BACKGROUND

As a part of Post Basic Bachelor Nursing Programme, we twenty students of second year, Hospital Major group were assigned to have clinical exposure in Western Regional Hospital for five weeks. We all were designated in three wards that is Medical, Surgical and Orthopedics with seven, six and seven students respectively. During, these five weeks long practicum, we had to accomplish different activities in order to fulfill our objectives. Accordingly we seven students ( Pramila shrestha, Pramila Baral, Pavitra Gurung, Meera Thapa, Nirmala Poudel, Nirmala Dhakal and Parbati lammichane)were posted in medical ward with morning and evening shifts.

Within this duration we got the opportunity to apply the theoretical knowledge into practice so as to bridge the gap between theory and practice. The learning in the real situation has broadened our knowledge and skills. We are very much benefited with this clinical posting.

For fulfilling the criteria of this clinical practicum, we had set different objectives.

General objective:
To perform clinical practicum in Western Regional Hospital (medical ward) for five weeks.

Specific objectives:
To communicate effectively with individual and different groups of people in a variety of settings/situations by Interviewing individual and groups in-order to obtain information. Interacting positively and supportively with health team member, patients, visitors in managing the health facility and caring the patients. Being aware of the verbal and non verbal behavior cues while interacting with the patients and families. Identifying cultural and economic factors which influence patient and family interactions. To identify the patients who need counseling and rehabilitation and provide as per their need. To counsel a patient as per his or her need in the presence of our teacher. To do a case study of a disabled patient along with counseling and rehabilitation. To find out ethical problem and dilemma encountered during five weeks posting which affect Nursing and Medical practice. To identify the problems/areas which need to be researched (researchable problems) and list them. To visit Rehabilitation centers that is Community Based Rehabilitation Service (CBRS) for four days and Green Pasture Hospital (GPH) for a day. To utilize knowledge from Nursing and Medical science to manage the care of patients of all age groups and condition in every situation. 2

To respect the values and rights of the patient. To identify the needs and problems of the disabled patients and demonstrate the understanding of the rehabilitation process in planning the care of them. To make appropriate decision by using the Nursing process and Nursing Theories in all activities. To apply the knowledge and concepts of economics in the management of Medical ward. To cope with different situation and provide Holistic care to patients with the use of nursing process. To demonstrate effective teaching and counseling skills to provide health teaching in order to prevent, promote and maintain health and also teach the family about how to care the disabled at home.

To demonstrate accountability to self (for our own actions), patients, families and to others. To supervise and guide juniors in their work. To recognize the importance of self-direction for personal and professional development. To demonstrate adaptability and flexibility in various work situations. To report and record pertinent information accurately and appropriately. To submit the following to our respected tutors: Case study with counseling and rehabilitation report. Report of counseling done to clients in presence of our teacher. Report of CBRS and GPH visit. List of identified ethical dilemma and researchable problems.

ETHICS:
Ethics is defined as a branch of philosophy which deals with the distinction between right and wrong and the moral consequences of the related persons action. It includes principles or standards which govern proper conduct. Ethics is also the formal reasoning process for the exploration of the goodness or badness and rightness or wrongness of an action.

PRINCIPLES OF ETHICS:
There are eight principles of ethics; which are: 1. Autonomy or personal liberty 2. Justice (fairness of equity Confidentiality) 3. Beneficiaries (being help, showing kindness) 4. Fidelity (the quality of being loyal) 5. Non maleficence 6. Confidentiality 7. Veracity 8. Standard of best interest

ETHICAL DILEMMAS ENCOUNTERED IN MEDICAL WARD

Ethical dilemmas area conflict in values and one is unsure of what is or includes proper conduct. In any ethical dilemmas, there is no absolute right or wrong , the person instead , conflicts of one individuals right with those of another, one individuals obligation with the right of another, or a combination of one groups

obligations and right conflicting with those of another group usually from the basis of the dilemmas. During these five weeks we faced different dilemmas in medical ward. The most frequently encountered ethical dilemmas are discuss below:

Patients treatment right Vs scarcity of material resources

In many situations, we faced ethical dilemmas due to scarcity of materials like gloves, mask, bed, sterile equipment, cotton etc. There are many infected cases like HBsAg positive, HIV positive etc. but in many situations, there were scarce of gloves to care them. For example in unit five (infected ward), there was a patient whose injection medication was not given or due as his intra venous cannula was swelling. But there was unavailability of gloves. In this case, the patient right was to get treatment in time but his right was ignored. Another most encountered situation was due to lack of bed. For example due to lack of or occupied bed in medical ward patients were not able to get treatment on time and they suffer. Here we can apply principle of justice and beneficence to solve this dilemma.

