Ethics is an integral part of nursing practice, particularly in a community setting where nurses are given the autonomy to provide care in a patient's home. Ethics is defined as a set of moral principles and beliefs that guide community nurses in making decisions, often ensuring a delicate balance between individual rights and the broader needs of society (Beauchamp and Childress, 2001).
Ethics is often subjective and, unlike law, has more ambiguous parameters. There is a breadth of ethical theories, for example deontology focuses on the duty placed on nurses in caring for their patients, such as the duty to be honest, while utilitarianism looks at actions that are more likely to benefit society as a whole (Racher, 2007). However, the subjective nature of ethics can result in a lack of definitive answers that guide nurses in decision making. Beauchamp and Childress (2001) developed a set of principles, also known as principlism, to ensure that decisions are made carefully and thoughtfully.
The first principle espoused by Beauchamp and Childress is autonomy. Ensuring that the patient is able to make choices without influence from either the community nurse or others is an integral part of informed consent. However, autonomy in decision making is often dependent on the information provided to the patient—is it sufficient, clear and without unnecessary jargon? At times, the patient may look to the community nurse for advice and guidance, and it is important to ensure that this guidance is factual and as objective as possible. It is also important to respect the patient's decision, even if the healthcare professional does not agree with it. Nevertheless, it is natural for a nurse to question a patient's decision from an ethical standpoint, especially when a patient refuses lifesaving treatment. In such situations, a more paternalistic approach—where the nurse might feel compelled to intervene and force the patient to receive treatment—could potentially save the patient's life. The patient may later be thankful to the nurse for taking this decision on their behalf. This is sometimes referred to as consequentialism, when the short-term effect may be detrimental to the patient, but the long-term effect is a positive and good outcome. Conversely, it may not lead to a positive and good outcome, and the patient may blame the nurse for taking a decision that conflicted with their wishes. Therefore, even if the decision is one with which a nurse may disagree, it is important to respect the patient's choice.
The second principle is beneficence. Beneficence is taking an action that is in the patient's best interest. When the community nurse is caring for a patient with full mental capacity, part of beneficence is to respect the patient's autonomy. Failure to respect the patient's autonomy could result in the nurse adopting a paternalistic approach, assuming that they know what is best for the patient (Pope et al, 2016). However, for patients with limited mental capacity or those who are under the age of 13 years, the nurse may have to make decisions about their care and treatment because the ability to give valid consent is compromised. These decisions are rooted in the patient's best interest and include advocating for the patient with other family members and health and social care professionals, when necessary.
The third principle is nonmaleficence. This simply means to do no harm. However, a distinction has to be made between avoidable harm and non-avoidable harm. While giving an injection may cause harm, this will be considered non-avoidable harm where the intent is to relieve the patient from either pain or infection.
The fourth principle is justice. This is the most ambiguous principle because justice is a subjective term. In essence, it means providing an equitable service to patients. However, patients have varying degrees of need, which means that equality and equability is not always possible and some patients may require more time and resources than others. This principle is about being fair to patients, and not being judgemental or unkind to them.
When considering dilemmas or issues from an ethics perspective, it is important to remember that a decision may be ethical, yet not necessarily legal. For example, a healthcare professional may believe in assisted dying, which is not currently legal in the UK, although efforts are being made in parliament to change the law. This belief is grounded in an ethical perspective, where individuals should have the right to make choices regarding their own death, if possible. On the other hand, it may be considered unethical to promote euthanasia because of concerns about potential coercion or religious beliefs.
Community nurses may also be required to promote public health measures that can be controversial and potentially perceived as unethical by some individuals or groups. For instance, administering influenza vaccinations can be seen as a classic example of utilitarianism, as the vaccine provides protection to members of society. However, some individuals may view it as a coercive and oppressive state-led policy, which contradicts the state's duty to support individual choice. Other areas that can be seen as oppressive include issues such as anti-smoking campaigns and the imposition of taxes on unhealthy foods, which are often viewed as paternalistic in their approach (Pope et al, 2016). However, most people also expect the state to take responsibility for its citizens, and public health measures are often a part of this responsibility.
Ethics is complex – taking a deontological approach, which asserts a duty to be honest with patients, can be undermined by situations where community nurses may withhold the truth or be less than completely honest, depending on the circumstances. For example, if a patient were to say, ‘I'm so sorry, but my house is messy,’ and the nurse responds, ‘No, it is not messy at all’, would this be considered unethical? From a deontological perspective, which upholds the duty of honesty, the nurse's response could be seen as unethical because it fails to adhere to the principle of truthfulness. Deontologists would argue that by not being honest, the nurse is not fulfilling their ethical duty. One approach is to act in a virtuous manner. Virtue ethics focus on the intention behind an action, examining whether the motivation for the lie was good or bad, rather than simply judging the action itself. If the intention was good, then it may be permissible to lie. However, it can diminish trust between the patient and the carer, and affect the therapeutic relationship. In such a scenario, if the nurse responds that the house is not messy, the patient may simply see the response as a lie. When discussing serious topics regarding treatment and care, the patient may lose confidence in the nurse if they feel that the nurse is not being fully truthful with them. This can lead to conflict with the Nursing and Midwifery Council's professional code (NMC, 2015). Section 14 states that nurses need to ‘be open and candid with all service users about all aspects of care and treatment, including when any mistakes or harm have taken place’. Nurses may find themselves in conflict when taking a virtuous approach, as it could clash with the regulator's expectations.
While acting ethically can be a challenge for nurses because of its subjective nature, trust is a key component of community nursing. Maintaining trust with patients encourages community nurses to act with honesty and integrity, while respecting individual choice. At the same time, nurses must support public health measures, even if these sometimes conflict with their ethical views. Ethics must be integrated with legal and professional duties, and sometimes legally and professionally nurses have no choice but to act, even if it does not align with their personal ethics or feelings.