Elsa Montgomery

Nursing and the law

This book presents and explains those parts of the law which are relevant to the nursing profession. It aims to inform nurses of their rights, and those of their patients, and demonstrate that the law protects rather than threatens them. After introducing the legal system, the authors relate the relevant parts of the law to particular groups of patients. They have attempted to make the book accessible to those who have no prior knowledge of the legal system.

Standards of professional conduct

Nurses have considerable power in that patients depend upon them, directly and intimately, and their standards of professional conduct. If a nurse makes a mistake or drops below the proper level of care then harm may be caused to patients and to the public reputation of nursing.

Montgomery on informed consent: an inexpert decision?

Montgomery v Lanarkshire HB is a deeply troubling decision when read closely. Paradoxically, its ruling supporting the principle of autonomy could be justified only by disregarding the individual patients actual choices and characteristics in favour of a stereotype. The decision demonstrates a lack of expertise in dealing with specific clinical issues and misrepresents professional guidance. More fundamentally, it fails to appreciate the nature of professional expertise. This calls into question the competence of the courts to adjudicate on matters of clinical judgement and makes an attractive formulation of the test for disclosure obligations inherently unpredictable.

The re-enactment of childhood sexual abuse in maternity care: a qualitative study.

BackgroundThe process of pregnancy and birth are profound events that can be particularly challenging for women with a history of childhood sexual abuse. The silence that surrounds childhood sexual abuse means that few women disclose it and those caring for them will often not be aware of their history. It is known from anecdotal accounts that distressing memories may be triggered by childbirth and maternity care but research data on the subject are rare. This paper explores aspects of a study on the maternity care experiences of women who were sexually abused in childhood that demonstrate ways that maternity care can be reminiscent of abuse. Its purpose is to inform those providing care for these women.MethodsThe experiences of women were explored through in-depth interviews in this feminist narrative study. The Voice-Centred Relational Method and thematic analysis were employed to examine interview data.ResultsWomen sometimes experienced re-enactment of abuse through intimate procedures but these were not necessarily problematic in themselves. How they were conducted was important. Women also experienced re-enactment of abuse through pain, loss of control, encounters with strangers and unexpected triggers. Many of these experiences were specific to the woman, often unpredictable and not necessarily avoidable. Maternity care was reminiscent of abuse for women irrespective of whether they had disclosed to midwives and was not necessarily prevented by sensitive care. ‘Re-enactment of abuse’ occurred both as a result of events that involved the crossing of a woman’s body boundaries and more subjective internal factors that related to her sense of agency.ConclusionsAs staff may not know of a woman’s history, they must be alert to unspoken messages and employ ‘universal precautions’ to mitigate hidden trauma. Demonstrating respect and enabling women to retain control is crucial. Getting to know women is important in the building of trusting relationships that will facilitate the delivery of sensitive care and enable women to feel safe so that the re-enactment of abuse in maternity care is minimised.

A feminist narrative study of the maternity care experiences of women who were sexually abused in childhood

BACKGROUND One in five women experience childhood sexual abuse and these women may suffer trauma during childbirth. Their maternity care is often reminiscent of their abuse. OBJECTIVE To inform practice by exploring the impact that childhood sexual abuse has on the maternity care experiences of adult women. DESIGN This was a narrative study from a feminist perspective. The part of the study reported here utilised in-depth interviews with women. Data were analysed using the Voice-Centred Relational Method of analysis and further thematic analysis. SETTING Users of one maternity service in the South of England PARTICIPANTS Nine women were interviewed following purposive sampling. FINDINGS The main themes identified were womens narratives of self, womens narratives of relationship, womens narratives of context and the childbirth journey. The concept of silence linked all these themes and aspects of the study relating to it are reported here. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Every day midwives will encounter women who were sexually abused in childhood. Most of these women do not disclose to those caring for them and may not respond to a direct question. They will not necessarily be distinguishable from other women accessing maternity services but they may find their experiences deeply traumatic. Silence is a challenge for those providing their care. Open communication and a genuine interest in women as individuals are required. Midwives need to listen for the unspoken messages women are trying to convey. If all women were treated with dignity and respect more may emerge from the experience of childbirth feeling empowered rather than violated.

