of good care (Chippendale 2006).
Ethical principles The principle-based approach to ethical reasoning derives from both deontological and utilitarian theories and forms the basis of The Code (NMC 2008). The four widely accepted ethical principles are (Beauchamp and Childress 2012): 1. Autonomy. 2. Beneficence. 3. Non-maleficence. 4. Justice.
Autonomy
Autonomy is the right of self-determination (Beauchamp and Childress 2012). It is the principle that guides many issues in the clinical setting, and is one that may only be overridden in exceptional circumstances (Cahill 2004). From the legal perspective, a person’s right to autonomy is based on his or her competence or capacity to make a particular decision; however, determining competence can be problematic (Dimond 2005). Several factors can affect autonomy, either temporarily or permanently, including (McParland et al 2000): Physical or mental illness. Culture. Education. Stress. Age. For the clinician involved in pressure ulcer prevention, issues of autonomy are similar to those in the wider healthcare setting, and can pertain to consent. Some NHS pressure ulcer prevention policies dictate that clinicians, including those from professions such as physiotherapy and speech and language therapy, should perform regular skin checks to determine risk as part of their initial assessments. In the author’s professional experience, many clinicians express concerns about the appropriateness of such invasive practice, which may compromise dignity among older and more vulnerable patient groups (Baillie 2009). When a patient refuses to consent to a skin check, the legal implications and potential consequences that may result from this are additional issues. The law states that all competent adults have the right to refuse treatment (Cahill 2004), however the clinician who supports such a refusal may also feel that, in doing so, they are failing in their duty of care to protect and promote patient health,
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particularly if the patient goes on to develop pressure area damage (NMC 2008). A further concern is the difficulty in determining mental capacity for consent or refusal of treatment. In Scotland, all persons are considered competent unless incapacity has been legally determined by medical assessment and subsequent completion of a Certificate of Incapacity under section 47 of the Adults with Incapacity (Scotland) Act 2000, which remains a component of their medical records. In England and Wales, the equivalent legislation is the Mental Capacity Act (2005), which has a supplementary code of practice to guide practitioners with its implementation. In Northern Ireland, recommendations from The Bamford Review of Mental Health and Learning Disability (2007) are being considered to shape future legislation in this area. Despite the existence of legal frameworks, a clinician who is the first to make professional contact with an individual could detect early signs of cognitive impairment that, although not yet legally recognised, may make mental capacity difficult to assess. Cahill (2004) adds that incapacity may not be all encompassing, suggesting that generalised cognitive impairment cannot be assumed to affect all areas of decision making. This means that a patient with legally confirmed incapacity may still, theoretically, be competent to refuse a skin check. The ability to assess competence is an important clinical skill (Mueller et al 2004). McParland et al (2000) remind clinicians that, even if they have difficulties in actively promoting patient autonomy, they are bound to refrain from interfering with it. Arguably, in determining mental capacity, the role of the patient advocate is crucial in maintaining patient autonomy (NMC 2008). This can include anything from upholding patients’ wishes in their treatment outcomes, to provision of relevant pressure ulcer prevention information leaflets to promote optimum levels of self-care.
Beneficence
Beneficence, the obligation to do good, is a fundamental ethical principle governing health care. It should, therefore, be the ultimate goal of all clinicians (Taylor 2005). Those involved in pressure ulcer prevention are duty bound in the four arenas of accountability to promote the health and wellbeing of those in their care (NMC 2008). Examples of beneficence in pressure ulcer prevention range from respecting individuality and treating patients with dignity, to the correct use of evidence-based tools such as the Waterlow Score to assess the risk of skin damage (Waterlow 2005).
Non-maleficence
Non-maleficence, closely linked to beneficence, is the duty to protect from harm (Beauchamp and Childress 2012). Taylor (2005) maintains that non-maleficence applies to all members of the general public, but has particular implications for healthcare professionals due to their relative position of power over patients. The zero tolerance for avoidable pressure ulcers mandate exemplifies a commitment to the principle of non-maleficence (Scottish Patient Safety Programme 2010).
