We at the Nursing Ethics Blog are big fans of critical thinking. In fact, we’re working on a new textbook (under contract to Oxford University Press) on critical thinking for nurses.

Critical thinking is “the systematic evaluation or formulation of beliefs, or statements, by rational standards.”* It involves thinking outside of the box, and a willingness to ask hard questions when the need arises. We’ve blogged a bit about the significance of critical thinking in nursing ethics in particular here and here.

But critical thinking is a tricky concept to apply within the context of nursing. After all, nurses simply cannot question every practice and assumption. Sometimes immediate action is needed, and now is not the time to sit back and ask probing questions. Being part of a self-regulating profession means that RNs need to stick closely to established technical and ethical standards. And most nurses work in more-or-less hierarchical teams and institutional settings that involve a huge number of rules, policies, and procedures that simply must be followed.

What is really required, then, is a critical approach to critical thinking: a responsible nurse needs to systematically about when and where to question established rules. The key, of course, is to develop the attitude and skills of a critical thinker, and to be ready to apply them in appropriate circumstances.

This is just one way of illustrating this general point about ethics: while individual judgment and critical thinking are essential to good ethical reasoning, it needs to be balanced against the collective wisdom that is often embodied in laws, rules, and social conventions.

*Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 3rd Canadian Edition, Oxford University Press, 2013.

Here’s an interesting story from The Telegraph: Psychiatrists and nurses admit lying to dementia patients.

Truth-telling is one of the ethical pillars of modern healthcare. Telling patients the truth is generally seen as a key part of treating them with respect. Lying to them is a form of manipulation that is usually incompatible with respecting patient autonomy.

Are patients with demential an exception? Certainly it’s hard to make a case for a blanket exception, given the enormous variation in cognitive capacities and emotional states that can fall under the general heading of “dementia.” It may well be that there are a limited number of particular circumstances with particular patients in which lying is justified. But nurses should never be complacent or come to think that lying is part of standard care.

Should healthcare professionals accept gifts from patients? Small gifts? Big ones? How about multi-million dollar gifts?

That’s the topic tackled in this opinion piece by bioethicist Art Caplan: Heiress’ gifts to medical workers raise thorny ethical issues.

The gifts in question in the case Caplan discusses are very large indeed. Most health professionals will never have to give serious consideration to the ethics of accepting a million dollar gift. But thinking through the ethics of a case like this one is a good way to focus discussion on the principles behind the need to maintain boundaries.

Nurse-patient ratios probably aren’t discussed in most nursing ethics classrooms. But it’s clearly an ethical issue. Check out this recent story out of Massachusetts:

Mass. Nurses Association demands mandatory nurse-patient ratios

The trade group representing nurses is pledging to put the “sweat equity” of its 23,000 members behind a push to impose statutory nurse-to-patient ratios, but hospital officials are decrying the proposal as running counter to the trend toward a health care system where providers are reimbursed based on the quality of care they deliver and patient satisfaction.

The Massachusetts Nurses Association on Monday outlined plans to press for passage of a 2014 ballot proposal if the Legislature does not act by the middle of next year to pass nurse staffing legislation, which would apply to acute care hospitals.

The proposal calls for one nurse for every four patients in medical/surgical units….

It’s clearly a complicated issue. Nursing ratios are of course crucial to patient care, in general, but I suspect it is very hard to describe a one-size-fit’s-all solution, which is more or less what regulation would require.

Note also the difficult challenge, here, from the point of view of responsible advocacy. The MNA wants to advocate from the point of view of patient safety, which is entirely appropriate. But any attempt to legislate nursing ratios will of course be perceived by some as an attempt to maintain employment levels for nurses.

Finally, note that this issue raises questions of interdisciplinarity and the role of allied health professionals. In some cases, nurse ratios are being reduced because nurses are being replaced (or supplemented) with other kinds of workers. Sometimes that will be a very bad thing (for patients). Sometimes that will probably be a good thing (for patients). Sorting out which is which is a significant ethical challenge.

Former Australian arts minister, Ros Bates, is facing criticism (and potential parliamentary censure) for claiming to be a Registered Nurse, when she had in fact allowed her license to laps.

It’s a bit of a tempest in a teapot. Bates is probably right that, in the context of parliamentary debate (rather than, say, in the context of being hired at a hospital), critics are “nit-picking” when the point to the difference between being a qualified nurse and being a registered nurse.

But the story is a good reminder of the social privilege that licensure implies. Compare: I’m a philosopher by training (that’s what my PhD is in). But no one ever gets in trouble for “falsely” claiming to be a philosopher!

This one isn’t really about nursing ethics, though it has plenty of implications for the ethics of nurse managers.
Hospital settles nurse’s discrimination suit.

After settling one lawsuit, a second was pending Friday against a Flint, Mich., hospital accused of honoring of a swastika-tattooed man’s request that African-American nurses not care for his newborn….

My main comment: The “customer” isn’t always right.

But fodder for discussion: what can (or do) hospitals do to handle such problems? What can or should they do when patients express preferences that are clearly discriminatory?

As has been widely reported, a recent study indicates that almost half of New Zealand nurses have considered leaving their jobs out of ‘moral distress.’ The high rate of moral distress among nurses is not surprising, given the morally-significant nature of their work. In fact, that’s a feature of clinical work of all kinds. I made this general point in reference to a specific clinical context almost a decade ago, in the Canadian Journal of Psychiatry, in an article called Treatment Resistance in Anorexia Nervosa and the Pervasiveness of Ethics in Clinical Decision making. Here’s a quote that sums up the main point:

But it is useful to remind ourselves that an ethical issue is not something that arises every few weeks in clinical settings, in those regrettable moments of crisis in which clinicians feel the need to seek advice from ethics consultants or committees. Ethical issues of an acute nature may (we hope) be rare, but ethics—the making of value judgements, of weighing our actions against shared standards—is a task inherent to clinical life.

As the New Zealand study illustrates, it’s a point that applies to nursing practice quite generally.


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