Of Nurses, Ethics And Law By Oluwatomi Ajayi

All over the world, Nurses fall within the structure of the general healthcare team where they are expected to safeguard and promote the interest of their patients while enhancing the reputation of their profession at the same time.

Bailliere’s Nurses Dictionary (2002) defines Nursing as the profession of performing the functions of a Nurse. In essence, Nurses are not only qualified in the art and science of nursing, they must have met certain prescribed standards of education and clinical competence, making them to be rightly termed “Registered Nurses.” The general presumption is that Nursing is a female dominated profession in Nigeria; therefore for the purposes of this article, female nurses would be considered synonymous with male nurses.

No doubt a Nurse possesses specialised skill, knowledge, experience and training well beyond that of the average lay person. Although a Nurse is not a medical Doctor, she is said to be familiar with medical terminologies, symbols, abbreviations and terms not understood by all. As a registered Nurse, she must have acquired and successfully passed the formal training in that field and possess the license to practice. Same apply to Midwives who must equally have been trained and certificates obtained in a registered school of Midwifery. Please note that auxiliary Nurses do not fall within the realm of registered Nurses as they lack the required training, expertise and professionalism.

In Nigeria, the Nursing and Midwifery (Registeration etc) Act of Cap, N143 Laws of the Federation of Nigeria 2004 provides that the Nursing and Midwifery Council of Nigeria is the only legal, administrative and statutory body charged with the responsibility to regulate the standards of Nursing and Midwifery practice and code of conduct in the country. This statute which relate to the ethical Nurse and patient relationship is mostly universal in nature for it is rare to see a wide gap between the ethics governing the Nigerian Nurse and her foreign counterpart, right from the Florence Nightingale Pledge of 1893, Nurses Pledge of 1950, American Nurses Association Code for Nurses, International Code of Nurses (ICN) and down to the National Association of Nigerian Nurses and Midwives (NANNM) Code of Ethics.

The overall objective is that Nurses have ethical responsibility for patients’ lives and well-being and while in the course of that, they must not undermine or bring the reputation of the Nursing profession into disrepute. Some unethical behaviours constituting misconduct for which Nurses and Midwives can be removed or suspended from the professional register, are listed as follows:

1. A Nurse should take instructions from a doctor and act strictly on the instructions given. (Barnett v Chelsea and Kessington Hospital Management Committee (1969) 1 QB 428). This presupposes she must acknowledge any limitation in her job description, knowledge and expertise and decline duties that falls within the Doctor’s competence. The caveat is Nurses should not perform tasks which outstrip their training. However, it has been argued that a Nurse can in certain cases, query potentially injurious orders given by a Doctor in a manner that preserves the Doctor’s ego and role in the healthcare hierarchy.(Patrice W. Iyer 2002)

2. A Nurse should not divulge or disclose personal information she receives from the patient to a third party or else that will be infringing on his right of privacy. A Nurse should therefore ensure unauthorized persons do not have access to patients’ medical records. The Nurse should also ensure that patient’s records are maintained and well-kept so that when the patient comes for consultation, it would be done with ease and patient will not be kept waiting unnecessarily.

3. A patient should understand what he is getting into. It is therefore wrong for a Nurse to harbour the erroneous impression that patients cannot understand medical information. This could lead to a situation where patients are misinformed during routine tests such as in checking the pulse, blood pressure, patients’ recovery and treatment decisions. In Montgomery v Lanarkshire Health Board (2015) UKSC, 11, the court stated that it is a questionable generalisation to believe patients are incapable of understanding medical matters and that times have moved on from the “Doctors Knows Best” approach since there are so many other sources of information available to patients through the internet, patient support groups, drug labelling etc.

4. It is unethical for a Nurse to label and stigmatise a patient with the disease or ailment affecting him. For example, depicting the patient with names such as ‘that man with prostrate, ‘HIV Man’ or ‘breast cancer woman’ is an abuse of the Nursing profession.

5. The Nurse’s duty is to save lives. Challenges such as shortage of Nurses, serious pressure of work and lack of upgraded facilities in the hospital are no excuses for laxity in saving lives. For example, the Somali Medical Association derived its Nursing Code of Ethics in Islam from a verse in the Holy Qur’an in which Allah says “If anyone has saved a life, it would be as if he has saved the life of the whole of mankind” (Al-Mai’dah 5:32).

6. In the course of her duty, professional demeanour is important. A Nurse must not be hostile or impolite to patients in order to create fear or demand respect. She must not add to the patient’s problem but rather be calm in order for her to stabilize the patient. There should be no preferential treatment or discrimination.

7. A Nurse should not dismiss the patients’ concerns and must realise each patient is unique requiring individual assessment. A patients’ choice must be respected except it has to do with a minor, an unconscious patient or a mental patient while female patient’s preference for a female nurse rather than a male nurse should equally be respected. Every patient has a right to hold opinions and exercise his freedom of expression without interference. Therefore, the Nurse must appreciate that consent, whether oral or written can also be withdrawn any time. In Toews v Weisner (2001) BCJ, 30, a public health Nurse was found to be liable in battery for vaccinating an 11-year-old plaintiff against Hepatitis B. The Nurse had noted that the plaintiff’s parents had given a verbal consent to the vaccination and she proceeded on this basis even though the plaintiff informed the Nurse that her parents did not want her to be vaccinated. The Court held that the record of the plaintiff’ parents verbal consent to the vaccination was made in error.

