PSYCHOLOGY IN NURSING
Professional culture and care: what is best for the patient? In this monthly column, Aysha Mendes discusses potential causes of ethical dilemmas and what actions can be taken to ensure health professions act in the best interests of their patients
Workplace culture One of the most common areas in which nurses experience ethical distress is end-of-life care (Mendes, 2014). A prime example of what is expected of a nurse running counter to what is best for a patient, is in the area of critical care when a patient’s condition does not seem to be improving, says Anne McLeod, a senior lecturer in critical care at City University London. Just as end-of-life care is often about comfort in a patient’s last days, critical care is about saving lives. This gives rise to a way of thinking and a cultural expectation that emergency care is about doing whatever can be done to preserve life to the last moment—sometimes providing futile care and robbing a patient of a ‘good’ death, as well as leaving a family in shock over their traumatic and unexpected loss (Mendes, 2015). While the intent may be to prolong life, as McLeod says in a recent article, technological advances in intensive care have actually, in some instances, prolonged the dying process (McLeod, 2014). McLeod says:
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‘In critical care settings, there can be a culture of “let’s do whatever we can” without perhaps recognising the likely poor outcome and therefore, arguably, an earlier decision about exactly would be in the best interest for that patient’
Lingering paternalism Another potential cause for such an ethical dilemma is a sense of paternalism on the part of the health professional. Despite the increasingly prevalent patient-centred partnership approach to care,the Expert Patients Programme for people living with long-term conditions (Department of Health (DH), 2007), and the no-decisionabout-me-without-me ‘movement’ (DH, 2012), as well as a push for more multidisciplinary working and decision-making, paternalism still lingers on in many healthcare contexts. ‘A paternalistic approach may still be present, when the patient’s autonomy with regards to decisionmaking may be impinged upon’ says McLeod. She continues: ‘A “doctor knows best” attitude may still be present despite informed consent’ Of course, there are cases where patients may not be as involved with the decisions made about them because of mental capacity issues. However, there are people with conditions, such as dementia or mental-health conditions, or who have suffered a stroke, but who may still have the capacity to make decisions about their care. There are also people who form part of certain groups, such as older adults, who must not be treated as lacking capacity unless proven through a capacity assessment (NHS Choices, 2015). As stated in the Mental Capacity Act (2005), just because a person makes a decision that those caring for them feel is ‘unwise’, this does not mean they lack capacity, and everyone has the right to make their own choices, where they have the capacity to do so (NHS Choices, 2015). In the case of critical care, health professionals fight to save a person’s life and that person is unlikely to be in a position to contribute his
or her thoughts on how this situation should be handled (McLeod, 2014). According to McLeod, however, recognition of the potential of these dilemmas, and a willingness for collaborative decision-making, as well as having these conversations early enough, is essential to ensuring the patient’s best interest remains at the heart of care.
