Controlled drugs and the principle of double effect: the role of the district nurse.

The role of district nurses in the effective management of pain in palliative care has been strengthened by the Misuse of Drugs (Amendment No.2) (England, Wales and Scotland) Regulations 2012 that allow district nurses who are independent or supplementary prescribers to prescribe and administer controlled drugs. However, prescribing controlled drugs brings increased responsibility and accountability for the safe management of these medicines. In this article Richard Griffith considers the principle of double effect that seeks to ensure that patients in intractable pain receive the analgesia they require to manage that pain while district nurses avoid liability and prosecution under the law of murder.

Can covert administration of medicines be in a patient's best interests?

In this article Richard Griffith considers whether it is ever in a patient's best interests to be given medicine by covert means, such as disguising it in food.

Covert administration of medicines: a contentious issue.

In its State of Care (2015) report the Care Quality Commission once again highlight unsafe management of medicines as a key concern in those care providers that require improvement. Underpinning the poor management of medicines is the unsafe and routine use of covert administration. In this article Richard Griffith looks at the legal and professional obligations for district nurses when they consider advising the use of covert medicines.

Understanding the Code: keeping accurate records.

In his continuing series looking at the legal and professional implications of the Nursing and Midwifery Council's revised Code of Conduct, Richard Griffith discusses the elements of accurate record keeping under Standard 10 of the Code. This article considers the importance of accurate record keeping for the safety of patients and protection of district nurses. The legal implications of records are explained along with how district nurses should write records to ensure these legal requirements are met.

Understanding the Code: the duty of candour.

A key recommendation of the Mid Staffordshire Inquiry (Francis, 2013) was to establish a culture of openness in all health services through a duty of candour. A professional duty of candour is a key requirement of the Nursing and Midwifery Council's revised Code (2015). It requires all district nurses to be candid with patients about any errors in their care and treatment. District nurses working in England are also subject to a statutory duty of candour imposed on their employer by the Care Quality Commission. In this article, the author considers the organisational and professional duties of candour and their effect on a district nurse's practice.

Understanding the Code: exceptions to the duty of patient confidentiality.

Last month's article considered the scope of a district nurse's duty to maintain the confidentiality of patient information under the Nursing and Midwifery Council (NMC) Code, their contract of employment, and the law. This month, Richard Griffith considers the exceptions to these duties and sets out when a district nurse would be justified in disclosing patient information.

Ethical concerns of visiting nurses caring for older people in the community.

BACKGROUND: An understanding of the ethical concerns encountered by visiting nurses in the community is needed. Yet, there is a lack of research on this topic. OBJECTIVES: The purpose of this study was to explore the ethical concerns that visiting nurses experience when caring for vulnerable older people living in a community. DESIGN AND SAMPLE: A qualitative thematic analysis was used to explore the nature of the ethical issues experienced by visiting nurses (N = 13) who care for vulnerable older people, over 65 years of age, in a South Korean community. METHODS: In-depth interviews were conducted with visiting nurses. Qualitative thematic analysis was used to explore the main themes of the phenomenon. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Review Board of Chung-Ang University Bioethics Committee in South Korea. RESULTS: Four ethical themes emerged from the qualitative data: (a) quantitative performance rather than quality care, (b) clients being invisible, (c) tuning the level of the relationship with clients, and (d) facing the visiting nurses' own limitations. CONCLUSION: This study provides a theoretical basis to understand the ethical aspects of visiting nurses' interactions with clients, which should facilitate the development of ethical guidelines for visiting nurses to use in making ethical decisions in their practice.

Development and psychometric evaluation of the Moral Competence Scale for Home Care Nurses in Japan.

PURPOSE: The purpose of this study was to evaluate the validity and reliability of the Moral Competence Scale for Home Care Nurses (MCSHCN). METHODS: A self-administered questionnaire that included the preliminary MCSHCN (90 items) was distributed to home care nurses (HCNs) in Japan. Usable data (from 1,961 questionnaires) were analyzed. RESULTS: Item and exploratory factor analysis for the MCSHCN revealed 45 items that loaded on 5 factors. This 5-factor model showed reasonable fit to the data by confirmatory factor analysis (root mean square error of approximation [RMSEA] = 0.070). Thus, the model closely corresponded to the theoretical components of moral competence. Cronbach's alpha ranged from .78 to .93. CONCLUSIONS: The construct validity and internal consistency reliability were supported. Further research is needed to refine this scale to increase the generalizability.

Maintaining professional boundaries: keep your distance.

Maintaining professional boundaries is essential to an effective nurse-patient relation whose sole focus must be on the care and treatment needs of the patient. Complaints about failures to maintain professional boundaries are increasing, with the Nursing and Midwifery Council reporting some 247 new cases in the year 2012-12. The article outlines the scope of the nurse-patient relationship, what activity is considered to be outside the professional and considers the consequences for community nurses if they are found to have breached a professional boundary.

Ethical tensions associated with the promotion of public health policy in health visiting: a qualitative investigation of health visitors' views.

