NURS5029: Nursing - Inquiry for Ethical and Legal Contexts - Assessment Answer

Nursing Assignment

Assignment Task

Rosa is a 65-year-old woman who has returned to the ward following a left total knee arthroplasty. Four hours post-operatively Rosa complains of pain in her left knee as well as generalised joint pain. Her height is 170cm and weight is 80kg. Rosa’s pain score is 7/10 at rest, she is alert and oriented with vital signs as follows;

T 36.5 C, BP 144/85, P 103b/min, RR 16 and O2 sats 98% on 2L/min via nasal prongs.

All analgesics have been delivered as charted and Rosa is not due for any further analgesia. Analgesics have been administered according to the following prescription since Rosa returned to the ward:

Assessment 2 Task

For this task, you must write a critical review based on the case study above. Your review should include the following components:

1. Conduct a literature review of the chronic condition Rheumatoid Arthritis, including the aetiology, pathophysiology, clinical manifestations (sign and symptoms) and recommendations for evidence-based therapeutic management of Rheumatoid Arthritis.
2. It is likely that Rosa has developed a tolerance to opioid analgesia. Explain how and why opioid tolerance occurs.
3. Critically review post-operative pain management strategies and recommend management strategies for Rosa, including pharmacological management. Your recommendations are based on the post-operative to discharge time period.

The purpose of this assignment task is to identify the principles of professional nursing practice, outline the ethical and legal frameworks for professional practice and apply the Ethical Decision Making Framework to a complex scenario to establish an ethically and legally sound decision. Remember to incorporate evidenced-based practice in relation to quality patient care. You MUST include in your referencing 4 (four) or more of the following;

• Health Practitioner Regulation National Law Act 2010 (WA)
• NMBA Registered Nurse Standards for Practice 2016
• NMBA National Code of Conduct for the Registered Nurse 2008
• NMBA Code of Ethics for Registered Nurses 2008
• NMBA National Framework for the Development of Decision Making Framework: Scope of Nursing Practice (2007)
• NMBA Professional Boundaries 2010

Relevant Acts and Laws relating to the subject and health care practitioners – remember ALL your work must be referenced.

Use the Model for Ethical Decision Making (included in your instructions, available on Blackboard) to determine the most favorable outcome of your chosen scenario.

General Instructions

There should be attention to spelling grammar and punctuation, this work is an academic paper and needs to reflect your ability to analyse, reflect and articulate in the written form. Take time to study the marking guide to assist you with your focus. Note that there is no requirement for an introduction or a conclusion. There should be evidence of critical thinking. Citations within text and reference list should conform to APA 6th ed format.

If you feel that you require assistance with your academic writing skills there are many facilities on campus and online to support you. Below is the link to access what is available.

Include a marking guide with your work. Put your name in full on your uploaded document; Surname first.

Using the Model for Ethical Decision Making (Kerridge, Lowe and McPhee, p85 2005) to determine the most favorable outcome:

Model for Ethical Decision-Making

• Please use these headings when writing your case study
• The word count provided is only an example – it also shows the weighting of the importance of each section.

Clearly state the problem: this should not be any more than 180 words (this is like an introduction)

Consider the problem within its context; ethical, medical, social and legal considerations.

This should be a very brief summary of the issues as you see it – extract the issues:

• What is the ethical ISSUE-what is the decision about?
• What is the medical condition, just state this in a few lines
• What is the social situation of the patient -is the person dependent, do they have support?
• What appear (prima facie) to be the legal issues? Is it assault; is it the application of an Advanced Directive or informed consent for example?

Example: The medical issues for this patient (Mr S) are; Diabetes type1, depression and Heart Failure. The ethical issue for Mr S is that he is concerned about the lack of autonomy and justice when he is in hospital. Mr S’s social situation is that he lives with his wife and one daughter, he states he is a Catholic. The legal issues for Mr S are namely consent, guardianship and refusal of treatment. These issues will be explored throughout this paper. (80 WORDS - you don’t have to put the word count in each section just at the end of your work – this is just an example for you).

Get the facts: this should not be any more than 400 words

Here you need to find out what are the facts of the case; – what is the medical condition & history, examination, relevant tests (investigations), define the medical condition what is the pathophysiology of the condition/s – use scientific references

• What is the prognosis?
• What are the implications of the condition/s -for example is it acute, chronic, and degenerative? What type of progression or prognosis might be expected?
• Are there any alternative treatments?
• What social factors might have an influence – family input, social interaction

Consider the four principles: this should not be any more than 320 words

• • You need to define each principle and relate the principle to the patient
  • Autonomy: what are the patient’s preferences?
  • Beneficence: what benefits can be obtained for the patient?
  • Non-maleficence: what are the risks and how can they be avoided?

