The Royal College of Nursing (RCN, 1981) and the Nursing and Midwifery Council (NMC, 2004; 2008) described the word accountability as one’s responsibility to somebody or for something, in this case nurses are accountable to the patients, the employers and the NMC principles. Responsibility is being accountable for one’s action or omission to patients in our care. Whereas Sempre & Cable argued that responsibility relates to one’s accountability to what one does and accountability is one responsible to the consequence of what one does (2003). Nurses are accountable to the NMC which legislates and regulates all nurses, midwives and specialist community nurses in the United Kingdom and it is the responsible of all registrant to abide to its principle. Therefore, the author will weave the tapestry of this essay to demonstrate that the NMC (2008) guidance may appear simple but it is a difficult responsibility to fulfil by nurses in practice. As the guideline relates to the first paragraph of the principles of The Code, firstly, trust in relation to caring of patients’ health and wellbeing will be defined and the discussion will posit around the kind treatment of the patients as individuals without discrimination, respecting their dignity and be an advocate for them whilst they are in the nursing care. Secondly, respecting their right to confidentiality as is of paramount importance and it is enshrined in the Data Protection Act (1989) and also the Human Right Act (1989) which makes it legal. Confidentiality will be defined and note that patients information cannot be disclosed without the patients’ consent. Thirdly, for nurses to respect the dignity of patients, to advocate for them and respect their confidentiality nurses must be able to use therapeutic communications to get the necessary information and nurses must be able to communicate with other health professionals to support the patients in their care. Nurses must be able to communicate with the patient in a language that is understood by the patient. Fourthly, the principle of ethics in the discharging of the roles of nurses is important to complete the jigsaw of this complex essay. Lastly, to bring theory into practice by using the five steps of nursing process model (Christensen and Kenney, 1990, 1995; Roper, Logan & Tierney, 1976; Pearson et al, 2005) will be explained by using the framework of the Clinical Governance (Department of Health (DH), 1999) as the benchmark for quality practice to explain the reason that it is a difficult responsibility for nurses to balance the different agendas.
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Hence, before an attempt is made to answer the topic of this essay theory of nursing is explained and the definition of nursing is postulate for the reader to understand the direction that this topic will be taken. Theory provides a template for practice as it provides the embodiment of nursing philosophies, presenting the beliefs, understandings, and purposes of nursing. It also guides research and education. A theory helps the understanding of nursing by the general public (Seedhouse, 1986). Theory is also a thinking process especially when a nurse is reflecting on the nursing process (assessment, diagnosis, planning, implementation and evaluation) of a patient (Bell & Duffy, 2008). Peplau (1952) argued that nurses use therapeutic communication as a way to tease out information from the patients in order that nurses gain the patients trust and they are treated with respect and dignity. (, patients most of the time are seeing the nurse for the first time,) Orem’s (1971) used the self-care model where he stated that nurses used the continuous self-care action to care for patients when the patients’ self-care exceeds their own abilities to meet their needs (self-care deficit). Though Horan et al, (2004); Rogers (1970, 1980), Neuman (1980) and Parse (1987) stated that nursing is both an art and science whereby the main aim is to help patient to achieve biological system homeostasis equilibrium after an illness and to sustain their health and wellbeing not forgetting their respect and dignity. RCN stated that “the use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever the disease or disability, until death” (RCN, 2003 pg 3).
Respecting the dignity of patients’ and caring for their health and wellbeing.
The World Health Organisation (WHO) stated that health is a human state of biopsychosocial wellbeing in the absence of illness. Seedhouse (1995) argued that the WHO definition is too broad and difficult to achieve and it does not take into consideration the different definition of illness. Roper et al (2000) argued that health is an important factor in the model for nursing. Therefore, one of the roles of nursing is not only caring for ill patients but the healthy clients especially when doing health promotion. Furthermore, nurses have to care for patients coming from different cultural and ethnical background, gender, sexual orientation. Firstly, nurses must treat people as individuals and respect their dignity and must not discriminate in any way against the patients in their care. Patient must be treated kindly and considerately. Nurses should act as an advocate for those in their care by helping them to access relevant health and social care information and to support them. Secondly, patients’ right to confidentiality is of paramount importance and is enshrined in the Data Protection Act (1989), furthermore, it is in the Human Right Act (1989).
Ethics and its moral dilemma when caring for patient’s health and wellbeing
Ethics are standards of behaviour which nurses are expected to act on when caring for patients and others (Tschudin, 1986; Edwards, 1996; Holland et al, 2008; Kozier et al, 2008) whereas moral is one’s personal standard of the difference between right and wrong in conduct, character and attitude. Ethics are found in the NMC Code of conduct and nurses are accountable for their ethical conduct (Kozier, 2008). Ethics and moral are sometimes used interchangeably in some literatures. Beauchamp & Childress (1989, 2009) developed a framework stated that there are four moral principles that nurses can work under. They are autonomy, nonmaleficence, beneficence and justice as explained below.