AIM: To explore whether and how health visitors experience ethical tensions between the public health agenda and the need to be responsive to individual clients. BACKGROUND: Current health policy in England gives health visitors a key role in implementing the government's public health agenda. Health visitors are also required by their Professional Code to respond to the health-related concerns and preferences of their individual clients. This may generate tensions. METHODS: A total of 17 semi-structured individual interviews covering participants' experiences of implementing public health interventions and perceptions of the ethical tensions involved were conducted. Interviews were audio-recorded, transcribed and analysed thematically using a Framework approach. FINDINGS: Health visitors raised a number of ethical concerns, which they attributed to organisational resource allocation and the introduction of protocols and targets relating to public health goals. They did not always regard it as appropriate to raise topics that employing organisations had identified as public health priorities with particular clients for whom they were not priorities, or who had other more pressing needs. They noted that resources that were allocated towards reaching public health targets were unavailable for clients who needed support in other areas. Organisational protocols designed to monitor performance put pressure on health visitors to prioritise achieving targets and undermined their ability to exercise professional judgement when supporting individual clients. This had implications for health visitors' sense of professionalism. Health visitors saw trusting relationships as key to effective health visiting practice, but the requirement to implement public health priorities, combined with a lack of resources in health visiting, eroded their ability to form these. Policies need to be evaluated with regard to their impact upon a broader range of processes and outcomes than public health goals. The erosion of health visitors' professional values and ability to develop relationships with clients could have numerous adverse implications.

Professional dignity in nursing in clinical and community workplaces.

The purpose of this qualitative study was to analyse nurses' professional dignity in their everyday working lives. We explored the factors that affect nursing professional dignity in practice that emerge in relationships with health professionals, among clinical nurses working in hospitals and in community settings in central Italy. The main themes identified were: (i) nursing professional dignity perceived as an achievement; (ii) recognition of dignity beyond professional roles. These two concepts are interconnected. This study provides insights into professional dignity in nursing being perceived as an achievement linked to the intrinsic dignity of every human being. The 'nursing professional dignity perceived as an achievement' was perceived as having declined in different social factors. Some factors of nursing professional dignity perceived as an achievement were attained more easily in community settings. 'Recognition of dignity beyond professional roles' underpins the intrinsic dignity as an expression of humanity, embedded in persons regardless of any profession, and values, such as: respect, moral integrity, humility, working conscientiously and kindness.

Acting faithfully in community.

The phenomenon of acting faithfully in the nurse-person relationship is an important ethical topic of interest to the discipline of nursing. It may also be conceptually defined and illuminated in nurse-community relationships. This column begins an articulation of what it potentially means to have straight thinking about nurses' obligations with persons in community. The language of nurse science from the humanbecoming school of thought will be used to explore the phenomenon.

Smoking cessation: promoting the health of older people who smoke.

Community nurses are well placed to address smoking behaviour with older people. Smoking cessation can significantly improve the health and wellbeing of older people, and to withhold support for smoking cessation is a form of age discrimination. This paper provides advice to community nurses about how to approach discussions about smoking behaviour with older clients as part of their health education practice. It addresses some of the ethical concerns that have been raised by community nurses, explains how smoking in older people may be reduced using a harm reduction apporoach and through working with the concept of the smoke-free home.

A process for developing a principle-centred district nursing service philosophy.

While it is well known that team vision and values statements in nursing can promote person-centred care, practitioner role clarity and empowerment, and service effectiveness, especially during times of change, their use in district nursing is limited. Accepted practice is to formulate vision and values statements 'from the top', and then seek buy-in from other staff groups, however, this inhibits practitioner engagement. This paper describes the use of group facilitation, based on principle-centred leadership practices, to engage practitioners in all the creative aspects of developing a values statement. Increasing practitioner engagement would be expected to provide the above benefits by improving communication with service-users and other key stakeholders and by motivating performance evaluation and improvement.

Relationships between nurses and older people within the home: exploring the boundaries of care.

AIM: To explore the nature of relationships between nurses and older people within the home and to illuminate the nature and quality of caring boundaries within this setting. BACKGROUND: Older people are increasingly receiving nursing care in the home. There has been little exploration of the nature of the nurse-older patient relationship within this setting. METHODS: An ethnographic approach using semi-structured interviews with 16 community nurses and 13 older patients (aged 65 years and over), were undertaken to explore the nature of care relationships within the home setting. FINDINGS: The study has highlighted the centrality of the location of care and the concept of 'the home' in terms of geographical and metaphorical meanings. Moreover, the study has clearly illuminated the complex nature of relationships and boundary construction from a number of perspectives. CONCLUSION: As the location of care for older people continues to move closer to home it is crucial that the implicit qualities that are valued within nurse-patient relationships within this context of care, and which contribute to the quality of care, are recognized and made more explicit at the organizational and policy level. PRACTICE IMPLICATIONS: For nurses working within the home there is a clear impetus to clearly define and articulate the full breadth of their role, the nature of relationships and issues surrounding professional boundary construction within this environment. There is also a need for the core qualities that underpin the receipt of care within the home and the facets of the nurse-patient relationship valued by older people to be fully recognized and accounted for.

Community nurses' experiences of ethical dilemmas in palliative care: a Swedish study.

AIM: The aim of this study was to highlight community nurses' experiences of ethical dilemmas in palliative care. BACKGROUND: There are many studies on palliative care but research on how community nurses experience ethical dilemmas in palliative home care is lacking. The ethical dilemmas to which these nurses are exposed seriously challenge their ethical competence. METHOD: Seven community nurses described their experiences of ethical dilemmas in palliative home care. The data was analysed by means of qualitative content analysis. FINDINGS: The core themes that emerged were: powerlessness, frustration, and concern in relation to ethical dilemmas in palliative care. The nurses were motivated and felt responsibility for their patients' end of life, and their relatives, and took their duties seriously. They wanted to satisfy all parties; the patient, the relatives and other palliative care professionals. CONCLUSION: The study confirms the need for knowledge about how community nurses experience dilemmas in ethical decision-making. They have the freedom to act and the willingness to make decisions, but they lack competence and knowledge about how their colleagues' experience and deal with such issues.