Does a nursing practitioner have a duty to work in a clinic without the fundamental resource of water?

Does a nursing practitioner have a duty to work in a clinic without the fundamental resource of water?

Ralehike MM*
(MSc Med in Bioethics and Health Law, PGDip Nursing Edu, PGDip Disaster Management, PGDip Labor Law, Univer. Adv. Diploma Occ. Health Nursing and BSocSc:Nursing)
School of Medicine, Faculty of Health Sciences, Steve Biko Centre for Bioethics and Health Law, University of Witwatersrand, Johannesburg, South Africa.

Received Date: August 16, 2024; Accepted Date: August 22, 2024; Published Date: September 27, 2024;
^*Corresponding author: Makhotso Ralehike, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. Email: makhotsoralehike@icloud.com

Citation: Ralehike MM. (2024) Does a nursing practitioner have a duty to work in a clinic without the fundamental resource of water? Adv Pub Health Com Trop Med: APCTM-204.

DOI: 10.37722/APHCTM.2024203

Abstract
This report delves into the impact of a lack of water in healthcare clinics on nurses' working environment and ethical considerations surrounding this issue. It argues that nursing practitioners should not be obligated to work in clinics without access to clean running water, as it can compromise patient care. The lack of water in healthcare facilities, especially in remote areas of South Africa, poses significant health risks to both nurses and patients. Existing professional and legal guidelines from the South African Nursing Council (SANC), as a nursing regulatory body, do not adequately address these issues and create ethical dilemmas for nursing practitioners who are working in clinical facilities that lack fundamental resources for quality care.

Aim: The research report highlights the significance of water supply in healthcare settings and its impact on the quality of nursing services.

Research objectives: The main aim is to argue that nurses should not be morally obligated to work in clinics without access to clean, running water. This includes describing the importance of water for healthcare provision and how its absence hinders nursing care quality. Additionally, the research aims to shed light on the lack of accessible running water in rural healthcare facilities and its implications on nursing services.

Method: A normative research design was employed to critically analyze the existing literature on ethical and legal guidelines that support nursing practitioners facing challenges of water unavailability in clinical facilities. Therefore, the methodology focused on analyzing relevant existing nursing guidelines, policies, legislations, and regulatory frameworks. Furthermore, it used a bioethical and philosophical technique to categorize, examine, interpret, and identify the limitations of existing literature.

Ethics: Study received an Ethical Waiver from the University Postgraduate Ethics Committee.

Background
The working conditions of nurses in developed countries tend to be more favorable compared to those in developing countries. Factors such as economic stability, healthcare policies, and resource availability play a significant role in shaping these countries. Addressing the disparities in nursing working conditions is crucial for improving healthcare outcomes worldwide. Recognizing the importance of nurses and supporting their work environment can enhance both nurse satisfaction and patient care quality. This article will address lack of water as a human need during nursing professional chores particularly in remote areas.

Obligation of the South African Government to supply water

In the initial discussion of this section, the focus is on the legal responsibility of the South African government to address the issue of water scarcity in health clinics, particularly in remote areas. The subsequent part will delve into the legal entitlement of nurses at the clinics to access water. Lastly, the section will explore the concept of water as a human right.

Over the years, researchers have emphasized the significance of water in healthcare settings (World Health Organization and UNICEF, 2019). According to these organizations, a substantial number of health facilities globally lack basic water services, with the situation deteriorating in regions like Eastern and Southern Africa (2019). "Globally, 26% of health facilities lack basic water services….and the situation is worsening in Eastern and Southern Africa" (World Health Organization and UNICEF, 2019). Studies have shown that rural clinics and government health facilities are more likely to experience gaps in water supply compared to hospitals (Mmanga, Holm, and Bella, 2020).

Access to clean water is deemed a human right for all individuals. Regardless of their background (World Health Organization and UNICEF, 2019). It is argued in this section that a nursing practitioner is not morally obliged to work in a clinic where the fundamental resource of water is lacking. This section examines the legal duty of the South African government concerning water scarcity in remote healthcare facilities.

