Essay on Fundamentals of Professional Practice

Demands on the health sector are constantly changing; patients’ and clients’ needs and expectations differ from person to person, particularly in the UK which has a multitude of cultures and backgrounds. Therefore, it is imperative that, as a health professional, one is versed in the key facets of the nursing profession, particularly how it is regulated, its primary functions and what is required of a practitioner legally, ethically and professionally in order to deliver a high standard of care that the patients deserve and expect (Wheeler, 2012).This essay aims to explore the legal, ethical and professional issues that are raised within the customised scenario (see Appendix 1) which are relevant to professional nursing practise.

The fictional scenario concerns a patient called Sam, who is a practising Sikh. He is admitted to the Accident and Emergency Department (A and E) with a mild head concussion. Sam is instructed by the nurse caring for him to remove his turban but refuses to do so as it is against his religious beliefs. Having never been to A&E before, Sam is confused of the procedures and protocol in such an environment and the nurse persistently tells him she needs to inspect the injury. Perhaps disregarding the ethical aspects of the situation, the nurse removes his turban anyway.

Legally, this clearly raises the issues of Equality and Discrimination. Therefore, the following acts of Parliament need to be disseminated: Equality Act 2010 and Human Rights Act 1998. The four ethical principles of care, autonomy, justice, beneficence and non-maleficence also seem to have been violated in this situation; one can assume that by not respecting Sam’s religious beliefs, the nurse has not acted in a beneficent manner and has caused him harm by acting in a maleficent way. Professional issues, relating to the Nursing and Midwifery Council (NMC) code of conduct, also need to be explored as it could be surmised that the care given by the nurse might have been in breach of these guidelines. In conjunction to this, the fundamental issues of the lack of nurse-patient communication and interpersonal skills will also be examined.

From a legal perspective, it is vital that nurses are aware of their obligations and liabilities because they are accountable for the care they provide. If a Nurse possesses such knowledge about law in their day to day practise, it will not only ensure that the care they deliver is consistent with current legal principles but it will also protect the them from litigation (Kozier et al., 2012). It is clear that within Sam’s scenario, the nurse acted in a discriminatory manner by removing his turban against his wishes and ignoring the fact that this is against his religion. The Equality Act 2010 and Human Rights Act 1998 are relevant to this case.

The Equality Act 2010 was formalised in October 2010. It contains 16 Parts and 28 Schedules and took the place of previous Acts of Parliament that were created to address areas of possible discrimination such as the Race Relations Act 1976 and the Disability Discrimination Act 1995. This act encourages doing what is morally right as well as what is legal. It explicitly mentions religious or philosophical beliefs as a protected characteristic. The act states that it is ‘unlawful to discriminate against, harass or victimise a person when providing a service … or when exercising a public function’ (Equality Act, 2010). Sikhism and other religions such as Hinduism are faiths recognised under this act. As Sam is visibly wearing a turban, which keeps his hair (Kesh) tidy, and carries a Kirpan (a dagger), this places him in the protected category identified by the act. According to BBC (2013), there are five physical symbols of faith worn by Sikhs, also known colloquially as the 5 Ks, that people adhere to after they are baptized. These show that they are a member of this religion and each particular K has significance; for instance, the Kirpan’s (ceremonial sword),etymological origins illustrate this. ‘Kirp‘ means the act of kindness and blessing; and ‘An’ signifies honour, respect or esteem. The 5 Ks taken together represent that who wears them has dedicated themselves to a life of devotion and commitment to respect themselves and their freedom of spirit.

From a religious viewpoint, it is clear that the nurse discriminates Sam, under the conditions of this act. Collins (2013) define discrimination as the ‘unfair treatment of a person, racial group, or minority’. Conversely, the nurse might argue that it was unintentional, as it was in his best interests to get checked. However, her motives are irrelevant in this case because it is the act that is unlawful, not her intentions. Additionally, the fact that the nurse ‘instructed’ and ‘persistently’ told him to remove his turban, ignoring his wishes, highlights that she may have been harassing him under the same act.