Autonomy states that a patient is an individual and his/her wishes should be respected eventhough the decision runs contrary to our own ethical issues.
Nonmaleficence the patient should not be placed – do no harm – it could happen intentionally, placing someone at harm risk or unintentionally causing harm.
Beneficence – doing good – implement actions that benefit patient and their supports person.
Justice – fairness – justifying one action against another action.
(Nursing theorists may say when a nurse in faced with a dilemma the decision should be based on two ethical models – utilitarianism – one that brings the most good and the least harm for the greatest number of people or deontological theory – action is not judged on its consequences but is judged on whether it agrees with moral principles)
Ethics can sometimes provide moral dilemmas that nurses face when caring for a patient especially if the patient has been diagnosed with an incurable disease whereby the family and their employer do not want it to be disclosed to the patient. In such circumstances the conflict it between ethics and moral dilemma that is enshrined in the NMC (2008) Code of Ethics their role as nurses and moral duty to the patient who wants to know the truth and the patient’s health and wellbeing (Benjamin & Curtis, 1992; Edwards, 1996). Thompson et al (2006) stated that ethics and moral cannot work in a vacuum further added that in order to justify moral judgement nurses need prior knowledge of ethical theory. Beauchamp and Childress (2009) added that one needs understanding of moral theory to be able to justify ethical decisions. This demonstrates the extra burden imposed on nurses thereby finding themselves constrained by the difficult responsibilities placed on them to fulfil the NMC (2008) Code of Ethics furthermore those of their employers.
(Nurses must have professional accountability and responsibility regardless of how simple or difficult the task may, they are personally accountable for their practice and are answerable for any action and omission committed whilst discharging their role. In this case responsibility refers to the accountability or liability associated with the duties undertaken by nurses).
Definition of important words
Before the essay tapestry is weaved some words definition are given to set the tone whether the NMC (2008) guidance appears simple and/or is it difficult responsibility to fulfil in nursing practice.
The Essence of Care (DH, 2003) is an NHS Policy helping health practitioners to take a patient-focused and structured approach to sharing and comparing practice.
Trust – Bell & Duffy suggested that being trustworthy is difficult as patients, peers, managers have different expectations on the definition of trust (2009). Trust is therefore defined as ….
Wilson argued that public has lost trust in nursing care due to the fact that they expect modern medicine could cure every possible ill and secondly someone has failed to deliver the service they were mandated to deliver (2002).
Health and wellbeing – health is defined as the absence of illness with complete physical, mental and social wellbeing (World Health Organisation (WHO), 1946; Seedhouse, 1986) and wellbeing being the (suggested) state of perfection (Wilmot, 2003)
Dignity is defined as the way an individual perceives and acquires values (privacy, respect and trust), sets standards according to these values and from these standards judges what is acceptable influenced by the individual cultural upbringing (Haddock, 1996; Seedhouse, 2000; DH, 2000; Matiti, 2002; DH, 2004; Matiti et al, 2007).
Griffith & Tengnah (2008) stated that NMC codes places both a normative and positive rules on the registrant (Normative rule – what a person should do or what they should refrain from doing and positive rule – imposes a legal obligation to do or refrain from doing something). Therefore, the NMC codes pull on both the normative and positive rule to underpin a shared set of values as enshrined by the regulatory body.
Apply the concept of dignity in delivering care by respecting the patient as an individual
The concept of dignity A concept is a label given to an observed phenomenon In the policy documents NHS Plan (Department of Health (DH), 2000) and Standards for Better Health (DH, 2004) DH states that patients would be treated as an individual first and treated with respect and dignity by focusing on their whole health and wellbeing not only their illness. It further added that the nurses would also be treated with respect and dignity. These words are echoed in the NMC (2008) Code though it does not mention the registrant.
Apply the concept of dignity
Deliver care with dignity
Identifying factors that influence and maintain patient dignity
Challenges situation/others when patient dignity may be compromised
Quality of care and clinical governance cycle
To the author who is a novice (Benner, 1984) the NMC guidance may appear to be a difficult responsibility to fulfil in practice but to an expert nurse the process and analysis of data happens on an unconscious level. This is done as the nurse may be able to deconstruct an incident by summoning his cognitive intuition (knowledge, experience) therefore the clinical decisions appears in his/her conscious mind readily formed (Lyneham et al. 2008; 2009).
So it reasonable to conclude that regimes of care should actually benefit clients, rather than simply not cause harm.
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