© Springer International Publishing AG 2017P. Anne Scott (ed.)Key Concepts and Issues in Nursing Ethics10.1007/978-3-319-49250-6_1
1. Nursing and the Ethical Dimension of Practice
National University of Ireland, Galway, Galway, Ireland
P. Anne Scott
Nurses are important to patients. Nurses touch people’s lives during some of the peaks and troughs of human existence. Therefore it is important that we think about nurses and nursing. What do our patients require from nurses and how do we, as a society, as nurses, and as health service leaders, meet patient need? The first step is to recognise that nursing, as a practice, has moral values at its core. The nurse-patient relationship, which is central to the provision of nursing care, has ethical importance and is of ethical significance. It is also vital to consider that the context within which nurses practice can shape and be shaped by the moral values of nursing. These moral values form what can be termed the ethical dimension of nursing. It is therefore important that we explore and examine these moral values. Codes of conduct are examples of the nursing profession’s collective attempt to express its underlying values. The institutions within which nurses work help or hinder the actual expression of these values in nursing practice and patient care. We need to recognise the interplay of these various factors in order to ensure that we as nurses, as potential patients, and as members of society understand what good nursing practice means, what it looks like in practice, and how it can be supported. This chapter sets out to identify the ethical domain of nursing practice, and signal its relevance for good nursing care and a safe, supportive patient experience. The chapters which follow provide theoretical and conceptual lenses through which to identify, analyse and discuss ethical issues in nursing practice, with a view to providing tools for the nurse to practice in an ethically sensitive and appropriate manner.
KeywordsEthical domainNurse-patient relationshipNursing ethicsPatient-centred careCodes of conduct
Nurses are important to patients: to their experience of illness, disease, treatment, and care (Institute of Medicine (IoM) 2011; Scott et al. 2014). Nurses can touch people’s lives during some of the peaks and troughs of human existence. Therefore it is important that we think about nurses and nursing. Professional codes of conduct such as those published by the Nursing and Midwifery Council (NMC) (2015), and the Nursing and Midwifery Board of Ireland (NMBI) (2014) are examples of the profession’s collective attempt to express the underlying values of the nursing profession. Many of these values are moral values. Recently, in the Irish nursing context, an initiative led by the Chief Nursing Officer, the Department of Health (DoH), and supported by NMBI, sets out to re-identify and recommit nurses to the core underlying values of nursing in Ireland: Compassion, Care, and Commitment (DoH 2016). These values are, clearly, moral values. However nursing practice also happens within a context. This context is the health service of the relevant locality, region, or country. It is necessary to acknowledge, and to fully appreciate, the impact that this context has on the individual practitioner’s ability to practice to the best of their ability, including providing ethically sensitive care. Given the nursing literature, education programmes, codes of conduct, initiatives such as that described above (DoH 2016), and recognising the impact of the context of nursing practice, it is important that we explore and examine the morally relevant aspects (in other words the ethical domain) of nursing practice.1
Nursing and the Ethical Domain of Practice
The ethical domain of human life relates to how we behave towards each other and the reasons we do so. As the American scholar Martha Levine, writing for practising nurses in the 1970s, succinctly and powerfully states:
Ethical behaviour is not the display of one’s moral rectitude in times of crisis. It is the day-to-day expression of one’s commitment to other persons and the ways in which human beings relate to one another in their daily interactions (Levine 1977, p. 845)
The way we relate to one another, behave towards one another, the attitudes we display to other people – whether strangers, neighbours, patients or clients – are moral actions, behaviours, and attitudes. These behaviours, actions, and attitudes are based on personal, as well as professionally socialised, attitudes, judgements and decisions. This is an important matter to recognise. It implies, for example, that despite a difficult working environment, there is personal responsibility on the individual nurse for the care she/he provides. There may also be corporate responsibility, as in situations such as those reported in Mid Staffordshire (Francis 2010, 2013), for a lack of humane, competent nursing care.2 The nurse may be very busy and stressed by work load, however how she/he receives the newly admitted patient, or responds to a patient’s call for help, is in part a personal ethical decision and behaviour. Being fully and continuously aware of this ethical dimension of nursing care is a topic that deserves some attention. It is a topic which we will explore in both this introductory chapter and in all the chapters that follow.
