Introduction

The practice of medicine is both a science and art. We should use the science of updated
medical knowledge to take decisions concerning our patients. The art of medicine lies in
knowing how, when and what to elicit from patients and offer appropriate assistance to
enable them to stay healthy. The art also indicates a need for adequate skills of
communication and a non-discriminatory attitude towards patients. Medical ethics is an
important part of both science and art of medicine. when we use unscientific reasons for
medical decisions , when we do not update our knowledge , when we are not analytically and
scientifically rational, when we do not attempt to communicate effectively or adequately
and discriminatory for whatever reason , we are practising unethical medicine . The practice
of good medicine is ethical medicine.

Children are a vulnerable segment of the population and special care must be taken in every
clinical decision to protect the interests of the child. As a health care provider we need to
advocate and protect the rights of the child.

Ethics and bioethics

Ethics is the Philosophic study of morality, moral judgements and moral problems. Ethical
issues may arise from a moral dilemma (a conflict of social values and ethical principles that
support different course of action)

Ethics involves determining the best course of action in a certain situation.Ethical reasoning
is the analysis of what is morally right and reasonable .Bioethics is the application of ethics
to health care . Ethical issues become more complex as developing techonology has allowed
more options in health care. These issues are controversial because a lack of agreement exists
over what is right or best and because moral support is possible for more than one course of
action.

Ethical dilemmas

An ethical dilemma is a situation in which no solution seems completely satisfactory .

Ethical dilemas are among the most difficult situations in nursing practice . Finding
solutions involves applying ethical theories and principles and determining the burdens and
burdens of any course of action.

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Ethical principles

Ethical principles are also important in solving ethical dilemmas. Four important principles
are there . Although principles guide decision making , in some situation application of one
principle may be impossible without encountering conflict with another. In such cases one
principle may outweigh another in importance.

Eg; treatements designed to do good may also cause harm . A child who undergoes
chemotherapy may see improvement or disappearance of the cancer , but chemotherapy that
cures cancer can harm other body organs.

Beneficence – doing or promoting good for others. This essentially means that as health care
professionals we need to do good for our patients. The objective of our intervention at
various stages (history, physical examination , investigations medical and surgical should be
to do best for the patient . A detailed elicitation of history and physical examination leading
to a sound clinical diagnosis is an example of beneficience

Nonmaleficence- not risking or causing harm to others. This means that we should not
intentionally harm our patients by our decisions or actions . The objective of our care should
be not to inflicit harm and we need to prevent all attempts to harm patients in our care. It is
common to balance the principles of do good against do no harm in medical practice. Eg;
the need for a painful injection such as DPT immunisation versus protection against all
three vaccine preventable diseases will have to be weighed in favour of vaccination despite
the pain and fever followed by vaccination.

Autonomy – people have the right to self determination this includes right to respect ,
privacy and information necessary to make decisions . This sugeests that patients have the
right to decide what is right and wrong for them . This principle suggests that the patient
have the right to take informed decisions regarding their own health care . This principle
make us respect the decision making capacity of individuals especially patients , respect
their privacy and keep confediential all aspects of information shared . As health care
professionals we should ask permission consent to perform any intervention after providing
adequate and appropriate information to patients thus enabiling them to take an informed
decision . eg; a family deciding who or where the child to be treated

Justice- all people should be treated equally and fairly regardless of disease or social or
economic status . This suggests that we should weigh and balance the effects on all parties

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involved in the care of patients , costs, benefits , distributions , risks , sideeffects ,
responsibilities and roles need to be evaluvated . As health care professionals we need to
make decisions after properly considering not just the individual’s point of view but also the
effect of these decisions on care takers ,guardians , parents and community . This may often
clash with the principle of autonomy. Merit , needs and efforts among other aspects will
have to be taken into consideration in deciding whether we have been fair and just in our
decision making . eg; admitting a critically ill patient irrespective of the socioeconomic
status and sex and purely on need is a decision taken based on justice

In addition truth and confedientality are two important factors to be considered in an ethical
decision making process. Being honest and truthful in dealing with a patient is the basis of a
good doctor- patient relationship . keeping information regarding a patient secret also
enhances this relationship.