The Equality Act 2010 states that there are three types of harassment: the first is relevant in this case as it applies to ‘all the protected characteristics’ which involve treating an individual in a manner that they do not wish to be treated. This ‘unwanted conduct may effectively create an intimidating, hostile, degrading, humiliating and offensive environment’ for the person and compromise their dignity (Equality Act, 2010).Taking into account Sam’s religion and beliefs, one could assume that he is a devout follower of Sikhism with strong values and ideals. He may have been made feel to feel ‘uncomfortable’ with the nurse’s behaviour towards him, and she has not demonstrated the necessary skills to understand that he was becoming stressed and anxious. The whole situation from Sam’s perspective could be seen as humiliating and degrading.

Another piece of relevant legislation that the nurse is in violation of is The Human Rights Act 1998. According to Kozier (2012, p.58), the Act consists of the rights and freedoms that are set out in the European Convention of Human Rights (ECHR). In a healthcare environment a nurse must be aware of their patients’ rights and freedoms and how they are protected by their Human rights as it is deemed unlawful to act in a way that is deprives an individual of such a right. Two articles are applicable in this scenario; Article 9 which protects a person’s right to freedom of thought, conscience and religion; including the freedom to manifest his religion, subject to limitations of the law, where it is in the interest of public safety. Though in Sam’s case he doesn’t present a risk to the general public, so by disregarding his rights and freedoms that are set in the Convention, the nurse is again in breach of this piece of legislation which prohibits discrimination (Article 14), (Human Rights, 1998).

Furthermore, this lack of attention and disrespectful behaviour is ethically and morally wrong. There are various definitions of ethics and morals. Morals are one’s private and personal standards of behaviour whereas ethics is more concerned with the rationale of such morals. Fundamentally, ethics is a set of values that explains what is right and wrong in the conduct, character or attitude of an individual and it serves as a framework for disciplinary issues (Beauchamp and Childress, 2001).

Ethics can challenge health practitioners on a daily basis with the decisions they make having such significance in the lives of the patients they are treating. Subsequently, it is important that certain ethical principles are used as guidance to all in the medical/nursing profession. These may not provide a definite answer to a problem, but will certainly enhance the nurse’s ability to analyse situations and facilitate them to take the correct course of action.

As stated previously, there are four major ethical principles developed by Beauchamp and Childress (2001) that ought to guide professionals in their practise: the respect for autonomy, beneficence, non-maleficence and justice.

The first principle states that, in this case, the nurse must respect Sam’s autonomy, the right to make decisions for himself. A patient has a right to deny any healthcare intervention, even if this refusal may not seem in their best interests from the nurse’s perspective, as it can lead to harm or death. Unless he is assessed as lacking sufficient mental capacity, his autonomy must be respected. The nurse has shown a lack of respect for his freedom to decide his personal behaviour and his wishes. As verbalised by the Mental Capacity Act (2005), ‘a person must be assumed to have capacity until it is proved otherwise’. Although Sam’s decision of not wanting to remove his turban may seem unwise given the circumstances, or the fact that he seemed confused, does not mean that he should ‘ be treated as lacking capacity to make a decision’. Patients have a right to choose how they live their lives. As nurses, we have to be aware that we live in a society governed by laws and with a variety of different ethical and cultural values. Therefore, the principle of autonomy demands that a patient’s right to self-determination is respected, even if it means not accepting to be treated. On the other hand, sometimes patients are not mentally competent to make such an autonomous decision. For example, if a patient is unconscious or has a severe learning disability; they lack the competence to make decisions in relation to their care, so health professionals may have to take decisions that are deemed to be in the best interests of their health (Mental Capacity Act, 2005).

