Nursing practice has evolved in the recent times, the main reason is nursing has identified itself as a profession and the complex medical systems have necessitated the growth. Professionalism is defined as the conceptualization of responsibilities, qualities, relations, attitudes, and role behaviors required of professionals in delivery of services to individual clients and to the society. Professionalism attributes include knowledge, essence of inquiry, accountability, autonomy, advocacy, collaboration and collegiality, and ethics Fantahun,et al(2014).
The intent of this discussion is to critically discuss how professionalism and delivery of nursing care has been greatly influenced by ethical and legal issues. Responsibility and accountability are the main cornerstones of making sound ethical decisions by professionals. “A nurse or a midwife should be able to give reasons for the decisions they make in their professional practice and should justify their decisions in the context of legislation, professional standards and guidelines, evidence-based practice and professional and ethical conduct”.NMBI(2014 pp19).Additionally ,An bord altranis stated that a nurse is legally accountable both legally and professionally for their practice, that is, for the decisions they make and the consequences of those decisions.
This has created more vigilance on ethical and legal concepts among nurses,regulatory bodies and organisations and lead to excellence in delivery of quality care to patients. Mertens(2010),stressed that emphasis quality care is vital when it comes to legal issues and ethical decision making.
PROFESSIONALISM IN NURSING
Professionalism is vital to the protection of the public and individuals in the care delivery by nurses. It can be defined as the knowledge, values, attitudes, and behaviors required to be a nurse Griffith et al (2013). Subsequently, Paulsen (2017) stated that the health care sector has undergone profound change during the last century, both in terms of what can be done (medically) and what can not be done (ethically). Fantahun et al (2012) furthermore, stated that professionalism is a multi-dimensional concept; there is no definite way to describe it, or how to assess .It underpins the integrity that is essential to public trust in nursing as a profession who through their actions must uphold that trust and reputation through professional behavior as stated by Griffith, ( 2017).
Nursing as a profession has a social mandate to provide distinctive service and that substantiates the publication of frameworks and guidelines by regulatory bodies such as code of conduct and scope of practice. Various factors contribute to professionalisation in nursing as discussed below.
Professionalism is commonly associated with competence it is elucidated in the code of conduct as the ability of the nurse or midwife to practice safely and effectively fulfilling their professional responsibility within their scope of practice NMBI(2014). Responsibility and accountability are interchangeably used in the nursing profession. Similarly, Griffith (2015) defined being accountable for being responsible for one’s acts and omissions. According to Huber (2015,) being accountable relates to our individual actions, personalities,and attitudes and are vital to nursing professionalism. Luhanga et al,(2010) added that nurses are accountable to clients, employers and their professional bodies. This prevents acts related to omissions which are regarded as misconduct and negligence as they can cause harm hence the term “breach of duty”.
Therefore, decision making is a prerequisite to being accountable. NMBI (2015) further stresses that a nurse or a midwife should be able to justify their decisions in the context of laws, professional values, and rules, evidence-based practice. In lieu with this autonomy is accentuated by Varjus et al, (2012) as an essential element of professional status. NMBI (2015) further, explains autonomy as self-determination; a person’s ability to make choices based on their own values. Autonomous decision and actions thereafter facilitate the necessity of reflective practice in the perspective to their decisions are linked to other persons. To expand on this, Somerville et al, (2004) highlighted that it’s focusing on how professionals interact with the environment to obtain a clearer picture of their own behavior and decisions. Therefore, both contribute greatly to helping nurse have the skills and knowledge in accountability of their own decisions during practice. Professionalism as concept overlaps due to the various attributes that contribute to it. Some core values have contributed positively such as; regulated education as an important element of professionalization as highlighted by Savic,(2016) .
Healthcare is complex in nature and nurses as the main professionals in the delivery of care this attributes to a spirit of collaboration with the rest of the team is essential. The collaborative practice among professionals occurs when collegial subculture is present from different professional backgrounds work together with patients, families, and communities to deliver the highest quality of care. World Health Organization (2010). Paulsen( 2017), states that” practices will change and new terms will seep into professional language”. Therefore, in that context working together eases out challenges that come about due to variations in the present or future concepts regarding delivery care.
Continuous professional development as highlighted in the scope of practice by NMBI (2015), as an individualized concept but greatly influence the quality of care as it necessitates the revalidation by nurses. Revalidation is defined a continuous process that a nurse engages throughout their careers NMC (2017.,pp3) this could be education and evidence-based research which facilitates reflection process for nurses after delivery of care for a period of time which is three years in the United Kingdom.
In view of all that’s discussed above professionalism has made tremendous changes and in that context, Paulsen(2017) stressed that, careful reflection on the meaning of clinical practices and how to fulfil roles and responsibilities, and through creating sustainable and trustworthy roles for both professionals and patients which the researcher further argued that an ethics of care ought to be central to such an endeavor.