Solving ethical dilemmas

Desicion making in ethical dilemmas may seem straight forward but it may not result in
answers agreeable to every one . Many agencies have bioethics committess to formulate
policies for ethical situations, provide education , and help make desicions in specific
cases . these committees include a variety of professionals such as nurses , physicians ,
social workers, ethicists and clergy members. The child and the family also participate .
some times solutions to ethical dilemmas may be in conflict with what is legal in their
field and place of practice.

Ethical concerns in child health nursing

Cessation of treatement

The decision to cease treatement is an ethical situation that is always difficult and seems
to be compounded when the client is an infant or child . children who would have died in
the past can now have their lives extended through the use of life support. Parents must be
involved in the decision process making immediately and informed about the available
options . laws in some states permit parents to provide advances directives for the minor
children.

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Terminating life support

Decisions to terminate life support systems continue to present gut- wrenching ethical and
legal situations to nurses especially when an infant or child is involved. Contrary to the
common belief that such decisions should be determined by quality of life , the legal system
plays a major role in this area of health care.

Parents frequently become attached to a primary care nurse and request that the nurse
participate in the decision regarding whether to terminate life support to their children. For
eg ; a nurse might be faced with such a situation in the neonatal intensive care unit with a
teenage parent

Of a premature infant with congenital heart defect . In such instances a team conference
should be arranged with the parents , primary nurse , physician and a hospital staff attorney
who is knowledgable about applicable laws in that particular state .Problems may arise
when families.

Physicians and nurses differ in their opnion of what is best. The issue of when first to
discuss with the adolescents the idea of cardiopulmonary resuscitation , mechanical
ventilation , and do not rescuitate orders is always sensitive . Adolescents who have
reached majority age must give consent if they are of sound mind . In most states minority
status ends at the age of eighteen years

INFORMED CONSENT

Informed consent is a formal preauthorization for an invasive procedure or participation in

research . consent must be given voluntarily , parents as the legal custodians of minor
children are requested to give informed consent on behalf of a child . when parents are
divorced either may give informed consent . both children and parents must understand that
they have the right to refuse treatement at anytime . In an emergency consent for treatement
to preserve life or limb is not required. Children under 18 or 21 years of age depending on
state law , can legally give informed consent in following circumstances. When they are
minor parents of the child patient . When they are emancipiated minors (self supporting
adolescents under eighteen years of age, not subject to parental control). When they are
adolescents between 16 and 18 years of age seeking birth control , mental health
counselling or abuse treatement. Mature minors (14 and 15 year old adolescents who are

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able to understand treatement risks ) can give consent for treatement or refuse treatement in
some states

Gender sensitisation

Gender and sex are some factors that affect decision making . sex refers to the biological
phenotype classified into two broad categories male and female . gender denotes legal
social and economical distinctions that follow from the biological difference of sex .the
male female ratio has gradually changed through the years with an unnatural decrease in the
female children . the reasons are female infanticide , prebirth elimination of females by
antenatal determination of sex

Steps in making ethical desicions

1. Collect information
 What desicions are needed?
 Who are the key persons involved?
 What information will make the situation more clear?
 Are there any legal constraints?
2. Identify the ethical issues or concerns of the situations
 What are their historical roots , the religious and philosophical positions?
 What are the current societal views of each issue ?
3. Define the personal and professional moral positions on the issues ?
 What personal constraints are raised by the issues?
 What is the professional code for guidance ?
 Are there any conflicting loyalities or obligations ?
 What are the moral positions of the key individuals involved?
4. Identify any value conflicts
 What is the basis for the conflict?
 What is the basis for the resolution ?
5. Desicion making
 Who should make the desicion ?
 What are the possible actions and their anticipated outcome ?
 What is the moral justification for each action ?

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  Which action fits the criteria for this situation?
 Decide on a course of action and carry out ?
6. Evaluvate the results of the desicion action
 Did the expected outcome occur?
 Is a new desicion needed?
 Is the desicion process complete

Ethical Issues of a Pediatric Nurse

Pediatric nurses are trained in child development, health care and diseases of children. They
deal with infants all the way up to adolescent children. These types of nurses specialize in
examining both the physical and psychosocial well-being of a child. The ethical issues
pediatric nurses face can be quite challenging at times, as they must often professionally
solve conflicts involving a family’s personal values.

