Standards of Professional Conduct for Nurses and Midwives

Discussion should make consistent reference to the following Maltese regulatory documents (and any other relevant documents):

• Code of Ethics and Standards of Professional Conduct for Nurses and Midwives (2020)
• Scope of Professional Practice for Nurses and Midwives (2018)
• Professional Boundaries for Nurses and Midwives (2020)
• Patient’s Charter (2016)

Case Scenario

When the nurse takes care of a 75-year-old lady with pulmonary oedema, she must be professional, compassionate, and responsible. The patient’s refusal of diuretics is a complex problem that needs to be treated sensitively, in accordance with ethical, legal, and professional standards, as outlined by Maltese law. 

Code of Ethics and Standards of Professional Conduct for Nurses and Midwives (2020)

The first responsibility of the nurse is to respect the lady’s autonomy and dignity. The Code of Ethics and Standards of Professional Conduct for Nurses and Midwives (2020) states clearly that patients have the right to be involved in decisions about their care, and their wishes should be respected even if they differ from what professionals believe is in their best interest (Collings-Hughes, Townsend and Williams, 2021). The nurse should never disdain or flippantly dismiss a refusal. Instead, she should approach it with compassion, gently inquiring about the patient’s refusal, whether it is because she fears side effects, feels discomfort, or does not understand what the treatment is supposed to do. Thus, the nurse’s role is to ensure that she is given accurate information that is clear and timely to make an informed choice. 

When a lady is of sound mind and adamant in her refusal of treatment, the nurse should respect her choice. The Code makes it clear that nurses must respect and maintain the dignity of the individual, even if the patient refuses care. Autonomy does not relieve the nurse of the responsibility for the patient’s wellbeing. As the patient’s advocate, the nurse should closely monitor the patient, alert the medical team if any concerns are noted, and ensure the decision and surrounding discussion are clarified in the medical record.

Scope of Professional Practice for Nurses and Midwives (2018)

The nurse’s practice must be guided by the Scope of Professional Practice for Nurses and Midwives (2018), which is defined as: nursing is the use of knowledge, skill, and judgment to attain optimal health, prevent disease, restore health, and alleviate suffering. Within this scope, the nurse is to evaluate the lady’s health, plan and review care, and counsel her about treatment alternatives (Ward, Rosser and Norton, 2023). In this example, she assesses the lady’s reluctance to take her medication, describes the benefits and risks, and provides ongoing care that honours her choice while protecting her health. The scope must also involve accountability and the awareness of circumstances that might result in harm to the patient. Therefore, the nurse has to honor the refusal, but take measures to minimize risk (informing the multidisciplinary team, monitoring for signs of deterioration, continuing supportive care).

Professional Boundaries for Nurses and Midwives (2020)

The situation further requires the nurse to maintain a therapeutic and professional relationship in line with the Professional Boundaries for Nurses and Midwives (2020). This document emphasises that the nurse–lady relationship is characterised by trust, respect, empathy, and the appropriate use of power. The lady is particularly vulnerable due to her age and illness, and the authority inherent to the nurse’s role is related to professional knowledge (Fenech, 2022). This power cannot be misused by the nurse through coercion and pressure to accept treatment. Instead, she should have clear communication, empathy, and trust to help her make her decision. The nurse must not over-involve herself, for example, by forcing treatment, or by disregarding her concerns, but must not withdraw from care or neglect her because of her refusal. The guidance also highlights that avoiding or treating a lady differently because of refusal or “non-compliance” may amount to neglect, and therefore the nurse remains accountable for her ongoing care and wellbeing regardless of her choice.

Patient’s Charter (2016)

The Patient’s Charter (2016) emphasizes the point of respecting a lady’s rights. According to its principle of Participation and Informed Consent, a competent lady has a right to accept or reject any treatment if she is informed of its risks, benefits, and implications. Refusal must be documented, signed by the lady, and countersigned by a witness. Thus, the nurse should record the decision and report to the medical team. The Charter also safeguards dignity, respect, and safe care. Even in the face of refusal to treatment, care must be compassionate, non-coercive, and respectful. The nurse should remain non-judgmental, involve the lady’s family/carers if she wishes, and monitor her condition extensively(Zammit, 2016).

Ultimately, the role of the nurse is to reconcile respect for the lady’s autonomy with the obligation of care. Being honest, sensitive, documenting well, respecting the refusal, ensuring professional boundaries are respected, incorporating the team, and continuing to monitor and support ensures that care is safe, ethical, and based on the lady’s needs. This is in line with the Code of Ethics (2020), Scope of Professional Practice (2018), Professional Boundaries (2020), and the Lady’s Charter (2016), which are representative of best practice within Maltese nursing regulation.