Justice
Justice is the duty to ensure fairness and equality in the allocation of resources and is considered the most problematic in terms of adherence (Taylor 2005). This is because it relies not only on the actions of individual clinicians, but also on those of society as a whole (Taylor 2005). In pressure ulcer prevention, justice may pertain to the fair distribution of resources, such as high-grade airflow mattresses, which are widely incorporated into pressure ulcer prevention care plans for patients in moderate to high-risk categories. Clinicians involved in pressure ulcer prevention often report practical challenges when making decisions around equality in the distribution of resources, for example the appropriateness of using specialist equipment such as airflow mattresses, which may have implications relating to noise, comfort or convenience of installation for patients at the end of life, for whom comfort may be the primary goal.
Principles in practice Beauchamp and Childress (2012) state that each of the four ethical principles is prima facie binding, which means that no single principle should dominate the others in ethical decision making. When they do come into conflict, the individual circumstances of the situation must be analysed to determine prioritisation (Taylor 2005). In such cases, the most important deciding factors include the subjective priorities and preferences of patients and families (Chippendale 2006). It is important to note that this argument may be subject to cultural interpretation. Autonomy is often viewed as the principle that carries the most weight in Western society, but that view does not necessarily follow internationally (World Medical Association 2009). The clinician should therefore have an awareness of multicultural aspects that increasingly define pressure ulcer prevention care provision, for example, ensuring the provision of culturally relevant and sensitive patient information leaflets. The four-principled approach to ethical reasoning has been criticised for its rigidity
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Art & science tissue viability supplement (Harris 2003), simplicity (Campbell 2003), and over-generalisation of complex issues (Campbell 2003, Gardiner 2003). Although the principles provide a useful framework for ethical decision making, clinicians involved in pressure ulcer prevention should be aware of the potential for cultural and personal interpretation by fellow clinicians, patients and carers. For example, ethical dilemmas that arise from issues including collusion and truth telling, breaking bad news and revelation of diagnosis may vary depending on the culture of the practitioner, the patient, and/or the family involved (Mystakidou et al 2005).
Virtue ethics and experiential knowledge In response to the above criticism of the four-principled approach, advocates of virtue ethics – a framework that places utmost importance on the emotional character and
reactive behaviours of the clinician who has to address ethical issues – argue that a flexible, creative approach is favourable to ensure recognition of the unique needs of any situation. Campbell (2003) attests that virtue ethics are a necessary complement to the four-principled approach towards ethical problem solving. Harris (2003) observes that a pluralistic, unprincipled approach ultimately brings personal objectives and outcomes to fruition. Experiential, practice-based knowledge is an additional source of ethical decision making, which often carries as much weight as that from more formal sources (Kennedy 2004). Carper (1978) cited four fundamentals of nursing knowledge, including empirics, ethics, aesthetics and personal knowledge. This knowledge derives from the expert nurse’s intuition (Benner and Wrubel 1984), personal and professional experience (Kennedy 2004), knowledge shared between
References Anderson I, Fletcher J (2013) Wound management. In Brooker C, Waugh A (Eds) Foundations of Nursing Practice: Fundamentals of Holistic Care. Mosby Elsevier, Oxford, 609-628. Aroskar M (1989) Community health nurses: their most significant ethical decision making problems. Nursing Clinics of North America. 24, 4, 967-975.
Cahill H (2004) Consent. In Holland S (Ed) Introducing Nursing Ethics: Themes in Theory and Practice. APS Publishing, Salisbury, 91-101. Campbell AV (2003) The virtues (and vices) of the four principles. Journal of Medical Ethics. 29, 5, 292-296. Carper B (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science. 1, 1, 13-23.
Bader D, Bouten C, Colin D, Oomens CJ (2010) Pressure Ulcer Research: Current and Future Perspectives. Springer, Heidelberg.
Checkland K, Marshall M, Harrison S (2004) Re-thinking accountability: trust versus confidence in medical practice. Quality Safe Health Care. 13, 2, 130-135.
Baillie L (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies. 46, 1, 23-37.
Chippendale S (2006) Ethical issues in palliative care. In Kinghorn S, Gaines R (Eds) Palliative Nursing: Bringing Comfort and Hope. Baillière Tindall, Edinburgh, 171-190.
