Discuss national and international ethical frameworks for health care that influence ethical decision making in practice;

Topic: Comparing interprofessional approaches (nursing and midwifery) to an ethical issue

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Comparing interprofessional approaches (nursing and midwifery) to an ethical issue
To COMPARE and CONTRAST interprofessional approaches to an ethical issues in the practice setting. Each interview of a health professional discussing an

ethical issue in clinical practice. The topic is on consent.
Similarities and differences between the two interprofessional responses (NURSING and MIDWIFERY) to the given ethical issue are to be identified and students

should discuss how the two professions might interact and collaborate in the given ethical issue in practice.
Students need to present an academic essay (not in the first person) that responds to each of the unit Learning Outcomes:
(answer these questions)
1. Discuss national and international ethical frameworks for health care that influence ethical decision making in practice;
2. Explain the Code of Ethics relevant to different health disciplines, and identify if there are no such Codes and how this may influence decision making and

patient care in scenarios where there is an ethical dilemma.
3. Differentiate between ethical and legal issues in health care in consenting vulnerable patients cohorts
4. Identify social and spiritual factors that influence the health professional values and beliefs in ethical decision making
5. Apply ethical normative frameworks that a health professional may appeal to in defending their position, individually and collaboratively, on moral and ethical

dilemmas encountered practice
This will enable students to structure their essay more succinctly. With regards to this permission to use headings in the essay, please note that the five questions

that are part of the headings are not to be included in your overall word count. The wording for these questions is approx 100 words therefore students should aim

for 2100 words in their word limit in using these questions in their essay ok.
An introduction and conclusion to the essay is still required, as well as a final list of references which needs to be presented in APA citation format.
As the essay word limit is 2000 words, consider evenly spreading your word limit over the five questions, making sure that you respond to each question in the

same amount of depth. The introduction should be between 100-150 words and present a framework for your essay – so indicating to the reader what the main

points are about to be discussed in the subsequent paragraphs or sections. The conclusion is usually approx 100-120 words and presents a summary of the key

points in your essay paragraphs or section. In academic essay writing, there is usually no new information presented in the conclusion or further direct quotes.
Please note that this essay is not to be presented in the first person but using academic language.
Students are expected to undertake self directed literature research as well, and incorporate at least two references for every 10% of academic weighting for the

essay. So as this assessment task is 45% that would be a minimum of 10 references for this essay to be incorporated into the discussion.

OK ‐ So this is a professional interview of a Health Care Professional
My name is Cameron Peak, I am one of the LICs for this subject and with me I have Peta Gale. Peta can you tell me a bit about yourself?
Yeah ‐ Hi Cameron, thanks for inviting me.
You’re welcome.
That’s alright. So my name is Peta Gale. I’ve been a registered nurse for 25 years and I’ve worked almost exclusively in the area of child and adolescent health, so

have spent large portions of my years at the Royal Children’s Hospital in Melbourne in the cardiac and renal unit there, looking after children at the ages from

neo‐nates all the way through to young adults. So I’ve had both acute and chronic experience, it’s just like with children of pretty much every age that exists.
OK. Sure. The purpose of this interview is to be talking about some of the healthcare ethical issues and considerations put in making a professional practice, and

we are going to deal mainly with consent and informed consent. Can you tell me what you think the key components of informed consent are in the provision of

Yeah, so I see that there are 4 key areas or components to informed consent. There is thecompetency of the person who is giving the consent. So obviously if they

are not deemed competent or at a level where they are able to participate in consent. Obviously there’s disclosure of information so there has to be adequate

disclosure of information of a broad range and covering all aspects. There also has to be understanding by the person who is giving consent, so not only do they

have to be competent they have to be at a level that they can fully understand the information being given to them in a reasonable fashion. And there is the decision

component to actually have consent. There are other areas in the area of paediatrics where this comes into play, but across all healthcare I think competency and

understanding are two of the biggest issues with regards to consent. Is the person competent to give consent and do they actually fully understand what it is that

they are giving consent to.
Sure. Would there be any examples from your specialty where consent is not obtained prior totreatment or care?
Yeah, obviously in really emergent situations. Particularly from my own background in the area of cardiac surgery. If we obviously had a child on the ward that

had been to surgery previously for an elective or non elective surgery and then required to return to theatre, there is often no time to get the parents on the phone to

actually obtain consent or inform them. We had to take the child back. In emergency situations I think it is always valid. We are saving the child’s life, therefore it

is not always possible to get consent prior.
OK. Do you think issues like paternalism is ethically justifiable in healthcare treatment.
This is a really interesting question, given the paediatric context of my speciality area, in terms of every child under the age of 16, consent is give for them by their