Coping Skills

1. If a child is recently diagnosed with a serious condition, it can be quite overwhelming

for both the child and family members. A pediatric nurse has the responsibility of helping
both the parents and child learn to cope with a serious illness.

Restraining a Child

2. There are certain procedures that require pediatric nurses to restrain a child. In some
situations it’s absolutely necessary in order to protect their safety; for example, if a child
is in need of stitches but refuses to hold still, the child would need to be retrained for the
procedure.

Refusing Treatment

3. The parent ultimately has the right to refuse treatment for their child, as children are
minors. Therefore, it can be quite challenging for a nurse to have to pull a child from life
support or not give a child certain treatments that may help them recover, when the nurse
feels that it’s ethically right to do so.

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 Religious Beliefs

4. Despite a pediatric nurse’s spiritual or religious beliefs, she must comply with the
family’s beliefs, not allowing her own feelings to personally get in the way.

Accepting Reality

5. Losing a child can be the most difficult thing a family will ever go through. However,
a pediatric nurse must help family members understand when there is nothing else that
can be done in order to save the child. In some cases, parents refuse to accept this, and
want to perform more treatments.

Culture

The future of any society depends on its children. Culture plays a critical role in the
socialization agenda of children through particular views of parenting and child development.
Culture is the context of the child’s experience of health, wellness and sickness . Culture is
the pattern of assumptions beliefs and practices that unconsciously frames or guides the
outlook and decisions of a group of people. A culture is composed of individuals who
shares a set of values , beliefs, practices (language , dress , diet , health care) social
relationships , laws ,politics , economics and norms of behaviour that are learned ,
integerative , social and satisfying.

Culture is a view of the world and a set of traditions that a specific social group use and
transmit to the next generation . Cultural values are prefferrd ways of acting based on those
traditions to understand why people react to health care in different ways it is important to
understand their cultural and background values. Cultural values often arise from their
environmental conditions . the usual values of a group are called norms . Actions that are
not acceptable are called taboos . Cultural values influence the manner in which people
carry out child rearing and respond to health and illness. Cultural differances occur across
not only different ethnic back grounds but also different lifestyles.Adolescents , urban city
youth .nursing care that is guided by cultural aspects and respects individual differances is
termed transcultural nursing .

Socio cultural differences and their implications for child health nursing

Respecting socio cultural values is important in child health because child rearing is a time
in life surrounded by Many cultural traditions . Nurses can better provide multicultural care
by understanding cultural concepts and sociocultural influences on families.

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SOCIAL ROLES

Children’s self concept is derived from their ideas about their social roles . Roles are
cultural creations , therefore culture prescribes patterns of behavior for persons in a variety
of social positions .

CHANGING CULTURAL CONCEPTS

Assimilation or acculturation refers to this trade of ethnic traditions for those of the
dominant culture. The process of assimilation means that cultural expression is lost by
taking on the concepts of the dominant culture.The belief that one’s own culture is
superior to all others is referred to as ethnocentrism. Ethnocenterism can lead to prejudice
because the feelings and ways of other cultures cannot be understood or appreciated
without the philosophy that the world is large enough to accommodate a diversity of ideas
or behaviours.

Cultural competence continuum

Cultural destructiveness

Making every one fit the same cultural pattern and exclusion of those who don’t fit- forced
assimilation . emphasis on differences and using differences as barriers.

Cultural blindness

Do not see or believe there are cultural differences among people . everyone is the same .

cultural awareness

Being aware that we all live and function within a culture of our own and that our identity is
shaped by it.

Cultural sensitivity

Understanding and accepting different cultural values , attitudes and behaviours

Cultural competence

The integeration of cultural elements to enhance communication and work effectively with
people is being strongly encouraged . When planning nursing care , it is important not only

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to respect people’s cultural differences but also to help people share their cultural beliefs
with health care providers so their beliefs can be considered and respected.

Socio cultural assessment

Assessing families as to whether socio economic or cultural influences are present that
special considerations of care necessary will make The composition of the family , and
functions , the roles and actions of the family need to be examined.

Communication patterns

Communication patterns not only what people say , but how they say it are determined by
culture . People who ordinarily associate only with members of their own culture speaking

their native language may have great difficulty detailing a health history in english to a
health care provider .Language barriers can be particularly significant if the health history
is given at a time when the child is ill because their ability to cope and express may be low
when they are ill.Sometimes people may not be able to recall english words for symptoms
such as nausea or dizziness when under stress. Children who are embrassed or bashful
about speaking may simply not talk , therefore their needs may go unmet .

