Ethico-Cultural Professional Issues In Nursing Practice: A Case Study Analysis

Assessment Task

In addition to NMBA Code of Conduct for Nurses and Registered Nurse Standards for Practice, using a minimum of 5 additional scholarly references (7 in total) answer the following questions in your essay.

Section A: 

Using this case study as context and using relevant scholarly references to support your discussion

• What are the components of a therapeutic, person-centred relationship?
• What are the benefits of forming a therapeutic, person-centred relationship with this client?

Section B:

Using this case study as context and using relevant scholarly references to support your discussion, how does the Code of Conduct for Nurses and the Registered Nurse Standards for Practice from the NMBA, influence the formation of the therapeutic relationship in this case study?

Section C:

Using relevant scholarly references to support your discussion, explain the concepts of paternalism and cultural safety and apply these principles to the case study.

The cultural safety and appropriateness has become one of the most integral aspects associated with the care planning and delivery in the present day scenario. It has to be mentioned that the aspect of patient centred care focuses on planning and delivering care that is culturally appropriate and respectful towards the individuality of the patient that is being care for (Zubair, 2015). The concept of therapeutic relationship also is based on respecting the patient and addressing the individualized needs that affects the overall health and wellbeing of the patient. The aspects of therapeutic relationship is incomplete without addressing the cultural appropriateness in the planning and implementation of the care services (Health.qld.gov.au, 2018).

Although, it also has to be acknowledged here that the patient assessment and care delivery programs often involve activities which might unintentionally hurt or overrule the cultural safety that for ethnically diverse communities. In such situations where there is a risk of ethical dilemma, it becomes very difficult for the care professional delivering care to be able to arrive at a verdict that is protecting both ends of the situation effectively. The NMBA nursing practice standards and ethical code of conduct serve as excellent guidance frameworks for the care professionals to follow in such challenging situations (Nursingmidwiferyboard.gov.au, 2018). This essay will focus on ethico-cultural professional issues, unintended paternalism that reflects in care planning for culturally diverse with respect to the NMBA guidelines and standards of care taking the assistance of a case study.

Section A:

The case study selected for this essay describes a patient who had been an aboriginal that required a vaginal examination which undoubtedly can be an extremely distressful or discomforting situation for conventional or traditional communities like the aboriginals. Although, the nurse in practice, Michael, described her why the examination was necessary he missed out asking her whether or not she was comfortable with the examination; which can be considered a breach of the informed consent policy. On a more elaborative note, the most important ethical aspect that has been breached in this case scenario had been the successful establishment of therapeutic relationship (McCabe & Holmes, 2014). According to the NMBA registered nurse practice standards, the 2^nd standard elaborates the nurse to have an effective therapeutic relationship with the patient in order to provide individualized therapeutic relationship (Standard 2, Nursingmidwiferyboard.gov.au, 2018). Elaborating more on the second standard, the therapeutic relationship is a fundamental aspect of care planning is mandatory for all nurses and midwives to maintain in order to be effectively engaged with the patient by the means of collegial generosity with mutual trust and respect for the patients under consideration. With respect to exploring the exact components of therapeutic relationship, first and foremost the professional boundaries and the different between professional and personal relationships so that the patient feels comfortable while being assessed or treated (Nursingmidwiferyboard.gov.au, 2018).

Section A

The next most important element of the therapeutic relationship is the effective communication and working alliance, which is by far the most important aspect of establishing a sound therapeutic relationship. In this case, the therapeutic relationship for the culturally diverse populations must encompass communication that is respect of the culture, dignity, values, believes, and rights of the patient under consideration (Gelso, 2014, pp 117-120). The next most important element of the therapeutic relationship is the shared decision making where the nursing professional caring for the patient must recognize that patients are the experts of their own life and lived experiences. Hence, the nursing professional will require to support and encourage them with adequate health related resources to take health related decisions on their own. Next, safeguarding and advocating the autonomy and legal capacity of the patients is the penultimate requirement of the therapeutic relationship. Lastly, the last component of the therapeutic relationship is cultural safety and appropriateness, which helps the nurse adhere to person centred care (Nursingmidwiferyboard.gov.au, 2018). However, as argued by Janis, Burlingame and Olsen (2018, p 105), therapeutic communication also encompasses components of alliance, cohesion and empathy as essential elements of therapeutic relationship.

