Like a number of other professions, nurses are faced with ethical dilemmas daily in their routine work.
Part of nursing is the relief of suffering, but complex interventions often cause patients to suffer while restoring them to health.
Nurses often encounter situations where they cannot do what they consider “the right thing”, and end up morally distressed.
While some have the courage to speak up or take action, others do not.
According to Health Ministry nursing chief assistant director Anny Mary Joseph, the ethical dilemmas that nurses face are vast in scope.
“Examples include diverse topics such as staffing ratios, punching in cards for their fellow nurses who don’t show up for work or are late, taking home medications from the stock, and end of life care.
“In medical emergencies, nurses may have to call upon the doctor if the situation is beyond their scope of practice.
“The nurse often finds herself in an ethical dilemma if the doctor does not respond and the patient’s condition turns from bad to worse, ” she says.
Dilemmas may also occur while caring for patients with disabilities that may place them at risk for self-harm.
For example, an elderly patient may want to walk without supervision.
The nurse desires to promote independence, but the risk of patient injury due to falls may be great.
The dilemma is how to balance the contrasting issues, i.e. which is more important: independence or safety?
Anny notes that nurses often experience an internal conflict when revealing bad news to the patient or their relatives.
She says that nurses should be prepared to deal with the difficulty patients or their family might experience in understanding such bad news.
“The disclosure should include empathy and knowledge, always taking into account the patient’s dignity, ” says Anny, who presented a paper on Ethical Dilemmas in Nursing Practice at the University Malaya Medical Centre International Nursing and Healthcare Conference in February (2020).
Above all, nurses are responsible for keeping patients safe.
She says, “An ethical dilemma happens when the nurse has too many patients and cannot provide adequate care for all of them on her own, and errors occur.
“Caregivers make decisions that are sometimes unsafe, such as refusing medication or treatment, or lifesaving procedures for a baby.
“The nurse finds herself in a dilemma because not giving the needed treatment goes against beneficence (promoting good) and giving it ignores autonomy.
“Nurses have to remember that patients have the right to accept or reject recommendations.”
Anny cited a case where two patients with very similar names – Siti Ramly and Siti Ramzy – were admitted at the same time to the same public hospital.
Siti Ramly, who was in the late stage of pregnancy, was admitted for observation.
The unborn child was particularly precious as she had been married for 10 years and this was her first successful pregnancy.
Meanwhile, Siti Ramzy was admitted to insert an intrauterine contraceptive device (IUD).
While the nurse was changing bedsheets, both patients arrived in the room and asked to swap beds as one preferred the bed by the window.
The nurse wrote a reminder note and placed it in her pocket – and subsequently, forgot about it.
“Needless to say, the baby had to be aborted as the IUD was placed in the wrong patient.
“Such errors should be adequately addressed and acknowledged.
“The commitment of the entire team of healthcare professionals is essential to appropriately cope with errors when they occur.”
To reduce dilemmas, Anny offers nurses these tips: “Know your scope of practice, acquire the necessary skills and attitude, respect another human, and take into consideration the spiritual beliefs, diet, treatment, rights and culture of the patients.
“And make sure the documentation is accurate.”
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