Soap Box
Your say about nursing issues
Helen Calabretto
School of Nursing, University of South Australia, SA
PP: 092 - 095
Article Text
Why care about informed consent?
The media reports debates about bioethics between theologians, healthcare professionals, legal practitioners and consumers. Kaleidoscopic points of controversy focus on abortion and other reproductive issues, euthanasia and dying with dignity. Very little, however, is published on informed consent, and yet it still remains a controversial issue. Not surprisingly, a large proportion of our society do not agree with the patient having the right of informed consent. Some main objections are that it is time-consuming, impracticable and is not in the best interests of patients' well-being (Johnstone 1989). Very few patients are informed of their rights when entering a health institution, and how the patients' rights are maintained will be up to each individual nurse.
How often does the nurse see a patient's right to informed consent being abused? And how often do nurses stand beside other health professionals and listen to information given to a patient, or in some cases their relatives, that is insufficient and incomprehensible for them to rightly consent? Negative incidents can result from misinterpretations of patients' behaviours or requests. A hypothetical example illustrates this point. A melancholic patient refuses to have a minor operation and is viewed by care-givers as being depressed and withdrawn.
She is then referred to a psychiatrist and subsequently administered anti-depressant medication. Refusing consent in this example may be morally justified; where this particular patient is simply anxious to be discharged from hospital to recontinue participation in the on-going care of a disabled, dependent loved one. Adequate time and consideration is needed and a reasonable alternative offered in any situation of informed consent. Other shameful incidents may occur when relatives are elderly, the patient has an unbeatable illness, and when death is imminent. Unfortunately it is all too easy for health professionals to manipulate patients' voluntary consent by exploiting their ignorance, fears and respect.
To qualify as being informed, from a moral point of view, a consent must satisfy certain criteria. Informed consent may be formal or informal, verbal or written and witnessed by an independent witness. It is the right of all patients to be adequately informed before they consent, and on some occasions an assessment may be required to ensure they are competent to consent. An informed and consenting patient can constantly revise or withdraw consent at any time, if they so wish. Informed consent promotes patient autonomy and is protective of patients while avoiding fraud and duress (Johnstone 1989).
The essential factors involved in informed consent are disclosure, comprehension, voluntariness, competence and consent. The level of detail necessary to adequately inform the patient, may vary with the nature of the circumstances and with the degree or risk of harm involved. Comprehension may be reduced to a minimum, particularly where there is diminished cognitive function, fear and cultural and language barriers. Patients who are children, mentally ill or intellectually disabled, who are in pain, who are sedated or anxious, or who are vulnerable to coercion, comprise a group of individuals whose competence or autonomy is obscure and whose diverse circumstances make them ineligible to give informed.
In some cases, relatives are involved in the decision-making process of informed consent. To maintain the ideal of a moralistic and humanistic decision, there is no alternative but to choose what the person would have chosen in such circumstances. Informed consent requires that a person gives consent voluntarily, without manipulation, coercion or persuasion of any kind. Reflected in informed consent (and informed refusal) is a person's ability to make an autonomous choice. Autonomy is a value but not an absolute value and a patient's demands should be respected, allowing for the option of accepting risk. In the past, it was accepted that physicians primarily made decisions about patients' on-going care without their consent. Today when on-going care is becoming increasingly technological and scientific, there is a strong need for informed consent to take on a systematic moral approach. Without this advancement, patients' rights could be negatively affected by unethical decision-making practices.
To be in line with the principles of justice, it is not morally fair for doctors or nurses to decide the on-going care for their patients without negotiation. Similarly, an equal balance of moral negotiations should occur between relatives, health professionals, lawyers, ethical experts or appropriate committees on behalf of an incompetent patient. It must be kept in mind, however, that justice must never be confused with legal requirements as justice and legal requirements are quite separate. Some nurses feel reluctant to promote and support a patient's decision-making or are preoccupied with eventful overburdened work-loads. Unless policy guide-lines are established, nurses will remain suppressed and restricted in their endeavour to enforce ethical responsibility and accountability in attempts to achieve good quality care of their patients. With an improved understanding of the components of informed consent, nurses make good advocates for ethical practices as they spend more hours in a day with a patient than does any other health professional.
They understand at what level patients can comprehend and furthermore, nurses can be more aware if a patient makes a negative decision because he or she has assumed high risk factors simply because she/he has been ill-informed. It is here that the nurse can approach the patient with care and sensitivity, constituting fairness and respect.
There is a strong need for nurses to continually re-evaluate current consent practices and to respect patients as autonomous choosers. As the twentieth century ends, a procession of economic restraints and budget cut-backs in health institutions affect working conditions and patient care, but it is gratifying to know that respecting a patient's right is of minimal cost to each individual nurse. Nurses do care about informed consent...because nurses endeavour to never lose sight of their moral and professional obligation to the person in their care. The ultimate of quality of care, can be proclaimed, only if it has been counter-signed with sound moral principles.
