Reflection on Ethical Dilemma: Person Centred Care

The aim of this essay is to describe a situation from practice that involved an ethical or legal dilemma, and to reflect on feelings during this time. To enable reflection, Bouds’ model of reflection will be used, because it allows experiences to be recaptured, thought about and learnt from (Boud et al 1985)

Reflective learning is the practice of inwardly considering and analysing an experience or an issue of concern, caused by an experience, which causes you to question yourself, and which results in a change in the way we see things and brings about changes in the way we react in the future (Boyd 1993).

An integral part of my job role is to provide person centred care (PCC), to all individuals in my care. PCC is made up of three different elements: warmth, empathy and authenticity (Rogers 1961). The Royal College of nursing (RCN 2014) suggested that patients should be put at the centre of their care, but that staff should be aware of and manage risks.

 According to the world health organisation Patients should be empowered to make choices about their care (WHO 2009). There are times when what a patient wants cannot be provided simply because we as healthcare workers have a duty to act on something if we are worried.  The Nursing and midwifery council (NMC 2018) produced a set of standards that tell me I should help people maintain good health and well-being; this can sometimes mean acting in the patients’ best interest even when they do not want you to.

I recently was asked to see a patient who I will call Joan (not her real name) she is an alcoholic, and lives in sheltered accommodation. I have met Joan on a number of occasions and seemed to have a good rapport with her, so I did not envisage any problems with her. I was attending to Joan as part of a regular weekly skin check to help maintain her skin integrity; she already had a sore to her sacrum. I approached her flat and knocked on the door,  I let myself in as I normally would have and was met by the sight of her on the floor, undressed and was sitting in urine and faeces. Next to Joan were empty bottles and she appeared very intoxicated, I also noted broken glass on the floor and blood coming from her foot. Joan is deemed to have full capacity.  Which according to the Mental Capacity Act (MCA 2005) means she is fully able to make her own decisions, I introduced myself and explained why I was there, and asked if I could help to clean her and dress her, and also take care of the wound on her foot. Joan became very angry, screaming at me to leave her house calling me names and threatening me with the bottle.

At the time I was very torn about how to deal with the situation, Joan did not want me there and she is able to make that choice for herself, I could not gain her consent, which the (NHS 2019) describe as voluntarily agreeing to be treated.  My own values meant I did not want to leave her in that condition and with the obvious dangers to her health with broken glass lying around. I explained that I wanted to help her, this added to her agitation, perhaps legally I should have left her property, but ethically I could not leave knowing she was in immediate danger of further injury, so against her will I picked up the broken glass and removed it. I visually observed and evaluated the cut on her foot and realised it was very superficial, I took a blanket from the sofa and left it next to her, documented everything in her notes and left.

I felt like I had failed her by leaving her in a mess, and very worried about how sitting in the wet would make her sore deteriorate. I made my way back to the office and spoke to my colleagues and manager, my manager told me there was nothing I could do if Joan was uncooperative and did not want any help. I felt as though I had done something wrong in the way I had approached the situation and it continued to play on my mind. I also realised that I had felt a little scared and vulnerable with the threats of violence towards me.   When documenting in her notes I noticed that this behaviour was not just aimed me, but she had times when she would go into a rage I had just not been with her in the past when this had happened.  I decided to go back with a colleague, the next day first thing in the morning as it seemed by her notes this was the time she would be less intoxicated and more compliant, which she was.

From this situation we can learn that situations and people can change very suddenly, and as a team we realised that due to the aggression and threats we should be going in to see Joan in twos for our own safety. Given the situation again I believe I would still behave the same, I couldn’t leave broken glass but perhaps I would have called a colleague to attend with me to see if a different face could have diffused the situation. When faced with difficult decisions it is easier sometimes to question yourself and feel like you have failed, but talking with my peers helps to gain another perspective. By reflecting on this episode I have realised that I was acting in the best interests of Joan, and I believe I was incorporating the 6 c’s of nursing, described by (NHS England 2012) as care, courage, compassion, commitment, communication and competence, into the care I provided. I did not put her feelings first by leaving when she asked me to, but I did not cause her any harm.

To summarise reflection is a positive way to learn from experience, and to consider how, where and why changes can be made for the benefit of the patient and the health care worker.

• Boud.D, Keogh.R and Walker.D (1985) p43: Reflection: turning experience into learning: London: Kogan page
• Boyd, E. M., & Fales, A. W. (1983). Reflective Learning: Key to Learning from Experience. Journal of Humanistic Psychology, 23(2), 99–117. https://doi.org/10.1177/0022167883232011  last accessed 03/07/19
• NHS England (2012) https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf last accessed 03/07/2019
•  NHS (2019) https://www.nhs.uk/conditions/consent-to-treatment/
• NMC (2018) https://www.nmc.org.uk/globalassets/sitedocuments/education-standards/nursing-associates-proficiency-standards.pdf last accessed 03/07/2019
• (MCA 2005) https://www.legislation.gov.uk/ukpga/2005/9/contents
• RCN (2014) Principles of nursing https://www.rcn.org.uk/professional-development/publications/pub-003863    last accessed 03/07/2019
• Rogers,C.R. (1961).On becoming a person: A psychotherapists view of psychotherapy. Houghton miffin.
• WHO guidelines on hand hygiene in health care: first global patient safety challenge. Clean care is safer care. World health organisation 2009, 2 patient empowerment.