Professional Standards in Mental Health Care - Essay Example

Many ethical dilemmas for the health professional are considered dilemmas because of the moral principles they involve. A dilemma in this sense is defined as the conflict between doing what is right, as opposed to what is wrong, in light of the consequences of a decision made or an action taken (Kelly-Hayes, 2003; Thompson, Melia & Boyd, 2000). Mistakes in regards to decisions made about dilemmas will always exist within medical practice. However, the aim of the medical professional should be to ensure that mistakes of this type occur infrequently. The use of medical ethics is a discipline that provides guidance as to how to assess the merits, risks and social concerns of a dilemma and its resolution (Kelly-Hayes, 2003). The ethical dilemma that this paper will address is that of a mental health nurse who receives a phone call from a doctor that asks her to breach patient confidentiality. Firstly, the ethical and legal considerations of the dilemma will be presented. Secondly, the managerial qualities that the nurse in question should display will be provided. Finally, the implications of a chosen solution for the nurse's personal professional practice shall be highlighted. The practice of mental health nursing requires scientific and technical knowledge, and also the ability to make value based judgments (General Medical Council, 2001; Thompson, Melia & Boyd, 2000). These judgments need to be critically analysed and evaluated in the same way that scientific information is assessed. The term ethics is a generic word used to represent a variety of methods for investigating and understanding moral life. As such, medical ethics requires that a mental health nurse go beyond the individual, and draw on presumed universal laws (General Medical Council, 2001). The United Kingdom Mental Health Act states that medical ethics must ensure that a patient is provided with reception, care and treatment, and adequate management of their property and related matters. It is postulated here that a patient's right to confidentiality is a matter that must be properly managed stipulated by the Act (General Medical Council, 2001). Medical ethics can be summarized into four general principles: 1) patient autonomy; 2) beneficence for the patient; 3) avoidance of harm to the patient (non-maleficence); and 4) justice (General Medical Council, 2001). The principles are intended to guide the value judgments of the nurse, not to substitute judgment. As such, each principle is followed until it conflicts with one or more of the other principles, although no principle is ranked higher than any other principle. However, in recent times, justice has become a significant issue. Justice involves not only the fair distribution of benefits from medicine, but also legal justice and doing what is required of the law. This includes human rights which are grounded in the ethics of justice. The current dilemma involves issues of patient confidentiality. It is argued here that the right of confidentiality would be included in the principle of patient justice, and their rights to confidentiality in regards to their medical treatments. A nurse's respect for confidentiality is vital to cultivate and maintain a sense of trust between themselves and their patients (British Medical Association [BMA], 1999). As such, a therapeutic relationship is unable to be conductive to the healing processes if the patient cannot be confident that their personal information will not remain confidential and private. The breach of confidentiality should only occur in the most exceptional of situations, and the medical professional who breaks confidentiality should be able to adequately justify their reason for doing so (BMA, 1999). The personal health information of a patient is collected by medical staff to provide the future care and treatment to the patient, in general, this information is not to be used for any other purpose if the patient has not been made aware of the other uses, and given permission fro their information to be used in this way (BMA, 1999). Also, a patient's health information is not to be shared with unless a significant reason for justification can be made, unless of course the patient has signed an informed consent form providing permission for their information to be disclosed to a third party (BMA, 1999). So it is important that the health professional determine the patient's opinion to disclosure of their private information if it is likely to be an issue of concern. Furthermore, there is the important issue of maintaining public trust in regards to confidentiality of personal information disclosed to medical personnel (BMA, 1999). As sense of trust within the community for health professionals will facilitate people to seek out medical assistance, and to share information that will aid in their care and treatment. Hence, it is essential that the right of confidentiality that a patient has be fostered by way of health professional practices. The British Medical Association (BMA) provides primary legislation support for the patient's right to confidentiality when receiving medical intervention. The BMA has encouraged the UK government to