Ethics in pediatric nursing: advocacy and the child's "determining self"

This article examines the evolving role of the nurse as patient advocate, building on Gadow's framework of "existential advocacy" (9) and Cooper's description of "covenantal relationships." (6) A new conception of advocacy relevant to pediatric nursing is proposed, based not on protection of patient autonomy, but instead emphasizing protection of the child's potential "determining self". This potential for self-determination is seen as an affirmation of the child's understanding and goals in his or her immediate circumstances which counters learned helplessness. Protection of the child's potential "determining self" is accomplished through the following nursing interventions: (1) alleviation of pain and discomfort, (2) thorough preparation of the child for procedures, (3) careful explanation to child and family about what will happen, how it will feel, and how child and family will be helped to cope, (4) inclusion of the family in planning care, and (5) safeguarding the family's decision-making prerogatives. A promise to care for the hospitalized child, based on Stenberg's notions of covenantal relationship, is seen as involving a commitment to the mastery of technical skills, an agreement to safeguard the patient, a promise to provide unqualified care, and a promise to free the patient from the fear of abandonment and unnecessary pain. It is argued that ethical practice in pediatric nursing may at times require that the nurse fulfill all of these commitments. It is also recognized, however, that certain organizational characteristics powerfully influence the ability of pediatric nurses to act in this new advocacy role. Characteristics of practice settings which are thought to facilitate or inhibit advocacy, such as staff nurse influence and nursing resources, are described.