Nursing is known as an ethically related practice. Ethics is the study of good and bad, of moral duty and moral obligations Gilililand (2010).Similarly, nurses today are bound to uphold the foundational moral virtues, duties,and principles central to the nursing profession, Ulrich et al,(2011). In modern healthcare systems ethical changes have been greatly contributed by clients and their families being more empowered. Ethical issues have progressively emerged in nursing care due to the close and direct nurse-patient relationships in everyday care.
Thus, the importance of nurses being expected to be ethical in their daily practice. Park et al, (2014).Code of ethics in different countries have been structured to guide nurses to practice in accordance with ethical conduct regulations set out in places of practice. The code of ethics states values of the profession and ideals for ethical practice carried out by institutions and professionals in them through policies and programs. Slomka et al(2008)
Irish Constitution (Government of Ireland,1937) and the Equal Status Acts (Government of Ireland, 2000-2011) which is referenced in terms of autonomy in relation to code of conduct NMBI, (2015;pp7) that nurses should respect each person’s right to self- determination as a basic human right. Regarding the right to self -determination, the prerequisite is informed consent which should be to inform and discuss with clients of both risks and benefits(beneficence) and make sure they understand prior to any form of care provided “above all not do harm”, Kings (2015).
In line with this, every individual needs to have received suf?cient information and understands what has been communicated. In addition, it is the person’s preferences and values, rather than those of some other individual such as the nurse, Elren (2010). Additionally, stated that nurses being involved in ethical discussions surrounding their patients it’s necessary to enable nurses in terms of knowledge and guidelines to always be the patient and family advocates in a meaningful way, Spence (2011).
Advocacy is crucial in ethical context by nurses. Spence (2011), stated that the moral ideal of caring becomes an essential component of a model of advocacy as the ethic of care is contextual. Nurses should concentrate on the patient and the relationships concerning that person within the context of each medical case and ethical dilemmas are embedded. With the great diversity in healthcare and the limitations of the working environment, it is often moral rather than ethical issues that give rise to angst and flux, Dawood (2015)
The increase to ethical dilemmas has been a challenge in the nursing profession. Greatly contributed to empowered and knowledgeable clients, cultural diversity, economic factors and social circumstances. These issues include; pressure to provide treatment of no clinical bene?t (abortions) when no health risks are present,end of life decisions such as do not resuscitate orders, limited resources to provide care, assisted suicide and many more. However, if the patient chooses what is ethically acceptable in the society, an ethical dilemma emerges whether a nurse is morally required to assist in such decisions that he or she believes to be ethically wrong, Pedersen et al (2018)
Ethical dilemmas such as end-of-life concerns were in a study conducted in California prevalent for nurses Ulrich et al, (2011), in the recent times do not resuscitate orders are more predominant, therefore, If one has a conscientious objection based on religious or moral beliefs which are relevant to the professional practice they should not interfere with patients or family’s own decision.
Krishna (2011), further stated, that this principle is based on patients remaining resolute in their wishes and unwavering in their goals as much as they need to be realistic about their possibilities. Therefore, it’s crucial to avoiding any confusion, as well as to avoid any potential legal pitfalls and proceed cautiously and hope to avoid any such as litigation, Ward(2009). Healthcare systems and it’s professionals can be unable manage complex medical dilemmas as it relies mostly on the government systems (constitution). In the setting of health-care provision, case law shows that ethical dilemmas often have no perfect solution. “Yet, inaction is not an option”, therefore, education and competence in decision-making is essential to augmenting patient safety and better care outcomes. Smyth et al(2016)
The ethical code is mainly governed by privacy, disclosure and confidentiality, they’re the foundations of ethical guidelines set by regulatory bodies. Confidentiality is crucial aspect in healthcare,it is important that patients trust healthcare practitioners and are not deterred from seeking treatment for fear that their personal information may be disclosed without approval or consent, Beech (2007).
Although, this is made as an assurance by nurses during disclosure and privacy there can be alterations in which is further explained in NHS (2010 )that it’s important to distinguish between serious harm to the individual to whom the information relates and serious harm to others. Confidential information can be disclosed without consent to prevent serious harm or death to others or the individual. This is likely to be defensible in common law in the public interest. The ethical principles of confidentiality in codes of conduct expand the legal basis of confidentiality and place additional duties on the health professional, Cornock (2011)
In conclusion, professionals should engage in reflective practice in daily practice when ethical issues and dilemmas on the rise and seek to attain knowledge, as nursing professionals must have an ethical commitment to be in a constant search to keep informed for themselves to avoid iatrogenesis in their professional practice and legal repercussions, Silva et al (2017)
LEGAL ISSUES IN NURSING
According to the American Nurses Association (ANA) (2010 pp.2), “the Standards of Professional Nursing Practice are authoritative statements of the duties that all registered nurses, regardless of role, population or specialty are expected to perform competently” legal duty arises in standards used in delivery of care provided in terms of quality .Griffith(2010) categorically stated that “every healthcare staff is accountable in law for any actions or omission of actions that directly result in harm caused to the patient in their care”.