Patients right Vs nurses safety

In the above mentioned situation, due to scarce of resources, in one hand patient right was overlooked and on the other hand our right to be on safe side was also ignored.

This created dilemma as it confused us either to give him medicine without gloves by ignoring our safety or not to give by ignoring patients right.

Here we can apply principle of beneficence to solve these dilemmas.

Patients right VS Limited financial resources.

There is a usual practice of using disposable syringes more than once for economic convenience of patients, though principally it is strictly instructed to use only once. In this practice patient can got infection due to repeated use of same syringes as the chance of contamination increases with subsequent use. So it is also a ethical dilemma which I faced in medical ward. Here we can apply the principle of justice and loyalty to solve the dilemma.

Patients right (confidentiality) Vs safety of others (nurses, patients, visitors)

There were many HIV and other infected cases. Most of them did not want to reveal their diagnosis with others due to social stigma.

In this case, if patients right to confidentiality is maintained, the safety of others is violated. As health workers being unknown does not apply universal precautions (like using gloves) and visitors also shared their utensils razors, contact with body fluids etc.

Here we can apply principle of autonomy,beneficence to solve this dilemma.

Holistic care Vs carelessness

Though there are many nurses including staff nurse, ANM, volunteer nurses, student nurses in medical ward and the nurse patient ratio is also maintained, but the patient didnt receive holistic care due to carelessness of nursing personnel. They also didnt treat the patient with regard to their financial, social, cultural background.

For example: when the patient had no medicine at bed side, the nurses did not check their stock of free medicines or try to manage it but they simply noted it as Not Available in the cardex.

Also, even when not busy, the patient never gets medication and care on time.

Here we can apply principle of beneficence, loyalty, fruitfulness to solve these dilemmas.

Patients right to treatment Vs student nurses right to learn

Many students from different nursing collage practice their skills in medical ward. In this case, patients right is to get good and best treatment and nursing care from trained nurses without errors and harm to them (like medication error, practice of cannula etc.) but student nurses right is also to learn in real situation.

Here we can apply principle of beneficence,and nonmaleficenceto solve these dilemmas

Patients right Vs hospital policy

The flow of poor patient is always increasing. In medical ward there are numbers of patient who are supplied with free medicines from poor fund. According to hospital policy poor funds medicine is not supplied without signature of medical superintendent and also not after office hours. In this case, though there is a poor fund facility, the patient is deprived from it.

The laboratory investigation is also not done 24 hours a day. Some special investigation like ECHO, colonoscopy, endoscopy etc. are not carried out in all days of weeks.

Patients right is to get treatment from his chosen doctor or continue treatment from same doctor but due to hospital policy, each day round is taken by different doctor.

Among above mentioned dilemmas, other was also faced in caring the patients with different disease condition and in different situations, which are:

Patients right to communicate and information was ignored due to lack of knowledge and unwillingness to explain.

Patients right is to involve in their own treatment and choose it but due to scarce of health personnel, lack of knowledge regarding patients right, the right of patient was neglected.

Right to safe drinking water and proper sanitation Vs improper hospital management. 8

In some situation, doctors give verbal order. In this case, patients right is to get timely treatment but from our side, to follow verbal order is not in our ethics. This situation kept us in dilemma.

We as a nurse face ethical dilemmas every day. The process of making ethical decisions can be complicated one; choice cannot be made blindly or haphazardly. So we nurses must make conscious efforts to resolve ethical problems intelligently that dont compromise their values (subjective estimate of things).

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