implement the requirement from Europe in the 1995 EC Data Protection Directive (Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995), which advocates the protection of individual's in regard to the processing of their personal information, and the free movement of this information (Royal College of Nursing, 2005). It is postulated by the BMA that adoption of the Directive will ensure comprehensive privacy legislation for patients within the UK. However, although this legislation could make the responsibilities of health professionals more clear, the BMA contends that more is necessary to make the framework for confidentiality complete (Royal College of Nursing, 2005). The issue of confidentiality has become more complex with the legal ruling by Mr. Justice Latham that the Department of Health was entitled to consider information confidential even though patient's remained anonymous (R and Department of Health (Respondent) ex parte Source Informatics Ltd (Applicant) (1999) LTL 2/6/99: TLR 14/6/99: (1999) 7 Lloyd's Rep Med 264: (1999) IT+CLR 374). This issue arose when a commercial company sought to purchase anonymous patient information from chemists to sell to another party (Royal College of Nursing, 2005). The UK government guidelines on confidentiality are stipulated in the Department of Health Code of Practice on Confidentiality (2003) (as cited in the Royal college of Nursing, 2005). Further confidential and other ethical obligations for nurses are set out in the Nursing and Midwifery Council's (NMC) Code of professional practice (2002) (Nursing & Midwifery Council, 2004; Royal College of Nursing, 2005). When a health professional breaches the confidentiality of a patient, that patient can sue through the civil court. Alternatively, the patient can lodge a complaint with the Information Commissioner if they are found to have legal grounds according to the 1998 Data Protection Act (DPA) (Parliament, 1998a). Hence, the patient's right to confidentiality is protected by common law; and by Article 8(1) of the European Convention on Human Rights, that has been included within the UK law by way of the Human Rights Act of 1998, which came into force in October 2000 (Parliament, 1998b; Royal College of Nursing, 2005). In the current dilemma, the legal ownership of the patient's health records resides with the organization, in this case the hospital. So, it is the organization that owns all the paper, IT and other forms of the information. Managerial qualities of the mental health nurse involved in this dilemma involve the ability to make appropriate value-based judgments by drawing on the ethical codes of the health profession, that also incorporate UK laws on human rights (Kelly-Hayes, 2003; Nursing & Midwifery Council, 2004). Firstly, the mental health nurse must be able to articulate the dilemma as logical statements to break down the problem and to be able to consider the options available, the ethical and legal requirements, and the consequences of each action. In this way judgments are able to focus on the validity of the reasoning used to reach a solution (Antrobus, 1999; Kelly-Hayes, 2003). Much will depend on the context of the current dilemma, as each case must be treated individually. The mental health nurse must also remain aware that the ethical guidelines may not lead to a resolution of agreement (Thompson, Melia & Boyd, 2000). In the managerial role, the health professional must keep in mind all the ethical dimensions of an issue, and must be prepared to publicly justify decisions made and actions taken. As such, the process by which the decision is made is extremely important (Kelly-Hayes, 2003). Firstly, the nurse needs to consider the relevant facts involved in the dilemma, such as the ethical and legal requirements of the parties involved. Secondly, the nurse needs to determine an appropriate-decision making process for the dilemma: Who will be held responsible When does the decision need to be made Who else should be involved in the decision-making process What are the procedural rules, if any, for such a dilemma All available options should then be written down as a list. The nurse should then determine the morally important aspects of the dilemma for each option: What did the patient agree to happen Was the patient competent when the decision was made If the patient was not competent, then what is in their 'best interests' What are the foreseeable consequences for each option Next the nurse should look to what is required by law and ethical codes for each option. Each option that is determined to be realistic, the nurse should identify the moral arguments that are for and against the option. An option can then be chosen based on a judgment of its relative merits by way of asking more questions: Are there key terms whose meaning needs to be agreed upon Are the arguments valid Have all foreseeable consequences been considered Do the chosen options 'respect the person' How does this situation compare with other situations The strongest counter-argument to the chosen option can now be identified. And attempts are made to rebut the argument, providing justifiable reasons for doing so. A decision can now be made as to whether to accept an option or