Section 5 Psychosocial and ethical care

5.1 Professional and practice issues

Philosophy

Nursing philosophies are in a constant state of development, debate and reformation. Nursing philosophy, therefore, is not prescriptive and does not seek to provide steadfast rules to be adhered to; rather, it serves as a platform for professional development and reflection, and as a method of finding meaning in the nursing profession (Sellman 2010). Good patient care is:

A central feature of nursing philosophies across all disciplines and areas of practice (Haggerty and Grace 2008).

Achieved by meeting patients’ needs on an individualized basis, which becomes easier with experience and the building of clinical wisdom.

One’s personal nursing philosophy, which includes good patient care, will therefore grow stronger as practical experience and ‘clinical wisdom’ is gained.

‘Clinical wisdom’ can be applied to everyday nursing practice by drawing from past experiences to make sound judgements and decisions on current situations. It further implies a moral commitment to one’s actions; that one has a personal conviction to the ideals and philosophies that shape one’s nursing practice. Past experiences and compounded practical knowledge that constitute clinical wisdom also support nurses’ abilities to determine which courses of action are advantageous to individual patients (Haggerty and Grace 2008).

When caring for patients, it is important to balance the use of procedural guidelines and standards of care with the provision of individualized care and a reliance on personal moral values (Haggerty and Grace 2008). Key points about philosophy and nursing are:

It is important to always uphold professional guidelines and codes of conduct, especially when they regard patient safety and care (McCurry et al 2009).

Nursing is a highly ‘doing-based’ profession, requiring strong interpersonal and communicative skills as well as an ability to make decisions and adapt to changing situations (Lykkeslet and Gjengedal 2006).

Nurses’ knowledge can be described as flexible, adaptive and action-based.

The integrative nature of nursing knowledge demands that applied skills be blended with experiential learning in order to respond to unique or unusual patient cases.

With regard to patient care, nurses should remember the importance of treating patients as people and of showing a personal commitment to supporting patient health, wellbeing and safety.

Nurses can improve upon their practice by reflecting on past experiences

Barriers to good care include: staff shortages, time restrictions, opposing personal values and limited autonomy in the workplace.

Experienced nurses have noted that these barriers can be overcome through task prioritization, team work, reflective thinking, value cohesion and motivation to inspire positive change (Miller 2006).

Ensure a high standard of professional care by:

Caring for others and supporting their health and wellbeing.

Maintaining and preserving human dignity.

Treating patients with compassion and showing a positive regard for the needs and wellbeing of others.

Applying skills and knowledge in a manner that prioritizes patient health and wellness.

Empathetic approach to understanding patients’ needs and experiences.

Demonstrating a commitment to care through integrity in one’s behaviours and words (Miller 2006).

Facilitating ‘humanization, meaning, choice, quality of life, and healing in living and dying’ for all individuals receiving care (Willis et al 2008).

Advancing nursing practice by drawing from, and identifying linkages between lines of theory, inquiry and evidence across the discipline (Willis et al 2008).

Professional code of ethics

The International Council of Nurses’ (ICN) Code of Ethics for Nurses (International Council of Nurses 2005) framework states that nurses have an ethical obligation ‘to promote health, to prevent illness, to restore health and to alleviate suffering’ (p. 1). This obligation must be carried out with due regard for human rights and personal dignity, regardless of creed, colour, gender or any other defining personal or social characteristic. These same ethical principles are outlined for nurses and midwives in The Code: Standards of conduct, performance and ethics for nurses and midwives (Nursing and Midwifery Council 2008).

Nurses’ relationships with their colleagues, patients and patients’ families should be guided by the following four principles of ethical conduct:

1. Nurses and people:

– Respect the values, beliefs and human rights of all individuals.

– Uphold the principle of informed consent by explaining procedures in full detail in developmentally appropriate language.

– Always protect patients’ and families’ confidentiality insofar as doing so is within legal bounds.

– Confidential information may only be shared with others in special legal circumstances.

