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Families at the Bedside

September 25, 2011 by Chris MacDonald

Nursing ethics isn’t just about ethical standards for nurses; it’s also about the stances that nurses and nursing organizations take on issues of health policy.

See this story, from the BBC: RCN wants longer hospital visiting hours

Hospital visiting times should be extended so patients’ relatives can become more involved in their care, the Royal College of Nursing has said.

RCN head Peter Carter said he did not want relatives performing tasks nurses were employed to carry out, but that there were “real benefits” for patients when family members helped with care.
…
But patients’ groups warned such a move could be “the tip of the iceberg”….

Make sure to read the comments under the BBC story — they reveal lots of additional reasons for and against extending visiting hours.

What do you think?

Posted in family, hospitals, patients | 2 Comments »

How We Approach Difficult Moral Dilemmas In Nursing

August 14, 2011 by Nancy Walton

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.

Posted in collegiality, critical thinking, ethics, moral distress, patients, professionalism |

Nurses, Unions, and Ethics

June 25, 2011 by Chris MacDonald

Unionization by health professionals is a touchy subject. And when it’s not, it ought to be.

See this story by James Warren for the New York Times: Finally, Nurses Are Set to Vote on Unionizing

The American Federation of State, County and Municipal Employees is still at it and will finally get a representation election next Wednesday and Thursday among about 270 registered nurses at one of the group’s locations, Our Lady of the Resurrection Medical Center.

It’s a drawn-out, nearly decade-long tussle fit for the times. The union has met resistance and filed 50 complaints about unfair labor practices with the National Labor Relations Board. The company voluntarily settled 18 of the 50 complaints brought against its various properties before any federal hearing….

Interestingly, Warren’s article makes absolutely no mention of the fact that nurses are not just regular employees, that they are health professionals. Nurses are licensed professionals with a code of ethics and an avowed commitment to the public good. That makes them pretty different from municipal employees or auto workers. That’s not to say that they shouldn’t unionize. But it does raise concerns about nurses joining unions that are not exclusively unions of nurses. Unionization has a purpose, and unions have their goals. But the goals of a union can quite easily conflict with the goals to which a health professional swears upon joining the profession.

Posted in codes of ethics, licensing, professionalism, unions |

Doctors, Nurses, and the Ethics of Bullying

May 9, 2011 by Chris MacDonald

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.

Posted in collegiality, communication, hierarchy, hospitals, moral distress, professionalism, safety, workplace | 4 Comments »

Critical Thinking in Nursing Ethics, Part 2: Analysis of Arguments

February 10, 2011 by Chris MacDonald

This is the 2nd in a series of postings on the value of critical thinking in nursing ethics.

(Notice that a story has been in the news recently about how poorly most US college students do at acquiring critical thinking skills during their post-secondary years. See: Study: Students slog through college, but don’t gain much in terms of critical thinking skills.)

One of the absolutely fundamental skills of critical thinking is argument analysis, or the interpretation of argument structure. And the fundamental elements of argument structure are argument premises and conclusions.

In everyday language, the word “argument” refers to a heated debate. When people are “having an argument,” they’re disagreeing vigorously with each other. But the word “argument,” in the context of critical thinking, refers to a series of statements, in which some of those statements (called “premises”) are offereds as reasons to believe another of the statements (called the “conclusion.”)

Understanding the way an argument is put together — its structure — is a very good step towards understanding its strengths and weaknesses. Knowing, for example, that a given argument has 3 separate premises rather than just 1, is fundamental to looking for its weaknesses: the more premises it has, for example, the more possible points of criticism. But even more fundamental is the fact that we gain a better appreciation of someone’s point if we can get a better perspective on the shape of their argument.

Look, for example, at this argument:

Nurses go through a rigorous licensing process. And nurses proclaim their dedication to putting the good of their patients before their own good. So, nurses should be respected as professionals.

We can represent this argument graphically, by means of a diagram, as follows:

The arrows in this diagram represent the author’s intended logical “flow” — they can be read roughly as representing the word “so” or “therefore.” This argument has 2 premises, each of which gives at least some support to the conclusion. (The fact that there are 2 arrows indicates that there are 2 separate chains of logic here; each premise gives some reason to believe the conclusion.) At this stage all we are doing is sketching the shape of the argument; we are not yet engaging in a critique. But from a critical perspective, this means that if you find fault with one of the premises, the conclusion is still supported — at least to some extent — by the other.

Next, compare that one to this argument:

Nurses around here are unionized. No unionized group can really be a profession. So, nursing (here) isn’t a true profession.

That argument can be diagrammed as follows:

This argument also has 2 premises. But notice that (as implied by the line joining them, and the single arrow flowing from that line to the argument’s conclusion) these 2 premises are working together. They need each other in order to lend support to the argument’s conclusion. This means that a convincing criticism of either one of those premises robs the argument of all of its force. That’s not to say that the conclusion is false, even if its premises fail; it’s just to say that this argument can’t support the conclusion, if even one of its premises is in doubt.

Now, those are very very simple arguments, and the analysis suggested here is not exactly profound. But the simple process of sketching the shape of an argument — your own or someone else’s — is useful in making clear just how much support the argument has, or doesn’t have, and where its weaknesses may be.

—-
The diagramming method used here is adapted from Lewis Vaughn and Chris MacDonald, The Power of Critical Thinking, 2nd Canadian Edition, Oxford University Press, 2010.

Posted in critical thinking, ethics |

Conscience Clauses and Inter-Professional Conflict

January 28, 2011 by Chris MacDonald

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.

Posted in autonomy, collegiality, conscience, professionalism |

Critical Thinking in Nursing Ethics, Part 1

January 28, 2011 by Chris MacDonald

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.
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.

Posted in codes of ethics, critical thinking, ethics |

Nurses Top Honesty and Ethics List

January 2, 2011 by Chris MacDonald

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?

Posted in ethics, professionalism | 1 Comment »

Plagiarism Among Nursing Students

November 21, 2010 by Nancy Walton

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.

Posted in codes of ethics, collegiality, conscience, ethics, patients | 3 Comments »

Disaster Relief, Positive Role Models, and Everyday Heroism

November 11, 2010 by Chris MacDonald

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.

Posted in codes of ethics, ethics, humanitarian, international | 1 Comment »

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