Free Health Essays - Professional And Ethical Practice With Reference To The Paediatric Nursing
Analyse and debate how nurses can act in a fair and anti-discriminatory way.
Discrimination, in the context of the title of this piece can be viewed from a number of different angles. On the one hand there is, perhaps, the most obvious connotation to be derived from the title, that there is the ability for nurses to be discriminatory about their patients. Any experienced healthcare professional will have dealt with an objectionable child who may be the spoilt offspring of rich parents or equally the rude, aggressive or anti social child who has only known a life of social deprivation.
There may be other reasons for discrimination, for example on the grounds of race, religion or even on the attitudes of parents to the nursing staff. It can be very difficult, even in this politically correct and arguably more tolerant society in which we live (at least by contrast with several decades ago), for the healthcare professional not to be influenced in their attitude and handling of patients, by so many of these, and other, factors. (Parker and Lawton 2003)
There is another connotation of the title which, on a moment's reflection, (Gibbs, G 1988), may also be appropriate, and that is how a nurse can act in a fair and anti-discriminatory way with their colleagues who also may work on the same paediatric ward. Again, the experienced healthcare professional will have come across situations where, particularly in the climate of the NHS at present, they will work in situations where they may feel disadvantaged by their working colleagues.
The influx of nurses from abroad, from Asia, Africa or even Eastern Europe, who may all be perfectly professionally competent, but yet may not have fully adjusted to the demands of working in a different society, with different values and possibly a different native language. This may be a source of potential friction and it is possible that in such circumstances, discriminatory behaviour may be found.
Discussion
In any consideration of the issues involved, it is always helpful to make a critical appraisal of the literature on the subject. It is clearly important to be critical as, just because something appears in print, it does not imply that it is either correct or based on a firm evidence base. (Sackett, 1996).
In the essay we are going to start with a, possibly controversial, view of the subject of discrimination in the field of paediatrics. It is not specifically relevant to the UK, but it is the subject of an eye-catching article in the BMJ. We start with this because it is possibly the grossest example of discrimination that we are likely to find in the literature today. It is an article by Khanna (et al. 2003) which looks at an aspect of discrimination by sex at the most fundamental level, which impinges on paediatric practice in India.
This is not quite as irrelevant to UK practice as may appear at first sight, as, with our current racially integrated society, all healthcare professionals must clearly be both aware of, and sensitive to, a whole range of cultural beliefs and values which may be alien to the mainstream culture of the UK today. (Das Gupta 1987)
The article starts with the fairly incontrovertible fact that the live birth rate in India today is 869 females per 1000 males which is roughly in line with other author's findings (Lopez 1983) (Census of India 2001). The authors go on to point out that the infant mortality in the first year of life is 1.3 times higher for girls than boys. (Park 1997)
They also then point out that nearly 25% of infant deaths were due to diarrhoea related illnesses and twice as many girls died from this as boys. One particularly worrying aspect of the paper was that 10% of infant deaths were without a history of any preceding illness and that in that category, 75% were girls. While the paper stops short of drawing the conclusion that selective infanticide may be one explanation of this apparent discrimination. It states quite clearly that there is little doubt that, in the author's opinion, girls are regarded as more expendable than boys and when financial considerations become a determinant of treatment, then a poor family is less likely to spend money on treating a girl infant than a boy.
We know that in western societies, females normally outnumber males, as the X chromosome gives a statistical degree of protection to the female against sex-linked recessive conditions and some infections. (Booth et al. 1994). In the Indian adult population however, the ratio is 933 women to each 1000 men (Census of India 2001), which may well be a reflection of this discriminatory practice in infancy. We will not dwell on this particular paper as it only has a limited relevance to paediatric practice in this country, but it none the less illustrates one of the most clear cut discriminatory practices that we have found in this area.
A paper that can be argued to take a more seminal approach to discrimination is the paper by Webb (1998) who examines the so-called Inverse square law which, in this respect, was first described by Tudor-Hart (1971). His original paper on the issue stated that:- The availability of good medical care tends to vary inversely with the need for it in the population served.
In short, the original hypothesis implies that the more disadvantaged a particular element of society is, the more likely it is to receive poor medical treatment. Although Tudor-Hart expounded the hypothesis, it fell to authors such as West and Lowe (1976) to examine and publish the hard evidence behind the theory.