The therapeutic relationship between the patient and the nursing professionals acts like a facilitator which not only eases the process of care delivery and receiving, but enhances the comfort and respect between both parties helping the patient to freely express their doubts and grievances regarding any care activity (Wilkinson, Rance & Fitzsimmons, 2017). The therapeutic relationship had also been extremely necessary for the care scenario as well. In this case, the patient who had been an aboriginal women, required a vaginal examination. Now it has to be mentioned that vaginal examination is a procedure that is extremely personal and is associated with negative experiences and extreme discomfort and embarrassment for one-third of the women that have to go through such a procedure (Ibáñez-Cuevas et al., 2015). For a conventional and traditional culture such as the aboriginals, such a personal and embarrassing examination can be interpreted offensive and violation of the cultural beliefs, principles and ideologies for the patient. The case analysis indicates that Michael had informed the patient about the need for the vaginal examination but he failed completely in taking her permission before doing so and ensuring that the patient is comfortable with the vaginal examination happening. As a result, the patient felt that she had no other choice but to complete the assessment and then filed a complaint against Michael for lack of cultural safety in the care experience. The lack of establishment of therapeutic relationship is evident in the case study. It has to be mentioned that therapeutic relationship encourages positive and effective interaction along with promoting openness and transparency in the communication procedure (Brown et al., 2016). It facilitates an empathetic respectful and dignified interaction with the patient which helps a patient feel being valued and respected. The benefit of establishing an effective therapeutic relationship with the patient in this case encompasses Michael being able to understand the ideals, principles and cultural requirement of the patient and would have been more careful with the vaginal examination; ensuring communicating about the vaginal examination and whether she is comfortable with it. Having effective communication which is an integral part of therapeutic relationship would have helped the patient freely express her objection to the vaginal examination rather than feeling helpless and having no other choices (Dell et al., 2016).

Section B

Section B:

The NMBA registered nursing practice standards and the ethical code of conduct serves as key framework models that help the nursing professionals engage in ethical, effective and successful practice all the while abiding by all the key legal legislations and protocols (Nursingmidwiferyboard.gov.au, 2018). In case of therapeutic relationship as well, the impact of the NMBA registered nurse practice standards and ethical code of conduct is extreme on helping the health care professionals understand how to establish therapeutic relationship with the patient. Michael had required to undertake a vaginal examination of an aboriginal patient; vaginal examination being already an embarrassing and private procedure that a considerable percentage of women feel an aversion to. For the aboriginal culture where body language, gesture and touch is associated with many restrictions and principles, an assessment like vaginal examination undoubtedly is associated with disagreement and disinterest. In this case, Michael had not been able to successfully implement the therapeutic relationship in this case scenario, and it can be deduced that Michael had not been following the protocols at all. Although the influence of the ethical code of conduct and NMBA registered standards cannot be ignored in a case of ethical dilemma like this.

First and foremost, considering the registered nurse practice standards, the therapeutic relationship encompasses the whole second standard for the patient. Therapeutic relationship is based on 6 principles, respect, dignity, empowerment, advocacy, open communication and connection; and unfortunately none of the above mentioned principles were addressed by the practicing nurse in this case study (Wilkinson, Rance & Fitzsimmons, 2017). As per the practice standards, the nurse must be sensitive to the situation of the patient and respond in a manner that reflects respect, compassion and kindness. As per the standard 2.2, the effective communication must also be concurrent with respecting the dignity, culture, values, principles, beliefs and rights of the patient. While addressing the woman, Michael knowingly or unknowingly had been expressed a paternalistic attitude where he assumed just informing the patient that he will perform a vaginal examination had been enough. This practice undoubtedly had been a violation of respect, cultural safety and informed consent protocols, which could have been avoided in case he abided by the steps of the code of conduct and practice standards documents (McKenzie & Brown, 2017).