What can be done? The nurse, in particular, will often have increased insight into a patient’s wishes, as nurses tend to be the health professionals who form close bonds with their patients—placing them in an ideal position to promote their autonomy (Dawson, 2008; McLeod, 2014). According to McLeod, in order to ensure that nurses act as patient advocates, they need to be active participants in the decision-making process and feel empowered to challenge decisions. Healthcare managers have the responsibility of facilitating supportive environments where team members feel comfortable expressing opinions and taking part in decision-making. McLeod notes that support for educational strategies, such as clinical supervision (which no longer falls under the remit of the Nursing and Midwifery Council (2015) and is expected to be taken over by the chief nursing officers), also forms an important part of addressing ethical dilemmas. Of course, the patient remains the single most important part of the healthcare equation—and his or her views must always come first when BJN determining the right thing to do. Dawson KA (2008) Palliative care for critically ill older adults: dimensions of nursing advocacy. Crit Care Nurs Q 31(1): 19–23. Department of Health (2007) The Expert Patients Programme. http://tinyurl.com/3ywjfwd (accessed 16 February 2015) Department of Health (2012) Liberating the NHS: No decision about me, without me. http://tinyurl.com/o6sd5xc (accessed 16 February 2015) McLeod A (2014) Nurses’ views of the causes of ethical dilemmas during treatment cessation in the ICU: a qualitative study. British Journal of Neuroscience Nursing 10(3): 131-7 Mendes A (2014) Managing ethical distress in nursing practice. Br J Nurs 23(22): 1219. doi: 10.12968/bjon.2014.23.22.1219 Mendes A (2015) Nursing care to facilitate and support ‘good’ grieving. Br J Nurs 24(2): 95. doi: 10.12968/bjon.2015.24.2.95 NHS Choices (2015) What is the Mental Capacity Act? http:// tinyurl.com/m2yosva (accessed 16 February 2015) Nursing and Midwifery Council (2015) The revised code. http:// tinyurl.com/lq4gr7h (accessed 16 February 2015)
Aysha Mendes Freelance Journalist, specialising in health, psychology and nursing
© 2015 MA Healthcare Ltd
A
recent article within this regular column covered the vast subject of managing ethical distress in nursing (Mendes, 2014). To expand on this subject, this article will discuss what can happen when what is expected of a nurse is not necessarily what he or she feels is best for the patient. There are several potential causes of this nature of conflict. One is the workplace culture nurses work in and what is expected within their organisation, department or team—and how this may or may not align with what is right for a patient in a given situation. Another cause may include a sense of paternalism on the part of the health professional, in cases where patients may lack some capacity with regard to decision-making, and in cases where they do not. Another important factor that will be covered in more detail in a future article in this series, but is worth mentioning here, is the role of a nurse’s personal ethical beliefs and how what an individual nurse may feel is best for the patient is not what is always expected of him or her in the provision of patient care and, importantly, is subjective and not always in a patient’s best interest.
British Journal of Nursing, 2015, Vol 24, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 165.123.034.086 on December 1, 2015. For personal use only. No other uses without permission. . All rights reserved.
Professional culture and care: what is best for the patient? In this monthly column, Aysha Mendes discusses potential causes of ethical dilemmas and what actions can be taken to ensure health professions act in the best interests of their patients
Workplace culture One of the most common areas in which nurses experience ethical distress is end-of-life care (Mendes, 2014). A prime example of what is expected of a nurse running counter to what is best for a patient, is in the area of critical care when a patient’s condition does not seem to be improving, says Anne McLeod, a senior lecturer in critical care at City University London. Just as end-of-life care is often about comfort in a patient’s last days, critical care is about saving lives. This gives rise to a way of thinking and a cultural expectation that emergency care is about doing whatever can be done to preserve life to the last moment—sometimes providing futile care and robbing a patient of a ‘good’ death, as well as leaving a family in shock over their traumatic and unexpected loss (Mendes, 2015). While the intent may be to prolong life, as McLeod says in a recent article, technological advances in intensive care have actually, in some instances, prolonged the dying process (McLeod, 2014). McLeod says:
222
‘In critical care settings, there can be a culture of “let’s do whatever we can” without perhaps recognising the likely poor outcome and therefore, arguably, an earlier decision about exactly would be in the best interest for that patient’
Lingering paternalism Another potential cause for such an ethical dilemma is a sense of paternalism on the part of the health professional. Despite the increasingly prevalent patient-centred partnership approach to care,the Expert Patients Programme for people living with long-term conditions (Department of Health (DH), 2007), and the no-decisionabout-me-without-me ‘movement’ (DH, 2012), as well as a push for more multidisciplinary working and decision-making, paternalism still lingers on in many healthcare contexts. ‘A paternalistic approach may still be present, when the patient’s autonomy with regards to decisionmaking may be impinged upon’ says McLeod. She continues: ‘A “doctor knows best” attitude may still be present despite informed consent’ Of course, there are cases where patients may not be as involved with the decisions made about them because of mental capacity issues. However, there are people with conditions, such as dementia or mental-health conditions, or who have suffered a stroke, but who may still have the capacity to make decisions about their care. There are also people who form part of certain groups, such as older adults, who must not be treated as lacking capacity unless proven through a capacity assessment (NHS Choices, 2015). As stated in the Mental Capacity Act (2005), just because a person makes a decision that those caring for them feel is ‘unwise’, this does not mean they lack capacity, and everyone has the right to make their own choices, where they have the capacity to do so (NHS Choices, 2015). In the case of critical care, health professionals fight to save a person’s life and that person is unlikely to be in a position to contribute his
or her thoughts on how this situation should be handled (McLeod, 2014). According to McLeod, however, recognition of the potential of these dilemmas, and a willingness for collaborative decision-making, as well as having these conversations early enough, is essential to ensuring the patient’s best interest remains at the heart of care.