parents. So in every instant, paternalism is used. It’s just like for consent. Whether or not it is justifiably right for children between the age of 10 and 16 who

would potentially be deemed competent, who’d just like to give their own consent, even though they are legally not allowed to give consent as they are not

considered adults or young adults, but certainly in society we demand that 10 and 11 year olds are able to make reasoned and reliable decisions, so especially in

areas of chronic health, why should they actually not be given the right to make their own decision in regard to health care and their own consent in regard to

treatment options.
OK. Is it easy or how easy is it for members of the nursing profession to advocate for a patient or client? Particularly if you believe adequate consent was not

obtained for a particular treatment.
In paediatrics it is actually very difficult to advocate for the children because the parents right supersede the children, so you are talking about areas where it may

be you have had a conversation with a child or young adult, and they fully grasp and understand what’s going on, you can facilitate conversations with their parents

with regards to that, but ultimately the parents legal right win out over the child in those instances. So it is actually sometimes extremely difficult to advocate for

the children in terms of the ability to give consent or you know, for procedures they may not necessarily want to undergo. So …. yeah.
OK. What sort of groups are particularly vulnerable in your clinical practice when it comes to ensuring that there’s informed consent given to the provision of

clinical care?
Umm, I looked at this question and I think this is a really difficult question to answer in a paediatric context. One of the issues and considerations I gave when

looking at this, was children of parents. When we look at this, if we go back to the original question about the key components of informed consent, if we consider

the parents are not necessarily competent or don’t have a level of understanding of what they are actually consenting for, then that group of children are really

vulnerable as they are having decisions made for them by people who are not necessarily, even though they are parents and have their child supposed best interest at

heart, they are not necessarily competent or have a level of understanding to actually make those decisions with regards to consent in the first place. So we do

actually have to be very careful about that group of children. There’s the whole group of children who come from low socio economic backgrounds, or immigrant

backgrounds and they are always vulnerable when you are talking about cultural clashes as well and I’m just going to go straight into the next question you are

about to ask on my piece of paper here, as there seems to be a nice little seaway there. That there’s a clash of cultures, is very significant, so people who emigrate

to Australia who have other beliefs and rights with regards to what they consider to be the best way to bring up their children, but then clash with western beliefs

and rights with regards to that. One of the biggest controversial ones that I don’t really want to get into, but there is the circumcision of young African girls, which

still occurs in Australia today and that happens without their consent, and you know there are no provisions for that so they are a really vulnerable group that we

really need to step up and protect.
OK. Finally, we talk about ethics and normally use allot of national / international ethical frameworks. What sort of national and international frameworks are

available to you to ensure ethical practice ‐ particularly when it comes to informed consent?
Obviously we are bound by all the ethical considerations and frameworks that exist for registered nurses. So the NMBA competencies, our legal obligations, but

when it comes to children, Australia is also a signatory to the World Health Organisation International Rights Of The Child. So we are actually bound by that to an

international level too when it comes to consent and ensuring what happens to the children and they are given the best possible opportunities. So in terms of

consent there shouldn’t be any consent that’s given for anything that is not in those children’s best interest or would actually hamper or impede their ability to

actually achieve their full potential. So we do have an extra set of international ethical frameworks that we need to adhere to in terms of the World Health

Organisation when it comes to children as well.
Sure. Ok, that’s all the questions I have for you today Peta. Thanks very much for your time and answering questions regarding ethical issues of consent in

healthcare, particularly as a registered nurse.
Wonderful, thanks very much Cameron.
Thanks Peta.
So we will start the interview now.
We’re interviewing health professionals about ethical issues relating to consent in practice and Jane is a midwife by profession and has her PHD in this area and

has been part of our teaching team in Melbourne for quite a long time – many years. So thank you Jane for giving us your time.
No problem.
Jane, the first question I would like to ask you with relation to this topic is what do you think are the key components of an informed consent – the provision of

healthcare, but particularly focusing upon the care of the woman with relation to midwifery and also with regards to the infant as well?
OK. So one of the most important things is that you must have an understanding that the person has the capacity to make the decision that you are asking them to

make. So we have 2 sorts of issues there, it can be that you are dealing with an infant so where the parents make the decision, or you might be dealing with a young

woman and perhaps she might not be of an age where we consider that she can have consent. So you know, 13 or 14 and she’s pregnant, you know, we have to

think about how we deal with that. I have to think about making sure that the person is given all of the information about the procedure or the test that we are

asking for and that has to be given in a really un‐biased manner so that I am giving all of the risks and benefits of that test or whatever it is -including the

likelihood that complications or whatever occurring, so it is about providing the evidence and making sure we do evidence based practice. And even if that means

