Tom Hardy, PHN—An Elderly Client Gives Up
Tom Hardy, PHN, has been assigned to monitor Mr. Jack, an elderly man who was diagnosed with tuberculosis (TB) (positive skin test, positive sputum and x-ray). Mr. Jack’s wife unexpectedly died recently, and he is depressed and wants to “join her.” He is not eating or sleeping much. He refuses to take his TB medications, nor his eight other medications for heart disease, thyroid insuf- ficiency, type 2 diabetes, glaucoma, high cholesterol and triglycerides, and hypertension. He has consistently refused any of Tom’s suggestions or assistance. He does not want to see a mental health counselor, and Tom wonders if he should continue to make home visits. He has a busy caseload and needs to focus on the most pressing cases. Mr. Jack’s children feel that his depression and refusal of medications is a “temporary condition” in response to his wife’s death, and ask for Tom’s assis- tance in keeping him healthy. Why is this an ethical dilemma? What are the ethical principles involved? What does Mr. Jack value? What are his children’s values? Prioritize your values. What are the possible actions you could take?
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icence by making decisions that actively promote commu- nity clients’ best interests and well-being. Examples might encompass the development of a seniors’ health program that ensures equal access to all in the community who are in need, and the support of programs to encourage pre- school immunizations.
Nonmaleficence
The principle of nonmaleficence means avoiding or pre- venting harm to others as a consequence of a person’s own choices and actions. This involves taking steps to avoid neg- ative consequences. Community health nurses can apply this ethical principle in decision-making by actions such as encouraging physicians to prescribe drugs with the fewest side effects, promoting legislation to protect the environ- ment from pollutants emitted from gasoline even if it raises prices, and lobbying for lower speed limits or gun controls to save lives.
Justice
The principle of justice refers to treating people fairly. It means the fair distribution of both benef its and costs among society’s members. Examples might include: equal access to health care, equitable distribution of services to rural as well as urban populations, not limiting the amount or quality of services because of income level, and fair dis- tribution of resources—all of these draw on the principle of justice.
Within this principle are three different views on allocation, or what constitutes the meaning of “fair” dis- tribution. One, distributive justice, says that benef its should be given first to the disadvantaged or those who need them most (see Levels of Prevention Pyramid). Deci- sions based on this view particularly help the needy, although it may mean withholding goods from others who also are also deserving but less in need (e.g., food stamps). The second view, egalitarian justice, promotes decisions based on equal distribution of benefits to every- one, regardless of need (e.g., Medicare). The third, restorative justice, determines that benef its should go primarily to those who have been wronged by prior injus- tice, such as victims of crime or racial discrimination.
Programs are in place to compensate victims for their injury or families for their loss—a beginning step to
“restore justice.” Another example includes the funds that were set up by several agencies, corporations, and groups to assist the families of the victims of the September 11, 2001 terrorist attacks. The principle of justice seeks to promote equity, a value that was discussed in the previous section.
Veracity
The principle of veracity refers to telling the truth. Com- munity clients deserve to be given accurate information in a timely manner. To withhold information or not tell the truth can be self-serving to the nurse or other health care providers and hurtful, as well as disrespectful, to clients.
Truth-telling involves treating clients as equals, and it expands the opportunity for greater client involvement, as
well as provides needed information for decision-making (Arries, 2006).
Fidelity
The final ethical principle, fidelity, means keeping prom- ises. People deserve to count on commitments being met.
This principle involves the issues of trust and trustworthi- ness. Nurses who follow through on what they have said earn their clients’ respect and trust. In turn, this influences the quality of the nurse’s relationship with clients, who then are more likely to share information, which leads to improved decisions and better health. Conversely, when a promise (e.g., a commitment to institute child care during health classes) is not kept, community members may lose faith and interest in participation.
Ethical Standards and Guidelines
As the number and complexity of ethical decisions in com- munity health increase, so too does the need for ethical stan- dards and guidelines to help nurses make the best choices possible. The ANA’s Code for Nurses with Interpretive Statements (2001) provides a helpful guide. Some health care organizations and community agencies, using the ANA code or a similar document, have developed their own spe- cific standards and guidelines.
More health care organizations are using ethics com- mittees or ethics rounds to deal with ethical aspects of client services (Guido, 2006). These committees are common in the acute care setting and in senior and long-term care set- tings, and they may focus on such issues as caregiving dilemmas that may involve practitioner negligence or poor client outcomes and the related health care decisions. How- ever, these committees also function in a variety of commu- nity health care settings. In long-term care and home care settings, such a committee may consider conflicts in client care issues that involve family members. In public health agencies, cases of clients with complicated communicable disease diagnoses and health care provider concerns are dis- cussed as they relate to policy, protocols, and the health and safety of the broader population.