Breastfeeding support for women following caesarean birth: An exploratory study

Breastmilk is the optimal source of nutrition for babies although there are a range of situations in which breastfeeding is difficult, including prematurity. Human milk is donated in the UK in both regulated and unregulated ways. A network of human milk banks receive and distribute donor milk, primarily to premature and sick infants, supported by NICE guidance (NICE, 2010) and the UK Association for Milk Banking (UKAMB). Variations in the geographical spread and funding of the banks mean that women who want to donate or receive breastmilk are not always able to do so. Discourse around the ethics of the provision and use of human milk in this way often emphasises issues of risk and safety. There are also ways in which breastmilk is donated informally, often using the terminology of ‘sharing’, usually to full-term infants. Some women feed each other’s babies via friendship groups whilst others contact each other using online (often international) networks specifically set up for the purpose of peer-to-peer human milk sharing. Health bodies in a number of countries (although not in the UK) have issued warnings against obtaining breastmilk in this way, focussing again on ‘danger’ and ‘risk’ and drawing on limited research evidence (Keim et al, 2013; Stuebe et al., 2014, cited in Palmquist and Doehler, 2014). In the UK the issues were raised in a recent BMJ editorial (Steele et al, 2015). Other researchers have compared the risk of sharing breastmilk with the (known) risks of formula feeding (Gribble and Hausman, 2012). These topics have been the subject of a range of academic papers as well as online discussions, raising questions about the ethical issues and obligations in both regulated and unregulated practices of milk donation. These include the nature of donation and whether donors and recipients are viewed differently according to the mode of donation (milk bank vs. milk sharing; donating vs. selling) and the situation of the recipient. Is the ethics of ‘giving’ a body product different when the product is human milk rather than blood or organs? Is this an area which should remain unregulated, as a private practice, or should it be more widely or formally considered? In addition there are a range of Issues relating to the perception of human milk – as both ‘white/liquid gold’ and ‘matter out of place’ (Douglas, 1966) – which draw on ideas of cultural unease about women’s bodily fluids. Milk for use in milk banks is depersonalised but there is unease about sharing intimate bodily fluids with known/unknown others. The focus here is on informal milk sharing – why and how it happens (the lived experience of donors and recipients) and how both donation and risk are framed and accounted for. What is known is mostly from the US and Australia; women who use websites for milk sharing talk about ‘informed choice’. Where they examine all the available evidence, share information about milk collection and storage and gather knowledge about the donor (e.g. is the donor breastfeeding her own baby?). Health professionals and non-professionals working with pregnant and lactating women may be asked for advice and need to consider these issues. My conclusion is that breastmilk donation differs from other forms of donation in important ways; donating and sharing breastmilk has increased in prevalence and possibilities but the scale and scope of informal milk sharing in the UK is unknown. Many opportunities to donate and receive breastmilk have arisen in grassroots woman-to-woman ways (in a similar way to other forms of parenting and breastfeeding support). Ideas of risk frame the ‘official’ reaction to sharing breastmilk via the internet (but not in the UK) and little is known about how individual women understand and make sense of these risks.Whether they live in low, middle or high income countries, many women encounter barriers to breastfeeding. Worldwide, fewer than 40% of infants under six months old are breastfed exclusively and more than half of newborns are not breastfed within the first hour of life (UNICEF Global Databases 2014). Many of the barriers to breastfeeding are socio-cultural, economic or relate to the lack of support from health services (Save the Children 2013). Socio-cultural barriers include societal norms for infant feeding, inappropriate advice from family and friends, lack of acceptability of breastfeeding in public spaces, and cultural beliefs e.g. that breastmilk alone is inadequate to meet the nutritional needs of babies. Economic barriers include the need for women to engage in paid employment soon after birth and the influence of commercial interests e.g. lobbying and advertising by breast-milk substitutes companies. Health service barriers include lack of skilled practitioners and lack of breastfeeding support programmes in hospitals and communities. The evidence for what enables women to breastfeeding highlights the importance of factors such as mother-to-mother support/peer counselling and initiatives such as the UNICEF Baby Friendly Initiative (Renfrew et al 2012), adequate paid maternity leave, legislation to support breastfeeding mothers in the workplace, and implementation and monitoring of the WHO Code of Marketing of Breastmilk Substitutes. Previous studies have highlighted that global and national organisations are key to protecting, promoting breastfeeding, and supporting women to breastfeed but their efforts are not always harmonised or effective (UNICEF 2013). This study aimed to explore the role of global and national organisations in influencing political will to protect, promote and support breastfeeding. The objectives were to: highlight examples of good practice where global and national organisations have successfully influenced national political commitment to breastfeeding; identify barriers that prevent global and national organisations from influencing national governments to prioritise breastfeeding; and make recommendations for how global organisations can more effectively influence political commitment to breastfeeding. . We conducted case studies of six countries: Bangladesh, Brazil, Indonesia, Nigeria, the Philippines and the United Kingdom. The countries were selected to represent different geographical regions, income levels and a range of experiences and achievements in protecting and promoting breastfeeding, and supporting women to breastfeed. Each case study comprised: 1. a desk-based review of published and grey literature; 2. telephone interviews with 23 key informants from 19 global organisations across the six countries (an additional 16 informants from 10 global organisations provided written responses to the interview questions) 3. an online survey of national organisations to which 20 organisations responded. Data were collected during November and December 2014. The research material was analysed and triangulated under key themes. Each case study was written up following a structured template and reviewed by respondents from global organisations who had participated in the study for accuracy and clarification. The findings of the case studies identified that global and national organisations were most effective when they worked collaboratively using strong, unified and consistent breastfeeding messages such as the Common Narrative approach used in Bangladesh. Our study highlighted four components that coalitions of global, national and government partners need to incorporate in their plans to successfully improve breastfeeding practices at scale. These are: creating an enabling environment for breastfeeding through implementing the International Code of Marketing of Breastmilk Substitutes (the Code) and maternity protection legislation; implementing infant and young child feeding programmes that focus on health facilities and community support, and include individual counselling; raising community awareness of the importance of breastfeeding using mass media such as television, radio and social media; and equipping all health workers with the knowledge and skills to support women to breastfeed. According to our study, the most common barrier to governments’ commitment to breastfeeding is inadequate implementation of the Code and the negative influence of representatives of BMS companies. Other barriers include a lack of effective global leadership for breastfeeding, lack of knowledge, capacity and staff turnover at national government level, lack of accurate data and lack of resources for breastfeeding programmes. Our study culminated in four over-arching recommendations: 1. Enhance and strengthen international leadership on breastfeeding 2. Facilitate and support national government ownership of breastfeeding-focussed initiatives, policies, plans and programmes 3. Initiate improved collaboration and coordination among global and national organisations operating at the national level 4. At both international and national levels, enhance breastfeeding advocacy and communications through the identification of breastfeeding champions, including pregnant women, breastfeeding mothers and families, and fathers, as well as the provision of consistent breastfeeding messages. References UNICEF Global Databases (2014). Infant and Young Child Feeding. Available at www.data.unicef.org/nutrition/iycf Save the Children (2013). Superfood for babies: how overcoming barriers to breastfeeding will save babies lives. London: Save the Children Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. (2012) Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, 5: DOI: 10.1002/14651858.CD001141.pub4. UNICEF (2014) Breastfeeding on the worldwide agenda: findings from a landscape analysis on political commitment for programmes to protect, promote and support breastfeeding. New York: United Nations Children’s Fund The study was funded by Save the Children UK and supported by a Project Advisory Group with representation from Alive & Thrive, Helen Keller Institute, MAINN, UNICEF IYCF Group and WHO. The full report is available at: http://www.savethechildren.org.uk/resources/online-library/breastfeeding-policy-matters

