Beneficence in Nursing practice and Human research

Beneficence in nursing practice and Human research. This slide prepared for educational requirments at Haramaya University, Ethiopia. Ph.D. Nursing

1. Beneficence Ethics in Nursing Research and Practice PhD in Nursing Course Code- NRPhD8072 By: Agezegn Asegid( Ph.D.Fellow ) 1

2. Presentation Outline Introduction Definition and concept Beneficence in clinical setting Beneficence in human research subjects Ethical issue in simulation BT Summary Conclusions 2

3. Introduction 3 Dilemma We seek solution Day to day practice

4. Introduction Purpose of ethical principles They explain why the issue at hand is an ethical issue (WHO 2015) Helps to solve ethical conflict and guide day to day ethical issue (WHO 2015). Makes our conduct in lined with social moral understanding (Williams & Hopper, 2003). Makes nurses to be more systematic , logical and enable us to give rational for our action ( DeLaune & Ladne , 2002 ). 4

5. Definition Beneficence is the duty to promote good and to prevent harm and/or evil. There are two elements of beneficence : Providing benefit Balancing benefits and harms Beneficence is an act of mercy and charity 5 (Bernstein, 2017) First appear as principles on Belmont report of 1979 (T Beauchamp & J Childress, 2013,PP152, & Bernstein , 2017 )

6. Can always possible to prevent all harm? No Unintentional harm are common in health care service Nosocomial infections adverse drug reactions the side effects of such treatments as irradiation and chemotherapy for cancer Thus the concern or ethical mandate is being disclose the information to patient and refrain from intentional harm. 6 (Ellis & Hartley, 2004 )

7. Forms of beneficence Positive beneficence He/she provided the benefit Provision of benefits including the prevention and removal of harm from other Promotion of welfare of others Principles of utility: Someone or nurse weigh risk and benefit and decide on best result which is called medical paternalism . Carefully analyze, evaluate and promote those actions that bring more benefits to others ( i.E. Patients) or the general public. Social beneficence: Research with human subjects regarded as ethical (or moral) only if we reasonably expect that it will produce results that substantially benefit the public ( David B. Resnik , 2018). 7 Punjani ( 2014); Mawere 2012) The deliberate overriding of a patient’s opportunity to exercise autonomy because of a perceived obligation of beneficence is called paternalism.

8. Forms of beneficence 8

9. Is not absolute …. Principle of beneficence is not absolute in biomedicine >>>>>>>> consider the context: Principle of utility It can be dangerous in research involving human subjects since :- Allow research to continue as long it produce much happiness Allow hastening of death for harvesting organ from donor 9 ( Mawere, 2012)

10. Paternalism Soft paternalism: protect persons from their own nonvoluntary conduct like substance abuse Hard paternalism: person’s risky choices and actions are informed, voluntary, and autonomous. Summary of justifiable reasons to practice hard paternalism :- A patient is at risk of a significant, preventable harm and if the paternalistic action will probably prevent the harm. The prevention of harm to the patient outweighs risks to the patient of the action taken . There is no morally better alternative to the limitation of autonomy that occurs. The least autonomy-restrictive alternative that will secure the benefits is adopted 10 Beauchamp, T. L., & Childress, J. F. (2013)

11. In Nursing literatures… Royal college of Nursing: Royal college of Nursing Principle C resonate the important of benefiting client during care “ Nurses and nursing staff manage risk, are vigilant about risk, and help to keep everyone safe in the places they receive health care ”(RCN, 2020). Brunner 12 th edition ( Smeltzer , Bare, Hinkle, & Cheever, 2010). If form of applied ethics and is the duty to do good and the active promotion of benevolent acts ( eg , goodness, kindness, charity). Using of ethical principles and value of caring promote nurses to render care with good rationale and widen scope of discussion with care takers when necessary. Lippincott’s review book, 2012: moral principles and duty of promoting good. And as duty nurse required to act in their patients’ best interest. William et al., 2007 is not just doing care with high technology, but it is care provided with respect for person expressed by adjusting care to persons believe, feeling and wishes. But what is good and who is appropriate to decide is common ethical challenges that nurses are facing during its applications 11

12. Clinical application of Beneficence 12

13. The exploration(culture and patient interest) and adjustment of care also can be taken as means of benefiting patient or beneficence it is unethical or it is not non-maleficence to ignore the principle of culture sensitive care provision since research proven that it will improve the wellbeing of patients ( Leininger’s transcultural care theory ) 13 (Cameron- Traub , 2002). Culture based care as beneficence

14. Trues telling dilemma Beneficence in dying/ terminally ill patient: We are trying to tell true prognosis which is our obligation and intended to benefit the patients. But, at the same time we may think of hiding the diagnosis and current stage of disease just to produce relatively comfortable condition for the dying patients which is a form of utility beneficence (Punjani et al., 2014) . 14 Obligation vs Beneficence

15. Rule of double effect It is l egal to give Morphine to treat pain or respiratory distress at the end of life: But…. Positive effect: May treat the pain and improve patient conditions Negative Effect: May cause cessation of breathing and hasten death 15

16. Our context is different 16 Providing Quality care is an act of beneficence/Non-maleficence But …..?

17. Threat to beneficence/Non-maleficence in clinical practice As we all know in Hiwot Fana STRH Student trained without supervision and adequate training over actual patient Invasive procedures done without adequate training Nurses already ignored their patient advocator role(ANA, 2015a) Poor monitoring of patient progress Poor communication among health care team Nurses lost their primary responsibility for patient Teaching first principles 17 Ph.D. Student assessment report, 2019 Breach of Ethical principles In Ethiopia From three year (2011-2013) report ethical committee analysis F ourteen ( 14/60) claims had proven ethical breach and or negligence . Some of them costs loss of life (Wamisho, Abeje et al. 2015) 

