Public discourse narratives: from 'Secret Aid Worker' discontent to shifting power in humanitarian systems.

Public discourse is rich in meaning, reflecting consensus, dissent, and change. Yet, very little public discourse on the humanitarian sector has been authored by aid workers themselves. We conducted a thematic analysis of the 'Secret Aid Worker' (SAW) series, published in The Guardian newspaper between 2015 and 2018, the only corpus of data on humanitarian life experiences publicly accessible through mainstream media. Our research questions were twofold: how did authors frame their work and appraise humanitarian structures?; and how did they reflect and amplify humanitarian issues of the time? The main themes included: personal challenges of humanitarian life; characterisation of stakeholders; and systemic issues within the humanitarian sector. The SAW narratives reveal a powerful discourse of discontent. They planted seeds of change regarding shifting power, coloniality and racism, sexual abuse, and duty of care. We argue that such public discourse has symbolic power, calling for greater accountability, equity, and justice in remaking the future of the humanitarian sector.

A guided framework for assessing off-label medication use in psychiatry.

OBJECTIVE: The objective of this article is to present a decision aid in the form of a flowchart, designed to assist psychiatrists in navigating the challenges of off-label medication use. This tool is believed to be the only one currently available that combines guidance from medical indemnity insurers, RANZCP guidelines, CATG frameworks, and relevant legislation to provide a practical guide for everyday psychiatric practice. CONCLUSIONS: There are clinical, legal, ethical, and financial considerations to take into account each time an off-label prescription is ordered. There is no legal barrier to prevent psychiatrists from prescribing off-label in Australia and New Zealand. The medication should be utilised if it is in the best interests of the patient. However, practitioners must be able to defend the rationale for their off-label medication use with evidence of sound quality. Off-label use medication use can lead to improved patient outcomes and quality of life. On the other hand, poor practice in off-label prescribing can result in adverse events, patient harm, legal implications, and damage to professional reputation. By evaluating available evidence, considering patient characteristics, obtaining informed consent, and documenting the rationale for off-label use, clinical decision-making can be enhanced whilst mitigating the risks associated with off-label prescribing.

The duty of care and the right to be cared for: is there a duty to treat the unvaccinated?

Vaccine hesitancy or refusal has been one of the major obstacles to herd immunity against Covid-19 in high-income countries and one of the causes for the emergence of variants. The refusal of people who are eligible for vaccination to receive vaccination creates an ethical dilemma between the duty of healthcare professionals (HCPs) to care for patients and their right to be taken care of. This paper argues for an extended social contract between patients and society wherein vaccination against Covid-19 is conceived as essential for the protection of the right of healthcare providers to be taken care of. Thus, a duty of care is only valid when those who can receive vaccination actually receive it. Whenever that is not the case, the continuing functioning of HCPs can only be perceived as supererogatory and not obligatory.

Legal duty of care and the community nurse.

In this month's Policy column, the author explores the concepts of duty of care, forseeability and proximity, and how the community nurse can be better prepared when caring for the patient.

Informed or misinformed consent and use of modified texture diets in dysphagia.

BACKGROUND: Use of modified texture diets-thickening of liquids and modifying the texture of foods-in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. MAIN TEXT: Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication-and no real attempt to obtain consent-by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. CONCLUSION: Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values.

Professionalising care into compliance: The challenge for personalised care models.

One of the most basic understandings of nursing is that a nurse is a caregiver for a patient who helps to prevent illness, treat health conditions, and manage the physical needs of patients. Nursing is often presented as a caring profession, which provides patient care driven by ideals of empathy, compassion and kindness. These ideals of care have further been foregrounded through the development and implementation of stress on patient centred care (PCC) and/or person-centred practice (PCP). Although the idealisation of nursing as a caring profession is common, and one certainly seen as integral by nurses and written into the heart of regulatory documentation, we contend that the actual delivery of care is being undercut by the very regulatory climate that strives to professionalise care. As we outline, with specific reference to the context of Australian Nursing, this transformation delivers a commodified, even McDonaldized, model of patient management rather than care. It seems that even with its explicit stress on PCC and PCP, Australian Nursing cannot live up to its own care ideals. Having outlined this problem, the paper then demonstrates the ways in which PCC is thwarted at the coal face of nursing practice and that there must be an institutionalised change to be able to provide genuine patient-centred care.

Ending the doctor-patient relationship.