Summary
Involvement in community health nursing research can be an exciting opportunity to contribute to the body of nursing knowledge and influence changes in nursing practice and in community health programs and policies. Research findings also enable community health nurses to promote health and prevent illness among at-risk populations and to design and evaluate community-based interventions. Evidence-based practice is essential to ensuring cost-efficient and effective interventions for our clients. Systematic reviews can provide direction for those who have developed a “burning clinical question.” Finding accurate, complete information and criti- cally appraising it is vital (see Evidence-Based Practice:
Handwashing).
Research is defined as the systematic collection and analysis of data related to a particular problem or phenome- non. Quantitative research concerns data that can be meas- ured objectively. It is helpful in identifying a problem or a CHAPTER 4 Evidence-based Practice and Ethics in Community Health Nursing
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relationship between two or more variables; however, because it requires the researcher to focus on a part instead of the whole, if used exclusively it can limit nursing knowl- edge. Qualitative research emphasizes subjectivity and the meaning of experiences to individuals.
The research process includes nine steps:
1. Identify an area of interest.
2. Formulate a research question or statement.
3. Review the literature.
4. Select a conceptual model.
5. Choose a research design.
6. Obtain Institutional Review Board or Human Sub- jects Committee approval.
7. Collect and analyze data.
8. Interpret results.
9. Communicate findings.
Although the process is the same regardless of nurs- ing specialty, community health nurses have a unique opportunity to expand nursing knowledge in relation to community health issues and the health needs of aggre- gates and families.
Research has a significant impact on community health and nursing practice in three ways. It provides new knowledge that helps to shape health policy, improve service delivery, and promote the public’s health. It contributes to nursing knowledge and the improvement of nursing practice. And it offers the potential to enhance nursing’s status and influence through documentation of the effectiveness of nursing inter- ventions and broader recognition of nursing’s contributions to health services.
Nurses must become responsible users of research, keeping abreast of new knowledge and applying it in practice.
Nurses must learn to evaluate nursing research articles crit- ically, assessing their validity and applicability to their own practice. Nurses should subscribe to and read nursing research journals and discuss research studies with colleagues and supervisors. More community health nurses must also conduct research studies of their own or in collaboration with other
community health professionals. A commitment to the use and conduct of research will move the nursing profession forward and enhance its influence on the health of at-risk populations.
Values and ethical principles strongly influence com- munity health nursing practice and ethical decision-mak- ing. Values are lasting beliefs that are important to individ- uals, groups, and cultures. A value system organizes these beliefs into a hierarchy of relative importance that moti- vates and guides human behavior. Values function as stan- dards for behavior, as criteria for attitudes, and as standards for moral judgments, and they give expression to human needs. The nature of values can be understood by examin- ing their qualities of endurance, their hierarchical arrange- ment, and their function as prescriptive–proscriptive beliefs, and by examining them in terms of reference and preference.
The nurse often is faced with decisions that affect client’s values and involve conflicting moral values and ethical dilemmas. Understanding what personal values are and how they affect behavior assists the nurse in mak- ing ethical evaluations and addressing ethical conflicts in practice. Various strategies can guide the nurse in making these decisions; one example is values clarif ication, which clarifies what values are important. Several frame- works for ethical decision-making that include the identi- f ication and clarif ication of values impinging on the making of ethical decisions were discussed in this chapter.
Three key human values influence client health and nurse decision-making: the right to make decisions regard- ing a person’s health (self-determination), the right to health and well-being, and the right to equal access and quality of health care. At times, these values are affected by the value of self-interest on the part of another person or a system. Seven fundamental principles guide community health nurses in making ethical decisions: respect, auton- omy, beneficence, nonmaleficence, justice, veracity, and fidelity. ■
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UNIT 1 Foundations of Community Health NursingAs nurses, we are taught the importance of handwashing.
In nursing school, we are educated to wash our hands before and after patient care—it is often drilled into us.
But, when you work in the community, you do not always have ready access to soap and water. Many PHNs choose to carry small bottles of hand sanitizer as a prac- tical alternative to handwashing. But, is this effective? A small study of health care workers in France found that handrubbing with an alcohol-based mixture was better than handwashing with antiseptic soap when it came to reducing hand bacterial contamination for workers in
intensive care settings (Girou, Loyeau, Legrand, et al., 2002). A larger French study found that handrubbing with an alcohol solution was as effective as handscrub- bing with antiseptic soap in preventing infections of sur- gical sites. They noted no statistical differences in devel- opment of nosocomial infections of patients’ surgical sites between the two groups (Parienti, Thibon, Heller, et al., 2002). Where would you go to find a systematic or integrative review of this subject? How would you go about presenting this information at a staff meeting to stimulate changes in policies and procedures?
EVIDENCE-BASED PRACTICE
Handwashing
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CHAPTER 4 Evidence-based Practice and Ethics in Community Health Nursing