The concept of vulnerability in relation to a fictitious study
Vulnerability is difficult to define. Although everyone is vulnerable to harm, some are more vulnerable than others ( Aday et al, 1993). Vulnerable patients are “exposed and unprotected," susceptible to physical or emotional harm, and unable in one way or another to protect or care for themselves( Lutzen etl al, 1993). According to the NMC report The Safeguarding Vulnerable Adults Act (2006) any adult receiving any form of healthcare is vulnerable. “there is no formal definition of vulnerability within healthcare although some people receiving health care may be at greater risk of harm than others, sometimes as a complication of their presenting condition and their individual circumstances." Where as the Department of Health white paper “No secrets" (DOH, 2000) said “a vulnerable adult is a person ages over 18 years who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or may be unable to take care of him or herself, or unable to protect against significant harm or exploitation". A different view was proposed by Shepard and Mahon (2002) who were of the opinion that vulnerability is a more overarching concept that results from an interplay between family, society, political, and health factors that are infulenced by an interplay between context and an identified problem. Whereas Horowitz et al(2002) defined vulnerability as “‘‘multidimensional construct that can be understood as a process of being at risk for altered health status as a result of inadequate economic social,psychological, familial, cognitive, or physical resources’’ “UNfortunately in our efforts to support families and individuals who we see as being at risk for becoming vulnerable, we treat them in ways that contribute to the vulnerability we are helping them avoid." ( Perry et al, 200…)
Peter is an extremely vulnerable individual, he belongs to many recognized at risk population groups. Peter is vulnerable due to his poor health a proportion of Peter’s health problems is poor mobility, for which he is awaiting an operation for in the next few weeks. His poor mobility makes him vulnerable because this in turn can make him socially isolated, not be able to get out to do shopping, so his nutrition is likely to suffer. Thus he will be more vulnerable to physical health problems. Peter will be dependent on others for help and so susceptible to abuse and exploitation because of this dependency. Indeed this is a real and significant problem a study of abuse and neglect in older adults found that 227,000 people aged 65 years or older in the UK had experienced mistreatment involving a care worker, family member or a close friend( O’keeffe et al, 2006, cited in griffith). Peter’s will also be particularly vulnerable to financial abuse. Peters advancing age makes him vulnerable, because of his age Peter is less likely to receive the healthcare treatment that he needs because of ageism in our society( NMC guidance for the care older people, p6). Peter’s point of view may make him vulnerable, his generation don’t like to think there a burden to society, so he may not seek medical attention. Moreover some elderly patients are very suggestible and over compliant, they do not want to be considered a burden( Speker et al, 2008). Therefore when consent is been sought one must be cautious he is not just expressing these sorts of sentiments, as Peter may be swayed to go ahead with the operation by the views of healthcare professionals and especially his daughter who is very keen for Peter’s operation to go ahead. Confusion could impact of Peter’s linguistic ability. Therefore making him vulnerable as he may lack the ability to express himself verbally in the decision making process, thus making informed consent hard to achieve, and leaving him open to abuse. Peter’s doubtful mental capacity makes him extremely vulnerable, he is open to suggestion and clouding of his judgment. Therefore Peter will need a greater level of support in the decision making process in order to overcome these vulnerabilities and help him to make an informed decision. The NMC The Code( NMC,2008) states that nurses and student nurses have a responsibility to protect vulnerable individuals. The code states that it is the duty of a nurse to act to identify and minimise the risk to patients. One must be alert to and act on suspicions that a vulnerable adult may be subjected to abuse or at risk of abuse.
