I was faced with an ethical dilemma that required delicate handling and shrewd decision making. My patient was a 15 months old female who was diagnosed with failure to thrive. This was the second time she had received this diagnosis in 6 weeks. Failure to thrive can be caused by a multitude of factors , among them poverty, poor feeding habits, physical abuse, mental trauma, mental conditions such as depression, et cetera.
The mother said that the child was usually emotional, threw tantrums, and refused to be held. However, I observed that in the time the patient was under my care, she was jovial, ate well, and was positively receptive to my touch. I noticed that the child drew back in the presence of the mother’s boyfriend. The mother presented as a caring and nurturing person, albeit a little immature. I suspected some form of neglect or abuse.
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The pediatrician handling the child also suspected abuse and called Child Protective Services (CPS) and a community health nurse to visit the family in their home. The child’s father also suspected abuse. He called the hospital asking to admit the child for some time, but it was against hospital policy, and we had to discharge the child. I was left with an uneasy feeling. I talked to my supervisor and senior doctor, and they felt that we should allow CPS to conduct their investigation. CPS did not find evidence of abuse, but the pediatrician requested a follow-up visit to the home.
As a nurse, I am legally obligated to report instances and suspicions of child abuse. I also have a responsibility to my patient’s welfare. However, since CPS was already involved, I felt conflicted about pursuing further action, especially without additional evidence ( Skarsaune & Bondas, 2015) . If I instigated further action and it turned out there was no abuse at all, or if the child was taken away, I would feel liable for the intrusion of privacy, and separating a family. On the other hand, if there was abuse going on (one that was not physical or obvious), it would continue between then and the time CPS concluded their investigation. Instigating further action without concrete evidence could also compromise my job and/or the hospital.
The dilemma presented two of what I thought were the most viable options. Firstly, I had the option of doing nothing at that moment. Since CPS and community health nurses were involved, I could let them finish their supervision. However, since their first investigation found no abuse, it could either mean there was no abuse at all, or there was abuse and it had ceased (momentarily), or the abuse was not physical or it was not immediately apparent. This option saved me from putting my job and the hospital in a compromising situation. It also saved me from intruding on the family’s privacy. If there was indeed abuse going on, it would allow the abuse to continue and make me liable for negligence (Grant, 2017). If I made this decision, the feelings of sadness and uneasiness would escalate.
The second option was to request a more thorough investigation into the mother and the boyfriend. My suspicions were that either one or both of them had something to do with the child’s diagnosis and behavior. Her clinging to me, a stranger, rather than her mother, made me uneasy. This decision would likely have compromised my job and put me at odds with my supervisor. On the other hand, I would have fulfilled my obligation to my patient, and my mind would be at peace.
After analyzing the options, I decided to take action. I let my supervisor know of my intention to contact CPS and the community health nurses with my suspicions. My supervisor did try to talk me out of it, but she ultimately acknowledged that I had a legal obligation to report my suspicions (Lines, Hutton & Grant, 2017). I specifically asked CPS to conduct an investigation on the mother and the boyfriend, including background checks and mental health checks. I also asked the agencies to look out for signs of emotional abuse on my patient. Since the other child in the same household was found happy and healthy, it is likely that the abuse/neglect (if any) was only directed at my patient.
My rationale for reporting was that children are naturally drawn to their caregivers. Therefore, my patient showing blatant aversion to her mother’s touch, and the boyfriend’s presence meant that there had to be a reason for that.
The aftermath was that CPS removed the two children from the home while they investigated the mother and the boyfriend. The father tried to gain custody of the kids from CPS, but was denied custody (Talsma, Bengtsson & Östberg , 2015). It probably was because of the same reason he lost custody of them after the divorce. The mother, in the company of the boyfriend, confronted at the hospital parking lot and angrily told me that I had ‘no right’ and it was ‘not in my place’ to order an investigation.
My supervisor seemingly had made peace with my decision. Our relationship was not compromised, I kept my job, and the hospital suffered no leg. I felt that this was the best decision to make since if the investigation turned up no abuse/neglect, then the child would be returned home to a certified safe environment. While instincts can be wrong at times, my experience as a nurse has taught me that instincts are mostly right than wrong.
References
Grant, P. D. (2017). Nursing Malpractice/Negligence and Liability. Law for Nurse Leaders , 51.
Lines, L. E., Hutton, A. E., & Grant, J. (2017). Integrative review: nurses' roles and experiences in keeping children safe. Journal of advanced nursing , 73 (2), 302-322.
Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Skarsaune, K., & Bondas, T. (2015). Neglected nursing responsibility when suspecting child abuse.
Talsma, M., Bengtsson Boström, K., & Östberg, A. L. (2015). Facing suspected child abuse–what keeps Swedish general practitioners from reporting to child protective services? Scandinavian journal of primary health care , 33 (1), 21-26.