not. Finally, the decision is reviewed and evaluated following it implementation to determine if anything can be learnt from it (Kelly-Hayes, 2003). The following section shall now consider the dilemma and its implications for the continuing of personal professional practice as a mental health nurse. It is evident that an important area of moral beliefs within medicine is the issue of patient confidentiality. Essentially, the consequences of a breach of confidentiality are the primary concern for the health professional (Nursing & Midwifery Council, 2004). In my current practice as a health professional, it is becoming increasingly apparent that the traditional concept of confidentiality is being challenged by the advent of technology. As such, it is becoming more difficult to control who actually has access to information. At the hospital in which I work there is an appointed specific person who overseas and safeguards issues of patient confidentiality. We also have induction programs and workshops to enhance the awareness of the standards and protocols required to maintain the rights of patient confidentiality. The hospital draws on the BMA approach to the standards to determine how to network hospital databases, and how identifiable patient information can be used. I am now very much more aware of how the ethical code of conduct at my hospital and of the NMC informs my nursing practice of the professional standards that are expected by the public, my patients, my colleagues and the legal community. Reading through the code has made me acutely aware of how I must be prepared to be accountable for the decisions that I make and for the actions that I take. I am also more aware of how these ethical codes inform the public and other health delivery professions of the quality of service that they can expect form a mental health nurse such as me. My experience throughout this dilemma has made it clear to me that my practice as a mental health nurse must focus on the protection and support of the patient as an individual, and that this practice extends itself to the protection and support of the wider community. Furthermore, that my actions must be ones that I am comfortable with justifying to the public and colleagues, as well as the patient, so as to foster their trust and confidence in the nursing profession as a whole. In this way my practices as a mental health nurse contribute to the perception of nursing as a reputable profession. As such, in the current dilemma, it was necessary that I be aware that the doctor did not have an automatic right to have access to the medical records of a patient that was no longer in his care. Additionally, I did not have the explicit consent of the hospital guardian for patient confidentiality to release the patient's information to the doctor. I determined that I would not forward copies of the patient's records to the doctor if I was not given explicit approval by the hospital guardian. The guardian was also consulted as to whether it was prudent to also gain permission from the patient themselves. I then contacted the doctor and informed him that if he was requesting the patient's records for a court hearing that he should consult with the relevant attorneys to obtain a court order requesting the records. I feel that I have begun to implement the managerial leadership knowledge I have gained from my studies, as I practically applied my knowledge in seeking advice from the hospital's appointed guardian of patient confidentiality rights, and by informing the doctor that he would be required to follow established procedures. I appreciate how the processes of reflection on my decisions and actions, and the consideration of consequences of my choices, contributes to my development of leadership qualities. Furthermore, as the doctor chose to follow procedure, and to obtain a court order for the patient records he required, I am assuming that my actions motivated his chosen course of action - a desirable trait in a leader. Additionally, my agentic behavior contributed to maintaining organisational harmony, by way of aligning my actions with hospital and mental health nursing protocols. On reflection I am able to understand how managerial leadership qualities of a mental nurse facilitate socio-political consciousness in that they encourage the nurse to draw on ethical and legal knowledge to reinforce the rights of the patient, and the purpose of nursing: To provide care. These qualities also provide guidelines to enhance inter-personal communications when nurses and doctors are delivering care to the patient. My choice of actions demonstrated; my ability for self-management, for consultation with colleagues more familiar with the ethical codes and legalities I was confronted with, for team-work in that I consulted others as well as maintaining respect for the doctor and giving him the benefit of the doubt, my patient-centred focus, my development of ethical and legal awareness. It is evident to me that the extension and enrichment of my managerial leadership qualities will improve the quality of my patient care. My developing management skills are fostering the use of good practices by my colleagues within the hospital in which I work. Effective