that I understand the information that I am giving, so it’s really important that my level of knowledge is really high and if I don’t know, then I need to seek out that

advice or guidance from another practitioner. And the final thing is that there is no opinions, so it is really important that even though I might have a different

belief to the person I am talking to, I have to respect that persons right to hold a different view from what I have and we see this often in midwifery. For example, a

woman might want to give birth in a particular manner, let’s say, an underwater birth, and I might think that this is not particularly safe for this woman, but I need

to give the information telling her the risks and benefits, but not actually steering her towards what I believe.
I’m interested in what you were saying about the pregnant woman that may be a minor, like mightbe a teenager, and just out of interest, what sort of …. to have an

informed consent of that young girl, how? What sorts of steps are important there? Who are the people that are involved usually that you find in your clinical

Normally we would involve that persons parents, or their guardians and that would be with consultation with her, so you know, if it was a girl that was 13 for

example, then I would be saying to her, I think it would be really good if we could speak to your mother or father and discuss, are you ok with that? Normally that

would be …. she would already be saying I want mum there or I want my guardian there, and we can get around the situation like that.
Mmm …. Jane, from your extensive clinical background and in your specialty area, can you think of an example where presumed consent might occur where you

actually don’t get consent formally from the woman, but where a presumed consent experience may occur?
There’s a few situations where that does happen in midwifery and particularly I think in very urgent emergency sort of situations, where we may not even actually

get verbal consent from the woman, but we usually would. So for example, if a woman had some emergency situation like the cord prolapsed, where the cord

dropped in front of the baby’s head before the birth. This is quite a dangerous situation for the baby because the cold air can stop the blood running through the

cord from the placenta to the baby and so we need to get that baby out quite rapidly and so I might be giving instructions to that woman to get her into a position

and then take her for emergency C‐section. There is an assumption by myself and probably other practitioners, that she would consent to that situation because it is

an emergency situation.
Mmm…..Or it might happen if we don’t give all the details to someone. For example, if there was a situation where a woman was going to have forceps or assisted

birth, we may not include all of the information about what that procedure might entail. I think in a way you are not getting consent in that, or presuming that

there’s consent. For example, the obstetrician might bring on the forceps and assist with the birth of the head, but at the same time, he or she may cut an

episiotomy to make the opening larger, but we haven’t specifically asked for the consent to the episiotomy. We’ve asked them the consent for the forceps or the

vontuse. So there’s a presumed consent that she would say yes she would have that because it is part of a procedure I guess.
So … sorry, go on.
I was just going to say sometimes we might also see that we steer people towards a decision that we might want them to take. And I call it protective steering, and

there has been some arguments written about this, where we push the person in a direction and we don’t give them quite all the information they need to make that

decision. For example, most babies in Victoria have Vitamin K after birth and so I might put that to the woman in that fashion. So you know, and then she just says

well if everyone has it, then that’s fine and I don’t quite give her the opportunity for that consent tohappen.
Yeah. I suppose that also leads me Jane to the next question, and probably ties in to what you’ve just said regarding paternalism and paternalism in health care and

whether or not you think in your clinical practice that it’s ever ethically justifiable and it seems to me that paternalism might be a bit of a strong word. I like the

steering point that you made, it seems to me that it is not paternalism but it is …. some might try and make those connections I think between that.
Yeah, I mean I think if you asked me if paternalism is ethically justifiable, I would say no. It’s not. But I think sometimes you think that you know best and it’s not

always the case for the individual and you have to think about that person as an individual. I think that if the person doesn’t want what you are advising them, and

you feel absolutely sure that they understand your advice, then you should accept that they are making their decision and so that’s where it should end really.
Yeah. Jane, how easy is it for members of the midwifery profession to advocate on behalf of their client in the provision of care? Especially if you think that

adequate consent hasn’t been obtained, is advocacy something that you see as being possible in your professional practice?
I think if we are talking about when you are a student or junior midwife, I think it’s one of the mostchallenging parts of our role. But I actually think that in this

course, we do actually try to help students or educate students to be an advocate for women in their care and that we promote an understanding that midwifery is

really based on ethical practice. So that involves working with women in a partnership and that each person in that partnership has equal value in their opinion and

so hopefully that helps the student to be able to advocate for the woman and the code of ethics and the code of competencies is so clear with that. So I think as a

midwife it is vital to know that I am the advocate for the woman and hopefully that we give the students the skills to help them to be able to take up this role and I

found that in my career, that the greater confidence I had in my practice, the easier it was for me to be an advocate for women. So I think that midwifery is caring

for women having a normal life event and that most of them are healthy and able to make decisions for themselves and that they know their body and that I don’t