Exploring further, the ethical code of conduct dictates that the impact of cultural assumptions must not influence the care that is being provided by the nursing professional. One of the most important requirements of the cultural safety and person centred care is to respect the uniqueness of the patent and provide a care that is individualized for the patient taking into consideration the wishes and grievances of the patient, even if it might clash with planned care, while challenging bias and personal assumptions is a requirement of providing culturally safe care to the patients, Michael ended up inflicting his assumptions and understanding on the patient instead of asking her whether she agrees with the vaginal examination being conducted by a male nurse at all (Güne? & Karaçam, 2017).

Section C

On the other hand, abiding by the NMBA registered nursing practice standards and ethical code of conduct has been reported to have a marked positive influence on the therapeutic relationship and care delivery process. Elaborating more, the standard 2 requires the nurse to be addressing the individual cultural and traditional beliefs of the patient while planning care and communicating with the patient in a culturally appropriate manner with best practice evidence the need for vaginal examination in her case and the option of having this assessment done by a female employee (Nursingmidwiferyboard.gov.au, 2018). This could have had an extremely positive influence on the therapeutic relationship in this case and would have helped the woman feel comfortable enough to experience her doubts and disagreeme4nt to the procedure before it happened.

Section C:

Cultural safety can be defined as the manner of care delivery that takes into consideration the cultural identity of the patient, their beliefs, principles, lived experiences and individuality all the while designing care that is devoid of any bias, discrimination or belittling. However, the care delivery for the patients even in the present day scenario is affected by the inherent paternalism in the society which is equally reflected in the health care scenario as well (Lee, 2017). It has to be mentioned in this case, that the aboriginals of Australia have lived through more than century of physical and emotional trauma from the colonial period, especially the women (Espín, 2018). Even through the societal position and status for the aboriginals have improved, the age old paternalistic decision making framework in the government and in turn in the health policies are still affecting the health care delivery of the aboriginal women (Zubair, 2015). According to Cooley (2015), the aboriginal or indigenous women are subjected to poorer health outcomes and reduced social and emotional wellbeing as compared to the non-aboriginal women. It has to be mentioned that the paternalistic attitudes have been predominant in the society until the 1900s, and even the feminine empowerment in the 20^th and the 21^st century has not been able to eradicate the paternalistic views and behaviours towards the culturally diverse and socially disadvantaged groups of women (Dorfmann, 2015). This case study is also indicative of the paternalistic attitude of the nurse who did not find it necessary for him to ask the aboriginal woman regarding whether or not she wanted to have the vaginal examination done by a male nurse or even she was at all agreeing to such a private examination being done with her.

Now relating the principle of paternalism with health care scenario, it has to be mentioned that paternalism is closely related to the principles of non-maleficence and beneficence and can be traced back to the Hippocratic approach to care. On a more elaborative note, clinical care providers that followed the principles of paternalism engaged in care practices that they assumed or believed to be effective for their patients, to some extent mimicking the role of a parent (Dorfmann, 2015). However, paternalism is an ethical principle that overlaps the clinical ethics of autonomy, on a more elaborative note, while following the principles of paternalism the care provider violates the right of the patient to exercise autonomy, which is a very important aspect of patient centred care. As opined by Murgic et al. (2015), the primary focus of the concept of patient centred care is to provide the right to decision making and planning their own care to the patient, prioritizing the right to choose each care activity that they participate in. Patient autonomy, one of the six fundamental ethical principles of nursing care, allows the patient with this opportunity to refuse to anything that they are uncomfortable with or are unsure of; hence, it can be stated that integrating patient autonomy in the care practices strengthens the patient centred-ness and cultural appropriateness of the care provided to the patients. On the other hand, paternalism invokes patient autonomy by not letting the patient express their choices which had been the case for the aboriginal women undergoing virginal examination in this case study as well (Lepping, Palmstierna & Raveesh, 2016). Hence, it is clear from the evaluation that care approach taken by Michael for the patient in the case study bears close link with paternalism principles and violated patient autonomy which is a fundamental element of culturally safe patient centred care.