– Patients must be treated as unique individuals.

– Patient–practitioner boundaries must be maintained at all times.

2. Nurses and practice:

– Ongoing professional skills development should be undertaken throughout the course of one’s career.

– Looking after one’s personal health is a prerequisite to caring for others.

– Tasks requiring a high level of clinical skill should only be undertaken when one has the necessary professional competence to do so.

– Deliver care at its highest possible standard.

– Practise thorough record keeping, provide evidence-based care and maintain an up-to-date skill set.

Nurses’ competencies are outlined by the Nursing and Midwifery Council UK in the regulatory guidelines Essential skills clusters (Nursing and Midwifery Council 2007) and An Bord Altranais (Republic of Ireland). All nursing procedures should adhere to the outcomes and proficiencies contained within the Standards of proficiency for pre-registration nursing education (Nursing and Midwifery Council 2004).

3. Nurses and the profession:

– A safe and equitable work environment is both the prerogative and responsibility of nurses.

– Nurses have an obligation to participate in professional development activities, such as research, management, education and the development of clinical standards.

– Practise honest communication and behave with integrity.

– Respect your professional position, your colleagues and those under your care by providing unprejudiced, unbiased care.

Principles/processes

The provision of medical treatment to children should follow the four principles approach to care – respect for autonomy, beneficence, non-maleficence and justice (Baines 2008). The principles are closely linked to key concepts such as accountability, advocacy, consent and safeguarding children.

Ethical and legal issues

A child’s ability to consent to medical treatment depends on the child’s understanding and developmental stage:

Very young children who lack the intellectual capacity to comprehend treatment options and their consequences are deemed incompetent and are thus unable to give consent for their own treatment (Parekh 2006).

In the UK, there is no definitive legal age at which incompetent children at once become competent. For children approaching middle childhood, competence to consent is usually determined by the child’s doctor, who also considers contextual factors, such as the severity and nature of the treatment options (Parekh 2006).

In the UK, children under 16 years of age cannot give consent to their own medical treatment unless they have been deemed Gillick competent. Children in middle/late childhood and early adolescence are ordinarily considered Gillick competent, otherwise known as Fraser competent.

In the Gillick case, the judges held that ‘parental rights were recognised by the law only as long as they were needed for the protection of the child and such rights yielded to the child’s right to make his own decisions when he reached a sufficient understanding and intelligence to be capable of making up his own mind’, (Gillick v West Norfolk and Wisbech Area Health Authority (1985) 3 All ER 402 1985).

Gillick-competent children can comprehend information about medical treatments, weigh the advantages and disadvantages of each, and arrive at an informed decision about their care.

For treatment decisions that are unlikely to have such grave consequences, therefore, a young person under 16 can consent to treatment provided he or she is competent to understand the nature, purpose and possible consequences of the treatment proposed.

Refusal of treatment

Ethical dilemmas arise when children do not consent to medical treatment which, if not delivered, would prevent the best interests of the child from being achieved. There are various reasons why a child may refuse consent to medical treatment. Fear of unknown or unwanted outcomes, moral or cultural conflicts, relationships with medical staff, previous negative experiences, unsatisfactory and lack of information may contribute to a child’s refusal (Vasey 2009).

Children must be given adequate opportunity to deliberate on proposed treatment before further action.

All attempts should be made to outline the social, ethical and medical consequences of treatment and its refusal.

Children must receive full information about a treatment or procedure in developmentally appropriate terms before nurses can reasonably seek to advocate (Parekh 2006)

Legal position

Although 16–18-year-olds have the right to consent to medical treatment in the absence of parental consent, subsequent cases have retreated from this position, particularly where they have involved treatment refusal by the young person. Gillick competence is contextually dependent; for example, a child’s ability to give informed consent to a major surgical procedure may be unreliable even at the Gillick-competent stage if their decision-making process appears to be largely motivated by an emotional response (Parekh 2006). Regardless of a child’s developmental stage, a court maintains the right to give consent to a child’s medical treatment in cases where the following two conditions are present:

Both the parents and child refuse treatment

The treatment in question is very strongly in the child’s best interests, as determined by the child’s doctor and ruled by the courts.