OBJECTIVE: Terminating a therapeutic relationship can be particularly challenging and onerous for the treating medical practitioner. There are multiple reasons why a practitioner may desire to terminate the relationship, ranging from inappropriate behaviour and assault through to threatened or actual litigation. This paper provides psychiatrists as well as all doctors and support staff who work alongside them with a simple, step-by-step visual guide to terminating a therapeutic relationship, giving due consideration to their professional and legal obligations in line with common recommendations by medical indemnity organisations. CONCLUSIONS: If a practitioner's ability to manage the patient is inadequate or compromised due to an emotional, financial, or legal circumstance, it is reasonable to consider termination of the relationship. Practical steps such as taking contemporaneous notes, writing to the patient and their primary care doctor, ensuring continuity of healthcare, and communicating with authorities where appropriate have been identified as components commonly recommended by medical indemnity insurance organisations.

The Duty of Care to Protect Employees against the Risk of Psychiatric Harm from Vicarious Trauma: Kozarov v Victoria.

An employer owes every employee a duty to take all reasonable steps to provide a safe place and system of work. Whether an employer will be liable for psychological harm suffered by an employee will depend on the particular circumstances of the case. In Kozarov v Victoria (2022) 273 CLR 115; [2022] HCA 12 (Kozarov), the High Court considered whether the Victorian Office of Public Prosecutions had been placed on notice of a risk of "vicarious trauma" to a solicitor employed in the Special Sexual Offenders Unit and whether it was required to make a response by taking active steps including offering a rotation to another section where the solicitor did not to have to manage cases of child rape and other sexual offences of gross depravity. The High Court also considered whether by failing to advise her employer of her developing mental illness in a timely way and not accessing the Employee Assistance Program, the solicitor had failed to take reasonable care of her mental health. The article argues that the Kozarov decision is likely to prove a landmark in terms of employers' occupational health and safety responsibilities in respect of exposure to vicarious trauma.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey.

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75-7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50-3.46, p < 0.001). Prioritizing protection from professional liability over patients' actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a 'risk management culture' and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

[Medical liability and criminal law in emergency medicine]. / Arzthaftung und Strafrecht in der Akutmedizin.

Medical liability is booming. Malpractice can entail both civil and criminal consequences. Besides financial and custodial penalties, at worst the license to practice medicine can be withdrawn. Physicians owe their patients a treatment according to current standards. Furthermore, physicians are obliged to fulfill their duty of care. Nevertheless, the patient's right of self-determination must not be violated. Especially in emergency situations, physicians have to focus on taking protective measures in order to avert further dangers to the health of patients. This article analyses common pitfalls in emergency medical treatment with respect to the legal aspects.

Regulatory Investigations: Regulators, Regulatees and the Public Interest.

The potential for adverse consequences of investigations by a regulatory authority into complaints made against a person whom it regulates raises important questions about how regulators or similar bodies are, or should be, held accountable for their actions. This article examines the legal duties or other obligations that a regulator of health practitioners owes to people it regulates as well as to those who make complaints or submit notifications and to the public at large. It raises the general question of what duties or obligations any regulator or similar body with investigatory or coercive powers owes to persons arising out of its investigations. It finds that although they do not have a legal duty of care to a regulatee to protect them from harm, there may be other reasons why a regulator may want to consider the welfare of those whom it regulates as well as other affected parties.

Needle and Syringe Programs in Prisons: Victoria's "Problematic" Policy Position.

With high rates of blood-borne virus infection in Australian prisons, a needle and syringe program (NSP) stands ready to deliver similar benefits to its community counterpart. Supplying sterile injecting equipment and safe-use guidance in prisons could improve prisoner health outcomes and the safety of the corrections system. Yet, despite the protestations of public health experts and the recommendations of State, national, and international bodies, Australian States and Territories refuse to implement prison-based NSPs, with serious consequences for prisoner health. This article focuses on the Australian State of Victoria as a case study representative of other jurisdictions. Victoria's inaction is arguably in breach of international standards and the Victorian Charter of Human Rights and Responsibilities, but less likely to constitute a breach of the common law duty of care. Undertaking a legal analysis of these areas, this article examines the potential of each area to support the case for reform of the Victorian Government's policy on a prison-based NSP. Looking ahead, this article suggests reforms to ensure the proper functioning and administration of prison NSPs.

Vulnerability, Moral responsibility, and Moral Obligations: the case of Industrial Action in the Medical and Allied Professions.