Touch is a form of communicatuion ,whether people greet one another with hugs
and kisses or omit touching one another is culturally determined . Some people don’t like
to touch or shake hands.Eg; some vitenamese Americans feel that palpating the fontanalles
is an intrusive gesture because they belive that head is the seat of the body’s spirit and
should not be touched . whether people look at one another while talking is also culturally
determined .Eg ; Chinese Americans may not make eye contact during conversation , a
social concept that shows respect to the health care professional.

Cultural shock

The term cultural shock describes the feelings of helplessness and discomfort and a state
of disorientation experienced by an outsider attempting to comprehend or effectively adapt
to a different cultural group because of differences in cultural practices values and beliefs
cultural shock is characterized by the inability to respond to or function in a new or
strange situation.Nurses are challenged to overcome culture shock and develop the

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dynamics of cultural sensitivity an awareness of cultural similarities and differences .thus
nurse is helped to practice culturally competent care.Sugeestions to gain cultural
competence include

Set a language goal

Use note cards when conversing

Use of conversational space

People of different cultures use the space around them differently. In the western world
examinations of children are by necessity conducted in a very tight (intimate )space
because Palpation is a part of the examination.conversation on other hand is held at a
distance between 18 inches and 4 feet . People from eastern culture may not be comfortable
at the same distance .Being aware that use of space is culturally determined helps use to
respect the use of space for clients .

TIME ORIENTATION

The cultural pattern in the united states is geared towards punctuality regarding
appointments . They consider time as money , other cultures may not have this concern for
time. They have a concept that time is to be enjoyed.In some south asian cultures being late
for appointments is considered as a sign of respect . Children and families who do not have
a strict time orientation may view the hospital compulsion of the set meal times as strange.
Another way time orientation differs is in whether a culture concenterates on the past ,
present or the future.eg The dominant US culture is present – future oriented . , people
are expected to take care of themselves at the present moment but also to make plans for
the future. Other cultures are past oriented , they carefully preserve past traditions
allowing only the slightest changes or variations in practices, still others are past
oriented.People from lower socio economic groups tend to be more present oriented than
those from middle or higher socio economic groups. People with strong religious
convictions may be future oriented .

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WORK ORIENTATION

The predominant culture in the united states stresses that every one should be employed
productively , and work should be a pleasure and valued . Other cultures do not value work
but consider work as a means to an end .

FAMILY ORIENTATION

Family structure and roles of family members may be culturally determined . In most
cultures nuclear family is the most common . In other cultures extended families and single
parent families may be more common. When caring for children be certain to identify a
child’s primary care giver before giving health care instructions. Most families are
interested in preserving their cultural heritage as a way of providing a sense of security
and continuity for their children.

Cultural influences

Nurses need to consider client’s cultural differences when providing health care . an
understanding of the various beliefs regarding the causation of illness and disease as well as
traditional health care practices is essential to successful intervention . the more nurses no
about the values and beliefs and customs of other ethinic groups , the better they are able to
meet the needs of these families .

Cultural realitivity

Clinical characterstics of a disease or condition are essentially the same across the
cultures , how a child or family intereprets or experiences the disease or condition varies
.cultural realitivity is the concept that any behaviour must be judged first in the context of
culture. The patient ‘s and family’s response to the health care they receive is influenced
by cultural factors , including their belief system and view of the world . the level of
adherence to a treatement plan is influenced by cultural beliefs and behaviours. some
cultures may view a chronic illness or disability as affecting only affecting particular
aspects of child’s life , and the child is viewed as normal . chiense families more frequently
describe the illness as having global effects on many aspects of the child’s present and
future life .

In some cultures the child’s gender may influence a family’s perception of the implication
of an illness and disability for eg, in Arabic and asian cultures and for some families of

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jewish , Italian greek or Indian origin , the male child is held in higher esteem than the
female child . the male child may receive better healthcare and food since this is the child
who take care of their parents during old age.disease is also influenced by culture some
cultures perceive diarrhoea as a cleansing of the body that is essential for health
maintainence and illness prevention or cure . nurses can recgonize a family’s health related
cultural perceptions and interpretations through discussion and observation . Implication of
this should be considered when planning culturally related interventions .