Baker R, Roland M (1999) Clinical Governance: A Practical Guide for Primary Care Teams. University of Manchester, Manchester. Beauchamp TL, Childress JF (2012) Principles of Biomedical Ethics. Seventh edition. Oxford University Press, New York NY. Benner P, Wrubel J (1984) The Primacy of Caring: Stress and Coping with Health and Illness. Addison-Wesley, Menlo Park CA.
Criggar N (1994) Universal prescriptivism: traditional moral decision making theory revisited. Journal of Advanced Nursing. 20, 3, 538-543. Dimond B (2005) Legal Aspects of Nursing. Fifth edition. Churchill Livingstone, Edinburgh. Donaldson L (2001) Professional accountability in a changing world.
Postgraduate Medical Journal. 77, 904, 65-67. Downie F, Guy H, Gilroy P, Royall D, Davies S (2013) Are 95% of hospital acquired pressure ulcers avoidable? Wounds UK. 9, 3, 16-22. Fletcher J, Crook H, Harris C (2013) Monitoring pressure ulcer prevalence: a precise methodology. Wounds UK. 9, 4, 48-53. Gardiner P (2003) A virtue ethics approach to moral dilemmas in medicine. Journal of Medical Ethics. 29, 5, 297-302. Gray M (2010) Moral sources and emergent ethical theories in social work. British Journal of Social Work. 40, 6, 1794-1811. Hare RM (1981) Moral Thinking: Its Levels, Method and Point. Clarendon Press, Oxford. Harris J (2003) In praise of unprincipled ethics. Journal of Medical Ethics. 29, 5, 303-306. Hibbs PJ (1988) Pressure Area Care Policy. City of Hackney Health Authority, London. Kennedy J (2004) A typology of knowledge for district nursing assessment practice. Journal of Advanced Nursing. 45, 4, 401-409.
Lamb D (1995) Therapy Abatement, Autonomy and Futility. Avebury, Aldershot. Lawton S, Cyster D (2002) Ethical Issues. In Lugton J, Kindlen M (Eds) Palliative Care: the Nursing Role. Churchill Livingstone, Edinburgh, 249-270. Lugton J, Kindlen M (Eds) (2002) Palliative Care: The Nursing Role. Churchill Livingstone, Edinburgh. McInnes A, Lawson-Brown V (2007) ‘God’ and other ‘do-gooders’: a comparison of the regulation of services provided by GPs and social work in England. Journal of Social Work. 7, 3, 341-354. McKie A, Baguley F, Guthrie C et al (2012) Exploring clinical wisdom in nursing education. Nursing Ethics. 19, 2, 252-267. McParland J, Scott PA, Dassen T, Gasell C, Lemonidou M, Leino-Kilpi H (2000) Autonomy and clinical practice. 1: identifying areas of concern. British Journal of Nursing. 9, 8, 507-513. Mueller PS, Hook CC, Fleming KC (2004) Ethical issues in geriatrics: a guide for clinicians. Mayo Clinic Proceedings. 79, 4, 554-562.
62 october 22 ::from vol 29 no 8 :: by 2014 NURSING STANDARD / RCN Downloaded RCNi.com ${individualUser.displayName} on Nov 16, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
colleagues (Kennedy 2004), and individual moral reasoning (Hare 1981). For the clinician involved in pressure ulcer prevention, practice-based knowledge may involve the recognition that non-adherence to treatment may be a significant factor in the failure to achieve policy outcomes. This is particularly so in community settings where clinicians are not physically present for extended periods and, therefore, cannot accurately monitor patient activity. In the clinical setting, a pluralistic approach to ethical problem solving is often adopted, meaning that in addition to referring to deontology, utilitarianism and ethical principles, the clinician’s individual body of knowledge and intuition are employed, achieving a less absolute middle ground (Snelling 2004). In accordance with the principles of evidence-based practice, clinicians should demonstrate awareness of the importance of patient preference in the implementation
Mystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L (2005) Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society. European Journal of Cancer Care. 14, 2, 175-181. National Education for Scotland (2009) Creating Viable Options. www.nes.scot.nhs.uk/ media/148790/creating_viable_ options_04_08_09.pdf (Last accessed: September 18 2014.) National Institute for Health and Care Excellence (2014) Pressure Ulcers: Prevention and Management. Clinical guideline No. 179. NICE, London. National Pressure Ulcer Advisory Panel (2014) NPUAP Pressure Ulcer Root Cause Analysis (RCA) Template. NPUAP, Washington DC. NHS Quality Improvement Scotland (2009) Best Practice Statement: Prevention and Management of Pressure Ulcers. NHS QIS, Edinburgh. NHS Quality Improvement Scotland (2011) Pressure Area Safety Cross. NHS QIS, Edinburgh. NHS Wales (2012) Pressure Ulcer Prevention: SKIN Bundle. Abertawe
of ethically sound pressure ulcer prevention (Sackett et al 2000).
