Archive for the ‘ethics’ Category

This is Part 1 in an series of postings we’ll be doing on the role of critical thinking in Nursing Ethics, here on the Nursing Ethics Blog.

Let’s start with a definition. Critical thinking can be defined as “the systematic evaluation or formulation of beliefs, or statements, by rational standards.”*

In terms of nursing ethics, that definition has several crucial elements.

The first has to do with the word “systematic.” Thinking critically about ethical standards in nursing is “systematic” in that it has to do with the application of distinct procedures and methods. At times, that might involve the use of very technical tools, such as the tools of formal logic, to assess the validity of arguments. In other cases, it will involve looking for well-known patterns of good or bad reasoning, including for example the many fallacies to which human reason is sometimes subject. In other cases, being systematic will simply mean looking carefully at the various parts of an argument (its premises and conclusions) and at how the argument is structured, in order better to assess its strengths and weaknesses. Thinking critically about nursing ethics means doing something more than having an opinion. It implies a careful, systematic approach.

Here’s an example. Imagine a fellow nurse, one administering a clinical trial, says to you, “If someone is my patient, then I owe that person a duty of care. Right? And according to the relevant regulations, I owe the participants in this clinical trial a duty of care, so they must therefore count as my patients!” That’s an ethically significant conclusion. But is the argument leading to it a good one?

At some level, that argument may sound plausible, and to many nurses, the conclusion will be an attractive one. But someone skilled in critical thinking might recognize that that argument has the following form:

If P, then Q.
Therefore, P.

Arguments of that form are pretty common (so common, in fact, that they’ve been given a technical name, “affirming the consequent”) and they are always, always faulty. The premises of an argument with that structure simply cannot support that conclusion. But good critical thinkers will also recognize that the failure of this argument doesn’t automatically spell doom for that argument’s conclusion: it just means that someone needs to try again.

The second implication of the definition of critical thinking offered above has to do with what it says about about “evaluation” and “formulation” of beliefs. This implies that critical thinking is to be applied to evaluating existing beliefs as well as to the process of building new ones. In terms of nursing ethics, then, critical thinking can be used in two ways. First, it can be used as part of reflective practice, as part of evaluating our own current beliefs about what constitutes ethical or unethical nursing practice. Second, it can be used in formulating new ethical standards, for example when a new code of ethics or is being devised.

The third implication has to do with the words “rational standards.” Those words imply that particular views about nursing ethics (or bioethics or professional ethics, more generally) ought to be judged by how well they are supported by good reasons. That is, a commitment to thinking critically about nursing ethics means only adopting points of view that you have good reasons to adopt, and committing to values you have good reasons to be committed to, rather than adhering to stale, unexamined beliefs or doing things a particular way “because that’s the way we’ve always done it.”

As this series progresses, we’ll look at different elements of critical thinking, and how some of the specific skills of critical thinking can be applied to thinking about nursing ethics.

*Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 2nd Canadian Edition, Oxford University Press, 2010.

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Here’s a headline worth shouting from the rooftops: Nurses Top Honesty and Ethics List for 11th Year

Nurses continue to outrank other professions in Gallup’s annual Honesty and Ethics survey. Eighty-one percent of Americans say nurses have “very high” or “high” honesty and ethical standards, a significantly greater percentage than for the next-highest-rated professions, military officers and pharmacists….

Interestingly, the high numbers (and top ranking) for nurses is essentially unchanged over the last several years. Why do nurses consistently rank so highly? The folks at Gallup speculate as follows:

The consistently most positively rated professions, including nurses and pharmacists, have generally been able to avoid widespread scandals and, as such, Americans continue to hold them in the highest regard.

What do you think?

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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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By Sharrie Williams, for CBS News 4 Miami: Nurses Head To Haiti On Teaching Mission

In September two Jackson Memorial Hospital nurses with more than three decades of experience between them took that knowledge and compassion to Port-au-Prince.

They volunteered to help Haitian nurses in the aftermath of January’s devastating earthquake and now, the two are going back again to try and help the crippled Haitian medical community….