Beneficence is defined as ‘the act of doing good’ (Beauchamp and Childress, 2001; Kozier et al.,2008). This ethical principle means that nurses are obliged to do good and help others; this means having to implement actions that benefit the patient, to ensure that they receive the optimum standard of care. Paradoxically, sometimes ‘doing good’ might pose a ‘risk of doing harm’. Therefore, as nurses, the principles of beneficence and non-maleficence should be looked at simultaneously, so the nurse’s care is of benefit to the patient rather than harm. In Sam’s case it can be argued that by not respecting his religious beliefs, the nurse is not acting beneficently, even though this is causing him physical pain. By removing his turban in order to inspect his injury, she put him in a vulnerable state, causing distress and anxiety, which had the potential of doing significant damage to his mental state. However, the nurse could argue that, according to the principle of beneficence, it was in his best interests that she behaved in such manner in order to check his injury so there was no risk of infection. On the other hand, as there was no risk to Sam’s life there isn’t any justification to her persistent and impersonal manner and forcibly removing his turban may have been the most upsetting and harmful act that she could have performed. Sam might arguably leave the hospital with problems, he did not wish to experience such psychological and emotional turmoil.

Finally, justice is usually associated with fairness. A nurse is obliged to treat patients in manner that is in accordance with their needs. Justice requires that a patient receives the care they require, free from any discrimination. Also, it relates to the fair distribution and ability of a patient to access scarce resources. In relation to the scenario, the nurse also breached the principle of justice as her behaviour towards Sam is deemed discriminative; she did not respect his religious beliefs amongst other issues that arose, which are not only a patient’s right but also legal requirements.

In the UK, professional nursing practise is informed by some commendable moral values such as honesty, kindness, compassion and caring towards others. In particular, there are certain standards that are imposed on registered nurses by the Nursing and Midwifery Council (NMC) which are within the Council’s Code: Standards of conduct, Performance and Ethics for Nurses and Midwives (Nursing and Midwifery Council, 2008). The NMC was founded by an Act of Parliament in 2002 and sets standards for practise, training and professional conduct and gives advice to nurses and midwives. The code was established in order to safeguard the health and wellbeing of the public ensuring that a nurse always has the patient’s best interests at heart by providing high standards of care to them. Every nurse must abide by the code’s rules and any allegations made against nurses not complying with the code, will be investigated and the nurse will be accountable for their actions. This could put a nurse’s fitness to practise in jeopardy, even potentially resulting in disciplinary action.

According to the NMC (2008) code, people in the care of a health practitioner, ‘must be able to trust’ the professional ‘with their health and wellbeing’ and to justify that trust, professionals must make their care their first concern and treat patients as individuals, respecting their dignity at all times. Unfortunately, this did not happen in Sam’s case. The nurse acted unlawfully by breaching the legislation of discrimination and acts aforementioned. The code states firmly that ‘you must not discriminate in any way those in your care’ (ibid.). This has the implication that nurses have a duty of care towards patients; all patients should be treated with respect, regardless of their beliefs or religion in this case.

Sam’s religion and beliefs are very prevalent in his life. He is a practicing Sikh and takes pride in wearing suitable religious attire. He has a right of freedom to express his beliefs, therefore, by not respecting his wishes of not wanting to remove his turban, the nurse violates the guidelines against discriminatory practise.

The manner in which she treats Sam is offensive and disrespectful; again the NMC Code of Conduct states that, as a nurse, you must collaborate with those in your care. More precisely, Clause 8 says that you ‘must listen to the people in your care and respond to their concerns and preferences’ (NMC, 2008). Sam expressed his preferences clearly, and these were dismissed by the nurse.

The Clauses regarding gaining consent of the patient have not been adhered to properly. Even though Sam did not require major treatment, the nurse did not ask for consent to inspect the injuries on his head. The code states that the professional must respect and support one’s right to decline treatment /care, ensuring they are fully involved in the decisions about their care. He was capable of making an informed decision if he was involved in such a dialogue, but he was not given this choice. Therefore, it would be unlikely that the nurse would be able to demonstrate that she acted in his best interests.

Clause 35 argues that, to provide an excellent standard of care at all times a nurse, ‘must deliver care on the best available practice’. The care given to Sam was not exemplary in any sense, for the reasons already mentioned, so the best practice was not given.

Clause 48 addresses that you must act with integrity and ‘show a personal and professional commitment to equality and diversity’. Neither personal nor professional commitment was given to equality or diversity because the nurse did not show respect for Sam’s religious beliefs or cultural background. Therefore, she did not act within the laws according of the country of practice- Clause 49 (NMC, 2008).