A crucial issue with any vulnerable adult such as Peter is the issue of safeguarding. “ safeguarding is a range of activity aimed at upholding an adult’s fundamental right to be safe, it is of particular importance for people who because of their circumstances are unable to keep themselves safe".(DOH, 2000) It is everyones responsibility to protect these individuals from abuse and harm. A number of reforms in recent years have lead to the greater protection of these vulnerable individuals. The No Secrets white paper ( DH, 2000) was published with the recommendation that local authorities must now take responsibility for coordinating local multi agency policy, procedures and systems. The Bichard enquiry(2004) was launched after the lack of protection for vulnerable children and adults alerted by the murders of Jessica Chapmen and Holly Wells in 2002. As a result of the enquiry the Safeguarding Vulnerable adults Act 2006 was passed by government in order to offer greater protection of those at risk. The act didn’t actually come in to force until 2009. It safeguards children and vulnerable adults from harm by employees or volunteers. The inquiry also recommended that individuals who want to work with children and vulnerable adults be registered. This is known as the vetting and barring scheme. The Independent Safeguarding Authority (ISA) assesses the suitability of those who want to work with vulnerable people. They do so in partnership with the Criminal Records Bureau (CRB). The ISA maintains a children barred list and an adult barred list for people who are barred from working with these vulnerable people. In the context of Peter these types of safeguarding policies would help to protect him from abuse and exploitation, as individuals who are deemed a risk to his safety would not have any contact with him. However these policies can only go so far as minimizing the risks. The potential for abuse and exploitation of these vulnerable individuals will always be there and it is the responsibility of healthcare professionals to be aware and help protect these individuals.
During 2008 the Department of health carried out a national consultation, entilted “Safeguarding Adults" with the aim to review how successful the No secrets report( DOH, 2000) was at protecting vulnerable adults from harm and abuse. It also aimed to see if the current situation could be improved. One of the key findings was that there was an absence of an adult safeguarding system within the NHS to ensure that any healthcare incidents that raised safeguarding concerns are considered in the wider safeguarding arena. The review also identified the key role that healthcare professionals can play in the safegurading of adults, by identifcation of abuse, harm and neglect, then developing appropriate reponses to it.
Autonomy is respecting that the patient has a choice in deciding what healthcare interventions they undergo, they should be able to make an informed choice about this care. Gillon(1994) defined autonomy as “having three concepts. Autonomy of thought which involves an individual making their own choices using all the information they have available to them. Autonomy of will involves the intention to do something as a result of a decision. And finally autonomy of action which involves doing something based on your decision, such as Peter refusing to consent to the operation based on the information available to him. It is a fundamental value of the NMC code to respect a patients autonomy.
Peter is within his rights to refuse consent for the operation, if it is deemed that he has capacity to do so. To go ahead with the operation when he has refused consent would amount to a violation of his human rights and would be classed as actual bodily harm under the offences against the persons act 1861.(dimmond 200.. p139) We must therefore respect his decision, indeed this is also the view of the NMC, the code sates that nurses must respect and support people’s rights to accept or decline treatment( NMC, The code, p … 2008).
Obtaining consent before any treatment is commenced is a fundamental part of the nurses role, The Code( NMC, 2008) states that you must ensure that you gain consent before you begin any treatment or care. In the case of Peter it will not be the nurse who gains Peter’s consent, but the doctor performing the operation. However the nurse still has a role to fulfill in the consent process. Patients often turn to nurses for advice about their treatment or operation. Here the nurse must act as an advocate for the patient, but must always be aware of the requirements of the NMC professional code of conduct. Consent is a complex field, consent can be either implied consent, for example if a patient offers her arm to be bandaged, her actions imply that she has consented to the procedure. A patient may also verbally consent to treatment and written consent to treatment( Tingle et al, p115). However such in the case of Peter, where the procedure involves an element of risk, then written consent is always preferred( Dimmond, 200.. p139).
However it is not just a simple matter of gaining verbal, implied or written consent. It is imperative that informed consent is achieved in order for any treatment or operation to go ahead. To gain informed consent from a patient one must give the patient all the relevant information and statistics, including risks and benefits. Patients must also be told of alternative treatments and that they have the right to refuse consent to treatment at any time. The aim is that the individual can fully understand the treatment and make their own choice based on the information given to them. For peter to make a decision he must be able to retain sufficient information about the procedure, be able to make a decision of his own free will, and have mental capacity to do so. Mental capacity is a crucial requirement to make an autonomous treatment choice, it is doubtful as to if peter has mental capacity or not. According to the Mental Capacity Act 2005, “a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of or a disturbance in the functioning of, the mind or the brain. It does not matter is if the disturbance is permanent or temporary". The mental capacity act also states that if the patient’s refusal to consent to an operation accelerates their deterioration it must be made absolutely sure that the patient has the capacity to refuse treatment. This would apply to Peter, if he doesn’t have the operation his mobility will decline, therefore one must be absolutely certain of any decisions made.