8. A Nurse should not embark on a sexual relationship with a patient especially if he is vulnerable. For example, an adult Psychiatric Nurse in the United Kingdom who married her patient was found guilty of misconduct but because she had an unblemished nursing career, she was given a caution.

9. Even though it is allowed that a Nurse can consider the views, culture and beliefs while providing care, a Nurse should as a duty place medical ethics over her personal faith or ethics. All manner of prejudices are unprofessional. For instance, it would be unethical for a Jehovah Witness Nurse who out of her religious convictions does not believe in taking blood transfusion, decline to administer blood transfusion on a patient who consents to it. On no account should a Nurse out of her personal belief in ‘spiritual or demonic attacks’ advice the patient to seek treatment from an herbalist or a pastor. Infact, there are few cases where Christian Nurses have been suspended or dismissed for preaching religion to patients. Recently, a Nurse has been relieved of her job at a UK hospital for discussing Christianity and offering to pray with a patient before preparing for surgery.

10. In extension of the Nurse’s duty in a typical Nigerian clinic where she usually dispenses drugs under the prescriptive direction of Doctors, she is trained to know that dispensing involve checking the validity of the prescription, giving the appropriate medicine that is being prescribed for a patient and labelling or providing information leaflets for the patient.

11. A Nurse should generally be aware of the definition of standard of care, what constitutes negligence; professional malpractice and misconduct; patient’s constitutional rights and autonomy; care in emergencies and breach of professional standards, etc

12. Nurses on duty who have been found to be drinking alcohol or who steal drugs intended for patients or who sell items to patients or who are indecently dressed are all engaging in acts constituting misconduct. In Columbia, a Nurse who danced just for few minutes to pop music and filmed herself while in the middle of an operation was sanctioned after she posted the video online.

Historically, Nurses are generally conceived to be handmaidens or subordinates to medical doctors so much so that with regard to expert evidence, Doctors used to serve as a voice for Nurses until the late 1970’s and early 1980’s when the court changed the status in the case of Maloney V Wake Hospital System & Avet v Mc Cormick (262SE, 2D 680 North Carolina 1980) where the court held that “the role of the Nurse is critical to providing a high standard of health care in modern medicine. Her expertise is different from, but no less exalted than that of the physician.” In Young V Board of Hospital Directors (#82-429 Florida 1984) the court held that a Psychiatrist was not familiar with the daily practices of a Psychiatrist Nurse and therefore could not testify to a deviation from nursing standard.

In addition to the various nursing code of ethics and the constitutionally guaranteed fundamental human rights provided under the Law, the ideal is that Nigeria should endeavor to emulate the redress mechanisms outlined under Article 2 of the European Convention on Human Rights which empowers each State through its legislative and administrative framework coupled with an effective judicial system to make regulations compelling public or private hospitals to take appropriate measures to protect patients’ lives and hold those responsible accountable. In Dodov v Bulgaria (No. 59548/00/2008), the European Court of Human Rights indicted the failure of supervision of a nursing home staff who could not account for the disappearance of the applicant’s sick mother who had Alzheimer.

Although an average Nigerian patient overlooks a Nurse’s misconduct, members of the public should not shy away from reporting any unethical or unprofessional act/conduct of a Nurse (whether in private or public hospitals). Reports can be to the Nurses and Midwifery Council of Nigeria for appropriate sanctions. In this clime, it is common to hear some Nurses calling themselves or assuming the position of Medical Doctors. This is totally wrong. Although in reality, Nurses and Midwives do carry out simple operative techniques or handle delivery cases, they can do so if they tell their patients they are really Nurses and not Doctors, which means they must ask for permission or consent to do so while obtaining the backing of their hospital in the process. For example, in the UK, a Nurse was reported to have assisted in removing a patient’s appendix in the presence of a Surgeon. This is possible so far the Doctor is convinced that the Nurse is competent and that what is done is in the best interest of the patient. In Royal College of Nursing v Department of Health & Social Security (1981) 1 ALL ER, 545, it was held that “the Doctor has responsibility for the whole abortion process and he is in charge of it throughout. It is he who decides what is to be carried out and that the Nurse’s action is done under his written instructions.”

It is significant that professional ethics should be the Nurse’s guiding principle and practice where she is bound by her profession’s code of conduct in order to ensure that the best interest of the patient is protected. For according to Lord Denning in Roe v Minister of Health (1954) 2 QB, 66, “we must insist on due care for the patient at every point.”

*Oluwatomi Ajayi is Legal Researcher & Member, African Women Lawyers Association (AWLA Nigeria) Source: This Day Newspaper, 22 November, 2016