Joy Alyward RN RM AMRCNA
Nurses need to debate the issue of deregulation
We believe that it is time to stop skirting around the edges when debating the issues associated with power and control in nursing. It is our view that what is needed is constructive debate which addresses how power is exercised within nursing beginning with a focus on the Nurses Act (South Australian Government 1984). In South Australia, the Nurses Act was legislated originally in the 1920s at a time when there was little trust placed in the views of women. Many nurses hoped that the Act would assist in getting other groups to recognize nursing as a profession. Under the auspices of the Act, registration was viewed as the means to protect the public from persons unqualified to perform nursing.
It is argued that neither of these goals was achieved, and that what eventuated was a structure of authority that disempowered nurses and has continued to make it necessary for nurses to make claim to their professional identity and power. The Nurses Act (1984) has, in fact, maintained and assisted in perpetuating the stereotype of women evident within the patriarchal society that existed then and continues to exist now. This stereotype ensures that a nurse's deliberative faculty; the capacity to think, judge and know, was and is without authority.
The Act was reviewed in 1984 and as is the requirement for legislature; a further review was commenced in 1991. Currently, the recommended changes suggested from this review are still to be addressed by Parliament. Changes that have been suggested include: alterations to the membership of the Board, appointment processes of members, and disciplinary changes to include the formation of a tribunal.
Another proposed change is the recommendation that in Section 23, instead of the Minister of Health gazetting all careworkers, the Nurses Board itself will gazette all care-workers and ensure that they work under the supervision of a registered nurse. These changes may be perceived as strengthening the profession and therefore further protecting the pub- lic. In reality however, we suggest that the result will be more of what occurs already; that is, increased surveillance of nurses by the statutory authority.
It is unlikely that the Minister will willingly give up his (the current Minister being male) power to gazette all care-workers. Even if this does eventuate, how will the Act be able to protect the public if it does not focus on more control and surveillance of nurses? Nurses need to think very carefully about who or what exercises power, and how this power is exercised and perhaps used oppressively against nurses.
Have nurses themselves become so caught up in the structure of a patriarchal society that many are content to maintain the structures which constrain the discipline? Do many nurses now go so far as to encourage their oppression by being unwilling to debate the crucial issues? How can the public be protected other than by the regulation of nurses? Is it not time to talk about deregulation and the reasons why some nurses do not trust other nurses? Shouldn't we question whether the maintenance of such an Act perpetuates medical domination in health care and thwarts the development of the discipline of nursing?
We believe that it is not only timely, but essential, given the completion of the movement of nursing education to the tertiary sector, the establishment of the Australian Nursing Council and the introduction of ANRAC competencies (which exist as another example of the authority and dogma which governs and potentially constrains nursing).
Tensions are evident in the profession and in society especially with respect to the role of women. Let us not marginalize the issues, let us debate and discuss alternatives, so that what eventuates will be new constructions and representations of what it means to be a nurse. Let us advance the discipline by addressing how the Nurses Act (1984) exercises power over nurses, and debate whether or not this structure is a real threat to the advancement of nursing.
Kay Price and Merri Paech
Private health care: How much choice?
While nurses strive to give expert technical and psychological care, the health care system within which they work requires close scrutiny too. Australian politicians are split on the virtues of the current system of care.
While some argue the merits of Medicare, others favour an increase in private medical insurance. Many doctors, it would seem, endorse an increase in private health care. Where do nurses stand on these issues? Is an increase in private health care the way forward? Will patients benefit from such a move? I offer for debate some ideas that call into question one of the major claims made by supporters of private medical care.
Giving potential patients choice, is frequently touted as the benefit of going private. Choice of doctor, hospital, and operation date are major refrains of the private health care lobby. And I might add, based on a feeling I get when talking with those who have private insurance, such schemes are viewed as offering a superior level of service. But how much choice is there in reality and is it necessarily a good thing? Choice of doctor; but how do I (speaking as an average consumer of health care) recognise a good doctor? I'm rarely in a position to be able to judge the worth of a particular doctor's treatment.
Things might be easier if there was a league table of doctors based on assessments of their skills and cure rates. Without such objective criteria, I'd rather not be left with the responsibility of choosing the best doctor for my particular condition. I prefer instead, to leave these decisions up to the doctors themselves. Most often, all I want from my doctor is a diagnosis and advice regarding treatment; and if this is given in a courteous and friendly manner, so much the better. Surely we do not need to invoke a private system to achieve this? I would expect such service from all doctors.