Of course, this is just a local news story, and there’s not much that’s unique about it. Many, many nurses have participated in humanitarian efforts in Haiti and other places. I’m posting this story just to make a brief point about role models, and the value of examples. Very often — regrettably often — the word “ethics” comes up in contexts where someone has done something bad. A scandal of some sort arises, or someone is accused of violating their Code of Ethics. But ethics, of course, is about far more than that. Ethics isn’t just about avoiding wrongdoing. It’s also about doing good things.

To most members of the public, getting on a plane to go and help in Haiti must seem utterly heroic. And, to be sure, the nurses in the story quoted above deserve praise — what they’re doing is truly wonderful. But it’s also worth remembering that, within the nursing profession, the line that most of the public sees between “just doing your job” and going “above and beyond” gets blurred. Nursing, as a profession, calls upon its members to go “above and beyond” on a daily basis. That’s part of the ethics of being a nurse. But of course, there are limits. Even nurses are only human. There’s only so much anyone can do, only so much anyone can give. I think one of the core ethical challenges for the nursing profession is, on an ongoing basis, to think about just where the profession itself will draw the line between what it considers “above and beyond,” and what it considers just everyday heroism.

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There has been a great deal in the news over the last month or so about end-of-life care and the initiation and use of do-not-resuscitate orders. Two separate cases, both at Sunnybrook Health Sciences Centre in Toronto, have highlighted the challenges when the views of the health care team and those of the patient and family are in conflict at the end-of-life. On September 4th, the case of Douglas (Dude) DeGuerre and his daughter Joy Wawrzyniak was highlighted in an article in the Toronto Star. More recently, Mann Kee Li‘s case has been featured.

Li, a 46-year-old Toronto accountant and father of two young boys, wants doctors to use all medical measures possible to save him in the event of a life-threatening emergency.He made those intentions clear to his doctors at Sunnybrook Health Sciences Centre when he entered the hospital in August. He wrote it in a power of attorney document and confirmed it in a videotape statement, his lawyers say. While his doctor initially agreed to respect those wishes, physicians unilaterally reversed the decision a week ago without consultation and imposed a “do not resuscitate” order, his family alleges.

These two cases have a couple of common characteristics. First, the journalists have stated that the values and wishes of the patient/family and the health care team have been in conflict. Second, the families of the patients have stated that they were not included in decision-making regarding end-of-life care and more specifically, the lack of aggressive life-saving care that would be provided at the end-of-life.

Interestingly, a while after these two stories appeared in the news, I saw this headline on CBC news: DNR Orders Must be Discussed. Frankly, I’m not sure when the decision was made to stop talking to patients about end of life issues or DNR orders. Each of the patients’ cases in the stories above emphasize that decisions regarding DNR orders were not discussed with the patients or families. The fact that families feel that they haven’t felt that they’ve been part of the decision-making processes regarding end-of-life care and wishes, means that something is definitely wrong with how the health care team is functioning, at a very basic level. What these patients’ and families’ stories are really about are communication and values. One thing I couldn’t help thinking as I read these two patients’ stories was: Weren’t the nurses talking about these issues with the patients and families? Isn’t it inevitable that they would have been asked to? If so, what happened?

There are significantly troubling issues that arise out of these cases — too many to address in one blog entry. There are entire courses on the ethical issues surrounding end-of-life care. To do these issues justice, one requires more than a blog entry, even a very long one. So let’s just consider the issue of communication and the role of the nurse in these types of cases. While nurses may not be able to write the actual DNR order in most jurisdictions, they are, many times, the ones that patients and families turn to, in order to talk about what a DNR order really means. Nurses are also the ones that patients and families turn to when they fear that their values and wishes will not be either honoured or respected. Often, the bedside nurse is seen as a much less intimidating confidante than the physician. In my own experience working in cardiac surgery, there were many times I watched as caring and communicative surgeons obtained informed consent from calm, agreeable and seemingly very willing patients for surgical procedures, only to have those same patients (and families) voice doubt, fear and confusion to me moments after the surgeons left. By virtue of a number of factors (clinical distance and proximity, time spent at the bedside, intimacy of care provided, accessibility, knowledge and skills), it remains that nurses are often still the ones who patients and families seek out, in times of intense personal crisis.

In turn, nurses have a unique responsibility to patients and families, in situations of value conflict or crisis. When patients or families feel that they do not ‘have a voice’, nurses need to advocate for them. This doesn’t mean that a nurse must ‘take a side’ or necessarily agree with the patient, the family or the physician. This obligation is one that exists regardless of the context, and is essentially a professional and ethical responsibility.