• Justice: how are the interests of different parties to be balanced?

Identify ethical conflicts: this should not be any more than 200 words

What are the ethical conflicts? To promote autonomy are we in conflict with beneficence (Autonomy vs Beneficence).

Explain why the conflicts occur relating this to the patient and how they may be resolved.

Ref the NMBA Code of Ethics / ICN Code of Ethics in this section

Consider the Law: this should not be any more than 480 words

Identify relevant legal concepts and laws and how they might guide management.

• Consider: the Practice Standards – how they apply to the case study ie (NMBA Registered Nurse Practice Standards 2016)

  • How does duty of care apply to the patient?

• How does the Practice Standards relate to the Act?
• You need to use the Acts (legislation) that apply to the case study for example:

  • Consent to Treatment – Age of Majority Act
  • Human Tissue and Transplant Act

Making the ethical decision: this should not be any more than 280 words

• Clearly state the clinical ethical decision and justify it eg:
• Specify how guiding principles were balanced and why ( i.e. justify the decision). Use the information that you have in the Law and Get the Facts section to support your decision. MUST Reference
• Take responsibility for the decision & provide alternative management – reference this!

Evaluate the decision and discuss the legal relevance and importance of accurate documentation: this should not be any more than 150 words

• Identify how you would evaluate your decision-what is our fundamental tool for establishing the efficacy/outcome of an action/decision? – here you will research what does the literature say about evaluation – also use the NMBA Competency Standards 2006
• State where you would document and why it is a fundamental practice in healthcare. Here you will research what the literature say about evaluation – also use the NMBA Competency Standards 2006

Ethics and Legal Context

Introduction

Facts derived from Corey et al. (2007) are applied in the ethical decision making in this paper. According to this model, various steps should be followed in identifying the best way forward during a dilemma. The problem is identified, followed by the potential issues. The ethical guidelines are then reviewed, as well as the relevant laws and regulations. Consultation is then obtained, and one considers the best action to take. One then establishes the consequences of these actions and a decision is then made on the most appropriate course of action. This model will be applied in identifying the best decision in the case of Mary Jane who is a 14-year-old suspected of suffering from sexual abuse. Mary Jane is responsible for taking care of her three siblings and her parents are separated, and in additional to this, she shows up to the hospital with symptoms that indicate that she could have ectopic pregnancy. The nurses responsible for diagnosing her are in a dilemma since they need to consider legal, as well as ethical issues which include confidentiality and consent as discussed in this paper.

Facts of the Case

For the past 24 hours, Mary Jane has been complaining of abdominal pain, moderate but is already severe, as well as vaginal spotting or bleeding. She looks pale, light headed, and sweaty, nauseated and is also suffering from stomach bloating. The temperature is at 37.8C, and has a pulse of 118bpm, Respirations of 28bpm, a BP of 90/50, and shallow breathing. The symptoms indicate the possibility of ectopic pregnancy. Ectopic pregnancies happen where instead of the fertilized egg moving to the uterus; it stays in the fallopian tube. This case takes place in one out of every 50 pregnancies (Koutoukidis, Stainton, Hughson, & Tabbner, 2013). Ectopic pregnancies are scary and sad, and the baby does not survive although she might survive in extremely rare cases. This is, however, impossible where it is a lubal pregnancy, or in the case it is cornual or cervical. Ectopic pregnancies are extremely dangerous to the patient, and require emergency treatment. In the case that the doctor suspects that the fallopian tube has raptured, there has to be an emergency surgery to help prevent bleeding. Some cases require removal of the ovary and the fallopian tube where these are damaged.

Where the fallopian tube has not been ruptured and the pregnancy is still in its early stages the only required surgery is the laparoscopic surgery where the embryo is removed and the damage is repaired. A laparoscope is a tiny object that is inserted through the incisions in the abdomen that ensures fallopian tube is not interfered with as only the embryo is removed (Pairman, 2015). Another alternative where the pregnancy is still at its early stage is the use of medication which stops the growth of the pregnancy tissue. The social factors which could have contributed to this situation include the nature of Mary Jane’s family. Apart from being separated, her parents work and hence lack time to take care of her and her siblings. She is, therefore, left with the responsibility of minding for her three siblings, a situation which is stressful considering that she is only 14 years old. The neglect could also have contributed to the sexual abuse which led to the ectopic pregnancy. The sexual abuse could also be facilitated by the fact that the abusers recognize the fact that there is no available adult to see the abuse. As such, they may take advantage of the parental absence to perpetrate the act, a possible situation in Mary Jane’s case.