The Constitution of the Republic of South Africa

The Constitution of the Republic of South Africa, Act 108 of 1996, serves as the supreme law of the country (The Constitution and Public Health Policy, n.d.). The Bill of Rights in Chapter 3 of the Constitution binds all levels of government to uphold the rights of citizens (Acutt and Hattingh, 2015). Section 24(a) of the Constitution guarantees every South African citizen the right to an environment that does not endanger their health or well-being. The provision of safe water and hygienic conditions in healthcare facilities is crucial for patient safety and quality care (WHO and UNICEF, 2019).

Schirrmacher and Johnson argued that governments, not South Africa in particular, "have a duty to assure that people have access to clean water" (2016). The responsibility for the provision of safe and clean water is outlined in the range of legislation and different sections of the Constitution, and as stated above, the Constitution of South Africa, Act of 108 in terms of Section 27 (1) (b) stipulates that: "everyone has a right to have access to sufficient…. water" (Constitution Act 108 of 1996).

The International Labour Organization (ILO) Article 12 of the Convention, adopted in 2014, stated that workers must be supplied with drinking water: "The Committee requests the government to provide…. or ensure that sufficient supply of wholesome drinking water is made available to workers" (International Labor Organization, 2017). Wholesome drinking water in this context implies healthy drinking water (International Labour Organization, 2017). Further, the WHO and UNICEF stated: "Water is important for the patients and workers, as it enables them to remain hydrated, clean themselves, and also reduce risk of infection" (2019).

National Health Act

South Africa's National Health Act (Act 61 of 2003) establishes a framework for a uniform health system that aligns with constitutional requirements and existing health legislation (Acutt and Hattingh, 2015). The Act aims to protect and fulfill the rights of individuals to a safe and healthy environment. It mandates health establishments to maintain an environment that minimizes the risk of disease outbreaks and transmission of infections to users, healthcare personnel, and visitors (National Health Act of 2003).

The WHO and UNICEF emphasized that "No one goes to a health facility to get sick…. yet hundreds of millions of people face an increased risk of infection by seeking care in health facilities that lack basic necessities, including water…" (2019). They stated that ensuring access to safe water and proper hygiene is crucial in preventing and protecting against infectious diseases, including COVID-19 (WHO and UNICEF, 2019).

The Occupational Health and Safety

The Occupational Health and Safety Act of South Africa (Act 85 of 1993) highlights the responsibility of employers to provide a safe working environment for employees (Acutt and Hattingh, 2015). Adequate water supply in healthcare facilities is essential to enhance health outcomes, quality care, and protect healthcare workers (WHO and UNICEF, 2019). The Act mandates health establishments to comply with the requirements of the Occupational Health and Safety Act to ensure workplace safety (National Health Act of 2003).

In my opinion, the provision of a safe working environment for nursing practitioners in the clinical setting is not limited to the general cleanliness of the clinic, but also the functional ablutions with hand washing facilities and access to water for any other use (either clinical or personal use). The Act specifies that: "The health establishment must ensure that there are hand washing facilities in every service area" (National Health Act of 2003).

Other National Legislation

Various national legislations, such as the Water Service Act and the National Environmental Management Act, emphasize the right to access basic water supply for health and well-being (Water Service Act 108 of 1997; National Environmental Management Act 59 of 2008). The provision of clean water is fundamental for maintaining a hygienically clean and safe healthcare environment (National Infection Prevention and Control Strategic Framework, 2020).

The National Infection Prevention and Control Strategic Framework developed by the Department of Health states that: "Delivery of quality healthcare should take place in a hygienically clean, safe environment with an adequate supply of clean running water…. for both patients and staff to reduce [infections]" (2020). In addition, the Department of Water and Sanitation in National Norms and Standards for Domestic Water and Sanitation Services document No. 41100, states: "No clinic or health Centre is allowed to function without potable water" (2017).

The WHO and UNICEF guideline definition for basic water services at the healthcare clinic states: The main water source must be an improved water source, located on the premises and the water should be available continuously (2019). In 2010, the United Nations General Assembly (UNGA) adopted a resolution that recognizes physical accessibility of water, which states that: "everyone has the right to water and sanitation services that are physically accessible within or near the…. workplace or health institution" (UN, 2010).