Conclusion:

On a concluding note, it has to be highlighted that health care is one of the most basic needs of human life, and it is crucial for the health care delivery to be devoid of any discrimination and disparities. This case study represented a scenario, where the impact of racial bias coupled with gender bias affected the care service delivery for an aboriginal patient which led to the patient feeling violated and helpless while seeking out the aid of health care. The indigenous advancement strategy of the Australian government has undoubtedly improved the health status and outcome of the first people of Australia, but the predominant and inherent paternalism towards these socially disadvantaged women is still affecting their ability to exercise their rights without facing violation. This case study successfully discovered the impact of paternalism on the cultural safety and patient centred-ness and the care provided and the influence adhering to legal guidance frameworks such as NMBA code of conduct and registered nurse practice standards can instil in avoiding paternalism and enhancing patient satisfaction.

References:

Brown, A. E., Middleton, P. F., Fereday, J. A., & Pincombe, J. I. (2016). Cultural safety and midwifery care for Aboriginal women–A phenomenological study. Women and Birth, 29(2), 196-202.

Communicating effectively with Aboriginal and Torres Strait Islander people. (2018). Retrieved from https://www.health.qld.gov.au/__data/assets/pdf_file/0021/151923/communicating.pdf

Cooley, D. R. (2015). Elder abuse and vulnerability: Avoiding illicit paternalism in healthcare, medical research, and life. Ethics, Medicine and Public Health, 1(1), 102-112.

Dell, E. M., Firestone, M., Smylie, J., & Vaillancourt, S. (2016). Cultural safety and providing care to Aboriginal patients in the emergency department. Canadian Journal of Emergency Medicine, 18(4), 301-305.

Dorfmann, J. (2015). Undermining Paternalism: UNDRIP and Aboriginal Rights in Australia. Harvard International Review, 37(1), 13.

Espín, O. M. (2018). Feminist approaches to therapy with women of color. In Latina Realities (pp. 51-70). Routledge.

Gelso, C. (2014). A tripartite model of the therapeutic relationship: Theory, research, and practice. Psychotherapy Research, 24(2), 117-131.

Güne?, G., & Karaçam, Z. (2017). The feeling of discomfort during vaginal examination, history of abuse and sexual abuse and post?traumatic stress disorder in women. Journal of clinical nursing, 26(15-16), 2362-2371.

Ibáñez-Cuevas, M., Heredia-Pi, I. B., Meneses-Navarro, S., Pelcastre-Villafuerte, B., & González-Block, M. A. (2015). Labor and delivery service use: indigenous women’s preference and the health sector response in the Chiapas Highlands of Mexico. International journal for equity in health, 14(1), 156.

Janis, R. A., Burlingame, G. M., & Olsen, J. A. (2018). Developing a therapeutic relationship monitoring system for group treatment. Psychotherapy, 55(2), 105.

Lee, V. S. (2017). Political determinants and Aboriginal and Torres Strait Islander women: don’t leave your integrity at the political gate. Journal of public health policy, 38(3), 387-393.

Lepping, P., Palmstierna, T., & Raveesh, B. N. (2016). Paternalism v. autonomy–are we barking up the wrong tree?. The British Journal of Psychiatry, 209(2), 95-96.

McCabe, J., & Holmes, D. (2014). Nursing, sexual health and youth with disabilities: a critical ethnography. Journal of advanced nursing, 70(1), 77-86.

McKenzie, J., & Brown, A. (2017). Yarning about cultural safety in midwifery practice for Aboriginal women. Women and Birth, 30, 5.

Murgic, L., Hébert, P. C., Sovic, S., & Pavlekovic, G. (2015). Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country. BMC medical ethics, 16(1), 65.

Nursing and Midwifery Board of Australia - Safety and quality guidelines for nurse practitioners. (2018). Retrieved from https://www.nursingmidwiferyboard.gov.au/registration-and-endorsement/endorsements-notations/safety-and-quality-guidelines-for-nurse-practitioners.aspx

Wilkinson, W. M., Rance, J., & Fitzsimmons, D. (2017). Understanding the importance of therapeutic relationships in the development of self-management behaviours during cancer rehabilitation: a qualitative research protocol. BMJ open, 7(1), e012625.

Zubair, A. (2015). Effects of stigma on therapeutic relationships. Australian Nursing and Midwifery Journal, 22(9), 34.