Male - female roles

In most cultures the male is the dominant figure . In such a culture if approval for or
therapy must be gained , it would be the man who would give this approval in a culture
where man is very dominant and woman is extremely passive . In contrast in some cultures
woman may be the dominant person in the family, the oldest woman in the family would be
the person who would give consent for the hosptlizaton . It is important to evaluvate the
male- female roles because knowing the dominant person in the household also helps to
understand the impact of illness.

Religion

Religious and spitritual dimensions of life are among the most important influences in
many people’s lives. Religion is culturally determined although there are wide variations in
what religion people practice . Religion guides people’s overall philosophy , it influences
how they feel about health and illness . knowing what religion family practices helps you
locate a support person when needed . It helps in planning care because many nutrition
practices such as whether family eats meat depends on their religious beliefs.Meeting the
spiritual needs of the child and family can provide strength where as unmet spiritual needs
can result in spiritual distress.holistic nursing care is promoted through an integeration of
spiritual and psychosocial care.the care focuses on activities that support a person’s system
of beliefs and worship such as prayers reading religious materials and assisting with
religious rituals.

Health beliefs

The beliefs related to the cause of illness and the maintainence of health are an integeral
part of the cultural heritage of families.Health beliefs are not universal .eg, in USA illness
is caused by documented factors such as bacteria , viruses or trauma. In other cultures

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illness may be viewed primarily as a punishment from the god, an evil spirit or the work of
a person who wishes harm on the sick person. People from some cultures may receive
more comfort from a spiritualist or a witch doctor than a physician. Understanding
different beliefs allows to respect cultural differences and work out mutual goal setting.eg;
burning a practice of some south east asian groups whereby small areas of skin are burned
to treat enuresis and tempertantrums.

Nutrition practices

Foods and their methods of preparation are strongly culturally related . In many instances
hospatilized children cannot find on the menu any foods that appeal to them because of
cultural preferences .in counselling for good nutrition during childhood rember that
respect for culturally preferred food is important. Some families may omit various foods
during an illness because of a nescessity to eat hot or cold foods to restore health.

Pain responses

People’s responses to pain is both individually and culturally determined . People may
have the same pain threshold sensation ( the amount of stimulus that results in pain )
people’s pain threshold ( the point at which the individual reports that a stimulus is
painful )and pain tolerance (the point at which an individual withdraws from a stimulus )
vary greatly. A person’s culture dictates attitude towards pain and what is the proper
response to pain . One child might report pain as terrible and cry where as another child
might report that pain is okay and remain quiet.

SUBCULTURAL INFLUENCES

Children grow and develop in a blend of cultures and subcultures . Many cultural
differences are related to geographic boundaries subcultures are not always restricted by
location.Children’s membership in a cultural sub group is involuntary . They are born into a
family with a specific ethnic and racial heritage , socio economic level , religious
beliefs.subcultures that seem to exert greatest influence on child rearing are ethinicity , social
roles and occupational roles. In addition school and peer group subcultures are strong
influences in the socialization of the child.

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Ethinicity

Ethnic differences extend to many areas and include such manifestations as family
structure ,food preferences, moral codes and expression of emotion some standards of
behaviour result from the cultural heritage of the specific ethnic group.Ethnic differences
in child rearing are probably diminishing .

Ethnocentrism- Is the emotional attitude that one’s own ethnic group is superior to others
that one’s beliefs , values and perceptions are correct ones.

Social class/ occupation

The greatest influence on childrearing practices and their consequences is the social
class of the family into which the child is born.Differences in childrearing goals and
practices as well as attitudes toward health , is greater between social classes than between
races or ethnic groups.

Poverty

Subcultural influence closely related to but different from social class is the condition
known as poverty .The term poverty implies both visible and invisible impoverishment.
visible poverty refers to lack of money or material resources which includes poor
santitation housing invisible poverty refers to cultural and social depreviation such as
limited employement opportunities.

Schools

Parents continue to exert the major influence on the children , in the school environment
teachers have the most significant psychological impact on their development and
socialization.