Gillick-competent adolescents can consent to their own medical treatment in the absence of parental consent; however, in cases where Gillick-competent minors refuse consent, their refusal can be overridden by parental consent until the child reaches 18 years of age (Vasey 2009).

Thus if a child refuses consent to their own medical treatment and it is in their best interest, parental consent in favour of the treatment overrides the child’s refusal (Parekh 2006).

The ethical justification for allowing courts and/or parents to commit a child to medical treatment despite his or her refusal to give consent stems from the belief that in many cases, a child’s refusal is a consequence of their developmental immaturity, especially in cases where lifesaving treatment is refused.

Similarly when parents may be asked to make decisions on behalf of a very young or severely developmentally disabled child, parental authority is never justified when parents make decisions that are clearly in conflict with the best interests of the child. In these instances, the treatment outcome will be decided by the courts under the advice of the physician (Baines 2008).

Advocacy

Advocacy is an integral part of a nurse’s role. In children’s nursing it is essential as children are vulnerable and unwell. Children are vulnerable to having their rights infringed, as the environment is adult controlled. Nurses have a professional responsibility to act as the child’s advocate in conjunction with the parents. Advocacy can be demonstrated in different ways:

Enabling the child to express their wishes

Promoting child’s right to self-determination

Protecting the child’s safety and wellbeing

Representing child’s wishes to other adults

Speaking on behalf of infant/child

Supporting child’s needs and wishes

Acting as a mediator.

Parents may also need nurses to act as their advocates. Some parents may find it difficult to speak on behalf of their child due to: shy personality; respect for professionals; lack of knowledge; feeling intimidated; uncertainty about rights; and lack of familiarity with hospital regulations. Nurses tend to build good relationships with parents because they provide continuous care. So nurses’ presence and familiarity with the family can help them feel more inclined to voice their concerns. Nurses can play a valuable role by:

Representing the expressed wishes of the parent

Speaking on behalf of the parent

Providing parents with opportunities to express their concerns

Helping parent to present their concerns to the doctor.

Confidentiality

Children are entitled to the same level of confidentiality as adults. Therefore if a child tells you something in confidence, then you must not share this information with others. The only exception is in the case of child protection issues. The decision to breach confidentiality should never be taken lightly. The child who has expressed the desire to keep information confidential should be informed of your decision to inform parents and the reason for doing so.

Strategies of care

Partnership model

The partnership model developed by Anne Casey in 1988 was fundamental to the introduction of the concepts of parent participation and partnership nursing as core principles for nursing children in hospital or the community. Parent participation may be seen as the care-giving activities performed by a parent/guardian for a child in the hospital setting. These concepts have evolved to a more inclusive term of family-centred care (FCC), which recognizes the importance of including both the child and families’ needs in planning and delivering high quality care. This should be underpinned by communication and negotiation of roles.

Key characteristics of FCC

The family must be viewed as the constant in the child’s life:

– Admission to hospital disrupts family life and routines

– Parents / primary carer want to provide emotional support

– Children of all ages desire their parents’ emotional support

– Parents know their child best, know their child’s preferences and can provide assistance in communicating with their child

– Children from 3 upwards are usually capable of expressing their preferences and their views should be sought on all matters that affect them

– Assessment process should include both child’s and family’s needs.

Parents’/primary carer’s preferences for participation may vary considerably so daily negotiation is essential:

– Planning of care should include both child’s and family’s preferences on how they would like to be involved in care delivery

– Care plans should document families’ role and preferences

– Listening and sharing information is essential for building collaboration and good relationships

– Families’ situation may alter daily therefore assessment and negotiation should be on-going

– Some families may be reluctant to perform technical nursing care and their preferences should be accommodated

– Families need assurances that nurses will provide the care for their child when they are unable to be there

– Nurses need to be aware of the importance of being there alongside families as a caring human presence

– Discharge planning should begin early so as to ensure that community support services are tailored to meet family’s and child’s needs

– Ensure parents and/or child are instructed in the management of care required for discharge so discharge is not delayed unnecessarily

– Ensure that parents and/or child are capable of performing the procedure safely, and know what to do in case of an adverse event occurring.