Peter is an 85 year old man who is inclined to be forgetful. Is his forgetfulness associated with the natural process of aging or it a more enduring problem that is affecting his reasoning and decision making capacity. Schaie (1989) tested cognitive abilities of US citizens in a longitudinal study. Test included measures of reasoning and spatial and verbal ability. A gradual cognitive decline was found to begin in the sixth decade of life. From the eighth decade of life cognitive impairment was found to accelerate significantly. Peter is an 85 years old and so is at the greatest point of age associated cognitive impairment. Baddeley (2002) said memory problems are often the first signs of dementia. However deteriorating memory is also characteristic of normal aging and even a disproportionate memory deficit is by no means necessarily a sign of dementia. Indeed the mental capacity ac t(2005) states that mental capacity should be assumed, until proved otherwise, and at present it has not been proved that peter lacks mental capacity, therefore on this basis it should be assumed he has the capacity to give informed consent for the operation or the capacity to refuse to give his consent for the operation should he ultimately do so.
Equally it could be the effect of the stress of the forthcoming operation and the pressure to make a decision that is actually making him forgetful. As the capacity of working memory is overloaded in a process known as preoccupied cognition, thus leaving less space available for other everyday tasks, hence the forgetfulness . A individual who is deemed to have mental capacity, and therefore has the ability to make an informed decision, may be impaired in this decision making process if they are under constant coercion. A court may be asked to intervene in these circumstances, but its jurisdiction will be limited in that it will only be able to help the person to make decisions without the external pressures( Munby et al 2009).
Peter’s forgetfulness could however be a sign of a more enduring cognitive deficit such as dementia which could affect his mental capacity and decision making capacity. If he is in the early stages of dementia then his ability to give informed consent will be reduced or completely diminished. Many people with memory problems that are in the early stages of dementia, but are not yet diagnosed, do not communicate to relatives just how much they are struggling with memory problems (Steelman et al, 2008). Therefore Peter could have a much more significant memory deficit that what we are currently aware of. He might already lack capacity to give his informed consent for the operation, as dementia suffers typically loose capacity to give consent within a year of onset( May et al, 2005).
According to The Mental Capacity Act, 2005, the only way to determine if Peter’s mental capacity to give or refuse consent is to carry out a full mental capacity test. If he can retain information given to him then that would suggest that he does have decision making capacity. It is however crucial that the decision is not made lightly, as if the operation goes ahead and Peter is later deemed mentally competent then the team is open to been sued for actual bodily harm.
If Peter is deemed to not have mental capacity to give or refuse consent then according to section 5 The Mental Capacity Act 2005 the operation can still go ahead without his consent, but that it is important to assess the patients best interests. The professional making the decision on Peter’s behalf should use a test of best interests. The person making the decisions would normally be an individual who has been appointed by the court as lasting power of attorney. The act states that patients should be encouraged to participate as far as possible in the decision making. To determine the Peter’s best interests then the decision maker must reflect and consider what the preferences would have been and to consult other people involved in the care. In peter’s case that would be his daughter, who acts as an advocate for him. Legal weight is given in the decision making process to advanced decisions, where the person has made the decision and provided informed consent previously when they had the capacity to do so. Peter previously gave consent and then changed his mind. This could be deemed that his intention is to go ahead with the operation as he made the decision before he became confused. It could be postulated that he no longer has capacity, but he has demonstrated his intention previously, so this should be considered in the decision making process. If the doctor received Peter’s signature on the form previously, at a time when it was considered he had the capacity to do so, then it can still be used as valid consent when at a later date he is not deemed to have capacity, as section 2 of the Mental Capacity Act 2005 states that it does not matter if the impairment is temporary or permanent, and providing Peter had capacity at the time he gave concept then it would be deemed to be valid informed consent. A test of best interest according to the mental health act 2005 must consider if the patient is likely to regain capacity in relation to the decision one has to make, and if this is likely should the treatment can be postponed until then. This is a crucial consideration for Peter, since there is some confusion around his capacity to give consent. However the best interests of peter are not very clear, they are somewhat ambiguous, the medical professionals and peters advocate are faced with difficult treatment decisions
The role of the nurse advocate is to prevent harm and promote good. Seedhouse (2000) believes the normal meaning of advocacy is to speak on the behalf of another person as that person perceives his or her interests. Efficient communication is an essential skill for a nurse advocate, research on communication between nursing staff and family members show that a nurse is able to create new possibilities and understandings among family members and between the family members and the patient through thoughtful questioning (Tapp, 2001). This type of communication provided insider knowledge that could be very valuable in determining if treatment should go ahead or not (Astedt-Kurki et al., 2001). However this insider knowledge isn’t always considered ( Bowman et al, 1998) and this could lead to an inappropriate decision making. An appropriate advocate for Peter could either be a nurse or his daughter. Although Peter’s daughter would be an advocate for her father, the daughter feels very strongly that Peter should have the operation even thought this may not be in Peter’s best interests. It maybe that Peter’s daughter is swayed by the emotional bond with her father. It may therefore be more beneficial for an independent mental capacity advocate (IMCA) to act of Peter’s behalf. If it is determined that there is no appropriate individual consult in determining the patients best interests, then an IMCA will be appointed from the local lists. The IMCA’s function is too represent and support patients who lack capacity, they talk to the patient, access medical records, talk to professionals treating the patient and other people know to the individual who would be aware of the individuals beliefs values and wishes.
