National institute of Nursing Education, PGIMER, Chandigarh

TOPIC: Ethical And Cultural Issues In Pediatric Nursing

SUBMITTED TO: SUBMITTED BY:

Ms. Anupama Deepshiekha
Tutor M.Sc. Nursing 1st year
NINE, PGIMER NINE, PGIMER
LESSON PLAN

SUBJECT Child Health Nursing

TOPIC Ethical And Cultural Issues In Pediatric
Nursing
GROUP OF STUDENTS M.Sc. Nursing 1st year
NO. OF STUDENTS 5
NAME OF STUDENT TEACHER Deepshiekha
METHOD OF TEACHING Lecture cum discussion
DATE OF TEACHING
DURATION OF TEACHING 60 min
TEACHING AIDS Power point presentation
VENUE M.Sc. Nursing 1st year class room
SUPERVISIOR Ms. Anupama

PREVIOUS KNOWLEDGE: - Students have general idea of ethics, culture and ethical considerations in nursing practices.
GENERAL OBJECTIVE: - At the end of the class, students will have the knowledge regarding Ethical and cultural issues in pediatric nursing
SPECIFIC OBJECTIVES:- At the end of class, students will be able to
 Define ethics.
 Enumerate ethical principles in nursing practice.
 Discuss ethical issues in Pediatric Nursing
 Define culture.
 Discuss child rearing practices in Indian culture.
 Discuss cultural issues in Pediatric Nursing.
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1 Student teacher 1 min Self-Introduction: I am Deepshiekha , student of M.Sc. nursing 1st year.
will be able to Today I am going to take your class.
establish rapport
with the group Please, attend to your roll calls

2 Appraise the topic 1 min Today’s topic is Ethical and Cultural Issues in Pediatric Nursing.
The topic will cover-
 Definition of Ethics.
 Ethical principles in Nursing Practice.
 Ethical issues in Pediatric Nursing.
 Definition of Culture.
 Child rearing practices in Indian Culture.
 Cultural issues in Pediatric Nursing.
 Summary
 Conclusion
3 Recall of 1 min Review of previous knowledge
Previous What are Ethics?
knowledge What is Culture?