Peer cultures

Peer groups also have an impact on the socialization of children . Peer relationships
become increasingly important and influential as children proceed through school. The
kind of socialization is provided by the peer group depends on the special subculture that
develops from the background, interests and capabilities of members . The peer group

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culture has secrets , they have traditions and folkways that are transefered from generation
to generation of school children and that have a great influence over the behaviour of the
members. There are age related activities and games eg; a school age child rides a bicycle
while a college student prefers a car

Biculture

Children are exposed to the values, roles ,life styles and relationships of two or more
cultures.the virtual straddling of two cultures is referred to as biculturation and involves
the ability to efficiently bridge the gap between an individual’s culture of the origin and
dominant culture.This may occur because child’s parents are from different cultures. The
biculture is particularly marked in language differences.There is less conflict for children
when their language and culture are supported by the school.

Customs and folkways

Nurses need to consider cultural differences in clients when providing health care.The
nurses know about the values and beliefs and customs of other ethnic groups.

RELATIOINSHIPS WITH HEALTH CARE PROVIDERS

The manner of relating with health care providers differs considerably among cultural
groups.eg in many cultural groups mother assumes the responsibility for health care. In
others both parents are involved equally in relationship with health workers.Nurses should
make themselves aware of any specific attitudes regarding the manner of approach to a
child in a given culture.

FOLKLORE RELATED TO PRENATAL INFLUENCES

The process of pregnancy and birth have been surrounded by strongly held beliefs and
superstitions that involve taboos and prescriptions for behaviour directed toward ensuring
the well-being of the unborn child. One of the most universal explanations of defective
development has been maternal impressions. It has been a widespread belief that
appearance of an unborn child will be improved if pregenant woman looks at beautiful things
eg; if a pregnant woman was frighetend by a rabbit it was belived that her child will be
born with a cleft lip

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Importance of culture and religion to nurses

Nurses and other health care providers should be aware of their own cultural values and how
those beliefs their thoughts and actions. Those who are aware of their own culturally founded
behaviour are more sensitive to cultural behaviour in others. Cultural standards and values
the family structure and function and past experiences with healthcare influence a family’s
feelings and attitudes towards health, their children and health care delivery systems. Being
aware of one’s own feelings and as well as respecting those of the family is essential to a
helping relationship and achievement of nursing goals. It is essential to make an effort to
adapt ethnic practices to the health needs of the family rather than attempt to change
longstanding beliefs. Bridging cultural gaps in delivery of health care to children requires the
establishment of a close relationship with families and other influential persons in the
community

Nursing diagnosis

Pain related to tissue trauma of surgery and cultural belief of not complaining

Interventions

 Assess for nonverbal indicators of pain

 Offer pain medication as ordered
 Explain the concept of pain and why the client is experiencing it
 Assess the child’s response to medications
 Assist the child in using Non pharmacological measures such as guided imagery
and deep breathing

Impaired Nutrition less than body requirements related to limited caloric intake
postoperatively and cultural beliefs about food and illness

Interventions

 Explain the need for adequate consumption of nutrients and calories to the child
and family
 Question the child about likes and dislikes
 Obtain a dietary consult to assist with menu planning
 Reinforce the dietician ‘s suggestions with the child and family prior to discharge

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 Bibliography

1) Dorothy.R.Marlow and Barbara.A.Redding. text book of pediatric nursing 6 th

edition

Philadelphia; Elseiveir; 2005. 885-886

2) Whaley and Wonngs pediatric nursing 5th edition USA Mosby; 1997. 900-911

3) Susan Rowen James. Nursing care of children principles and pratice 2 nd edition

China; Sounders; 2002; 780-787

4) Jane Bolt and Ruth Bindler. Pediatric nursing 2 nd edition USA. Appleton and

Lange, 1999 .577-580

5) Cuttler, L, Whittaker, J.L, & Kodish, E.D. (2005). The overweight adolescent:

Clinical and ethical issues in intensive treatments for pediatric obesity. The

Journal of Pediatrics, 146(4), 559-564.

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 HOLY FAMILY COLLEGE OF NURSING

ON
ETHICAL AND CULTURAL ISSUES IN PEDIATRIC NURSING

SUBMITTED TO: SUBMITTED BY:

MS.SHERLY THOMAS MISS. TANVI KUNDRA
ASSTANAT PROFESSOR I STYEAR M.SC
DEPARTMENT OFCHILD HEALTH H.F.C.O.N
.

DATE OF SUBMISSION
02 -11-18

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