Families from different cultures have unique social, cultural and linguistic needs and different understandings of FCC:

– Families have diverse needs and different forms of coping

– Some families especially dual earners may find it difficult to be present with their child at all times

– Hospital stays can be very expensive, e.g. car parking, food, and travel

– Families will require emotional, physical and some financial support

– There needs to be space for siblings on the ward so that they can visit or accompany a parent if desired.

Hospital system and policies need to be flexible and responsive to families needs:

– Services and resources should be designed and delivered around the child and family

– Families need resources and facilities for washing, eating, sleeping and relaxing

– The impact of resident parents on nurses’ workload needs to be acknowledged by hospital management

– Staffing levels need to be optimum so that nurses have time to meet families’ needs

– Care should be evaluated frequently so that care plans are kept up-to-date and relevant to child and families’ needs.

Caring for siblings’ needs

During the child’s illness the siblings can feel neglected or abandoned. They can also feel guilty because they are well and not ill in hospital. Parents may experience difficulty meeting siblings’ needs. There are general principles for helping take care of siblings that apply:

Speak to the parents and encourage them to involve the siblings.

Elicit siblings concerns and provide explanations to dispel any myths or misconceptions (e.g. that they caused the illness).

Include siblings in discussions early on and keep them informed using simple explanations.

Whenever possible emphasize the positive side of treatments.

Allow siblings into hospital to share experiences.

Encourage parents to take turns staying at home or in hospital.

Education/school activities

Most hospital or wards that care for children have the service of a school within the hospital staffed by school teachers. For children who are bed bound, the teacher will visit each child and ensure that homework is provided.

Ensure that schooling continues is beneficial for children as it promotes normality and daily routine.

Chronic illness can cause serious disruption to schooling so maintaining progress in school work is essential.

Children education should not be disadvantaged by hospitalization.

Hospital teachers can liaise with school teachers to plan that education will continue and the child is provided with appropriate schoolwork.

Play in hospital

Play is an integral aspect of childhood, child development and a basic need of all children. The first 5 years of a child’s life is a period of rapid development in physical, mental and social skills such as walking, talking, understanding and imitating. One of the most important ways in which a child learns to develop these skills is through play. It is an activity that assists in the normal development, as children learn physical, mental and social skills through play. It is a universal activity in all cultures so child’s freedom to play must be preserved in hospital.

All children irrespective of gender, culture or racial origin, background or individual ability, should have equal access to play experiences while in hospital (Department of Health and Children 2004, Department of Health 2004).

Hospitals are alien environments for many children because they encounter unfamiliar people, treatments, medical equipment and language. Play helps reduce the adverse effects of hospitalization by acting as a diversion and refocusing attention away from stressors and unfamiliar environment.

Play specialists play a key role in facilitating children’s opportunities for play and preparing children for procedures through therapeutic play.

Means of play

Toys, e.g. games, soft toys, jigsaws, computer games, mp3 players, games consoles

Functions of play

Fun activity for children

Mental, physical and social stimulation

Integral to child development and acquisition of skills

Provides opportunity for self-expression (Wikstrom 2005)

Encourages creativity and imagination

Provides outlet for emotion

Allows children to practise roles and situations

Helps provide or restore normality

Helps nurses to build a relationship with the child

Helps the child to assimilate new information

Helps the child to adjust to and gain control over a potentially frightening environment

Play material such as dolls and props useful for explaining procedures

Using play to explain procedures, lessens the stress caused by fear of the unknown, enhances child’s coping abilities and promotes cooperation (Brewer et al 2006)

Assists coping with painful procedures

Helps provide distraction

Pet therapy programmes are useful aids for enhancing well-being and in promoting normalcy (Kaminski et al 2002).