In instances where healthcare facilities lack water, nursing practitioners are exposed to preventable health risks, compromising patient safety and the quality of care provided. Access to sufficient and clean water is vital for performing clinical procedures, maintaining hygiene, and preventing infections (WHO, 2019).

The legal entitlement of nurses at the clinics to access water

In a healthcare setting, water plays a crucial role in general consumption, cleaning, and handwashing practices essential for staff and patient hygiene (Mmanga, Holm, and Bella, 2020). The provision of safe water and proper hygiene practices are pivotal in preventing the transmission of infections, including Cholera, Hepatitis, COVID-19, etc., (WHO and UNICEF, 2020).

Global initiatives such as the joint monitoring program by the WHO and UNICEF aim to ensure that every healthcare facility has reliable water, sanitation, and hygiene facilities by 2030 to provide quality care and prevent disease transmission (Potgieter, Banda, Becker, et al., 2021). The lack of water in clinics can lead to healthcare-associated infections due to poor hygiene practices, endangering the health of both nurses and patients (Potgieter, Banda, Becker, et al., 2021).

Water as a Human Right

The right to access clean water is not only a legal entitlement but also a fundamental human right necessary for leading a dignified life (Kwesell, 2020). Water is essential to human life (Vettel, 2009; Salman and Mclnerney-Lankford, 2014). Salman and Mclnerney-Lankford endorsed Maurice Cranson's definition of human rights as a universal moral entitlement that every person should have at all times, simply by being human (2014). The South African Human Rights Commission (SAHRC) argued that access to water is fundamental to the realization of other human rights (2014). In addition, the South African Constitution recognizes water as a right of everyone in terms of Section 27 (1) (b) on the Bill of Rights, which claims that water is essential for a dignified life (1996).

According to the WHO, human rights standards and international humanitarian law are two distinct, but complementary bodies of law, concerned with the protection of life, health, and dignity (2019).

Ersel defined the right to water as access to water for sufficient cleanliness and good sanitation to meet individual needs (2015). Further argued that "Good hygiene practices, the provision of safe drinking water, and the reduction of environmental health risks are conditions that allow people to have a healthy life" (Ersel, 2015).

The human right to water entails the important key aspects that are suggestively important: Firstly, the SAHRC claimed that: "Water services are an obligation, not a charitable act" (2014), which means provision of water services at healthcare facilities should be seen as the obligation of the state and a human right, including nursing practitioners.

Secondly, the SAHRC claimed that: "Human rights are interrelated, and all must be respected: No human right may be sacrificed to achieve another human right" (SAHRC, 2014). The Human Rights Commission noted that it is unacceptable to justify a human rights violation by claiming to be fulfilling another (SAHRC, 2014). In my opinion, a right to access health services is important, but the standards at which care is rendered must be considered. The clinical facilities that function without access to water services, particularly in remote areas, compromise the health of both patients and nurses.

As mentioned earlier, the WHO and UNICEF claimed that "Not only does lack of water, sanitation and hygiene services in health care facilities compromise patient safety and dignity, but has a potential to exacerbate the spread of diseases and undermines efforts to improve the health of patients" (2019). Again, nursing practitioners' right to work in a safe environment should not prompt a moral debate and must be formally and publicly acknowledged by the professional body as well as by national governance. As discussed earlier, South African legislation and law are in support of a "safe environment" for nurses in healthcare facilities.

In conclusion, the legal obligations and human rights regarding access to clean water in healthcare facilities are crucial for ensuring patient safety, improving healthcare outcomes, and protecting the well-being of nursing practitioners. In the preceding first part of this section, I discussed the legal obligations of the South African government to respond to the lack of water in health clinics. The next section will delve into the existing literature on how the lack of clean water in clinics impacts the quality of nursing care delivery.