The article addresses issues at the nexus of physician industrial action, moral agency, and responsibility. There are situations in which we find ourselves best placed to offer aid to those who may be in vulnerable positions, a behavior that is consistent with our everyday moral intuitions. In both our interpersonal relationships and social life, we make frequent judgments about whether to praise or blame someone for their actions when we determine that they should have acted to help a vulnerable person. While the average person is unlikely to confront these kinds of situations often, those in the medical professions, physicians especially, may confront these and similar situations regularly. Therefore, when physicians withhold their services for whatever reason in support of industrial action, it raises issues of moral responsibility to patients who may be in a vulnerable position. Using theories of moral responsibility, vulnerability, and ethics, this paper explores the moral implications of physician industrial action. We explore issues of vulnerability of patients, as well as the moral responsibility and moral agency of doctors to patients. Determining when a person is vulnerable, and when an individual becomes a moral agent, worthy of praise or blame for an act or non-action, is at the core of the framework. Notwithstanding the right of physicians to act in their self-interest, we argue that vulnerability leads to moral obligations, that physicians are moral agents, and the imperatives of their obligations to patients clear, even if limited by certain conditions. We suggest that both doctors and governments have a collective responsibility to prevent harm to patients and present the theoretical and practical implications of the paper.

HIV contact notification in sexual assault cases-ethical, legal, and procedural challenges.

HIV notification of sexual contacts is an essential public health aspect of reducing transmission. This process can be challenging at times, and even more so in instances of alleged sexual assault. This article highlights the multiple complexities associated with HIV contact notification in sexual assault cases when the complainant is HIV positive, and their sexual contact (the alleged perpetrator) is in police custody. We examine ethical and legal challenges associated with a practitioner's duty of care towards all involved parties, as well as potential issues with consent to notify sexual contact(s). Further, logistical challenges with this process, along with possible investigative implications are discussed. We contend that clinical forensic medical practitioners play a fundamental role in this context of HIV contact notification.

Medical Error Litigation in Nigeria: A Proposal for Change.

Negligence actions are the most important and dynamic of all torts because they are the principal means of compensating victims of accidents, including medical errors. Unfortunately, victims of medical error in Nigeria have not historically been able to enjoy the relief available through negligence suits. This article explores the Nigerian legal and regulatory framework for addressing medical errors and offers suggestions that could help improve such medical error response.

Duty versus distributive justice during the COVID-19 pandemic.

The COVID-19 pandemic exposed vulnerabilities in inadequately prioritized healthcare systems in low- and middle-income countries such as Kenya. In this prolonged pandemic, nurses and midwives working at the frontline face multiple ethical problems, including their obligation to care for their patients and the risk for infection with severe acute respiratory syndrome coronavirus 2. Despite the frequency of emergencies in Africa, there is a paucity of literature on ethical issues during epidemics. Furthermore, nursing regulatory bodies in African countries such as Kenya have primarily adopted a Western code of ethics that may not reflect the realities of the healthcare systems and cultural context in which nurses and midwives care for patients. In this article, we discuss the tension between nurses' and midwives' duty of care and resource allocation in the context of the COVID-19 pandemic. There is an urgent need to clarify nurses' and midwives' rights and responsibilities, especially in the current political setting, limited resources, and ambiguous professional codes of ethics that guide their practice.

Ethical dilemmas, perceived risk, and motivation among nurses during the COVID-19 pandemic.

BACKGROUND: Positioned at the frontlines of the battle against COVID-19 disease, nurses are at increased risk of contraction, yet as they feel obligated to provide care, they also experience ethical pressure. RESEARCH QUESTION AND OBJECTIVES: The study examined how Israeli nurses respond to ethical dilemmas and tension during the COVID-19 outbreak, and to what extent this is associated with their perceived risk and motivation to provide care? RESEARCH DESIGN: The study implemented a descriptive correlative study using a 53-section online questionnaire, including 4 open-ended questions. PARTICIPANTS AND RESEARCH CONTEXT: The questionnaire was complete by 231 registered and intern nurses after being posted on nurses' Facebook and WhatsApp groups, and through snowball sampling. ETHICAL CONSIDERATIONS: The research was pre-approved by the ethics committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa, Israel. FINDINGS: In all, 68.8% of the respondents had received some form of training about COVID-19. Respondents positioned themselves at perceived high risk levels for contracting the virus. About one-third feared going to work because of potential contraction and due to feeling inadequately protected. While 40.9% were scared to care for COVID-19 patients, 74.7% did not believe they have the right to refuse to treat certain patients. When asked about defining an age limit for providing patients with scarce resources (such as ventilation machines) in cases of insufficient supplies, respondents stated that the maximum age in such scenarios should be 84 (standard deviation (SD = 19) - yet most respondents (81.4%) believed that every patient has the right to receive optimal treatment, regardless of their age and medical background. DISCUSSION: Correlating with their strong commitment to care, nurses did not convey intention to leave the profession despite their stress, perceived risk, and feelings of insufficient support and protection at work. The nurses did not hold a utilitarian approach to resource allocation, thereby acknowledging the value of all people and their entitlement to care, regardless of optimal outcomes. CONCLUSION: While experiencing significant personal risk and emotional burden, nurses conveyed strong dedication to providing care, and did not regret working in the nursing profession, yet they did seek a supportive climate for their needs and ethical concerns.