Students will be
able to
4 Define Ethics 2min Ethics Lecture Power What are
cum point ethics?
Derived from the Greek word “ethos”, which means “way of living”, ethics is discussion presentati
a branch of philosophy that is concerned with human conduct, more on.
specifically the behaviour of individuals in society. Ethics examines the
rational justification for our moral judgments; it studies what is morally right
or wrong, just or unjust.
5 Discuss general 15 General ethical principles Lecture Power What are
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ethical principles min cum point general
of pediatric discussion presentati ethical
The ideal code of ethically-acceptable practice may be approached, if not on principles?
nursing.
fully achieved, by applying the following accepted principles in the decision-
making process.
 Respect of the individual’s autonomy
Autonomy implies that all are free to take an active and totally
independent role in the decision-making process. For this to occur,
patients and study participants must be fully informed and understand the
implications of their medical condition or involvement in research, any
treatment, complications and outcome. In practice, however, many
including young children do not have the ability to be truly informed, and
may rely on others for guidance. Informed consent is not necessary simply
to satisfy medico-legal requirements, but is indeed a pivotal issue with
regard to patients’ ‘free choice’ and active participation in their own
management. It is fraught with problems in the competent adult, and is
doubly more difficult to achieve in minors. Truly informed consent can
only exist when patients are sufficiently informed to weigh up all the pros
and cons of treatment, and their consent is given freely without coercion,
vested interest or bias from physicians, researchers or third parties. If
anything, the situation relating to children heightens the doctors’ and/or
researchers’ responsibility to ensure true informed consent, albeit through
third parties.
 Respect of the individual’s competence
Competence implies the patient’s level of understanding that allows him
or her to weigh up the ethical issues posed by a clinical situation,
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assimilate these and reach a rational decision. This degree of
comprehension is often a problem with young children and those with
developmental disabilities, thereby increasing the responsibility of parents
to assume the role of competent advocates on their behalf.
 Respect beneficence
Beneficence defines the medical principle of ‘do no harm’, a hallmark of
the Hippocratic oath, and should apply in all cases. Medical practice
frequently entails a compromise between benefit and harm, especially
with regard to interventional procedures and drug therapy, but should
always be biased toward ‘benefit’. Hence, in practice, it may be perfectly
acceptable to embark on high-risk therapy in a fully informed individual,
provided there is a realistic chance of reasonable benefit.
 Respect of the truth
There is never a case for wilfully lying to patients. Similarly, there is
rarely any justification in withholding or omitting information from
patients, unless this is deemed to be against their best interests, and this
option only adopted after considerable in-depth reflection and broad
consultation. For those whose ability to comprehend the nuances of
complex medical issues is limited by their tender age, then this
responsibility is passed on to third parties.
 Respect of patient confidentiality
All patients have a right to confidentiality. However, disclosure of
confidential information without consent may be justified in situations
where failure to report may lead to greater disadvantage to the patient, e.g.
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in some cases of child abuse.
 Avoidance of paternalism and bias
Practitioners should strive to remain truly objective and avoid all
personal, racial, cultural, religious or other bias when counselling or
treating patients. Personal prejudice and preconceived ideas must never
influence the provision or withholding of medical care to children,
regardless of whether they are disadvantaged, have a pre-existing
disability or otherwise. The wishes of parents and guardians must also be
respected, again regardless of any personal bias.
 Avoidance of all conflicts of interest
The child must always come first, before any vested interest of any third-
party including physicians, parents, guardians, extended family and
society. Numerous conflicts of interest may be associated with research
activities (e.g recruitment in clinical trials, treatment arms, outcomes,
pharmaceutical support), and cannot be allowed to influence any decisions
whatsoever. It is ‘good practice’ and, indeed, should now be mandatory
for all ‘interests’ to be declared by all co-workers and co-authors involved
in any given research project. Special attention is required in the
formulation of letters of instructions and consent forms dealing with
research studies, such that these are specially designed to be ‘child-
friendly’ and also account for the ultimate responsibility being taken by
third parties.
 Respect the limitations of medical care
Medical care should strive to support the patient, and should be tailored to
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the needs of the individual. It is ethically appropriate to appreciate
realistic goals which medical care can achieve, and wrong to aim toward
exaggerated or impossible expectations. Hence, it is equally unacceptable
to ‘treat at all costs’, as it is to ‘play god’.
6 Discuss ethical 15 Ethical issues related to Pediatric Care Lecture Power What are
issues in pediatric min cum point ethical
Honesty vs. withholding information discussion presentati issues in
nursing
on pediatric
Family members may want to withhold medical information from sick
nursing?
patients to protect their emotions. However, patients have the right to know
about their medical conditions. Deciding how to share this information,
especially if it goes against the family’s beliefs, can be a touchy situation.
Healthcare needs vs. resource allocation
The rising cost of healthcare is increasingly putting nurse managers at odds
with budgeting constraints and patient needs. A large number of medical
facilities have scarce resources, which puts patients at risk for not getting the
care they need. These resources range from medical equipment to healthcare
staff. Research suggests that nurse leaders must include staff in the budgeting
process so that they can better understand the needs and demands.
Autonomy vs. beneficence
Nurses are required to administer prescribed medicine, but patients, at the
same time, can refuse them. Patient autonomy can go against medical
directives, despite clearly defined needs. Patients have a right to refuse all