A nurse must ensure that one maintains their accountability, responsibility and duty of care to the patient. Responsibility is ensuring that one is liable to be called to account, answerable for, or accountable for ones actions( Dimmond, 2008). Accountability is a fundamental concept in nursing that is vital for patient protection. Lewis and Batey (1982) defined accountability as the fulfillment of a formal obligation to disclose to reverent others the purposes, principles, procedures, relationships, results, income and expenditures for which one has authority( cited in grittithp36). Nurses should be accountable for their acts and omissions, this view taken by the NMC, The Code(2008) states that “ you are personally accountable for your acts and omissions in your practice and must always be able to justify your decisions"( NMC, 2008, cited in Gritthith p 36). There is often some confusion between accountability and responsibility even though the meaning is different, accountability means been responsible to a higher authority for your actions, but responsibility means having control or authority over someone( Grittith, 2008, p37). The purpose of accountability is to ensure that patients are not harmed by ones acts or omissions and to provide a means of redress to those who have been harmed. Nurses must hold the necessary knowledge, and be aware of the limits that the law imposes on the profession, but also the powers it also gives. The four arenas of accountability are accountability in the public arena, including criminal law and criminal courts. Secondly accountability in the patient arena including civil law and civil courts. Thirdly accountability in the professional arena including the Code of Professional Conduct, The Nursing and Midwifery Council and Conduct and Competence Committee. And Finally the fourth arena of accountability is the employer including the contract of employment and employment tribunal. A student nurse is only accountable too the employer arena which is the university, and the professional arena
Nurses have a duty of care to act in beneficence which is to help patients in what they do and non-maleficence which is not to hurt them (Hinson-Penticuff 1989). In law nurses have no duty of care to the public as a whole, but they owe their patients a duty of care and are accountable to the patient if they cause harm by breaching that duty. The duty of care to a patient also requires a nurse to kept up to date ones knowledge throughout their career( Griffith et al, 2010). In the case of Peter any registered nurses have a duty of care to act as an advocate, to help in determining peters best interests and provide him with the relevant information and support to facilitate the decision making process. Any breach of this duty of care would account to negligence. One of the defining principles of nurses is that they should do no harm, when harm occurs the patient is able to seek redress through the civil law system. Negligence in relation to nursing can be defined as reasonably foreseeable harm. In the case of negligence to see if professional standard of practice had been maintained would be determined by a Bolam test. It seeks the professional opinion of other registered nurses. If the nurses actions are deemed to be in keeping with the respected body of professional opinion, then they are deemed to not have fallen below the standards required in law and therefore will have no liability in negligence( Griffith et al, 2010 p 42).
In conclusion Peter is an extremely vulnerable individual, his case is somewhat ambiguous. It is not clear if Peter has the mental capacity to consent to or refuse treatment therefore extreme caution should exercised during any decision making. Peter’s mental capacity needs to be measured, using the guidance of The Mental Capacity Act 2005. If Peter is deemed to lack capacity then any decision that is made must be in Peter’s best interests. It is the nurses duty of care to act as an advocate for Peter and ensure that the right decision is made. Peter should always be involved in the decision making process as far as reasonable possible.