Clause 61 of the code requires that, as a professional, you must uphold the reputation of your profession at all times. The nurse was not acting in the desired manner which the NMC requires, by not maintaining a professional approach, she also sullied the reputation of the institution she was working for.

The nurse in this scenario did not respect Sam’s wishes. Consequently, issues of discriminatory and maleficent behaviour were raised. Conversely, it seems apt to mention that at this stage the nurse at least tried to deal with the problem that had been created from her actions. It is required of a nurse, when ‘someone in your care has suffered harm for any reason’, that you act in order ‘to put matters right’ (ibid). The nurse realised it would be in Sam’s best interests to refer him to another nurse, who took over in a bid to recover the trust that somehow had been lost. It was left to the second nurse to be rectify the situation, apologise for the unacceptable manner which he was treated in and explain ‘fully’ to Sam that what had happened. This is not typical behaviour from nurses. By using the right interpersonal skills, she was able to put Sam at ease, and gain his trust and cooperation.Subsequently, he was later discharged with a clean bill of health.

The nurse’s unprofessional conduct led to an unproductive therapeutic relationship at first, based on his negative experience. This could have affected his confidence in a future relationship with a health professional. The nurse’s lack of understanding towards the patient could be due to her lack of knowledge about the religion in question, therefore in future it would be wise to educate her on such matters, be more open with communication and develop her self- awareness of cultural issues.

Burnard (1995) construes self-aware as knowing aspects of the self, whether psychological, physical or behavioural, with the intention of developing personal and interpersonal attributes. Fundamentally, if you do not know yourself; your strengths, your limitations for example; how can you help and care for others in an effective way?

It is crucial that a health professional possesses essential communication and interpersonal skills. This is mainly because as a nurse you are required to communicate with patients from a plethora of different cultures and backgrounds, such as an individual like Sam. Unfortunately, the nurse’s lack of some basic skills made it impossible from the start of this encounter for a holistic connection to take place, which a more patient, caring, kind and helpful personality could instigate. It could be argued that these should already be inbuilt in someone going into the nursing profession.

Walsh (2002) observes that some skills can be learnt and should be practised in order for the communication with patients or members of staff to be effective. This starts from the initial contact as first impressions are very important in communication. Engaging in conversation will help the patient connect with a nurse and an understanding of the patient’s feelings, emotions and needs will enable a nurse to respond in a considerate manner i.e. by explaining or educating the patient about the situation. Acting in such a manner shows that a nurse values the patient’s opinion, thus building a rapport between the two.

In relation to Sam, the nurse has not shown any consideration or regard for respecting his dignity. In the A and E department it is the normal to be busy and for it to be a noisy environment. Additionally, this is his first time in an emergency department, so it is reasonable to accept that he seemed confused. The nurse failed to gain his trust in the fist encounter, she merely acted in a way that raised the issue of her surfeit of interpersonal skills. Her loud tone of voice and constant instruction to remove his turban, masked her active listening skills. She failed to listen to his explanation, almost as if it was easier to dismiss; though she could have asked closed questions, to get a sense of the patient and to obtain factual information; and keep him informed on what was happening.

Empathy is another valuable tool to aid communication. It involves the health practitioner putting themselves in a patient’s situation and trying to understand how things appear from their point of view. This is ‘the ability to understand the thoughts and emotions of another person’ (Mini dictionary for Nurses, 2011). To do this, the nurse has to display active listening skills to be aware of the tone of the patient’s voice and their non-verbal communication as well as what they are saying.

In conclusion, it is clear that a lack of communication and interpersonal skills presented in the scenario are responsible for some of the issues discussed in this essay. As professionals in the healthcare sector, nurses are expected to be caring, compassionate and concerned by putting the patients’ best interests first, ensuring that a therapeutic relationship is achieved. Exploring the legal, ethical and professional issues raised by Sam’s treatment showed that the nurse clearly is in breach of the law, mainly behaving in a discriminative manner, and in violation of the assorted NMC codes which she is required to comply with. By not choosing a person centred approach, and not communicating with Sam adequately, she caused him unnecessary harm whilst he was under her care and took away his right of ‘the best possible healthcare experience’, thus the nurse is legally accountable for her actions. In reality, legal action could be taken against her, which have to consider all the issues addressed. This could even mean that the professional is removed from the register, and unable to practise as a nurse.