Webb suggests that it is the case that not only does the provision of services operate on an inverse square law, but also it is the access to these services that operates in the same fashion. To quote Whitehead (1988):
Those with least need of health care use the health services more, and more effectively, than do those with greatest need.
Generally, with access goes both the ability to access preventative or prophylactic interventions as well as actual physical treatments. This then perpetuates the cycle off illness and further discrimination. (Foucault M 2001)
In terms of the title of this essay, the corollary to all of these arguments is that the nurse must be aware of these eventualities if they are to act in a way that is truly anti-discriminatory. (Kuhse & Singer 2001)
Part of the professional remit of the nurse is to be a resource of health promotion (Marks-Moran et al 1996). Given that the fact that the statistics point to the fact that health promotion, (at least in the standard types of format), are most accessed by the most economically advantaged faction in society and who, by our previous examination, have been shown to be those who actually need it the least, (Judge 1995), the nurse can make a positive impact when they are dealing with a socially or economically disadvantaged children, by spending time in empowerment and education of both the child and the parents, as appropriate. (Marinker M.1997)
In terms of actual numbers, the Webb paper is very informative and helpful as it quotes over half a million socio-economically deprived youngsters are effectively marginalised, as far as healthcare access is concerned, within the UK (Spencer N. 1996), and that the authors quote Lissauer (et al. 1993) in observing that over 30% of children in the UK grow up in conditions of socio-economic deprivation at least for one period in their childhood lives.
In terms of markers for the paediatric nurse, they specifically quote homeless children, those in care, travellers, and refugees as being those categories in which socio-economic deprivation is most likely to be observed. In terms of numbers who are living rough clearly it is difficult to give a precise number, but Webb points to the fact that every year over 10,000 children leave the care system and a good proportion of them do end up living rough (Barrie-Foy 1996).
It is also worthy of note that the single most disadvantaged group, and therefore the most discriminated against, are the children of Romany travellers, who hold the statistical distinction of having the poorest health of any minority group in the UK population (Hawes 1997)
If we turn our attention now to a different aspect of discrimination, there is a very interesting recent paper by Escher (et al 2004) which considers that, given the fact that the NHS is basically an organisation that has to ration healthcare (because there will never be enough money to provide for every conceivable health need of the population),(Eisenberg 1979), they examine just what are the criteria for discrimination in a rationing environment, as decisions have to be made as to who gets what in the specific terms of healthcare. The specific aspect that they chose to examine is the critical care environment. Although this was not specifically related to the paediatric critical care, the findings were sufficiently general to be instructive in the consideration of this essay.
We can take comfort in the fact that the vast majority of healthcare professionals who participated in the survey, used non-discriminatory criteria for admission to a critical care environment, (Joynt et al 2001), but there was a significant minority where the authors were able to point to positive discrimination on the grounds of socio-economic status, religious beliefs and even emotional state, up to a total of 11% of the total criteria.
It is accepted that the nursing role may not be paramount in the decisions of who to admit to the intensive care units in the country, but the nurse has the, almost unique, status to act as the professional advocate for the disadvantaged patient. (Gilbert T 1995). There is clearly scope in these circumstances for the nurse to act in a positive and anti discriminatory way to combat discrimination when they see it in circumstances such as these.
Pooling both of the arguments that we have just put forwards with regard to positive discrimination on the paediatric wards one can reflect (Gibbs 1988) on the arguments put forward by Blecker (et al 2000) in the article with the rather provocative title Partnerships with patients . In the segment of this essay where we explored the links between poverty, ill health and discrimination, we pointed to the fact that there was a significant segment of society which was not able to access healthcare on an equal footing with the rest of society and we also pointed to the fact that the conscientious nurse could make a real difference to this segment by positively targeting them for health promotion empowerment and education.
Blecker takes this approach rather further by examining the community based projects that have been set up, (primarily involving community based nurses), to tackle the discrimination that arises from such socio-economic deprivation.
Part of the reason that the article is noteworthy, is that many articles on this type of subject tend to be written from the point of view of what facilities are available for the patients to take advantage of. In this paper, the authors pursue the topic from a different viewpoint, and that is just how it is that the local community teams, (including paediatric specialist nurses), reach out and make contact with the community, thereby empowering and educating the more disadvantaged to take advantage of what is already on offer. (Thomas P 2000)
It also examines the degree to which such moves are successful and also what lasting measures are in place to perpetuate the empowerment once it has been set up and the project has finished.