In one Canadian document regarding end of life care, the Canadian Nurses Association Position Statement on Providing Nursing Care At The End Of Life (2008), it’s easy to see that the nurse has a number of responsibilities when it comes to providing end-of-life care, but a very important one is collaboration between all involved to foster an approach that is holistic, respectful of diverse values and based on consistent and meaningful communication. Here’s an excerpt:

Quality end-of life care is “best provided through the collaborative practice of an interdisciplinary team to meet the physical, emotional, social and spiritual needs of the person and their family.” Nurses, as members of the interprofessional team, collaborate with the person, the person’s family and all those involved in providing care (such as physicians, other health-care professionals and volunteers) to support a holistic approach; incorporate the person’s priorities, values and choices in all aspects of care; and address any specific concerns that may arise….

…Nurses are uniquely situated to develop therapeutic relationships with dying people and their families. Nurses who provide care at the end of life are witness to, and part of, a complex process that is physically, psychologically, emotionally and spiritually intimate and profound for most individuals, their families and their health-care providers.

It’s far too easy to ‘doctor-bash’ and claim that the physicians made decisions without including the values and wishes of the families and patients involved and that all the blame should be put on the doctors involved. However, everyone on the interdisciplinary team shares the responsibilities for ensuring holistic and collaborative care along with effective and therapeutic communication. When values conflict, everyone on the team knows – and action must be taken to encourage communication by everyone involved. I’m certainly not saying that there is any kind of easy answer — “Simply speak up for the patient and everything will be fixed!” — but I do think that the obligation to advocate for the patient and to ensure that communication is ongoing within the health care team is a very weighty one, and one that nurses must take on.

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Why a nursing ethics blog?

Why a nursing ethics blog?

This seems like an obvious question for the topic of a first blog entry. Why write a nursing ethics blog? Between Chris MacDonald and myself, we already have four blogs on ethics that keep us busy in addition to our academic and professional work. Why take on something more?

Well, simply put, there are two reasons for deciding to write a nursing ethics blog. First, there is a need. Nurses, in my experience, at all stages of professional life, have both a strong need and a yearning to have a place to read and talk about ethical challenges and issues that arise in practice. The classes I teach on ethics are always the ones in which there is the most active and engaged discussion, the most sharing of individual stories and the times when I receive the most after-class emails following up on topics, issues and cases. While presenting Dax Cowart as a case study might seem like old news to some bioethics colleagues, this case, as one example, is something that, year after year, my nursing students find compelling, troubling and worthy of reflection and intense discussion.

Second, there are nursing blogs out there, for sure. There are also plenty of nursing websites that contribute to nursing knowledge and have sections on ethics. There is also high quality, innovative work being done at the boundaries between social media and nursing, like Rob Fraser’s website, Nursing Ideas. But there isn’t anything that I can find that merges consistent and informed commentary on issues in health care, bioethics and nursing ethics in the way I have tried to do on the Research Ethics Blog (which was built on the advisory expertise of Chris MacDonald’s Business Ethics Blog, Biotech Ethics Blog and Food Ethics Blog).

On this blog, we’re aiming to try to discuss issues that are relevant and meaningful to nurses in modern practice today — nurses at the bedside, in administrative positions, in academia, in settings from intensive care units in busy downtown hospitals to rural and remote positions. We hope it will be a place where broader issues in health care and bioethics can be explored. We’re also hoping to write about enduring issues in nursing ethics like moral distress, moral integrity, empowerment, and professional stress, but write about these issues in an accessible, straightforward yet innovative and modern way.

This doesn’t mean we’re only going to write about issues “at the bedside”. Clearly, there is a strong element of interdisciplinarity and interprofessional work in nursing. So to ignore stories and issues in medical ethics or more generally, health care ethics, would not be a wise or prudent decision. Here are some examples: ethical issues that are prevalent in areas like end-of-life care, beginning of life care, resource allocation, and decision-making will be addressed here as will concepts such as morally problematic practices, consent, autonomy and the value of professional advice.

Above all, we’re simply hoping to engage scholars, students, and nurses at a variety of stages in their professional lives tackling difficult and complex issues in ethics. We hope you’ll check in and see what we’re doing!

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