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The Macquarie dictionary defines ethics as a system of moral principles, by


which human actions and proposals may be judged good or bad or right or
wrong͟(Delbridge& Bernard, 2005). An ethical problem is a situation involving
conflict about what is the right thing to do. The right thing to do is based on
our own values and beliefs, regulations that govern us and the environment
we are in when the dilemma presents itself (Wood, 2005). Ethics is concerned
with what is right and wrong and sometimes agreeing with what is right from
two or more perspectives can be challenging.

In a health care setting a decision that involves completing values is an ethical


problem( Cameron, 2002). There are four main ethical principles and they
revolve around autonomy and that is the respect for individuals and th eir right
to self determinate. Beneficence, and that is to do good. The third ethical
principle is non maleficence, and that is to do no harm. Finally, its justice and
that is to treat individuals fairly without bias(Hendrick, 2004). In most cases
when these principles are at odds with each other an individual is faced with
an ethical dilemma.

In this assignment, I will reflect on an incident that I was involved in using the
critical incident framework. As part of my research I will discuss the ethical
issues underlying the critical incident in relation to theory and literature in the
area of ageing and the care of older people. To begin we need to critically
analyse the incident.
The incident I was involved in occurredduring an afternoon shift at a private
run nursing home in the eastern suburbs.The incident involved a co worker
and myself and occurred as a result of my co worker submitting a written
complaint against me to the Director of Nursing implying that I was not
working as a team player and that I assisted only7 residents with their evening
meal while she had to assist the remaining 12 residents with their meals.

This complaint made me very upset as I felt I was doing the best I could for the
residents in my care. The incident made me feel like I was letting the team
down, that I was incompetent and a bad nurse for not helping the other
residents with their evening meal. On further introspection, I realized that my
actions were right and I needed to justify my actions with the Director of
Nursing.

At the meeting,I advised the Director of Nursing that the residents I assisted
with their evening meal ate all their food because I partly helped,prompted
and encouraged them to do so. I drew her attention to the fact that 5 of these
residents had lost weight over the last two months and that staff were aware
that these residents needed extra time and assistance with their meals. This
fact was also highlighted in the residentsprogress notes, ACFI assessment and
care plan. The Director of Nursing agreed in part with my explanation but
advised me that I needed to manage my time better. She suggested that I set
the meal up for the residents and in between assisting the other residents go
back to these residents room and encourage them with their meals. I advised
her that it wasn͛t that simple and that the other residents also needed more
time and assistance with their meals. I also highlighted that it was unfair that
the evening shift had half the number of staff in comparison to the morning
shift but had to assist the same amount of residents with their meal. The
Director of Nursing agreed that the system wasn͛t right and stated that
everything stemmed from the lack of funding and that as nurses we need ed to
do the best we could in the given circumstances . Inspite, of drawing her
attention to these facts the Director of Nursing advised me that I needed to
manage my time better and she requested that I attend a time management
inservice the following week.

After the meeting I felt angry and confused about my own clinical judgment as
a carer. I was disappointed that the outcome of the meeting was for me to
attend a time management in service. The ethical and moral dilemma I faced
was do I continue to do what I believedwas the right discharge in my duty of
care to the residentsor do I conform to the substandard care practices of the
nursing home.

After further introspection I realized that to resolve this incident I needed to


look at both sides of the argument. I spoke to my co worker who was sad and
sorry that she had put a complaint against me. According to her it was done
out of frustration and to draw attention to the workload the evening shift
were forced to deal with. From my discussion with her I realized that my co
worker and Director of Nursing also faced an ethical dilemma

The ethical dilemma I faced with this incident was the conflict arising from
opposing ethical principles. I was faced with upholding the ethical principles of
respecting resident autonomy and beneficence over that of maleficence and
justice. In this incident I felt the patient had the right to autonomy and self
determination and as a carer it was my duty of care to help them achieve this.
In terms ofbeneficence,my actions were doing good for the resident in that I
was contributing to the health and of well being of the resident. With respect
to maleficence,in this context I was harming the other residents by not
assistingthem with their evening meal and in turn causing stress to my co
worker. In terms of justice, by choosing to help just a few residents well, I was
not treating the other residents equally with respect to my time and assistance.

