Ethical and Legal Dilemmas in Nursing: A Case Study Analysis

This essay addresses ethical and legal issues in nursing through a case study of a 70-year-old patient, Mavis, who exhibits altered vital signs, confusion, and aggressive behavior following surgery. The essay explores the conflicts between patient autonomy and beneficence, considering the ethical implications of various actions, such as allowing the patient to leave, implementing de-escalation techniques, and using restraints or medication. It examines the legal and ethical concerns, including the nurse's responsibilities regarding patient safety, informed consent, and adherence to nursing standards, while also considering the potential consequences of inaction or inappropriate interventions. The analysis incorporates ethical principles, legal obligations, and nursing standards of care to provide a comprehensive understanding of the dilemmas faced by nurses and the importance of balancing patient rights with their well-being. The essay emphasizes the need for immediate intervention to address the patient's aggression and highlights the importance of de-escalation strategies, acknowledging the legal and ethical considerations associated with different approaches to patient care.

Running head: NURSING
Nursing
Name of the student:
Name of the University:
Author’s note

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Introduction:
Maintaining patient safety and high quality of care is an important care priority in
nursing. However, maintaining legal and ethical aspects of care is vital to promote safety of
patient too. Moral value emphasizes on the protection of humanity and dignity of patient. In
addition, nurses are bound to comply with many legal obligations while providing care. Hence,
as patient safety is a multidimensional area, focussing on legal and ethical imperatives of care is
important (Kadivar et al., 2017). This essay looks at the case scenario of Mavis to explore legal
and ethical concerns for nurse while providing care to patients. All possible actions to be taken
based on patient situation and the implications of those actions will be discussed based on
consideration of ethical principles, legal obligations and nursing standards of care.
Overview of the case study scenario
The case study is about Mavis, a 70 year old retired nurse who has undergone a
laparotomy following an acute bowel obstruction. Her recovery was uneventful in the first post
op. However, in the morning, her vital signs altered evidenced by heart rate of 92 bpm, blood
pressure of 105/70 and temperature of 38.0 C. During nursing assessment, she was also found to
be confused, disoriented and anxious. Her condition has significantly changed compared to the
last assessment few hours ago. Current Mavis has turned aggressive towards nurse and is willing
to start work. The issue that arises is that when nurse comes back to the shift coordinator after
informing about Mavis condition, she found that Mavis is not in the room. She was found in the
visitor’s room with her gown open and dressings removed from the wound site. Mavis has also
smeared faeces across her abdomen and surgical wounds. When the nurse attempted to take the

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patient to the bathroom, then also she was yelling at the nurse and wanted to go home so that she
could go to work.
Ethical and legal concerns in the case study:
There are many issues or challenges that the nurse need to confront while handling
Mavis. Firstly, dealing with her aggressive behaviour would be a challenge as this could increase
safety risk both for patient and the nurse. In addition, the scenario also presents conflict in
relation to patient autonomy and beneficence. The ethical principle of autonomy focuses on
allowing or enable patient to take control over their health and taking their own decisions on
treatment and care. It involves discussion around truth telling, fidelity and confidentiality.
However, the vulnerability of patient autonomy is understood from the fact that although this
right protects patient from unwanted treatment, but it also expose patients to risk of harm when
they deny a treatment which is immediately needed for them (Ubel, Scherr & Fagerlin, 2017).
Similar issue is seen in the case scenario too. Mavis is hell bent on going to work. If the nurses
respect her wishes, it will preserve the ethical rights of patient autonomy. However, this will
seriously affect beneficence of patient as currently her condition has deteriorated and she is in
urgent need of medical attention. Issues related to patient dignity and clinical safety issue is also
present as Mavis has removed her dressing. Her current action could lead to risk of infection and
delay in post operative recovery. This essay will review possible actions or inactions from a legal
and ethical perspective.
Possible actions or inactions and its implications:
The first possible course of action that the nurse can take to resolve aggressive behaviour
is to allow her to go home. This action is relevant with patient’s personal wish and the ethical

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theory of autonomy which focus on self determination, freedom of will, self knowledge and
independence of patient (Cohen, 2019). This action is also relevant with the NMBA (Nursing
and Midwifery Board of Australia) code of ethics as the ethical statement values ethical
management of information and mandates nurse to respect patient’s wishes in care (NMBA,
2014). It will ensure that Mavis’s decision is respected and she is allowed to GO home.
However, the implication of this action is that it can lead to further clinical deterioration of
patient. This is because her vital sign has fluctuated significantly post operation and as she is just
one day post op, it would not be feasible to discharge her right now. To ensure quick recovery of
patient after laparotomy for an acute bowel obstruction, routine nursing assessment and
monitoring along with proper surgical care and pharmacological management is crucial for her.
Post surgery, patients need to recover in the post anaesthesia care unit (PACU) before their
condition is perfectly stable (Adekhera, 2016). However, if the nurse respect patient’s wish, it
will prevent nurse from providing appropriate postoperative care which would further deteriorate
condition of Mavis.
Going with the above action can make surgery might turn out to be unsuccessful and she
might become unconscious at home because of low blood pressure and rapid heart rate. Hence,
going with the decision of allowing Mavis to go home would lead to many negative health
consequences for patient. This is turn would violate the ethical principle of beneficence and non
maleficence. Beneficence is the right to provide benefit to person and contribute to their welfare,
whereas non maleficence is the obligation not to inflict harm intentionally to patient (Bronzino &
Peterson, 2016). The action of discharging Mavis will seriously violate the ethical principle of
malefience and non maleficence for patient. Hence, the scenario presents dilemma for nurse in
deciding whether to give more emphasis to autonomy or beneficence of patient. This is a