Infection Prevention and Control Measures and High-Quality Service Delivery at Clinics

This section discusses the significance of clean, running water in healthcare facilities, particularly clinics. For infection prevention and control, high-quality service delivery, especially during disease outbreaks like the COVID-19 pandemic, Monkey-pox, and cholera outbreaks. The lack of water can hinder nurse's ability to provide quality care and prevent the spread of infections. Studies and guidelines from Organizations like the World Health Organization (WHO) and UNICEF highlight the importance of water availability for hand hygiene and patient safety.

Water is argued as a limited natural resource around the globe (WHO and UNICEF, 2019). The ICESCR General Comment No.15 also states: "Water is a limited natural resource and public good fundamental for life and health" (2002). The availability of clean water in healthcare facilities is crucial for maintaining a hygienic environment, preventing the spread of diseases, and improving health outcomes (WHO, 2019).

According to the World Health Organization (WHO) and UNICEF, "An estimated 896 million people use health care facilities with no water services…." (2019). The WHO and UNICEF further state that: "Many people are likely served by health care facilities lacking hand hygiene facilities…" (2019). It was also indicated by the WHO and UNICEF that, "Water, sanitation and hygiene services are likely to be available in hospitals than in other types of other health care facilities, and in urban areas than in rural areas" (WHO and UNICEF, 2019).

In healthcare facilities such as clinics, infection prevention control is considered crucial for safe and high-quality service delivery (Soul City Institute, n.d.). The South African Nursing Council (SANC) emphasizes the importance of nursing practitioners ensuring quality healthcare and preventing diseases and infections (SANC Ethics Guideline, 2013). Quality nursing care is essential for patient outcomes and safety according to Burhans and Alligood (2010), who argue that meeting the human needs of patients through caring is fundamental to quality care. A safe healthcare environment is necessary for the delivery of safe healthcare (Cronk, Guo, Folz, et al., 2021).

Nurses working in facilities with access to clean, running water are more likely to have effective infection prevention and control measures compared to those without water accessibility (Biniyam, Azed, Tadesse, et al., 2018). Inadequate infection prevention practices increase the risk of healthcare workers acquiring infections through exposure to blood and body fluids (Biniyam, et al., 2018). The National Health Act of 2003 and the WHO stress the importance of infection prevention and control programs in healthcare facilities to prevent harm to healthcare workers and patients (National Health Act of 2003; WHO, 2020).

Healthcare refers to the organized provision of medical care to individuals or communities, designed to give wide range of services to improve health, manage illnesses and provide preventive care (WHO, 2019). Contracting infections in healthcare settings challenges the concept that healthcare is meant to promote well-being (Biniyam, et al., 2018). Poor hygiene conditions in healthcare facilities contribute to higher mortality rates among patients (Cronk, et al., 2021). The National Infection Prevention and Control Framework and the United Nations Sustainable Development Goals highlight the need for clean water and sanitation services in healthcare facilities for safe and effective service delivery (2020; UN Global Sustainable Development Report, 2015).

The National Health Act of 2003 sets out norms and standards for healthcare facilities, including the provision of washing facilities in every service area (National Health Act 61 of 2003). Unsafe healthcare environments can lead to maternal and neonatal morbidity and mortality worldwide (Cronk, et al., 2021).

Cronk et al.'s study highlighted the importance of a safe healthcare environment in reducing healthcare-associated infections and improving outcomes for mothers and babies (2021). The study by Cronk et al. indicated that a lack of essential conditions in health care facilities, which includes low availability of hygiene items such as soap, poor supply of water, unclean facilities, and inadequate hygienic practices, contribute to an estimated 34-fold higher mortality risk among patients due to sepsis (2021). They emphasized the importance of implementation of safe hygiene practices as a key focus area. The World Health Organization's 'Six Cleans' guidelines were mentioned as essential for maintaining hygienic conditions during childbirth (2021).

Clean water supply in clinics was emphasized to ensure a reliable standard of nursing care (Cronk, et al., 2021). Adequate availability of resources for hand hygiene such as soap and water, at the point of care, is essential for nurses to comply with infection prevention practices.

Enhancing environmental conditions and promoting good infection control practices are essential steps in improving the quality of care in healthcare facilities.