The author points to the fact that this type of project is now enshrined in Government policy in the form of the Document Our Healthier Nation (Department of Health 1999), thus encapsulating recognition, at the highest level, that discrimination does exist, and that the Government does intend to endeavour to tackle and confront the issue.
The next issue relating to discrimination that we shall examine is a rather paradoxical and tangential one. It is highlighted in the article by Yarney (1999). It highlights the danger of being critical (some would say over critical in this particular case) of a situation where the facts have not been fully examined. It highlights discrimination of the worst and most insidious kind in a paediatric context. It concerns the situation that arose at the Brompton hospital in the late 90s when a whistleblower sent a report to Private Eye magazine claiming that the senior Paediatric cardio-thoracic surgeons were actively discriminating against children with Down's syndrome, both in terms of operating on them with different criteria from other children and also of having a higher mortality when they did operate.
It is clear that if this were found to be true, then this would represent discrimination of the most insidious and pernicious kind. It would also underline the observations that have already been made (above) relating to the nurse's status as patient advocate in these circumstances.
Fortunately for all concerned (except the anonymous whistleblower), the allegations proved to be completely unfounded as all the decisions had been made on proper clinical grounds.
We present this article in the overall context of this essay as a paradoxical illustration of the potential for discrimination to appear to exist, even when, in reality, it does not. (Sugarman J & Sulmasy 2001)
This is an important learning point. It illustrates the fact that it is clearly entirely commendable for a nurse to tackle discrimination head on as and when it is seen. It is generally regarded as part of a nurse's professional mandate to do so. It also follows that discrimination must actually be demonstrated to occur. Misinformation or misguided anti-discrimination measures, however well meaning, are actually counter-productive in many instances, and do little to further the cause of the truly disadvantaged.
In this particular case, an enormous amount of both money and resources were tied up investigating and publishing the results of this whole affair which, inevitably, detracted from the amount of money that was available for overall patient care at the Brompton hospital.
While we are considering the issues related to Down's syndrome, there is another consideration in the wider context of discrimination which exists in this area. It may not traditionally be thought of as discrimination in the normally applied sense of the word, but discrimination it still is. We are referring here to the discrimination in the most fundamental sense at the level of antenatal screening for conditions such as Down's syndrome.
In this essay we are asked to consider the role of the paediatric nurse in the area of discrimination. This issue is, arguably, one of the more important areas where a paediatric nurse can have a positive input. The mother who may have one Down's syndrome child or who perhaps, is in an at risk group and who needs screening is often both vulnerable and in need of the support that a nurse is ideally placed to give. The decisions that will have to be made as a result of this, most fundamental type of discrimination, will have to be dealt with in real, human and practical terms, by healthcare professionals as part of their daily work.
We can point to an excellent article which highlights many of these issues (Hall et al 2000), together with the possible psychological sequelae that may occur in a patient if the process is insensitively handled. The reason that this paper is singled out, is that it specifically targets the second area of the essay title and that is how nurses can act when discrimination is found. It is not appropriate to detail all of the measures, as they are examined in some detail, but a deep insight can be gained into the parent's psyche after the screening (or discrimination) has taken place, including the element of looking for someone to blame, which can be of great help in assisting a nurse to fully empathise with their patient if they have to deal with this type of situation (Henriksen and Kaplan 2003)
Conclusions
In this essay we have examined not only the barn door obvious elements of discrimination that exist in a typical paediatric nursing practice, but we have also tried to cover those areas of discrimination that may not be so obvious.
Clearly discrimination can occur at many levels and in many forms.
It should be noted that we recognise and appreciate that not all forms of discrimination are bad or counterproductive. The discrimination that occurs to ultimately fit a particular patient to a particular process, treatment or facility, can be beneficial for all concerned. Discrimination to select which particular group may be most amenable or suitable for a particular vaccination, for example, may be positive discrimination for both a good reason and a positive outcome.
A paediatric nurse could and should indulge in such discrimination with a positive attitude. The negative discrimination that occurs because of socio-economic disadvantage, parental circumstance or just ignorance,
(Veitch RM 2002), is most certainly also within the professional remit of the conscientious paediatric nurse and they should regard it is part of their professional remit to tackle it head on whenever it is encountered.
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