Nurses' challenges, concerns and unfair requirements during the COVID-19 outbreak.

BACKGROUND: During disease outbreaks, nurses express concerns regarding the organizational and social support required to manage role conflicts. OBJECTIVES: The study examined concerns, threats, and attitudes relating to care provision during the COVID-19 outbreak among nurses in Israel. DESIGN: A 53-item questionnaire was designed for this research, including four open-ended questions. The article used a qualitative research to analyze the responses to the open-ended questions and their association with responses to the close-ended ones. PARTICIPANTS AND RESEARCH CONTEXT: In all, 231 registered nurses and fourth-year nursing students throughout the whole country. The questionnaire was delivered in nursing Facebook and WhatsApp groups and through snowball sampling. ETHICAL CONSIDERATIONS: The research was pre-approved by the Ethics Committee at the researchers' university. RESULTS: Nurses mostly referred to personal risk, followed by dilemmas regarding care provision. On average, 38.6% of quotations stated that during the pandemic, nurses are not asked to perform unfair duties. Nurses discussed activities and requirements that impact their personal and familial safety, their relationship with employer, organization or the state, and their duty to providing care. Other than fear of contraction, respondents' most frequent themes of concerns were related to work condition and patients' interests, inter-collegiate relationships, and uncertainty and worries about the future. Respondents' ethical dilemmas mostly referred to clinical questions, providing care without adequate equipment or managerial support, and in conditions of uncertainty and increased risk. DISCUSSION: Nurses raise important issues concerning their relationships with employers and family members, and significant insights regarding the pandemic and their revised responsibilities and definition of work. They raise serious concerns regarding their rights at work and their standing for them. CONCLUSIONS: Health managers should find ways to enhance the ethical climate and institutional support to enable a better work-life balance in times of pandemic and support nurses' working needs and labor rights.

[Legal Liability for Negligence: Nurse Aides Working in Hospitals].

Nurse aides are the most important direct-care providers and are indispensable in caring for hospitalized patients. Most of the hospitalized patients who need care in their daily lives hire nurse aides as regular caregivers. Care work involves numerous risks, and negligent care that results in patient injury may put a nurse aid caregiver at risk of litigation. To help nurse aides better understand their care duties, the concept of risk and prevention in care and three civil lawsuit cases involving negligence in care are presented in this paper. In the legal cases, the nurse aides were found guilty of causing death or injury due to negligence, highlighting that these caregivers did not meet their duty of care in providing care to their patients. These cases are used to analyze the causes of care negligence and the types of negligence and to propose preventive strategies for hospitals, care providers, and nurse aides to implement preventive measures and enforce self-autonomy. In addition, regular government programs focused on inspection, supervision, and accreditation can strengthen the supervision and responsibilities of hospitals. Nurse aides are expected to fulfill their care duties and develop ethical norms as well as internalize these into their personal beliefs as the framework for providing care. It is hoped that nurse aides will understand and fulfill their care duties to prevent patient injury or death due to negligence as part of their duty to protect patient rights.

[Legal Risk Management in Nursing Practice: The Importance of Duty of Care].

The steady and continued rise in medical-related disputes and lawsuits is one indicator of the myriad risks and challenges faced in today's nursing practice. When nurses become defendants, the lengthy litigation process and pressures that ensue greatly impact their professional and personal lives. Nursing practice dispute categories marked by particularly high severity and frequency over the past ten years include: (1) Failure to operate according to standard procedures, (2) Insufficient nursing sensitivity and negligent care, (3) Failure to communicate and deal with issues promptly and appropriately, (4) Beyond the scope of nursing practice, and (5) Falsification or alteration of nursing records. In this paper, the important duties of care in four major nursing practices are first summarized based on the relevant legal risks. Next, based on this, risk management procedures are prioritized, evidence-oriented nursing routine standards are set, and systematic analysis and management are conducted. In addition, to strengthen the legal awareness of nurses, nursing staffs, supervisors, and institutions must all understand clearly the three types of civil and criminal legal liabilities and their respective administrative responsibilities. Nurses should proactively work to handle the related legal risks and avoid the unpleasant consequences of civil liability in the realms of compensation, criminal punishment for negligent injury and homicide, and administrative disciplinary action.