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common dilemma in medical ethics and Cohen (2019) supports that interaction between
beneficence and respect for autonomy is common. Recognition of full spectrum of these
interactions can only ensure fulfilment of moral duties in care.
Currently, Mavis is very aggressive because he is not allowed to go home. Hence, if the
patient is not discharged because of beneficence issue, there is a need to consider ways to control
his aggression. Innovative therapeutic measure need to be implemented to balance both patient
autonomy as well as beneficence. Inaction or poor response in relation to patient autonomy can
lead to negative legal implication because according to Australian common law, all competent
individual can refuse medical treatment. If consent is not established in proper manner, there can
be legal consequences for health staffs (Australian Government, 2014). However, the nurse may
not be at risk of such legal concerns because according to current symptom of Mavis, he does not
seem competent to take rational decision for himself. This is supported by the study by Kuin et
al. (2015) which states that psychiatric symptoms like depression and aggression influence
patient’s capacity to make choice about treatment. They are at risk of engaging in risk decision
making. Hence, nurses must be aware of these anomalies while engaging in decision making
with patient.
The most important action for the nurse at the moment is control aggression of Mavis.
This is because inaction of the nurse in response to aggressiveness can create many safety issues
for patient. The significant impact of aggressiveness in nursing care delivery is evidenced by the
fact that the Mavis is behaving irrationally and not allowing nurse to attend to her hygiene needs
too following smearing of faeces. Aggressiveness can lead to harm for nurse too if the symptom
is not controlled properly. Pekurinen et al. (2017) report patient aggression as a major safety
issue that can violate not only well being of patient, but well being of nurse. In addition, if

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inappropriate intervention is implemented, it can lead to patient dissatisfaction or increase in
aggression too. As Mavis was not allowing nurse to attend to her hygiene needs, the most
immediate action that can be taken is to immediately call the nursing supervisor and consider
providing tranquilizer drugs to patient. According to the standard 9 of the NSQHS (National
Safety and Quality Health Service) standard, the most relevant actions to be taken during events
of clinical deterioration is to immediately escalate care and activate rapid response system to
provide ideal care to patient (ACSQHS, 2017). In the context of Mavis, there is a consider ways
to deescalate behaviour of patient.
De-escalation is an important evidence based strategy to effectively response to patient
with aggression (Hallett & Dickens, 2017). The National Institute for Health and Care
Excellence (NICE) recommends implementing de-escalation technique in care by recognising
early signs of agitation, evaluating the likely cause of aggression, implement calming techniques,
respecting personal space of patient and responding in a reasonable way to avoid provocation
(Parker, 2015). In the context of Mavis, the cause of aggression and time of such symptoms has
been already identified by patient. However, the nurse now needs to decide best ways to provide
quality care and prevent immediate harm for patient. The significance of calming technique and
respecting personal space is that maintain patient dignity and respect. It is relevant with the
human dignity principle as it can help to maintain high quality care provision along with patient
dignity protection (Raee, Abedi & Shahriari, 2017). The key implications of de-escalation
strategy are that it is associated with minimal legal and ethical concerns for patient as well as
resolution of risk of injury for Mavis. Price et al. (2018) explains de-escalation as a range of
intervention focusing on communication, verbal and non verbal skills and self regulation and
safety maintenance and the success of this therapy is dependent on conveying empathy and

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avoiding negative emotional responses with patient. However, the barriers that should be
considered by nurse during implementation are the issue of power and control and disrespect of
patient. This can help to preserve ethical principle of human dignity in care.
The above strategy can be combined with other intervention to address the problem in the
case study. Two other options available for nurse is to use restraint to control behaviour of Mavis
and use tranquilizing drugs to relax patient and provide wound care in the surgical site. Physical
restraint is most commonly used in psychiatric hospitals to reduce risk of harm for patient.
However, there is moral argument against the use of restraint because it violates patient’s
personal space and limits patient’s physical movement. Similar ethical implications can be
experienced after implementing the same action for Mavis too. The exact situation under which
this action can be ethically correct is debatable. Physical restraint employs force to restrict
patient in a specific area and prevent harm towards others. The legal framework for the use of
restrictive practice in Australia suggests that use of restrictive practice is any form is a human
right issue in Australia. Public Advocate in Australia propose the need to unregulated this
practice in Australia and clarity the legality of the use of such practices (justice.qld.gov.au,
2019).
The second option of providing tranquilisation drug can be taken in collaboration with
other nursing supervisors. The implication of this action is that Mavis can be made to relax and
the nurse can immediately attend to wound care and bleedings from the dressing. It involves
giving medication parenterally to minimize agitation and violence. Some recommended options
include benzodiazepine lorazepam and haloperidol (Parker, 2015). Ethical risk can be minimized
if patient accepts this drug and ensuring that the drug is administered after obtaining consent
from patient. This would lead to successful cooperation and establishment of therapeutic effect.

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However, taking such consent may be challenging based on current symptom of (Mavis Hirsch
& Steinert, 2019).
From the exploration of ethical and legal issues in the care of Mavis, an aggressive
patient with post surgical wound, it can be summarized that patient autonomy and beneficence
are two major ethical principles that come in conflict with each other during care delivery. The
case scenario presented similar dilemma for nurse. Several possible action or inactions and its
implications for patient was considered. This included discharging patient, deescalating
aggressive behaviour, use of verbal skills, tranquilization and physical restraint. The ethical and
legal concerns and its implication for each action were discussed. Mavis was at risk of serious
infection or injuries in the surgical site because of her behaviour. This could lead to disciplinary
action for nurse because of inability to take prompt response to clinical deterioration of patient.
However, the combination of pharmacological and non pharmacological intervention along with
consideration of ethical and legal values can help to provide ethically appropriate care to Mavis.

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