During the clinical placements, I met Catherine, a patient with very severe mental health problems and significant learning disabilities. Catherine was isolated by being locked in her room for most of the day. She was separated from the other clients and most of her personal care was carried out in her room. Catherine frequently took off her clothes and would walk around the room naked. Due to her condition, the staff observed her CCTV. Every staff member could see her through the monitor that was kept in a cupboard.
This seemed to me an ethical dilemma and even more so because I was new to learning disabilities and mental health problems. Catherine could easily be seen by male staff, even when she was naked. This infringed on her dignity and right to privacy. Further, the male staff members did not leave the room when Catherine took her bath. While naked, male staff members often attempted to restrain her while another attempted to dress her. Catherine would try to fight them off her and on reflection, I figured she might be very frightened by the forceful attempts to dress her. The nursing services provided to Catherine seemed to fail to meet Catherine’s best interests.
There were a number of competing loyalties between the organization and the patient. To begin with, the staffing situation was such that allowing only female staff into her room would have upset the entire scheduling though I still felt that this could have been looked into. The managers also pointed out that if anything happened to Catherine while she was in their care they would be liable. To them, this necessitated the use of CCTV to ensure around-the-clock observation. My ethical response to the situation was that Catherine should only be attended to by the female staff especially when she was naked and that only the female staff needed to have access to the CCTV. This would at least preserve her dignity and infringe less on her privacy rights.
The managers certainly had a different ethical response in relation to Catherine’s care, especially where the use of CCTV was concerned. They felt that Catherine was in need of constant observation and the only option short of having a member of staff with her in the room all the time was using CCTV.
In their view, a staff member’s constant presence in the room would cause her more distress. In addition, it was not a viable option, since there were other many patients to be attended to and they would be inadequately catered for if someone was always present with Catherine. In response to having male staff restrain Mary, management argued that the male staff members were the least likely to be overpowered by Catherine when she struggled to free herself. Catherine’s family saw her when she was dressed and were unaware of who had access to the CCTV surveillance in her room.
The potential risks involved in Catherine’s condition and care cannot be ignored and contributed a lot to the kind of nursing care she received. Risk management has to do with the prevention of harms and crises occurring in the future through interventions and strategies planned beforehand (Ryan, 1996). Catherine’s severe mental condition put her at risk of harming herself, use of the CCTV was therefore an intervention aimed at preventing self-harm by observing her at all times. This empowered the nurses because it created awareness about any time that Catherine may have behaved as she could hurt herself.
In Catherine’s case, risk management was not only about physical harm to herself but also about financial loss. This is because any physical harm happening to Catherine while nursing care was being delivered to her would have left the organization liable. In addition, since her dignity was reduced by her tendency to undress and pace around naked, the other immediate and effective intervention was to dress her up as soon as possible hence the restraining to ensure she would be dressed up. Risk management was especially important in the management of Catherine’s condition since as found by Ryan; women regard a wider range of risks in relation to mental illness than men (Ryan, 1999).
In Catherine’s situation, some of the elements of risk management that managers considered were identification of the exposure to risk and avoidance of potential litigation (Reiley, 1993). However, the use of male staff members to restrain her and CCTV that could be viewed by male staff are aspects of Catherine’s care that could cause dissatisfaction especially if her relatives and family were aware of the situation. This could lead to erosion of the therapeutic relationship between nurses and family increasing the chances for litigation.
The absence of attempts at giving Catherine consistent information concerning her condition and the need to restrain her and dress her is another factor that could contribute to potential litigation. The objective of risk management is to contain as much as possible the physical, financial, and emotional harm that could result from injury to the patient (Ryan, 1996). Restraining Catherine however may have served to increase her depression and frighten her more. To reduce liability the nurses should have as much consistent information as is possible with Catherine and her family and the information should be kept documented.
A possible decision-making model to guide action in case of an ethical dilemma may follow these steps. First, it is necessary to gather data concerning the moral claims that are conflicting. This involves identifying the duties, principles, rights, loyalties, beliefs, and values that make the situation an ethical problem. Once identified the issues should be ranked in order of importance and any emotions that have an effect on the situation need to be identified (Burkhardt and Nathaniel, 2002)
Identification of the key participants is the second step in the model. It is important to determine whether the participants are legally empowered to make decisions. In Catherine’s case, her family is more empowered than her due to her severe mental illness. In reference to the participants, the issue of who is affected and how is also important as well as the level of competence of the person who is affected the most by the decision that is being made. Catherine’s situation was such that though her level of competence was not very though decisions concerning her care affected her condition greatly since anything that would aggravate her more would likely women her condition. In considering the key participants, their rights, duties, capabilities, authority, and context are also important points to note (Burkhardt and Nathaniel, 2002).
The third step involves the moral perspective of the participants and their moral development stage. This means finding out whether the participants think interims of rights or duties whether the parties involved have any similarities of moral perspective highlighting the common ground and differences as well as the principles most important to the parties. The fourth step is to identify the desired outcome with respect to each consequence of such an outcome and a description of what outcome would be unacceptable to either party (Burkhardt and Nathaniel, 2002)
Once the expected outcome has been identified, the options that will arrive at this outcome are then determined. The fit to the lifestyle and values of the people affected are considered as well as the legal considerations, and the acceptability of the various options. The options are then ranked in order of priority (Burkhardt and Nathaniel, 2002). Implementation of the option selected is the next step and involves acting on a choice. It is necessary for the nurse to be empowered to make a decision, however difficult while paying great attention to any emotions involved.
The final step is the evaluation of the outcome of the action. In the evaluation process, the issues focused on are whether the ethical dilemma has been solved, whether other dilemmas have been created as a result, what effect the process has had on those affected, and whether any other actions are required (Burkhardt and Nathaniel, 2002). This model is generally an adaptation of the Nursing process which has interactive steps that follow the sequence of assessment, diagnosis, planning, implementation, and evaluation.
References
Burkhadt MA and Nathaniel AK, 2002. Ethics and Issues in Contemporary Nursing Margaret Thomson Delmar Learning ISBN 0766836290.
Reiley P, 1993. Risk Management in the Practice of Nursing, Risk Management Foundation. Web.
Ryan T, 1996. Risk Management and people with mental health problems in H Kernsball and J Pritchard eds, Good Practice in Risk Assessment and Risk Management vol 1 Jessica Kingsley Productions pp. 93-108.
Ryan T, 1999. Managing Crisis and Risk in Mental Health. Nelson Thornes ISBN 0748733361.