The four Principles

The four principles of healthcare ethics are; "autonomy, beneficence, non-maleficence, and justice" (Huston, 2014). Autonomy refers to the patient’s rights to make decisions concerning their medical care without influence from the health provider. The autonomous individual acts without interference from other parties but with understanding on the issues in hand. The nurses, therefore, have the responsibility of explaining the medical options available for Mary Jane, as well as the risk factors. Mary Jane, on the other hand, would make her choice on the best course of action. The doctors, as well as her parents will then support her decision on the matter and go ahead with the choice made. Beneficence, on the other hand, refers to the actions which are taken with the aim of getting people out of harm’s way. These actions can help improve the situation, or even reduce risks for others. Physicians have a duty to protect their patients from harm. In this case, therefore, the nurses should weigh on the best option depending on the nature of the pregnancy. They would then perform the best form of surgery on Mary Jane so as to achieve the highest possible results from the situation. During the application of these principles, it is important to consider the registered nurse standards for practice. These are included in the Nursing and Midwifery Board which provides that the practitioner should think critically and analyze the nursing practice (Nursing and Midwifery Board of Australia, 2016). Further, the registered nurse should maintain capability of practice, and develop a plan for the nursing practice. There should be assessments comprehensively conducted. The nurse should also engage in therapeutic, as well as professional relations. The nurse should also provide safe, as well as appropriate responsive for quality practice in nursing. More importantly, the nurse should evaluate the outcomes so as to inform the practice during nursing.

Non-maleficence is taken to mean “do no harm (Hally, 2008).” The physicians must ensure the provision of effective treatments, hence avoidance of malice from the patients. As such, the nurse responsible for Mary Jane case should not provide ineffective treatment, and as such, they have to balance the proportional benefits from taking particular actions. Mary Jane should also be involved in the decision-making process so as to decide whether the benefits outweigh the harms that could potentially occur due to the treatment. Justice refers to the belief that benefits accrued from application of new treatment occur to all parties involved. The procedures must uphold the law, as well as fairness for all parties (Paola, Walker, & Nixon, 2010). The factors considered include competing needs, rights and obligations, conflicts with the law, as well as the fair distribution of resources. As such, the action to be taken in the case of Mary Jane must be beneficial to her, the parents, and must be in line with the laws concerning child sexual abuse and confidentiality.

Ethical Conflicts

Some of the most ethical issues come to play where the patient’s autonomous decision conflicts the beneficent duty of the medical practitioner (Heartfield, & Andre, 2013). According to the Code of Ethics for Nurses, the nurses should value informed decision-making, and value the diversity of people. Further, the nurses should value respect, as well as kindness for others and self. They should also value culture during the provision of heath care. It is also important for the nurses to value the quality of care provided to all people (Nursing and midwifery Board of Australia, 2008).There should be ethical management of the information by the burses, as well as respect for the social, economic, as well as ecological sustainable of the environment to promote health, as well as the wellbeing. In our case, for instance, Mary Jane may consider going through the laparoscopic surgery, whereas the nurses find it safe to undergo the complete surgery. It is provided that in the case that the patient understands the situation at hand and is not influenced by delusional ideas, the doctors should respect her decision. The doctors, however, have the chance to convince the patient on the importance of changing that decision. As such, the nurses should ensure that all the convincing means are exhausted before undertaking the action selected. In this case, for instance, Mary Jane is only 14 years old and may not understand the implications of the decision not to undergo the surgery. It is, therefore, the duty of the nurses to convince her of the same. As the nurse makes the decision, it is vital that she considers the ICN Code of Ethics for Nurses which is based on the values and needs. According to this code, the nursing should respect the human rights, including right to life, as well as to dignity of the patient and treatment with respect. The nurse should also consider the professional standards according to the Nursing and Midwifery Board of Australia (NMBA). These standards guide the nurses on the codes of conduct and ethics, as well as the standards of competency and practice.

The Law

The registered nurse (RN) is a practice that is evidence-based and person-centered with curative, preventive, supportive and restorative elements. The RNs are regulated health professionals who are accountable to the NMBA which is the Nursing and Midwifery Board of Australia. The practice of the RNs should, therefore, adhere with the provisions of this board. These include the NMBA standards, codes, as well as the guidelines for practice. As such, the registered nurses should follow some standards (Hamlin, Richardson-Tench, & Davies, 2011). These include: Think critically and analyze the nursing practice. They should also maintain the capability of practice, and ensure engagement in the therapeutic as well as professional relationships. They should also conduct assessments in a comprehensive manner, and ensure the provision of appropriate, as well as responsive and quality nursing practice. It is also important that the practicing nurses evaluate the outcomes so as to inform the nursing practice. According to the law of Australia, duty of care is recognized as a relationship at law. As such, the health professional is required to exercise reasonable care, as well as skill in the provision of treatment and advice to the patients. In our case, therefore, the nurses have a duty to ensure that the treatment offered to Mary Jane ensures that maximum benefits are accrued by the patient. The decision-making process, therefore, should ensure that all the factors are considered to provide the most favorable to the patient.