From the point of view of my co-workerand Director of Nursing the ethical


dilemma faced by them would be upholding beneficence and justice over
patient autonomy and maleficence. With respect to beneficenceon their part it
would be ensuring that all residents were provided and assisted with their
evening mealand that staff worked as a team thereby reducing carer stress. In
terms of justice, both my co worker and Director of Nursing believed that the
residents should be treated equally. By upholding these principles they were
choosing to sacrifice patient autonomy and self determination by not giving
the residents the appropriate assistance and as a result forgoing beneficence
by doing more harm than good to the resident.

To morally justify whose actions were right one has to discuss it within the
framework oftwo major theories. These two theories are teleological and
deontological system of ethics. The teleological theories emphasize that what
is right and wrong is based on judgement focused end results. These are also
referred to as ͞consequence orientated theories͟(Woods,2005) . In reference
to this incident my co ʹworker and the Director of Nursing have based their
decision in line with this theoryas they both believedthat what was finally
important was that all residents were provided with an evening meal and given
some assistance to finish it .From this it would seem that their actions were
morally right.
On the other hand, if we look at the deontological system of ethics the
rightness and wrongness of an act is completely independent from what is
achieved in the end and the action is determined to be right if it adheres to
some governing rule (Carter,2002). With this in mind my action to ensure that
the residents were provided with assistance in order for them to maintain
their autonomy and determination was based inline with the guidelines set out
by the Quality of Care Principles 1997 andthe Code of Ethics for Residential
Care. The Code of Ethics for Residential Care states, that one must uphold
͞ the rights of the individual to be treated with respect͟, ͞the right of
competent individuals to self determination and ͞the right to an appropriate
standard of care͟(Commonwealth of Australia, 2001).Therefore, it can be said
that under this system of theory my actions were morally right.

From my analysis of the critical incident using the deontological and


teleological theories it is hard to justify whose actions takes precedence over
the other. Thereforeit is important to look at the other factors that might have
contributed to this dilemma and influenced our conduct. To do this we need to
have a look at the role of the nursing home as an approved provider and the
role of the Department of Health & Ageing.

In order to do this, we need to take a closer look at the Foucauldian approach


to ethics.According to Foucault the ͞moral conduct of nurses occurs through
the application of moral codes that in the foucauld ian sense have been devised
to govern, shape and fashion conduct to achieve a desired goal͟ (Winch,
2006)..These moral codes ͞comprise of rules that establish possible behaviours
ranging from forbidden to the required, plus the resulting of positive and
negative values͟(Winch, 2006). He goes further to state that the morality of
caring is based on a ͞ set of rules of action that are recommended to
individuals through the intermediary of various prescriptive agencies͟ which in
this case would be the nursing home and Department of Health and Ageing
(Winch, 2006). Therefore, the actions of staff in the nursing home setting is
not just based on their own values and beliefs but is influenced greatly by the
͞prescriptive agencies͟ that govern them(Winch, 2006).

To further illustrate this we need to draw on Foucault͛s thesis on pastoral


power and use it to theorize the relationship between subordinates (the flock)
and the various authorities (the shepherd). The author Susan Winch cites
Foucault statingthat ͞the aim of the authorities is to promote the well being of
its subjects by means of detailed and comprehensive regulation of their
behaviour͟(Winch, 2006).According to Foucault pastor power ,it is power used
to ͞ensure͟ ͞sustain͟ and ͞improve͟its members.(Winch, 2006). With this in
mind we can look at the relationship between the Department of Health and
Ageing and the nursing homeas that of the pastor and one of the flock. In this
case, it is the Department of Health and Ageing that has the power to ͞ensure͟
that the nursing home complies with its legislative requirements through the
Aged and Accreditation Standards Agency. The Department ͞sustains͟ the
nursing home with the relevant funding via ACFI and through initiatives like the
publishing of The Standard it tries to ͞improve͟ the performance of nursing
home. This same metaphor can also be used to describe the relationship
between the nursing home as the approved provider and its staff. In this
instance, the nursing home is the pastor and the staff are the flock. Therefore,
the role of the nursing homes management is to ͞ensure͟ that the staff
comply by setting out policies and procedures for them to adhere to . The
management of the home ͞sustains͟ the staff by providing them with a wage
and͞improves͟ the performance of staff by initiating quality improvement
activities and providing them with education opportunities.
This metaphor does well to describe the role of the various bodies that govern
and influence staff behaviour. If all goes well the pastor will be able to manage
his flock. However, if the pastor doesn͛t ͞ensure͟, ͟sustain͟ and ͞empower͟
his flock it would certainly affect the behaviour of his flock.