care delivery is only possible when quality leadership exists, which in itself supports and encourages the awareness of, and application of, good practices. As nursing differentiates itself from other health delivery services, I can see in my own practice how our unique body of knowledge and methods of providing patient care necessitate the development of clinical decision-making processes. My dilemma brought home to me the importance of both theoretical and practical knowledge, as conflicts of interests and ethical dilemmas are quite common in the practices of the mental health nurse. The decision-making qualities of a leader guide the choice among a range of options, which requires myself in practice to critically analysis the strengths and weaknesses of each choice in view of the outcomes of that decision for all stakeholders involved in the situation. I can see now how drawing on my knowledge of ethics and legalities pertaining to a dilemma can decrease the uncertainty of the final decision I must make. The decision-making process allows me to identify all facets of my decision, so that each element can be questioned, debated and adapted as necessary. And whilst I am aware that I will encounter situations in which my decision-making process does not directly solve my dilemma, I know that the process will positively contribute to my discovering available options. Overall, I have become very aware that ethical issues are not cut and dried, and that not all health professionals will arrive at the same decision from a set of over-riding principles. It is evident that the 'right thing to do' will differ from situation to situation. This is due to the necessity to examine the consequences of each principle in light of a real situation. Especially, the right of a patient to confidentiality of their personal details and medical record has direct influence on the public trust in the profession of nursing. A nurse who breaches the patient's confidentiality runs the risk of alienating the patient from seeking future medical assistance, or of disclosing medical details that are necessary to provide care and treatment. Furthermore, it is obvious from my practice that word-of-mouth is an important element of public perception of mental health nursing, and so even a single disillusioned patient can directly influence the personal health choices of numerous others. By maintaining a patient's right to confidentiality the mental health nurse is able to portray themselves as competent and trustworthy in the eyes of the patient, the nurse's colleagues, and the wider community. Ultimately, though the expectations on me as a mental health nurse are to recognise and apply the knowledge that I have a duty of care toward the patient, who has the right to be delivered a safe and competent care service. In order do this it is essential that in my practice I abide the laws of my country, and the ethical codes of my profession and organization. References Antrobus, S. (1999) Nursing Leadership: influencing and shaping Health Policy & Nursing Practice, in Journal of Advanced Nursing, 43(1):19-27. British Medical Association [BMA] (1999) "Confidentiality and disclosure of health information", Retrieved June 1, 2006, from http://www.bma.org.uk/ap.nsf/Content/Confidentialitydisclosure General Medical Council (2001) "Good medical practice", Retrieved June 1, 2006, from http://www.gmc-uk.org/guidance/good_medical_practice/index.asp Kelly-Hayes, P. (2003) Nursing Leadership & Management. Clifton Park, NY : Thomson Delmar Learning. Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London NMC. Parliament (1998a) The Data Protection Act, London: HMSO Parliament (1998b) The Human Rights Act, London: HMSO Royal College of Nursing (2005) Confidentiality, Retrieved June 1, 2006 from http://www.rcn.org.uk/publications/pdf/confidentiality.pdf Thompson, I., Melia, K. & Boyd, K. (2000) Nursing Ethics 4th ed. London: Churchill. Appendix I was at work on reception at the hospital one morning, when a phone call came through from a Doctor T--- who had previously been employed at the hospital for about 10 years. He was quite well known and respected, and often I saw him returning from a round of golf with the hospital Director or board members. I had never spoken to him before the phone call, but form what I had heard about him, and what I had seen of him when he worked here, made me feel very intimidated by his authoritarian manner. Earlier this year the doctor had transferred to a larger hospital in the south of England. The morning of the phone call the doctor informed me that he was to give evidence at a tribunal in regards to one of his patients he had treated previously at this hospital. Dr T--- asked me to forward to him by express post several documents that were the personal medical records of the patient in question. He told me that it would not be a breach in confidentiality as he had hand written most of the records. Personally, I did not see how this made a difference, but at the time felt intimidated and unsure of my ethical obligation. So I told the doctor I would 'see what I could do'. I then when and sought advice from my supervisor, and consulted my ethical codes of practice. Read More