On reflection of my overall learning in this module, from a personal perspective, I realised that, whilst the law of our country is very clear, when presented with an issue, I am aware that the ethical grounds could be very challenging, with plenty of ambiguity. Prior to studying this module, my knowledge of ethics was very limited, though now I have expanded on this. Furthermore, it has made me more confident in inevitable future situations I will face when having any doubts about anything I come across during my practise. I know where to search for guidance, and will ensure I keep up to date with the different laws and guidelines set by the Nursing and Midwifery Council.

Appendix 1- Scenarios

Scenario

Sam is an active individual who enjoys a game of football with friends. During a match, Sam was involved in an incident with a fellow player and fell to the ground, sustaining a mild head injury. Sam was subsequently taken to the local Accident & Emergency Department, diagnosed with having a minor injury, received appropriate care and was discharged within a few hours.

Customised scenario

Sam is a 45 year old individual who is a practising Sikh. In accordance with his religious beliefs, he is required to adhere to the 5 Ks (Punj Katkar) which include wearing a turban and carrying the Kirpan, a dagger which symbolises his bravery. The Kirpan is held in a cloth holster on the right shoulder under his clothing. On this particular day, Sam was watching his friends playing football, and got hit hard in the head by the ball, fell to the ground, sustaining a head injury. On admission to the Accident and Emergency department he is instructed rather loudly to remove his turban for examination of his head. He refuses to do so as it is against his religious beliefs. Sam has never been to A and E before, he seems confused and the nurse caring for him persistently tells him she needs to inspect the injury. She totally dismisses he is becoming uncomfortable with the situation and removes his turban anyway.

References

BBC (2013) Religions ‘The Five Ks Sikhism’, 2009-09-29 Available at: http://www.bbc.co.uk/religion/religions/sikhism/customs/fiveks.shtml (Accessed: 02/12/2013).

Beauchamp, T. and Childress, J. (2001) Principles of biomedical ethics. 5^th edn Oxford: Oxford University Press.

Burnard (1990) Learning Human Skills.London: Heinmann.

Collins (2013) The Collins English dictionary: Definition of ‘discrimination’ Available at: http://www.collinsdictionary.com/dictionary/english/discrimination (Accessed: 02/12/2013).

Equality Act 2010, c.10 Available at: http://www.legislation.gov.uk/ukpga/2010/15/notes/division/3/2/1/7 (Accessed: 02/12/2013).

Equality Act 2010, c.26. Available at: http://www.legislation.gov.uk/ukpga/2010/15/notes/division/3/2/2/14 (Accessed: 02/12/2013).

Human Rights Act 1998, c.42 Schedule1 Available at: http://www.legislation.gov.uk/ukpga/1998/42/schedule/1 (Accessed: 02/12/2013).

Kozier, B. et al. (2012) Fundamentals of Nursing: concepts, process and practice. 2^nd edn. Harlow: Pearson Education Ltd.

Martin, E. (2011) Oxford Minidictionary for Nurses. 6^th edn. Oxford: Oxford University Press.

Mental Capacity Act 2005, c.9 section1 Available at: http://www.legislation.gov.uk/ukpga/2005/9/section/1 (Accessed: 02/12/2013).

Nursing And Midwifery Council (2008) The NMC Code of Professional Conduct: Standards of Conduct, Performance and Ethics for nurses and midwives. London: Nursing and Midwifery Council.

Walsh, M. (2002) Watsons Clinical Nursing and Related Sciences. 6^th edn. London: Elsevier Science Limited.

Wheeler, H. (2012) Law, Ethics and Professional Issues for Nursing: A Reflective And Portfolio-Building Approach. Cornwall: TJ International Ltd.