The administration of drugs

This chapter considers the special problems that arise in connection with the administration of medicines. These are often dealt with by the law as specific applications of the principles discussed in Chapters 3–5. Where this is so, only a brief summary will be given here and the relevant chapter will be indicated. There are also special rules designed to reduce the risks of accidents concerning drugs and to facilitate victims of accidents getting compensation. Much of this law affects manufacturers, pharmacists and doctors rather than nurses. The areas discussed here are those that affect nursing practice.

Nursing responsibility in context

The previous chapter considered the rules of law that govern the setting of standards for the nursing profession through the law of negligence. Those rules govern the conduct of individual nurses. They might seem to suggest that the law sees nurses as working in a vacuum, unconnected with fellow nurses, or with other health professionals such as doctors, anaesthetists and midwives. In fact, the law of negligence allows the context of nursing to be taken into account. Identifying the standard of care means asking how a responsible body of colleagues would have expected a nurse to act. Nevertheless, there are other ways in which the context in which nurses find themselves working is taken into account. This chapter is concerned with the principles governing the nurse’s relationship with her colleagues.

The patient as an individual

Respect for the individuality of patients is a fundamental principle of nursing ethics, Clause 6 of the Code of Professional Conduct outlines one of the consequences of this principle where it says: ‘Take account of the customs, values and spiritual beliefs of patients/clients.’ Nurses must be prepared to recognise that their patients are entitled to see things in ways that may seem strange and to have their choices respected even if they appear irrational.

People with a mental disorder

People with mental disorders present nurses with special problems — legal and moral as well as clinical. Major issues of civil liberties are involved. Some patients with mental disorders can be detained and treated against their wishes. Other patients may comply with the suggestions of doctors, social workers and nurses only through fear of being detained. Many, whether in hospital or not, lose the right to manage their own property and income. Most of the special legal powers and procedures are given to doctors to exercise, but nurses working with people with mental disorders are in a particularly powerful position to protect and enhance the rights and dignity of their patients — or to abuse them. This chapter describes: the legal role and powers of nurses involved in detaining mentally disordered patients nurses’ legal powers to restrain mentally disordered patients and to be involved in treating them against their will when patients can be prosecuted for their crimes the law relating to patients’ sexual expression and potential liability of nurses.