know their body and so I need to just be very careful the way that I give advice. And so at times, it is difficult to be an advocate, but it’s really, really rewarding

when you can be.
Jane, I’m interested in, also from your experience, of what groups are particularly vulnerable do you believe in clinical practice, when it comes to ensuring that

there is informed consent in provision of treatment or care? So what groups do you think would be that case predominantly?
Well I think all pregnant women are actually a vulnerable individual because they are carrying another life and I think they’re often subjected to views from other

people about how they should be behaving and so even if they don’t ask for advice, people will give it to them. How many times do
we see that people feel quite free to touch a woman’s belly in pregnancy and comment on the size and the shape and the growing uterus and they wouldn’t do that

to someone if it wasn’t in their pregnancy. And sometimes they’re very free to feel very judgemental about a woman’s behaviour in pregnancy. For example, we are

at a party and we are watching someone over there having a glass of wine and she is obviously pregnant. You know people feel free to make a comment about that.

I think a woman is very vulnerable to people’s judgemental behaviours at this time. And we look after women from all walks of life, all ages and we need to be

very respectful of their cultural beliefs and so I think women from non English speaking backgrounds are very vulnerable, as they may not understand everything

we are saying or we are making assumptions that they understand our healthcare system, which is not necessarily true. So, I think that we need to make sure as

midwifes that we use interpreters appropriately and that also, we don’t make assumptions about people just because we look at them and we can make a

generalisation about what they believe. It may not be true. So yeah, I think we need to take all of that into consideration. Yes, there are lots of vulnerable

populations that are pregnant.
Jane, what are some of the cultural / social / spiritual factors that influence decision making you found in the women that you care for, when it comes to informed

consent, and I suppose there might be an example that you can think of to bring that to the discussion with regards to consent.
Yeah, I think, you know, there are lots of different beliefs and practices around birth. It is a very special time in every culture and it’s vital that we don’t make

assumptions just because of that, that someone will be following a certain practice. So each woman needs to be treated as an individual and respected for what she

is and so I think of things like, you know, a certain culture might want to take a placenta home after the birth of the baby. And yet, our culture would tell us that

it’s an infectious waste product that we need to dispose of in a certain way.Yet different cultures might want to take it home and bury it underneath a tree or they

may store it until the child goes to school on its first day and then have a ceremony to honour that placenta for looking after that life until that point. So we need to

be very sensitive to peoples cultural beliefs so that we can advocate for them in a decision making process about that. So you know at times, we’ve said no we

can’t throw away that placenta as it’s very important to that person and we need to store it in a way that will make it acceptable for that person to take home and to

perform whatever ritual it is attached to that particular thing. So you know, it’s very important that we follow the practices that that person believes even if it

doesn’t fit our modern day practice here.
Mmmm. I know earlier when you mentioned about the code of ethics and as midwives in Australia, that is one ethical framework that is part of a professional

approach to healthcare ethics in midwifery. Are there any other national / international frameworks that the midwifery health professionals that are listening to this

interview, can access or are available for them to guide them
in what is ethical practice relating to consent of the woman? Yes, so you know as you said we have the code of ethics for midwives and the competency standards

for the midwifes which are endorsed by The Nursing Midwifery Board of Australia now, but at an international level we look to the International Federation of

Midwives. Our code of ethics is based
on that as well. But they have an international code which acknowledges the woman’s human rights to justice, equality and access to healthcare based on that

mutual understanding of respect and partnership. So their very …. our own standards are based on these international standards and they all stress importance of

information sharing that leads to informed decision making and supports a woman’s right to participate in decisions about their choice for themselves and for their

Yeah, Jane was there any other thoughts that you had that we haven’t covered with these questions that you would like to contribute before we finish with this

I’d just like to say that it is a stressful thing for the student to deal with informed consent sometimes and we have students who actually struggle when they go out

in clinical practice and observe the consent process and can see that it’s not actually fully informed consent that they’re observing so I think it can raise issues for

that student in a moral and ethical way. And so you know if they ask then they should seek the support services that are around in the university for that.
It’s interesting, there is an increasing amount of literature for both nursing and midwifery regarding moral distress and about how there is that challenge for nurses

and midwives in particular to cope with some of those moral dilemmas that come up and being able to, as more so novice practitioners, and how to go about that

and the type of distress it causes. It is an area of ethical scholarship that is increasing and also within midwifery relating to feminist ethics as well so it is

something that if any students are interested in that area, you can do a search and see a little bit more about moral distress and midwifery care or nursing care in

Thanks very much Jane for your time, I really appreciate it and I hope the students find …. especially the midwifery students, find your comments and feedback

really insightful towards assessment.



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