According to the Minors Act, a child aged 14 years or over has the right to consent to his medical, as well as dental treatment. The Consent to Medical Treatment and Palliative Act 1995 provides that a person who is 16 years and above has the validity to consent his medical treatment (Gillon, 2014). Further, it is indicated that as long as a medical practitioner believes that the child has full understanding on the treatment options as well as the risks involved, the treatment process chosen is valid. It is also provided that a particular treatment option can be applied to the child where the parents or guardian consents it. In this case, therefore, Mary Jane has various options to take in accordance with the Act (Werhane, 2013). First, she may choose the best treatment option, as long as the nurses feel that it is beneficial. Alternatively, seeing that Mary Jane is a minor, her parents can decide on the best way forward. It is, however, important that the nurses are involved in the decision-making process. It is, however, established in the Age of Majority Act that a person is said to reach the majority age when they become 19 as opposed to initial age of 21 years. As such, Mary Jane may be considered not to have attained the right age to make important decisions.

Making the Ethical Decision

While deciding on the reporting requirements for sexual abuse, it is important to consider the Australian mandatory reporting legislation. The mandatory report for the sexual abuse amongst children was introduced in 2009 in the Western Australia (Beauchamp, & Childress, 2001). The information has been used by doctors, teachers, officers, as well as nurses and midwives. The protection of children is the responsibility of the entire community. This is most especially where it is not offered by the parents and guardians. This explains the establishment of the Children and Community Services Amendment of 2008, which is based on reporting sexual abuse amongst children (Bush, 2014). According to the act, the individuals who are bound by the mandatory reporting of children sexual abuse include nurses, doctors, teachers, as well as the police officers. The Nursing and Midwifery Board on the Codes and Guidelines provide the framework for decision-making which provide that the nurses should enhance the safety, as well as the quality of the approach used in the risk management. As such, the nurses dealing with the case of Mary Jane should ensure that the decision made facilitates the patient’s safety, and risks are managed properly. The guide for nursing decisions provided by the NMBA states that the main motivation for the decisions made in meeting the needs of the patient facilitate the health outcomes. It is also provided that the nurses are responsible for making professional judgments concerning the situation when a particular activity is above their scope of practice (Nursing and Midwifery Board of Australia, 2007). As such, they provide circumstances when they need to consult from other health care practitioners. The national framework for decision-making also provides that the registered nurses have the responsibility to decide on the most appropriate person to perform nursing plan activities. Further, it is provided that the nursing practice decisions are best made after the collaborative context involving planning, risk management, as well as evaluation.

Therefore, in spite of the confidentiality requirement, the nurses are bound by this act to report the sexual abuse suffered by Mary Jane. The nurses would, therefore, report this, as it is the best for the sake of the patient. While arriving at this decision, various factors are considered, some of which conflict. First, the ICN Code of Ethics for Nurses, the nurses should ensure that the decision made protects not only the rights of the patient but her dignity as well. Further, the law on mandatory reporting of child abuse requires reporting of such issues. The confidentiality requirement, on the other hand, calls for the protection of the patient’s confidentiality (Australian Nursing Council., Royal College of Nursing, Australia, & Australian Nursing Federation, 2012). However, the decision to report is arrived at after weighing the benefits to the patient. Reporting the case would facilitate steps to stop continuation of the abuse. This, therefore, is the best decision for Mary Jane.

Evaluate the decision and discuss the legal relevance and importance of accurate documentation

According to the NMBA Competency Standards 2006, the healthpractitioner should demonstrate analytical skills while evaluating the heath information as well as the research. The decision to report the sexual abuse shows analytical skills since other than bringing justice to the abuser, the parties involved are in a position to get to the bottom of the problem. Mary Jane’s parents, for instance will be in a position to reevaluate their parenting skills and come up with strategies top protect their children.According to the NMBA nursing and competency standards 2006 good record keeping comprise one of the major steps in the provision of effective care (Snyder, & Gauthier, 2008). The records are used in supporting delivery, as well as the continuity of care of the patient, as well as in the identification of risk factors. The records serve the accountability purpose hence facilitating the legal purpose. This is so since the records are used in interventions relating to patients and the practitioner. These records are, therefore, referenced in cases where the patients sue practitioners for different grounds.