Conclusion Pressure ulcers are increasingly viewed as patient harm and it is vital that healthcare providers and individual clinicians employ standardised, measurable means of ensuring their prevention. Clinicians involved in pressure ulcer prevention may encounter ethical dilemmas relating to policy and practice. They should be aware of personal and professional accountability, as well as ensuring compliance with policy, best-practice statements and formal guidance. The use of a pluralistic, culturally aware approach to ethical dilemmas employing ethical theory, ethical principles, virtue ethics and experiential knowledge is recommended. Patient preference should also be considered, in line with evidence-based practice NS
Bro Morgannwg University Health Board, Wales. Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. NMC, London. Parsky K, Corrigan P (2002) Quality Improvement in Health Care: Putting Evidence into Practice. Second edition. Nelson, Cheltenham. Polvsen L, Borup IK (2011) Holism in nursing and health promotion: distinct or related perspectives? A literature review. Scandinavian Journal of Caring Sciences. 25, 4, 798-805. Posnett J, Franks PJ (2008) The burden of chronic wounds in the UK. Nursing Times. 104, 3, 44-45. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-based Medicine: How to Practice and Teach EBM. Second edition. Churchill Livingstone, New York NY. Savage J, Moore L (2004) Interpreting Accountability: an Ethnographic Study of Practice Nurses. Accountability and Multidisciplinary Team Decision-Making in the Context of Clinical Governance. Royal College of Nursing, London.
Scally G, Donaldson LJ (1998) Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal. 317, 7150, 61-65. Scottish Intercollegiate Guidelines Network (2010) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. Clinical guideline No. 118. SIGN, Edinburgh. Scottish Patient Safety Programme (2010) What is the Scottish Patient Safety Programme? NHS Scotland, Glasgow. Snelling J (2004) Consequences count: against absolutism at the end of life. Journal of Advanced Nursing. 46, 4, 350-357. Stanzak RK (2006) Medical Malfeasance. In Bottom Line Medicine. A Layman’s Guide to Evidence-Based Practice. Algora, New York NY, 93-123. Taylor R (2005) Ethical aspects of palliative care in neurology. Continuum: Lifelong Learning in Neurology. 11, 6, 78-93. The Bamford Review of Mental Health and Learning Disability (Northern Ireland) (2007) A Comprehensive Legislative
Framework: Consultation Report. The Bamford Review of Mental Health and Learning Disability, Belfast. Thompson I (2006) Professional responsibility and accountability in nursing. In Thompson IE, Melis KM, Boyd KM, Horsburgh D (Eds) Nursing Ethics. Fifth edition. Churchill Livingstone, Edinburgh, 101-115. Tulloch G (2005) A feminist utilitarian perspective on euthanasia: from Nancy Crick to Terri Schiavo. Nursing Inquiry. 12, 2, 155-160. Waterlow J (1988) Prevention is cheaper than cure. Nursing Times. 84, 25, 69-70. Waterlow J (2005) Waterlow Score Card. www.judy-waterlow.co.uk/ the-waterlow-score-card.htm (Last accessed: September 18 2014.) World Medical Association (2009) Medical Ethics Manual. Ferney-Voltaire, France. www.wma. net/en/30publications/30ethicsm anual/index.html (Last accessed: September 18 2014.) Wounds International (2013) Zero Tolerance Approach Results in Reduced Pressure Ulcer Incidence. http://tinyurl. com/ogejz2d (Last accessed: October 2 2014.)
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