Nurses face many issues involving their client’s wellbeing. Confusion relating to the balance of a clients need for autonomy with family members responsibilities and clients wellbeing can make some decisions difficult. Protecting the nurse’s own standards of care and an orgnaistations /employers policies while supporting clients and family members can lead to distress for not only the clients but also the Nurse. By utilising an ethical decision-making tool, I will attempt to tackle some of the legal, ethical and social aspects of child abuse and mandatory reporting faced in nursing (State Government of Victoria, Department of Human Services 2010).
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THE PROBLEM
Physical child abuse is characterised by physical injury resulting from hitting, punching, kicking, biting, burning, shaking or otherwise harming a child. Certainty that injury or condition was caused by neglect or by non-accidental means is not a necessity, ‘reasonable cause’ to entertain the possibility of abuse is all that is required, to meet the criteria of mandatory reporting (Funnell, Koutoukidis, Lawrence 2009).
Most children know that negative consequences can result if they break the silence about abuse, and become reluctant to report any abuse for fear of the consequences. Therefore, abuse may continue for months and even years, particularly if the abuser is someone close to the child. Disclosure of abuse with string attached such, as “you have to promise not to tell anyone” can also be distressing for a nurses as there is a legal, ethical and social obligation report such cases to Child Protection or the new Child FIRST intake service (Department of Human Services Child Protection 2010)
Sections 182(1) a-e, 184 and 162 c-d of the Children, Youth and Families Act 2005 (Vic.) states registered nurses are legally required to report cases of child abuse if there is a “belief on reasonable grounds that a child is in need of protection on a ground referred to in Section 162(c) or 162(d), or formed in the course of practicing in his or her office, position or employment. A nurse has a duty to all clients to act as a patient advocate, whilst encompassing the ethical principles of Beneficence (active well doing), Non Maleficence (to do no harm), Justice (fairness and equality), and Autonomy (liberty, free will, rights and self determination) (Australian Government, Australian Institute of Family Studies 2011).
In some cases, this may be against the wishes of the client and pose further dilemmas, and conflicts for the nurse and client.
FACTS
Christine, a 12-year-old girl. has been admitted for observations and investigation of a recent and severe episode of abdominal pain. Shortly after Christine’s admission, whilst assisting her to have a shower, the nurse notices bruising on her arms and back. Christine tells the nurse that her mother beats her regularly. She also says that the bruises on her arms and back are the result of a particularly vicious beating her mother had given her recently using a wooden coat hanger. Christine also discloses that some weeks earlier she had taken an overdose of panadol to ‘try and make her mother stop beating her’ but that all her mother had done at the time was to laugh at her and tell her ‘how stupid she was’ and sent her to her room to ‘sleep it off’. Christine then begs the nurse not to tell anyone pleading ‘If my mother finds out that I’ve told anyone she will beat me up I will be much worse for me’. The nurse reassures Christine that she won’t tell any-one. As soon as Christine is settled in her bed the enrolled nurse who is concerned for Christine’s welfare informs the registered nurse about the beatings and drug overdose
Christine, a 12-year-old girl has been admitted for observations and investigation of a recent and severe episode of abdominal pain. Whilst assisting her shower, bruising on her arms and back was noticed. Christine claims her mother beats her regularly. Christine also disclosed that some weeks earlier she had taken an overdose of Australian and Nursing Midwifery Council 2008 done at the time was to laugh at her and tell her ‘how stupid she was’ and sent her to her room to ‘sleep it off’. Christine has pleading ‘If my mother finds out that I’ve told anyone she will beat me up, It will be much worse for me’ and has requested not to tell anyone this information (Gault 2011).
THE FUNDAMENTAL ETHICAL PRINCIPLES AND THEIR IMPACT
Ethics in nursing focuses on the virtues that make a good nurse, and obligations to respect the human rights of the patient. This is reflected in a number of professional codes for nurses . The fundamental principles are:
Autonomy: the ability to function independently and retain control over decision making in all aspects of health care (Guilt 2011).
Beneficence: an act of doing something good that has a benefit for others, such as care giving, empathy, compassion, kindness and sympathy (Guilt 2011).
Non-Maleficence: avoiding all unjust suffering, injuries and harm (Guilt 2011).
Justice: the use of equality, fairness, harmony, mercy whilst encompassing current and appropriate legislation and guidelines (Guilt 2011).
Duty of Care: The moral and legal obligation and responsibility to provide health care to the best of health care workers and organizational capabilities, encompassing guidelines and legislation (Guilt 2011).
HOW THE PROBLEM MAY LOOK FROM ANOTHER PERSPECTIVE
Although cases present challenging ethical problems, Nursing Medical advances, economic pressure, and social demands make it inevitable that even more difficult ethical dilemmas will be seen in the future.
A combination of individual, family, and socioeconomic stressors all play apart in child abuse. Caregivers may be suffering from issues that require treatment (Low self esteem, depression, abused as a child themselves, substance abuse and character disorders). With the appropriate services and support orientated to people in need, there is a potential for all parties involved to receive help required and make the changes necessary to keep children safe.