What can be done? The nurse, in particular, will often have increased insight into a patient’s wishes, as nurses tend to be the health professionals who form close bonds with their patients—placing them in an ideal position to promote their autonomy (Dawson, 2008; McLeod, 2014). According to McLeod, in order to ensure that nurses act as patient advocates, they need to be active participants in the decision-making process and feel empowered to challenge decisions. Healthcare managers have the responsibility of facilitating supportive environments where team members feel comfortable expressing opinions and taking part in decision-making. McLeod notes that support for educational strategies, such as clinical supervision (which no longer falls under the remit of the Nursing and Midwifery Council (2015) and is expected to be taken over by the chief nursing officers), also forms an important part of addressing ethical dilemmas. Of course, the patient remains the single most important part of the healthcare equation—and his or her views must always come first when BJN determining the right thing to do. Dawson KA (2008) Palliative care for critically ill older adults: dimensions of nursing advocacy. Crit Care Nurs Q 31(1): 19–23. Department of Health (2007) The Expert Patients Programme. http://tinyurl.com/3ywjfwd (accessed 16 February 2015) Department of Health (2012) Liberating the NHS: No decision about me, without me. http://tinyurl.com/o6sd5xc (accessed 16 February 2015) McLeod A (2014) Nurses’ views of the causes of ethical dilemmas during treatment cessation in the ICU: a qualitative study. British Journal of Neuroscience Nursing 10(3): 131-7 Mendes A (2014) Managing ethical distress in nursing practice. Br J Nurs 23(22): 1219. doi: 10.12968/bjon.2014.23.22.1219 Mendes A (2015) Nursing care to facilitate and support ‘good’ grieving. Br J Nurs 24(2): 95. doi: 10.12968/bjon.2015.24.2.95 NHS Choices (2015) What is the Mental Capacity Act? http:// tinyurl.com/m2yosva (accessed 16 February 2015) Nursing and Midwifery Council (2015) The revised code. http:// tinyurl.com/lq4gr7h (accessed 16 February 2015)
Aysha Mendes Freelance Journalist, specialising in health, psychology and nursing
© 2015 MA Healthcare Ltd
A
recent article within this regular column covered the vast subject of managing ethical distress in nursing (Mendes, 2014). To expand on this subject, this article will discuss what can happen when what is expected of a nurse is not necessarily what he or she feels is best for the patient. There are several potential causes of this nature of conflict. One is the workplace culture nurses work in and what is expected within their organisation, department or team—and how this may or may not align with what is right for a patient in a given situation. Another cause may include a sense of paternalism on the part of the health professional, in cases where patients may lack some capacity with regard to decision-making, and in cases where they do not. Another important factor that will be covered in more detail in a future article in this series, but is worth mentioning here, is the role of a nurse’s personal ethical beliefs and how what an individual nurse may feel is best for the patient is not what is always expected of him or her in the provision of patient care and, importantly, is subjective and not always in a patient’s best interest.
British Journal of Nursing, 2015, Vol 24, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 165.123.034.086 on December 1, 2015. For personal use only. No other uses without permission. . All rights reserved.