This affect is reflected in the growing body of literature that shows that the
Department of Health and Ageing(pastor) is not adequately funding the aged
care providers (flock). The Department fails to ensure that nursing homes are
run well and this can be seen in the increased number of complaints being
registered at the office of aged care quality and compliance (OACQC) about the
quality of care delivery in nursing homes. In terms of the nursing home (pastor)
there is growing evidence of the poor standard of care delivery, increased
resident to staff ratios, elder abuse,decreased staff retention and staff burnout
(Carter, 2002). An Access Economics report conducted on the Future of Aged
Carein Australia found that the current funding model was not working. It
indicated that the financial pressures were affecting nursing home providers
and this impacted on staffing levels and the level and quality of care being
provided (Access Economic, 2010).

From this incident I realized that the ethical dilemma faced by my co worker
and myself was a direct consequence of broader issues facing the aged care
industry. Staff were expected to deliver a high standard of care in poorly
managed environmentsthat were subject to staff shortages, time constraints,
lack of monetary incentives and inadequate provision of resources
(Tuckett,2005). Many staff subject to these working conditions will face ethical
dilemmas. They will have to choose between conforming to these poor
working conditions or choosing to followtheir professional code of ethics and
conduct.In this incident the ethical dilemma would arise from conforming to
the substandard practices of the nursing home or following the codes set out
by the Australian Nursing & Midwifery Council which state that nurses should
provide quality nursing for all people and that nurses should practice in
accordance with the standards of their profession and the broader heath
system (Australian Nursing and Midwifery Council, 2009). In the aged care
industry these standards of practice refers to Quality of Care Principles 1997
which places emphasis on person centred care.Under these principles the
provision of care is to be identified through assessments and activities
undertaken need to be aimed atproviding the resident with social, material
and emotional supports that will allow them to flourish into a position where
their autonomy can be realised (Dodds,2007). In the current aged care
environment these standards will be hard to achieve.

Staff working under these conditionsperform task orientated care rather than
affective care. Staff are forced to focus on the provis ion of physical care rather
than psychosocial aspects of the care. In this setting where work practices take
precedence over a residents needs, residents are forced to accept help as
doing what is ordered and by the fitting into nursesroutines. Whichever angle
one chooses to view this critical incident there are more ethical dilemmas to
be found.

In order to resolve this incident I thought it best to request another meeting


with my co worker, the Director of Nursing and myself. After discussing our
point of views, the resolution was to get two of the therapy staff to come into
work half an hour early and stay half an hour later in order to help evening
staff cope with assisting residents with their meals. As part of the resolution I
agreed to attend the time management inservice. Although, this solution will
not help staff manage the workload on the weekends it was still a step in the
right direction.

This critical incident made me realize that ethical dilemmas are not easily fixed
and there are enough theories to give all parties involved a strong enough
argument in favour of their actions. Our own values, beliefs and in some cases
our egos can get in the way of resolving ethical dilemmas. The health care
system is besieged with varying codes of ethics,codes for professional conduct
and industry standards however if these are not supported by sound reform,
funding and support systems it will only add to the ethical dilemmas faced by
healthcare workers in the aged care sector. Studies have ͞revealed that the
personal and moral well being of nurses as individuals is dependant on the ir
ability to resolve ethical issues when caring for older people ͟(Rees, King,
Schmitz,2009) With the aged care sector facing pressures on many fronts
resolving ethical issues will not be easy. Since there is no easy fix in sight staff
working under these conditions need to understand the realities of the
situation, weigh up both sides and then find the best solution that will meet
the needs of all concerned. Sometimes the solution will be the best of two evils.
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