I don't see why I should have to pay any extra for these qualities. At the very least, their training, which incidentally takes place in public universities, should equip them with these attributes. It is ironic that some doctors argue the merits of a private system when they operate (please forgive the pun) within a closed shop; far removed from the realities of a market economy. Unlike other private businesses, doctors do not compete, at least publicly, for patients.
One never sees offers of better skills and a more competent service if one chooses Dr Heart instead of Dr Brain. There are no promotional offers or 'freebies'. They do not produce objective criteria to guide prospective patients in their choice of doctor. Unlike schools, for example, doctors do not produce publicly available statistics regarding their success or otherwise. In business it is acceptable to negotiate a price for services rendered; this is not done when dealing with the doctor.
Doctors do not offer a refund if the treatment is not a success. The numbers of people who can train to be doctors are controlled, thereby eliminating the possibility of them competing against each other for clients. If doctors are not subject to market forces, then it seems folly to allow them (along with the private health insurers) to have such a free hand regarding fees and services. Choice of hospital? There shouldn't be a need for this. All hospitals should offer optimum care. Any differences between hospitals should lie only in the medical conditions they can treat.
When patients are ill they should expect to be sent to the hospital with the expertise to manage their illness. Deciding who goes where is the province of the doctor, and we should not try to take away medical responsibility for this important decision. Some may believe that some hospitals are better than others (whatever that means).
If this is so, then we should be sending the most ill to the 'best' hospital and in the meantime doing our utmost to bring all hospitals up to the same standard. Hospitals should not be treated like hotels; with the three star hospitals reserved for those who can afford them. All gastric ulcers require the same standard of professional care, regardless of whose stomach they are in. Timing of operation. Certainly, for non-urgent operations it is sensible to be able to choose when to go into hospital. However, when there are thousands of people, and many with serious complaints, waiting for hospital treatment it is iniquitous for any system to support queue jumping by those who can afford treatment for minor, non-urgent care.
Such a situation flies in the face of nursing and medical ethics. If your condition is urgent you should expect to receive prompt care. It is surprising that doctors (and nurses) are not more vocal on these issues, given that their training encourages them to consider the patient and his or her illness irrespective of financial considerations. People are right to be concerned about the quality of care they receive, but in a situation where many of us lack the technical skill to evaluate our treatment we often fall back on assessing peripheral phenomena; for example, the doctor's manner, the surgery decor or the quality of food provided, to guide our evaluation of care. However, favourable impressions of these aspects may be poor indicators of medical care.
Often the safest and most up-to-date equipment is in the public sector. My experience, although limited, of the small private clinics is that some operate with old, out-of-date equipment. Relying on the number of tests performed is no guarantee of quality care either. A friend sang the praises of his doctor. 'He gave me the works' he announced with pride.
It didn't occur to him to question the usefulness of the many tests he had undergone. Once a diagnosis is made, tests are rarely justified if their results are not going to materially alter treatment. Others feel that having the services of the most senior doctor guarantees high quality care. A colleague was pleased that she had the 'top surgeon' do her 'minor' operation.
Securing the services of a senior surgeon may be a costly and unnecessary expense as more junior doctors can be just as skilled when the operation is routine. A private health care system might be tolerable if doctors embraced the free market and offered clients real choice and competitive services. Present reality points to a monopoly of service, and an illusory sense of choice. Change could be brought about through legislation. Doctors could be asked to advertise their services, and to compete openly for customers.
Consumer watchdogs could be set up to give value for money ratings of doctors' care. Refunds could be given when treatments failed, and so on. Perhaps, in such a system people would be able to shop around for the best deal. But is this what the public wants? Keeping up-to-date with the latest supermarket specials is difficult enough; keeping abreast of the latest medical treatments and which doctor offers the best value for money would, I suspect, be a nightmare for all but the most dedicated. And when one is very ill it may not be feasible to shop around. For those who would rather not pursue the realities of a health care system that is subject to the vagaries of market forces, there is another option. An alternative is to implement a comprehensive health care service that is free at the point of entry.
Doctors, like nurses, would be salaried and patients, when ill, would not be burdened with making choices regarding who was best to care for them. Instead, they would rely on the integrity of the doctor and / o r nurse to decide what care was required and by whom it should be given. In this way, there would be less conflict of interest for health-care providers. In a fee for service system, it must be very tempting to over-prescribe treatments. If patients feel that doctors are compromised in this way, there is a real danger that the doctor-patient relationship, which is based on trust, will break down. And patients will become suspicious and cynical of the doctor's intent and possibly that of the nurse as well.
Gerald Farrell
References
Johnstone M-J (1989) Bioethics, a nursing perspective. WB Saunders/Balliere Tindall, Sydney.
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