medical care. It is important for nurses and nurse managers to understand
patient backgrounds and individual circumstances to inform the patient of the
medical necessity. Using ethical principles to arrive at a solution should be
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done in an atmosphere of caring, respect, openness, and honesty. This process
should be based on a sound ethical, decision-making model, using the best
evidence-based-practice guidelines available.
Childhood Immunizations- need vs pain
The issue of immunizing infants and children highlights the role of justice in
pediatric ethics. Parents frequently question the need for the immunizations
recommended for their children. To address their concerns, the physician
must know the risks and benefits of immunizations in order to identify the
best interest of the child. Immunizations are generally intramuscular, painful
injections; and the current immunization schedule recommends that the
patient receive as many as four or five injections during one visit. Each
vaccination has established side effects, and parents need to be aware of
these.
Parents may be hesitant to immunize their children against diseases such as
polio when the child's risk of contracting the disease is exceedingly low.
Confidentiality vs need of disclosure
As part of the process of individuation, adolescents desire more privacy in
their personal lives. At the same time, they are encountering increasingly
complex and dangerous health issues. Not infrequently, issues of
confidentiality arise within the physician/patient/parent triad, and
management can be quite delicate in terms of the limits of confidentiality and
the circumstances under which disclosure must occur. Although the legal
community gives adolescents who demonstrate some degree of maturity the
discretion to make healthcare decisions for themselves and without the
involvement of their parents regarding issues such as substance abuse,
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sexually transmitted diseases, pregnancy, contraception, and mental health.
Variously known as emancipated minors, mature minors, or medically
emancipated minors, some subgroups of adolescents are considered capable
of providing informed consent for all forms of care by virtue of their life
experiences, which may include financial independence, pregnancy,
homelessness, or marriage. In all cases, the primary duty of the physician is to
optimize the adolescent's care by advocating for his best interest. A critical
role of the nurse is to facilitate communication between the adolescent patient
and the parents. Under most circumstances, the adolescent should be
encouraged to involve the parents in her healthcare because they can ideally
provide support on a continual basis. Conversely, the nurse should also
encourage the parents to embrace the adolescent's emerging sense of
independence. Confidentiality in the nurse–adolescent patient relationship
must be a priority in the physician's effort to be a confidant and caregiver and
to ultimately act in the patient's best interest.
Consent: Making Medical Decisions for Children
Decision making for children is a unique and challenging process. Most
children have not reached the developmental stage at which they can ethically
or legally give informed consent. To further complicate matters, many parties
may be involved in the decision-making process, including the patient,
parents, family members, nurses, doctors, social workers, clergy, and the
courts.
Beneficence is the foundation of decision making for children. This principle
encourages identification of the child's best interest through a shared decision-
making process involving the clinician, patient, and parents. Each member of
this triad brings information that helps identify the child's best interest. The
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clinician provides a thorough understanding of the available medical evidence
regarding the condition along with a repertoire of clinical knowledge and
experience. The parents bring their intimate familiarity with the child and the
family. As the child's primary caregivers, parents give informed consent by
proxy (otherwise known as "informed permission") because they are usually
best able to determine the child's best interest. Physicians have the
responsibility to ensure that parental motivations are based on the child's
needs rather than the parents' wishes. All of the tenets of informed consent
apply to informed permission; however, the adult parents are the ones who
ultimately make the decision instead of the child patient.
Genetic Testing in Children
Deciding when to undertake a genetic evaluation in pediatrics can be a
challenge. As with other medical decisions for children, physicians should use
beneficence as their guide. Newborns should undergo screening to detect a
number of metabolic and inherited conditions that can threaten the health of
the child. The screening procedure reflects society's obligation to optimize
health by detecting and treating particular infant or early childhood
conditions. Theoretically, screening tests are carefully chosen to satisfy a
number of criteria. Tests must be sensitive enough to identify cases among
masses of screened newborns, specific enough to avoid the anxiety that comes
from a multitude of falsely positive tests, and widely available. In addition,
effective preventive or treatment interventions must be available that
significantly alter the morbidity and mortality of the condition. Perhaps the
most important criterion is that the test must provide a clear benefit for the
child.
End-of-Life Issues
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Caring for dying children is one of the most challenging responsibilities in
pediatrics. The emotions engendered by anticipation of a child's death have a
powerful impact on families and caregivers and may sometimes be an
obstacle to the appropriate care of the child. Again, beneficence must guide
any decisions at the end of life. Through a shared decision-making process,
the clinician should obtain informed permission from the parents as well as
patient assent, when possible, to optimize these interests. Careful, continual
evaluation is critical so that when the burdens of treatment outweigh the
benefits, the treatment plan can be appropriately modified.
Medical research and children
A significant proportion of the benefits resulting from biomedical research
will help future patients rather than those directly involved in the research.
Given that patients should never be used as a means to an end, and difficulties
with informed consent in the non-competent child or disabled person, it is
hard to reconcile the participation of these groups in active research.
However, a total ban on such research activity will restrict other children and
disabled patients from benefiting from any potential advances. ‘Good
