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Archive for the ‘collegiality’ Category

A recent book review in the Chronicle of Higher Education highlights the most recent work of neuroscientist, philosopher and author Patricia Churchland, who offers some interesting views on modern day morality, in her new book Braintrust: What Neuroscience Tells Us About Morality(Princeton University Press)

Here’s an excerpt from the Chronicle review of Churchland’s book: Rule Breaker: When it comes to morality, the philosopher Patricia Churchland refuses to stand on principle

Hers is a bottom-up, biological story, but, in her telling, it also has implications for ethical theory. Morality turns out to be not a quest for overarching principles but rather a process and practice not very different from negotiating our way through day-to-day social life. Brain scans, she points out, show little to no difference between how the brain works when solving social problems and how it works when solving ethical dilemmas.

Churchland thinks the search for what she invariably calls "exceptionless rules" has deformed modern moral philosophy. "There have been a lot of interesting attempts, and interesting insights, but the target is like perpetual youth or a perpetual-motion machine. You're not going to find an exceptionless rule," she says. "What seems more likely is that there is a basic platform that people share and that things shape themselves based on that platform, and based on ecology, and on certain needs and certain traditions."

The upshot of that approach? "Sometimes there isn't an answer in the moral domain, and sometimes we have to agree to disagree, and come together and arrive at a good solution about what we will live with.”

The point I found most interesting, reading the review, was that Churchland feels that the emphasis on finding "exceptionless" moral rules is futile. According to her, we should place more emphasis on how we can agree to disagree rather than consistently search to find "exceptionless rules" to apply in difficult moral dilemmas.

She makes a good point and one that many of us should consider. Think of the many times we are faced with moral dilemmas in the context of nursing. Often the most effort goes into attempts to make others see situations from our perspective, and to agree with us. Frequently we hear statements like, "This should never happen" or "We should not allow this in any case" when our colleagues, patients and families are discussing difficult moral issues, like end-of-life care or allocation of scarce resources. These kinds of expressive statements, such as "I believe X is wrong" (instead of “X”, substitute any contentious bioethics concept such as: abortion, euthanasia, harm reduction), reflect a kind of "exceptionless" stance. When we approach difficult moral dilemmas with this kind of a stance, we typically are, in fact, looking for others to agree with us and align with our values to justify an "exceptionless rule" of sorts. However, it's clear that this is almost impossible in diverse societies and groups in which a broad range of values exist.

We accept diversity in many kinds of everyday health care situations and out of that acceptance arises our role of advocate and facilitator. For example, a patient may not wish to take a prescribed sleep aid, may refuse physiotherapy or may wish to delay a procedure. As nurses, we advocate for the choices and wishes of our patients and we try to facilitate their decision-making. We often allow patients to make choices that we perhaps would not make ourselves or that we would not support if we were the only decision-makers. This is part of respecting the autonomy of others and is a straightforward value in nursing and health care. However, when dealing with more difficult or challenging dilemmas, we tend to turn first to our own values and beliefs instead of first trying to consider the different values of others. This isn’t unusual and is a response many have when faced with morally challenging situations: we turn to our own consistently-held values and beliefs in a search for an anchoring answer. In other words, in simple day-to-day health care situations, we often quite easily accept that patients will make choices that reflect different values and beliefs than ours and in turn, we respect those diverse decisions. In more serious or morally challenging situations, however, we may find ourselves turning instead to our own values and beliefs to determine what the “right” option should be.

Churchland notes that trying to find answers to difficult moral problems is just like trying to find our way through less challenging, day-to-day social problems. As she notes, brain scans show very similar activity when sorting out everyday problems or working through serious and difficult moral dilemmas. For many of us, it is perfectly acceptable to “agree to disagree” on the food a patient may eat, the time for a procedure to be done, scheduling therapy or taking a sleeping aid. However, when faced with a patient who is, for example, seeking euthanasia or an abortion for a reason with which we may not agree, many nurses find it disturbing, upsetting and often distressing to care for patients whose values and beliefs, in this context, may be much different than their own. Churchland would likely say that trying to seek alignment of values, in difficult cases like this is neither satisfying or possible and that we should not focus so much attention on trying to do so.

The review in the Chronicle is a thorough one, highlighting a number of other key points in Churchland’s work. I haven’t read the book yet so it’s difficult to comment too much on her views, as noted by the reviewer, without reading about them firsthand, so I will read the book and, hopefully, will review it here as well.

The point that struck me was that we don’t really think enough (or at all!) about how we approach moral dilemmas. In nursing, these kinds of dilemmas arise often unexpectedly or quickly and must be dealt with in the moment. We expend a majority of our emotional and working energy trying to sort through a few incredibly challenging problems but often don’t take the time to reflect upon “how we did” and whether we were simply seeking an “exceptionless rule”, i.e. seeking the alignment of others with our own values rather than trying to find a more middle-of-the-road moral ground that everyone can live with. In terms of expending our energy, doing so to understand just a little better the way we’re wired as well as the way we react to and process these kinds of difficult moral dilemmas makes good sense.

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Bullying, or even subtler forms of interpersonal conflict, can be common in any kind of workplace. But it’s particularly corrosive, and dangerous, in healthcare settings, where effective teamwork really can make the difference between life and death.