Integrated care pathways (ICPs)

Over the last two decades, ICPs have become increasing popular for healthcare systems in Europe and worldwide. Integrated care pathways are documented policies and guidelines for delivering integrated care. ICPs have been adopted for variety of health conditions and patient populations. Although integrated care contributes to improved clinical outcomes and patient satisfaction, more empirical evidence is needed to demonstrate clinical efficacy (Allen et al 2009, Doocey and Reddy 2010).

Functions of ICPs

Organizational tools that direct the flow of care in cases where patients require multidisciplinary intervention.

Often consist of care matrices and protocol documents.

Are process-based and temporal, often taking the form of a set of clinical benchmarks charted on a timescale.

Define possible treatment pathways for patients with conditions requiring multiple clinicians’ expertise.

Promote adherence to clinical guidelines (Middleton et al 2001).

Documentation reduces variation in care by defining the roles and responsibilities to be assumed by each member of the care team.

Clinicians working with ICP models can expect a high degree of protocol-driven guidance (Allen et al 2009).

Advantages to ICPs

Models of care that support multidisciplinary teamwork and collaboration.

Most valuable when applied to conditions and patient populations which follow predictable trajectories of care.

Offer valuable guidelines for clinicians whose mixed disciplinary backgrounds present challenges to caring for patients with multiple healthcare needs.

Practitioners can more freely share patient information in an atmosphere of collaborative work care plans and benefit patients as they consider needs from a holistic perspective.

Beneficial for guiding complex, multidisciplinary decision-making processes, and for improving communication between patients and clinicians (Allen et al 2009).

Most appropriate for: high-risk conditions and areas of care which are poorly implemented or in need of reform (Middleton et al 2001).

Because they require systemic change and policy development, ICPs are most effective when implemented on an organizational level (e.g. within specific wards or integrated into hospital-wide policies).

Successful ICPs have a strong medical focus and are managed by elected facilitators who liaise with clinicians in the care team (Middleton et al. 2001).

Challenges to using ICPs

Paucity of research is thought to contribute to the slow rate at which ICPs have been made available for implementation. For healthcare practitioners, this creates a situation whereby the implementation of integrated care is encouraged, but a framework for doing so is immaturely developed or unavailable (Doocey and Reddy 2010).

Major goal of integrated care is to bridge the gap between primary and secondary care, yet this has taken a minor role in what is currently observed in practice (Panella et al 2009).

ICPs are not useful to all cases requiring multidisciplinary care; complex or infrequently occurring conditions, for example, can actually be impeded by prescribing to the protocol-driven guidelines of ICPs (Allen et al 2009).

If participating agencies and institutions are new to integrative care, they may lack the policies and guidelines required for many of the activities that integrated care inspires (Doocey and Reddy 2010).

Children’s nurses working in multidisciplinary, integrated care teams may encounter ethical and organizational dilemmas involving (Doocey and Reddy 2010):

– Competing philosophies/approaches to care

– Emphasis on integrated primary and secondary care collaboration which blurs previously established roles and decision-making pathways

– Poorly developed transitional pathways for children progressing to adult services and for hospital patients migrating to home- or community-based care.

Widening the focus of ICPs

Practitioners and researchers want to widen the focus of integrative care so that it includes a stronger emphasis on the use of evidence-based, multidisciplinary treatment guidelines (Panella et al 2009).

Aim of the integrative approach is to respond to developed countries ageing demographics by developing stronger transitional links between acute and chronic care.

Integrative care is therefore in the process of expanding beyond its original goals of cost-containment and collaboration to include provisions for organizational reform (Panella et al 2009).