18. Suggested solution Synthesize data Advocate patient bill of right implementation by all parties Empower nurses at each level Improve Nursing leadership Initiate CPD for Nurses Indicate/assign student research topic on the area 18 

19. Beneficence in Research involving human subjects 19

20. WHO concern on human research Recommendation:- Each research should be scrutinized against on how much research benefit the community, participants are safe in the process and fairness of treatment during research process . ( WHO, 2015) 20 Thus we can understood that application of ethical principles still is current issue

21. Application in Research Analysis of risks/benefits Assessing whether risks is reasonable in relation to benefits Anonymity and confidentiality are most common method of maximizing benefit of participants Mainly relies on researcher genuine analysis and application. 21

22. Maximum benefit …. There is absolutely no justification for inhumane treatment Risks to participants should always be reduced to the maximum extent possible. If a significant risk is involved, justification of the research must be examined with particular care . Whenever vulnerable persons are participants, the need to involve them must be carefully demonstrated . 22

23. Role of IRB in Beneficence Act as gatekeeper safeguard the participant and maximize their benefit as gatekeeper for research process all over the world. obligate any research process to maximize benefit protect harm and implementation of appropriate compensation for participants and intentionally controlled groups 23 ( Vitak , Shilton , & Ashktorab , 2016). Prior to conducting research the researcher/sponsor should: Ensure the research responds to the health needs and priorities of the target community. Ensure any product developed will be made available to the community. Research in limited resource setting Our context:- Most for academic requirements Community need and direct application is secondary objective

24. Challenge of Beneficence in research Anonymity and keeping participant confidential is the two most common method of maximizing benefit of participants. Research need to address the top urgent community problems. Challenge In the era of electronic media and technological advancement, many research have been conducted in distance with help of online technology. It is not easy to keep confidentiality of participant in online data collection ( Vitak et al., 2016 ). Focusing of market based trial than magnitude based research title selection (WHO,2015) 24

25. Saving Community, How ? The WHO recommends following activity to save community from harmful research conduct:- Ethical integrity on the part of researchers and research organizations Research ethics committees perform the important role of assessing the potential risks and benefits of involved individual, family and community in research Data safety monitoring boards (DSMBs) for clinical trial Assigning independent clinical monitors 25 (WHO, 2015)

26. I suggest All parties at all level should motivate to abide to already existed ethical principles of research IRB at all area and level should get period capacity building service Academician and potential researcher need to or participated on periodic training 26

27. Ethical issues in Simulation based teaching 27 Issues Possible solution Principle addressed Use of standard patient     Portraying and expressing feeling and situations of illness may produce discomfort SP ( Truog and Meyer,2013) Multiple exercise and developing guideline to train well Non-maleficence Concern for self safety Use less risky material, procedure and good communication as research team Non-maleficence As human subjects of research Need to convinced about activity by proper communication(take informed consent) Show compassion and respect throughout work Autonomy and/or Respect for person Resource constraint Use of colleague

28. 28 Issues Possible solution Principle addressed Participants(students)     Overloaded and busy student schedule and potential deflation in student class grade Scheduling challenge/ appropriate time for study Non-maleficence Fear and anxiety in participant ( Hulsman et al., 2010)( Budić et al., 2018) Since fear and anxiety disturb overall physiology adequate discussion and orientation needed Non-maleficence Participant as human subjects of research Need to voluntarily invited to research Autonomy and/or Respect for person Control group Adequate compensation for not getting Rx during study Beneficence Simulation death create anxiety over the students Proper demonstration and orientations Non-Maleficence Ethical issues in Simulation based teaching

29. Nursing implication Beneficence is beyond moral obligation and it is our primary role There is a decline in patient advocacy role that threaten patient benefit and welfare Nurses s hould motivate again to keep the interest of their patient and community Beneficence is must and non-maleficence is minimum, but breach in both principle leads to malpractice 29

30. Summary Beneficence is one of major principle of professional ethics for clinical practice and research involving human subjects Beneficence have t hree forms: Positive, utility and social beneficence Researcher and agency commitment is pivotal to keep benefit of community IRB acts as gatekeeper for preventing harmful research and maximize benefit Our clinical setting is on a critical condition in keeping maximum benefit for the patients 30

31. Conclusion In light of beneficence detail analysis of research benefit and risk with genuine and scientific procedure needed before field work. The motivation to maximize patient benefit and keeping safety is at alarming level in our hospital 31

32. Sample reference Beauchamp, T. (2019). The Principle of Beneficence in Applied Ethics. from Stanford Encyclopedia of Philosophy Bernstein, R. (2017, August 11, 2017). Beneficence Nursing and Ethics. Beneficence Nursing and Ethics. Retrieved from https://online.husson.edu/beneficence-nursing-ethics/ Zaccagnini , M., & White, K. (2011). The doctor of nursing practice essentials : a new model for advanced practice nursing (A. Sibley, P. Donnelly, & R. Shuster Eds.). USA: Kevin Sullivan. Mawere, M. (2012). Critical reflections on the principle of beneficence in biomedicine. Pan African Medical Journal, 11 (29). DeLaune , S., & Ladne , P. (2002). Fundamentals of nursing: Standards & practice (2nd ed.): Delmar, a division of Thomson Learning, Inc. Ellis, J., & Hartley, C. (2004). Nursing in todays world: Trends, Issue and Management A Wolters KLUWER COMPANY lippincott Williams & Wilkins. 32

33. Thank you very much 33