Legal issues in the past decade have been on a rise due to the multi-faceted aspect of healthcare currently as issues of litigation suits being made against professionals and organisations. Mertens (2010), highlighted that most litigation cases in the United States were commonly poor obstetrical malpractices due to substandard care, where 2% of these settlements were presented in the jury and the rest were settled out of court. This is high-cost expenditure for organisations and individuals themselves. Competency is a requirement to effectively and safely deliver care which is defined in NMBI(2015,pp15) scope of practice as the attainment of knowledge, intellectual capacities, practice skills, integrity and professional and ethical values required for safe, accountable and effective practice as a registered nurse or registered midwife.
Thirdly, An bord altranis (2015 pp16) substantiates that competence changes and progresses over time. A nurse’s or midwife’s level of competence is influenced by their educational advancement, the frequency of clinical exposure and the duration of their experience in clinical settings. “Knowledge of existing legal requirements may prevent legal problems from arising,” Aliakbari et al (2015). Most medico-legal issues are common with malpractices, lack of documentation,negligence, and lack of consent from clients. It is vital that all treatment decisions and care provided are documented to provide evidence in probable legal proceedings; there is circumstantial evidence that such documentation may improve patient care and prevent complaints Guy( 2010).
Documentation is proof in legal cases and therefore every nurse should be accountable and responsible for what they write. “What’s not documented is not done”. Therefore, every professional is responsible for ensuring the exact information is evidence-based, factual and written down. Modern healthcare systems reason for documentation guarantees continuity of care provides legal evidence of the process of care delivered by all health professionals and supports an assessment of the quality of patient care, Scruth (2014).The most common type of document that causes legal stir up in health care setting is an Informed consent.
The informed consent form is a document indicating that the conversation between the health care professionals and the patient has resulted in mutual understanding, Joolaee et al (2017).The author further stressed that. In traditional mode of care delivery, a paternalistic approach was more common, where patients decisions were primarily based on the good intentions of the healthcare professional decisions made on their behalf. Today the autonomy of patients increasingly being realized and recommended by both organisations, legal structures and nursing bodies, this approach is what all health professionals should include during consent approval. This is reflected in the acquisition of a valid informed consent.
Joolee et al (2017), additionally highlighted that the consent is valid only when obtained from a patient who can decide and has received enough information, and not under pressure to coercion. For this purpose, healthcare staffs need to provide full information and and obtain the informed consent only after making sure that the patient has fully comprehended the information provided and signed it. Besides, all consent forms must be designed in accordance with the patient’s conditions such as; age, understanding capacity, in cases where safe guarding the patients who are vulnerable such as children and mentally incapacitated persons then nurses should advocate for them and be responsible by use of right protocols to gain consent according to standards set by the code of laws ,work place policies or the constitutional laws.
Scruth (2014) further stressed that a failure to maintain a reasonable standard of documentation of nursing interventions administered to a patient could be viewed as professional misconduct potentially resulting in a nurse facing charges against his or her professional competency. Commonly known as negligence, malpractice,breach of duty. Similarly, confidentiality, privacy and data protection should be ensured to the clients always, both of these codes and scope of practice in healthcare are a legal duty that is derived from constitutional and case law and forming part of the duty of care to a patient. It is a requirement within professional codes of conduct and their scope, Beech(2007.This should adhere to each individual when it’s not followed then it can be termed as professional negligence by putting patients in harm’s way through disclosure of personal information.
Negligence is defined as ‘the failure to provide care that meets current standards of practice. To determine these standards, a nurse should find out what her institution’s policies are, what her professional nursing body has published on this subject, and what the literature says, and she can ask herself what another prudent nurse would do under similar circumstances’ Genell (2000). Clinical negligence claims are on the increase, According to the NHS litigation authority in United Kingdom 10,965 new clinical negligence claims in 2015/16, NHS Litigation Authority (2015).Every nurse practitioner has a duty to care commonly known as the ‘neighbor principle’ and should at all-time prevent any harm to a patient and are accountable in law for any actions or omission of actions that directly result in harm caused to the patient in their care Guy(2010).
Nurses practice in a litigious environment and nursing faculty are often unaware of the measures they should take to protect themselves from legal liability Patton, et al (2015). Working collaboratively with others to create resolutions and inform policy formulation, such as increased transparency and sincerity in relation to incidents which result in harm some of the recommendations made by the NHS litigation authority(2015). This ensures trust among patients and nurse practitioners.
Professionalism is mainly founded by the scope of practice and code of conduct, a nurse should follow the regulations set in it, according to the literature that has affirmed to this concept. Failure to adhere to the code of conduct and scope of practice set standards then legal implications happen. Emphasis on reflexive practice, education, acquiring of knowledge and collaborative practice has been discussed to being essential in all of the above concepts in delivery of quality care.