Disease Outbreaks and Water

Current threats by epidemics and pandemics have become increasingly evident as an ongoing universal challenge to public health (The National Infection Prevention and Control Framework, 2020). These challenges have been given priority for action on the global health agenda with patient safety and water in healthcare facilities (The National Infection Prevention and Control Framework, 2020).

The importance of water, hygiene, and cleanliness in healthcare facilities cannot be understood, especially during disease outbreaks such as the COVID-19 pandemic. Access to clean running water is essential for maintaining good hygiene practices which can help prevent the spread of diseases. Investing in core public health infrastructure, including water systems, is crucial for pandemic preparedness and response (The World Bank, 2020).

Ensuring the availability of water, sanitation, and hygiene services in healthcare facilities can not only improve health outcomes for patients but also protect healthcare workers from becoming infected. Healthcare facilities must prioritize hygiene protocols and provide a clean water supply to mitigate the risk of further spreading disease and ultimately safeguard the well-being of patients and nurses (The World Bank, 2020).

The World Bank also argued that beyond the human tragedy, the impact of the COVID-19 pandemic is anticipated to affect the most vulnerable communities, especially those who have no access to water, hygiene, and sanitation services in place (2020). Improving water and hygiene access in healthcare facilities may improve the health outcomes of patients in low- and middle-income countries (Mmanga, Holm, and Bella, 2020).

According to Maipas, Panayiotides, Tsiodras, et al., "The social determinates of environmental health, such as lack of access to safe water, poor hygienic conditions…. significantly interact with the ongoing pandemic as evident by the significant spread, especially in rural areas" (2021). In conclusion, during an infectious disease outbreak, health services should meet the minimum quality standards.

Nursing practitioners are required to adhere to established standards of care. Working in an clinical facilities lacking basic necessities such as water can compromise the quality of care provided, potentially leading to negligence claims or breaches of professional standards.

The next section sets out the real moral duties and professional responsibilities of a nursing practitioner at a clinic. Addressing and analyzing the concept of basic ethical principles, namely beneficence, non-maleficence, autonomy, and justice, according to Beauchamp and Childress (2013), and moral theories to support that nursing practitioners do not have a moral theory to work in a clinic without water.

Nursing Practitioners' Ethical Duties in the Context of Limited Fundamental Resources

Nurses are health professionals working with patients and have a duty to provide care and relieve suffering (Shaibu et al., 2021). The Declaration of Geneva outlined the ethical responsibilities of nursing practitioners towards patients, emphasizing the duty to always act in the best interests of patients and strive to improve patient outcomes (Dhai and McQuoid-Mason, 2011).

In the COVID-19 pandemic, nursing practitioners were faced with ethical dilemmas related to caring for patients amidst the risk of infection (Shaibu, et al., 2021). Measures such as hand hygiene and environmental cleanliness have been implemented to protect healthcare workers and patients (Shaibu, et al., 2021). However, the pandemic has also highlighted ethical challenges for nurses, including limited resources and poor working conditions that put them at risk of exposure to the virus (Shaibu, et al., 2021).

Ethical dilemmas in nursing practice require a thoughtful and balanced approach, incorporating ethical and moral theories to ensure the best outcomes for patients and nurses. Nursing practitioners have a crucial ethical duty to provide care to patients in healthcare facilities. However, when faced with limited fundamental resources such as clean water, nurses are placed in a challenging position where they must balance their duty of care with their health and safety.

According to the SANC, "In carrying out his/her duty to patients, the nurse operates within the ethical rules governing the profession…." (SANC Guideline, 2016). A nursing practitioner has to ensure that s/he provides safe, adequate nursing services to the patients (SANC Guideline, 2016). The principles of beneficence, non-maleficence, respect for autonomy, and justice guide ethical decision-making in nursing practice. These ethical principles emphasize the importance of providing quality care while protecting the well-being of both patients and healthcare workers.

Shaibu et al, claimed that: "duty of care is consistent with the principle of beneficence" (2021). The principle of beneficence is defined as doing no harm (Rawlings, Brandt, Ferreres, et al., 2020). The challenge of being expected to render quality nursing care to patients in a healthcare facility where there is no adequate supply of a fundamental resource such as water exposes nurses to the ethical dilemmas of balancing harm with care and demanding a safe working environment for their health and wellbeing.