5.2 Psychosocial Issues

Attachment and loss

The concept of attachment is one way of describing the closeness-seeking and care-eliciting behaviours of children to their main carer. John Bowlby (Bowlby et al 1956, Bowlby 1952, 1980) was an eminent psychiatrist who developed a theory to explain the process of attachment and separation. Bowlby defined attachment as need for the infant/child to stay in close proximity to the primary care-giver usually the mother and to be comforted by her presence, sound and touch. Attachment theory is based on the following, that:

1. Attachment behaviour and the internalization of how the care-giver will respond is most acutely developed between 6 months and 5 years of age

2. Children who are able to predict the availability of their care-giver will suffer less fear and alarm in frightening situations than children who cannot predict the behaviour of their care-giver

3. The child’s experience of seeking care and receiving protection is pivotal to continued healthy development.

4. Linked to attachment is the development of basic trust – the child experiences the world as nurturing, reliable and trustworthy.

5. Another term used to denote attachment is bonding. The bond between a child and parent is usually established within the first year of life.

Attachment figure

Defined as any person with whom the child has an emotional bond and these are most often the child’s parents or main caregivers.

The child will seek out or search for their attachment figures when they are feeling fearful, frightened or anxious (Cassidy and Shaver 2008).

The child will seek out physical and emotional closeness to their attachment figures when strangers, strange places or strange situations face them.

Being admitted to hospital means the child is confronted by all three so it is important that you identify those adults to whom the child is psychologically attached in order to provide emotional security during their illness.

Features of attachment behaviour

Secure attachment

If the child experiences their carer as responsive, nurturing, supportive and available, they are cooperative, easily comforted and eager to explore new situations. Most children are securely attached to their primary carer usually the mother, and if left alone may become clingy when mother returns.

Insecure attachment

If the child experiences their carer as unresponsive, detached, distant, and unavailable they become insecure and display behaviours that are termed as:

Avoidant – show little distress when the parent is absent. When the parent returns they tend to avoid interacting. The mother/parents are often insensitive to their child’s signals – they avoid close contact, and are often angry and irritable.

Ambivalent – show frequent distress whether the mother is present or absent. When the parent returns, they show ambivalence by intermittently seeking closeness and then angrily rejecting the parent. The mother/parents are often insensitive to their child’s signals, but are not as rejecting as avoidant mothers.

Disorganized – child demonstrates a mixture of avoidance, anger and behavioural issues. The mother/parents are often insensitive to their child’s signals, avoid contact, do not display affection and alternate between being present or rejecting.

Consequences of insecure attachment

Harmful consequences for a child’s emotional welfare and development

Can develop delay in thinking, talking and social development

Have difficulty interacting with their peers

Have behavioural and social difficulties.

Promoting the process of attachment

The strength and quality of the emotional bond affects the emotional behaviour of the child and is fundamental to the child’s psychological wellbeing.

Parents need time to develop an attachment to their baby so nurses can help facilitate and support this relationship.

Nurses can help mothers become more aware of their babies behaviour and learn how to respond.

New mothers are usually anxious and the provision of advice and guidance to their babies’ responses will reduce anxiety.

Parents who show mutual reciprocal interaction and affection with their babies are showing attachment.

Reducing separation anxiety

Children under the age of 5 years are particularly vulnerable.

Children begin to show separation anxiety from 8 months.

The impact of separation is increased if there has been a poor quality relationship with the parent.

Parents of young children should be able to sleep alongside their child.

Parents of older children should be provided with accommodation so that they can stay with their child in hospital.

Babies and young children who experience long stays in hospital will form attachments so they need to be provided with a primary nurse carer.

Unaccompanied children need particular care to ensure that they are not left alone for long periods.

Effects on a child admitted to hospital

Most children experience hospitalization as a stressful event. Numerous studies have reported that children have concerns about experiencing pain, mutilation, immobility, separation from significant others, loss of control, and disruption to normal activities. The experience of illness itself causes disruption to children’s sense of well-being and consequently hospitalization may represent a threat to children’s independence, usual self-caring abilities and self-control (Coyne 2006).

Reaction to hospitalization

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Tags: A Survival Guide to Childrens Nursing

Jun 15, 2016 | Posted by admin in NURSING | Comments Off

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5: Psychosocial and ethical care

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