See this editorial by Theresa Brown, for the NY Times: Physician, Heel Thyself

…while most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

Of course, as Brown recognizes, the issue is much more complex than simply ‘MD vs RN.’

…because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

But even this puts too much emphasis on the behaviour of doctors; I strongly suspect that nurses (and other professionals) are perfectly capable of bullying (or “eating their own young”) even without MDs setting a negative example. The bullying that goes on within nursing (and among different parts of the nursing profession, broadly understood, including between RNs, NPs, LPNs, etc.) is just as important as the bulling that goes on between MDs and RNs.

The hardest questions I’ve ever been asked by med students and nursing students have to do with bullying, and with the difficulties inherent in being at the bottom of their respective professional hierarchies. Students understandably find it difficult — and a source of moral distress — to be not only subject to bullying, but to sometimes be involved in courses of action that they see as unethical and yet powerless to do anything about it. It’s hard to know what to tell them, because sometimes there really is very little they can do. But one thing they can do, I tell them, is to consider, starting right now, how they think they should treat those beneath them in the hierarchy, once they inevitably move up it, and how they are going to make sure they don’t fall into those all-too-common toxic behaviours.

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In most stories about conscience clauses and nurses, the nurse involved is the one appealing to conscience-clause legislation to justify non-participation in some medical procedure.

But that’s not always the case.

See this story, from CNBC: Idaho board: No action in Walgreens complaint

The Idaho Board of Pharmacy says it has no basis to start proceedings against Walgreen Co. in a complaint that alleged one of the drug store chain’s pharmacists in Nampa improperly refused to fill a prescription.

A nurse practitioner from Planned Parenthood of the Great Northwest contended the pharmacist abused the state’s 2010 conscience law in November after balking at filling a prescription for a drug that helps control bleeding after childbirth or abortions….

This I think is a little-discussed aspect of “conscience clauses” or “conscience laws”: they can be a focal point for disagreement between members of different professions. Also, while conscience clauses may sometimes help nurses avoid participation in procedures that go against deeply-held values, in other cases such clauses are going to frustrate nurses’ attempts to help patients obtain the services of other health professionals.

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In a recent article from the Chronicle of Higher Education, a “ghost writer” talks about the proliferation of students having papers and assignments written by others. The writer mentions nursing students in particular as a frequent client of his services. Here’s the story: The Shadow Scholar: The man who writes your students’ papers tells his story

With respect to America’s nurses, fear not. Our lives are in capable hands — just hands that can’t write a lick. Nursing students account for one of my company’s biggest customer bases. I’ve written case-management plans, reports on nursing ethics, and essays on why nurse practitioners are lighting the way to the future of medicine. I’ve even written pharmaceutical-treatment courses, for patients who I hope were hypothetical….

The ghost writer mentions the fact that these nurses “can’t write a lick”. It is, however, much more than that. Asking someone else to write your paper for you necessarily means you will not learn what it is you’re supposed to learn form the assignment, which is a far more serious consequence.

I’ve been teaching nursing students for many years now and the topics of plagiarism and cheating is one that comes up again and again. Here are a few things I try to communicate to my students: From the moment that they walk in the door on the first day of university in a nursing degree program, the expectations of them are much higher than the expectations of a student in a non-professional program, like a history or political science major. Nursing students are evolving professionals with clear responsibilities for the lives and well being of others, from the moment that they set foot in a patient care area. When a history major has someone else write her paper on the outcomes of civil wars in the sixteenth century, there are two results: First, she is quite clearly cheating. Second, she’ll know little to nothing about the civil wars in the sixteenth century, if asked later, since someone else did her research and wrote her paper. However, when a nursing student has someone else write his paper on the pathophysiology of cancer, those same two things happen but with more serious implications. Yes, the nursing student, like the history student, has cheated. But the nursing student will end up knowing little to nothing about the pathophysiology of cancer, something a nurse should know.

I realize that, sometimes, the demands we put on what are often very young nursing students struggling to manage heavy academic workloads, shifts in their clinical placements, and personal commitments, can be overwhelming. Students in all kinds of professional programs balance very intense programs, clinical placements and multiple responsibilities. And yes, the demands are extreme at times. as are the demands of nursing work, across all settings. But to cite overwhelming demands as a valid excuse for cheating is to diminish the very real importance of learning positive, constructive and responsible ways of dealing with stress and overwork, something nurses and nursing students must be encouraged to do.

The public has always put a great deal of trust in nurses. Time and time again, in surveys of the public, nurses rate very high in terms of degree of public trust. This trust forms the basis of the therapeutic relationship that nurses are able to form with patients and families. The public doesn’t want nurses who cheat or who get others to do their work for them. Instead, they want nurses who they can trust to both deliver safe and knowledgeable care in the most routine situations and also in life-and-death circumstances.

The public expects that if a nurse has a degree and has, by virtue of that degree, claimed to study how drugs interact and how intravenous therapy should be delivered, he’ll actually know this and be able to apply this knowledge to the care of others. If nursing students are, as the ghost writer here suggests many are, paying for their papers to be written by others, they are not only cheating themselves but also the patients who expect a high level of both professionalism and knowledge from nurses.

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