The principle of non-maleficence holds that there is an obligation not to inflict harm on others; it is closely associated with, "First do no harm" (Beauchamp and Childress, 2013). The principle of non-maleficence in this situation means that the dilemma for nurses is whether to prioritize patient care over care for themselves.

Nursing practitioners are faced with a significant challenge in some rural clinics in South Africa, particularly when working in a clinic with no water supply. Such a compromised working environment in rural clinics negatively affects the quality and standard of care the patients get at the clinic, i.e., a risk for infection exposure due to poor hygiene practices. This claim is supported by the article by Shaibu et al., which argued that: "Nurses must balance their obligations of beneficence and duty of care for patients with their rights and responsibilities while addressing the inadequacies of resources in the health systems in which they practice" (2021).

In an ethical dilemma where nurses have to decide on providing nursing care while risking their health, the application of a philosophical perspective can be enough to give a clear-cut direction to how nurses ought to handle ethical and moral issues they are faced with (Shaibu et al., 2021).

Application of Philosophical Perspectives and Moral Theories

Beyond legal implications, there are also ethical considerations in this issue. Nursing Practitioners have a duty to advocate for their patients and wellbeing, ensuring a safe and effective care environment. Working in substandard conditions without basic necessities like water, for hand hygiene and sanitation facilities could violate ethical principles of care.

Underlying Ethical principles

In healthcare delivery, there are four core ethical principles developed by Beauchamp and Childress: respect for autonomy, beneficence, non-maleficence, and justice (Rawlings et al., 2020; Beauchamp and Childress, 2013). These principles form the principlism framework, guiding healthcare professionals in their moral obligations and virtues (Beauchamp and Childress, 2013). These principles hold equal weight and should be applied contextually, with principles being binding unless conflicting with other obligations (Mathibe-Neke, 2015; Beauchamp and Childress, 2013). In cases of conflict, a framework is used to find balance or prioritize certain principles (Beauchamp and Childress, 2013).

Respect for autonomy involves acknowledging patient choices and decision-making rights, while beneficence requires promoting patient well-being (Mpeli, 2018; Rawlings et al., 2020; Beauchamp and Childress, 2013). Non-maleficence dictates avoiding harm to patients, and justice calls for fair treatment and the equitable distribution of benefits and burdens (Beauchamp and Childress, 2013). These principles are crucial in providing quality healthcare and ensuring patient safety and practitioner well-being.

In cases where healthcare facilities lack essential resources like clean water, these ethical principles are compromised. The duty of care, benevolence, and justice are challenged when practitioners face resource shortages. The right to refuse to work in unsafe conditions is justified, with ethical considerations prioritizing patient care while ensuring practitioner safety.

Moral theories application

A deontological moral theory is a philosophical concept that defines a moral action as right only if the motive behind it is right (Rachels and Rachels, 2019). Deontologists emphasize that the right action is one done out of goodwill, regardless of its outcomes or consequences (Mathibe-Neke, 2015). It focuses on one's duties to others and their rights, often referred to as duty-based ethics (Grellet, n.d.).

Immanuel Kant, a philosopher, believed in definite moral rules and argued that actions are morally justifiable based on moral obligations, intending to always do the right thing, which is rooted in the principle that rational beings deserve basic respect simply because they are human (Rachels and Rachels, 2019; Rosenstand, 2017).

Nurses, like all healthcare workers, must provide care in safe environments, as stated by the American Nurses Association and South African laws. According to the American Nurses Association (ANA), "Nurses have the right to work in an environment that is safe for themselves and their patients" (American Nurses Association, n.d.). The South African Occupational Health and Safety Act No. 85 of 1993, Section 8 (1) requires every employer to provide and maintain a working environment that is safe and without risk to the health of their employees (OHS Act 85 of 1993). This law demonstrated that employers must promote a healthy working environment for nurses by providing resources essential for good hygiene and general environmental cleanliness.