IDENTIFY ETHICAL CONFLICTS
Conflicts between the fundamental ethical principles, law and a nurses own moral judgment are all difficult obstacles facing a nurse during all decision making processes. Identifying and risk/benefit analysis of conflicts helps to achieve a therapeutic outcome (Gault 2011) (Australian Nursing and Midwifery Council 2008) Australian and Nursing Midwifery Council 2008 . Ethical conflicts in Christina’s case include Beneficence versus non-maleficence; reporting the abuse to child protection is aimed to benefit Christina, with the intention for her to receive protection and support that she requires. But this may also produce additional suffering and family strain as a result of possible consequences such as repercussions from her mother, or being separated from her family (Gault 2011) (Australian Nursing and Midwifery Council 2008).
Autonomy versus Non-maleficence; consent and free will is closely joined to capacity to make decisions for ones self. A 12-year cannot legally decide on a treatment plan and the act of preventing harm is of utmost importance even though it is against her wishes. The accused abuser is the primary decision maker in Christina’s life, this poses Communication constraints effecting the nurse, mother and Christina.
Confidentiality versus Non-malefience: maintaining trust and confidences are superseded by the need to avoid harm. Issues such as privacy, respecting the wishes of the child and communication with both child and parent will also be in conflict (Gault 2011) (Australian Nursing and Midwifery Council 2008).
CONSIDER THE LAW
The law in relation to nursing provides a framework for establishing nursing actions in the care of clients, differentiates the nurse’s responsibilities from those of other health professionals, helps establish the boundaries for independent nursing actions, and maintains a standard of nursing practice by making nurse’s accountable under the law
Relevant acts in Christine’s case include but are not limited to the Child protection Act, Nurses Act and Health Professions Registration Act. All heath care acts are devised from the Australian Charter of Health Care Rights, these include:
Access: A right to be able to access appropriate health care. Regardless of any discriminatory issues, age, sex, or location (The Australian Commission on Safety and Quality in Healthcare 2010).
Safety: A right to high quality and safe health care. Key elements in safety are attention to clients needs, ensuring clients have a complete understanding of treatments they are to receive and complying with existing safety systems, guidelines protocols and laws (The Australian Commission on Safety and Quality in Healthcare 2010).
Respect: A right to be shown respect, dignity and consideration regardless of client’s environment and background and health care that is appropriate to the client’s individual needs (The Australian Commission on Safety and Quality in Healthcare 2010).
Communication: A right to be informed on all services, treatments, options and costs in a clear and open way. By being alert to signs of misunderstanding or confusion health care providers can best assess if additional arrangements for communication are required (The Australian Commission on Safety and Quality in Healthcare 2010).
Participation: A right to be included in decisions and choices about care. Discussing nature of treatment and options, rights and responsibilities, and always inviting clients consent. Health care providers should take into consideration the circumstances of the individual when providing care (The Australian Commission on Safety and Quality in Healthcare 2010).
Privacy: A right to privacy and confidentiality of provided information. Information is only to be shared with appropriate health professionals whilst ensuring sensitivity to privacy needs (The Australian Commission on Safety and Quality in Healthcare 2010).
Comment: A right to comment on care and have any concerns addressed. Health care providers must always be attentive to the concerns of patients (The Australian Commission on Safety and Quality in Healthcare 2010).
THE ETHICAL DECISION
Kerridges model for ethical decision-making concentrates on justice, in recognition that healthcare choices are constrained by inequality in resources. The decision-making model may be applied in situations to decide on the best course of action. The following steps are necessary to the Kerridges model to achieve resolution of conflict:
â- Clearly state the problem (definition).
â- Identify the facts (listen to the patient, caregiver, and health professionals
Involved).
â- Consider the ethical principles and how they impact on the problem.
â- Consider how the problem would look from another’s point of view
â- Identify the ethical conflicts.
â- Consider the legal aspects.
â- Make the ethical decision
In executing these tasks the most important treatment priority is ensuring the health and safety of the child.
I agree with the action taken by Christine’s nurse, and if I were in this situation I would have encompassed Kerridges decision-making tool and have explained my mandatory ethical and legal obligations to report cases of abuse or suspected abuse, using appropriate communication or a 12-year-old girl. Being extremely mindful to be very comforting, reassuring and to take all of her concerns on board, whilst enlisting the help of appropriate allied health care professionals, including my unit manager (Gault 2011).
CONCLUSION
Mandatory reporting of physical child abuse involves moral, legal and responsibility obligations of health care workers and organisational capabilities that must encompass guidelines and legislation. Health care workers must to take into consideration the circumstances of the individual client and needs when care.
By using a Ethical reasoning and decision making tool assists with the complex moral reasoning and systematic consideration of all aspects the situation, identifying ethical conflicts and promoting an ethical decision that ensures the protection of clients, and abides by all codes, and standards of nursing care
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