practice’ research involves randomisation, use of placebos, and similar
concepts that may be very difficult if not impossible for many, but especially
for children, to comprehend. Research trials must be unbiased, and avoid any
discrimination whilst protecting all participants. ‘Negative’ findings may be
equally if not more important than ‘positive’ results in research that aims to
add to dependable, evidence-based medical practice. To this end, therefore,
clear ethical, legal and methodological guidelines are essential in the design
and conduct of clinical trials involving all subjects, but especially children.
7 Define culture. 4 min Culture Lecture Power What do
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cum point you mean
discussion presentati by culture?
Culture refers to the cumulative deposit of knowledge, experience, beliefs, on
values, attitudes, meanings, hierarchies, religion, notions of time, roles,
spatial relations, concepts of the universe, and material objects and
possessions acquired by a group of people in the course of generations
through individual and group striving.
Culture is the systems of knowledge shared by a relatively large group of
people.
Culture is the characteristics and knowledge of a particular group of people,
encompassing language, religion, cuisine, social habits, music and arts.
8 Discuss child 10 Child-rearing Beliefs and Practices in Indian Culture Lecture Power What are
rearing practices in min cum point child
Indian culture.  The traditional Indian parenting is shaped by the cultural and religious discussion presentati rearing
values of the land, generational wisdom, and life experiences. on practices in
 The goal of parenting is comprehensive development of children and india?
it integrates the cognitive, emotional, and spiritual components of an
individual’s growth. It includes both the personal and social
dimensions of human growth and development.
 Another characteristic of Indian parenting is that children are brought
up in an atmosphere of emphatic richness. The supportive
environment of the extended family system provides support and
encouragement to parents. The parent-child bond is established by
such child rearing practices as breast-feeding that provides not only
nourishment to the baby, but also allows increasing physical contact
between the mother and the child. Cuddling adds physical contact
between the mother and the child and also provides a sense of security
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for the child. The strong emotional bond established between Indian
parent and child during early childhood is said to be lifelong.
 The traditional Indian parenting is value-based parenting. Deference
for authority in social relationships is an expected behavioral norm.
The family extends horizontally and laterally. People are bound up
by their duty to family, to parents, to children, and to society. Parents
are to be honored and cared for. The community is seen as the
extended family. Values of interdependence and community are
promoted. It is expected that one will live up to one’s family name,
and also fulfill one’s dharma (duties) to the family and to the
community. Norms of personal chastity and modesty in private and
social behavior is reinforced. The practice of self-control is central to
character formation.
 The traditional Indian parenting is not without its share of
disparagement. It is pointed out that the authoritarian type of Indian
parenting limits individual autonomy. The stress on community and
interdependence is detrimental to developing individual self-identity.
Overprotective Indian parenting inhibits personal agency and
assertiveness. Corporeal punishment, tolerated in traditional Indian
parenting, is said to have long lasting emotional scars on children.
In spite of these criticisms, traditional Indian parenting has a great deal to
offer to the Indian immigrant parent. Such features as the focus on
comprehensive development of the child, the significance of character
formation, the impact of empathic richness in Indian parenting, the thrust on
personal chastity and modesty in private and social behavior, and the
importance of community and interdependence, are all culturally appropriate
parenting practices for the Indian immigrant parent to adopt. Child-rearing
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customs and beliefs are not the same for all Indians. India is composed of a
diverse population with assorted religious, political and cultural views on
child-rearing practices.
9 Discuss cultural 5 min Cultural issues related to Pediatric Care Lecture Power What can
issues in pediatric cum point be cultural
nursing.  Science vs. spirituality discussion presentati issues in
Healthcare, which is science-based and results driven, can impede on. pediatric
religious or personal beliefs. Some religions restrict medical nursing?
interventions and lifesaving techniques. Nurses focus on providing
medical care to reduce suffering and to allow patients to concentrate
on self-care. For patients or their families with strong religious or
spiritual convictions, the focus may be on adhering to a strict set of
guidelines. The Code of Ethics states that nurses should respect the
“unique differences of the patient,” including “lifestyle, value system,
and religious beliefs.” However, respect for the belief “does not imply
that the nurse condones those beliefs or practices on a personal level.”
 Exclusive breastfeed vs pre-lacteal feeds
 Application of kajal in the eyes of newborn.
24 Summary 1 min Today, we have covered- Lecture Power
 Definition of Ethics. cum point
 Ethical principles in Nursing Practice. discussion presentati
 Ethical issues in Pediatric Nursing. on
 Definition of Culture.
 Child rearing practices in Indian Culture.
 Cultural issues in Pediatric Nursing.
 Summary
 Conclusion
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25 Conclusion 1 min Nurses should have a basic and clear understanding of key ethical principles. Lecture Power
The nursing profession must remain true to patient care while advocating for cum point
patient rights to self-identify needs and cultural norms. discussion presentati
on

26 References 1 min References: Lecture Power

cum point
1) Ethical Issues in Nursing: Explanations & Solutions; Duquesne discussion presentati
university college of nursing. June 5, 2020. Available at: on
https://onlinenursing.duq.edu/blog/ethical-issues-in-nursing/
2) Pediatrics, overview of ethical issues in; available at
https://www.encyclopedia.com/science/encyclopedias-almanacs-
transcripts-and-maps/pediatrics-overview-ethical-
issues#:~:text=Pediatric%20ethics%20is%20a%20branch,%2Dlife
%20care%2C%20and%20justice
3) http://www.indiatribune.com/index.php?
option=com_content&view=article&id=4357:-traditional-indian-
parenting-practices&catid=99:column&Itemid=462