Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You are an Advanced Practitioner. A soldier presents with lower back pain.  Following an assessment, you take him off guard duty but he informs you that if he doesn’t do guard duty it will impact on his promotion prospects.  What should you do?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding the autonomy of the patient to make their own decisions about their care, and the right to confidentiality balanced against the right of an employer to know the medical fitness of their employees.

Step 2 – ANALYSE

Patient: 3 principles apply; autonomy, beneficence and non-maleficence. The patient has the final right to autonomy – however it is important that they fully understand the consequences (health and wider employment) of refusing treatment. There may be wider personal circumstances that need to be explored in order to understand the soldier’s reluctance to be taken off duty.

Clinical: while there may be understandable reasons for the patient’s reluctance, it is important to explain the reasons for not allowing them guard duty. There may be implications if the soldier’s lower back pain is left untreated (even for a short time) on their continued employment on the operational tour.  

Legal: The International Council of Nurses Code of Ethics is at: https://www.icn.ch/sites/default/files/2023-04/ICN_Code-of-Ethics_EN_Web_0_0.pdf . This requires the ANP to ensure informed consent, accept the patient’s rights to choose or refuse treatments, and to hold in confidence personal information regarding a patient. However, the ANP must also inform the soldier that medical confidentiality is not an absolute right and whilst it expected the that the ANP will not divulge the specifics of the injury, for public protection, the ANP could be justified in informing the soldiers employee that despite the soldiers wishes to do guard duty, the soldier is actually unfit to perform this duty currently.

Societal/Military: the employer (Adjutant) has the right to know about the fitness for work of his employees and also has a duty to provide welfare support to military personnel. In this instance the ‘military necessity’ of ensuring personnel on operations are medically fit may take precedence over the soldier’s right of confidentiality. There is also the issue that an unfit soldier on guard duty could compromise operational effectiveness and the safety of other soldiers.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario balances patient autonomy, clinical care, and military duty. There might also be a discussion about the dual loyalty of clinical professionalism and military obligations. Despite the soldier wanting to do guard duty the ANP need to ensure that they do not cause harm to the patient by allowing them to do so.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

This is likely to be a complex personal issue for both the ANP and the patient with multiple dimensions to the consequences of not being able to perform a duty during an operational tour and the ANP either legitimately breaching the patient’s confidentiality to the chain of command or allowing an unfit soldier to do guard duty. It may be reasonable to withhold notification of the soldier’s inability to do guard duty to their chain of command for only a short period. However, it will be necessary to tell the chain of command and to apply military policy as soon as possible in order to not compromise operational effectiveness and ensure the soldier can recover from the injury thereby protecting the employer from any risks associated with the deployment.

References and Further Reading

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Nursing Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council (nmc.org.uk) accessed 24 August 2023

Nursing and Midwifery Board of Australia. Available at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx; accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.