Kant's formula of humanity emphasizes treating individuals as ends in themselves, promoting their welfare, and avoiding harm (Rachels and Rachels, 2019). Deontologists advocate for the value of every person, human rights, and equal respect (Rachels and Rachels, 2019). They believe that actions should be based on duty and moral obligation, regardless of the outcomes (Rachels and Rachels, 2019).

In healthcare settings lacking necessary resources like water, deontologists argue that nurses should not be obligated to work in unsafe conditions that compromise patient care. Nurses have a right to be respected and work in environments that support their ability to provide quality care. Kant's philosophy supports individual rights, emphasizing that people should be respected for their own sake, not as a means to an end.

A Kantian approach in this case would insist that nurses working in healthcare facilities that lack water supply should act from the duty of beneficence. "[Nursing practitioners] should do their best to help [patients] live with dignity, at least not cause harm, and treat [patients] with respect and empathy while performing their moral and clinical duties" (Tseng and Wang, 2021).

Moreover, deontology argues that [nurses] should be committed to providing quality nursing care to protect humans [patients] from any disease, secure everyone's well-being and protect each individual from being hurt (Tseng and Wang, 2021). Deontology takes into account the principle of doing no harm, with Tseng and Wang claiming that: "Based on deontological ethics, medical professionals should try to minimize the harm that may occur from treatments…." (2021).

From a deontological perspective, nurses have a duty to provide quality nursing care in an environment that promotes good health. Nurses have a right to practice in environments that allow them to act in accordance with professional standards.

Deontological ethics, in contrast to utilitarian ethics, focuses on doing no harm and providing quality care to protect patients. Ultimately, ethical principles guide good medical practice by considering autonomy, beneficence, non-maleficence, and justice.

Utilitarian ethics also referred to as Utilitarianism, advocates for maximizing patient well-being and public benefit, ensuring resources are allocated efficiently to benefit the majority. Utilitarianism also supports maximizing healthcare resources to achieve optimal patient outcomes, emphasizing the importance of benefiting the greatest number of people. Water justice, equitable distribution of water resources, and the ethical principles of autonomy, non-maleficence, beneficence, and justice play a crucial role in managing water resources in healthcare settings.

The lack of essential resources like water compromises the ability of nurses to fulfill their professional obligations and exposes them to increased risk of infection. Nurses have a right to a safe working environment and the necessary resources to provide quality care, which is essential for upholding ethical standards and promoting the well-being of all individuals involved in healthcare delivery.

Conclusions
The shortage of water supply in healthcare facilities is a growing issue in South Africa, presenting a moral dilemma for nursing practitioners. The lack of guidance from the South African Nursing Council (SANC) on how to navigate this issue, particularly in situations like the COVID-19 pandemic, where the risk of infection is high due to poor hygiene practices, is concerning. The current ethical guidelines adopted by the SANC may not adequately address the realities of the healthcare system in South Africa. The SANC must provide clear direction on how nurses should balance their duty of care with the limitations of resources in healthcare facilities lacking water supply.

Nursing practitioners in rural clinics face challenges when there is insufficient water for basic hygiene practices, raising ethical questions about their obligations to patients. The SANC guidelines should emphasize nurses' right to prioritize their health and safety, especially in situations where they are at risk of infection due to inadequate resources in healthcare facilities. The SANC needs to address the ethical dilemmas faced by nurses and provide guidance on how to navigate these challenges while upholding their professional obligations.

Recommendations include ensuring that nurses' autonomy and rights are respected and that they are not forced to prioritize patient care at the expense of their health in environments lacking essential resources like water. The SANC has a responsibility to promote ethical practice and protect the rights of both patients and nurses, as mandated by the government. Developing regulations for ethical practice in settings with limited resources, such as a lack of water supply, will improve patient outcomes and ensure a safe working environment for nurses. The SANC must collaborate with existing legislatures, laws, and guidelines to address these ethical issues in under-resourced healthcare facilities.

Acknowledgements

Dr Mary O’Grady for supervising the project.

University of Witwatersrand Steve Biko Centre of Bioethics for their support.

Democratic Nursing Association of South Africa (DENOSA) for funding the project in 2021.

Mrs K. Manjinja for mentorship (University of the Free State)

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