In nursing we interact with human beings made more than ordinarily vulnerable (Sellman 2011, p. 67) by illness, disease, or other life circumstances. These human beings need our professional help and care. Good nursing practice therefore requires us to engage at a human as well as a professional level. Patients assume professional competence, until we prove them wrong (de Raeve 2002, p. 158). They seek kindness and compassion as the basis of developing confidence and trust that they are ‘in good hands’. They seek to be cared about as individuals, as well as being cared for, by the nurses they encounter. We, the nurses responsible for the care of these patients, may show kindness and compassion through many ordinary interactions and interventions that acknowledge the individuality and human context of the patient – or we may choose not to do so. These choices are at the heart of the ethical domain of our nursing practice.
The ability to recognise the need of the patient: to relate, respond to, and recognise those who are “more than ordinarily vulnerable” (Sellman 2011, p. 67) suggests the ability, in the nurse, to develop a basic connection as human being with another human being. In developing this connection we are setting the foundations for a nurse-patient relationship. This is the vehicle through which we provide engaged, connected, and patient-led care. Nurse-patient interaction and engagement, as manifest through the nurse-patient relationship, is at the heart of the moral domain of nursing practice.
Nurse-Patient Interaction: The Nurse – Patient Relationship (Including Case Study)
The American nurse scholar Janice Morse (1991) argues that the relationship between the patient and the nurse is not only the basis and frame within which nursing care happens: the patient-nurse relationship is a direct outcome of a series of interactions, observations, and engagements between the patient and nurse. The nurse-patient and patient-nurse relationship is a negotiated and evolving reality for the duration of the patient-nurse contact. Morse (1991) in her seminal study of the nurse-patient relationship identified four different types of relationship: the clinical relationship, the therapeutic relationship, the connected relationship and the over-involved relationship. The type of relationship that develops, Morse argues, depends “on the durations of the contact between the nurse and the patient, the needs of the patient, the commitment of the nurse and the patient’s willingness to trust the nurse…” (Morse 1991, p. 455).
The clinical relationship is that which is appropriate when the contact is short, functional, and the needs of the patient very discreet – such as the removal of sutures as an outpatient, or the dressing of a minor wound. The therapeutic relationship, which Morse suggests is the most often encountered, goes somewhat deeper than the clinical relationship – contact between the nurse and patient is still relatively brief, patient need is relatively minor, care is given quickly and effectively. In this type of relationship the patient expects to be treated as a patient and has family and friends to meet other psychosocial support needs. Morse suggests that within the context of this type of relationship some degree of testing of the relationship will occur from the patient’s perspective, to see if the patient can “trust” the nurse to look after them properly, until they can care for themselves again. This can involve ringing the call bell for a minor matter to see if the nurse will answer, or observing a nurse to see if they will actually return when they have indicated to the patient that they will get back to them on a specific issue. This is likely to be the most common form of nurse-patient relationship encountered in modern acute care settings. However for very dependent and acutely ill individuals their needs require the nurse to be able to flex between the therapeutic and connected forms of the nurse–patient relationship.
The connected relationship either evolves over time, as patient and nurse get to know each other over an extended care period, or is stimulated by the ability of a nurse to respond to the intensity of the patient’s need. Morse suggests that
in this relationship, the patient believes that the nurse ‘has gone the extra mile’, respects the nurse’s judgement and feels grateful, the nurse believes that her care has made a difference to the patient. (Morse 1991, p. 458)
In the over-involved relationship the nurse treats the patient as a person and friend first and a patient second. The nurse can become territorial over the patient believing she/he is the only one who can care properly for this patient. The nurse may become over-extended, lose a sense of balance and suffer impaired judgement. This kind of scenario can lead to impaired patient care and burnout.
The case-study below will help bring focus to our discussion of the nurse-patient relationship, and provide some insight into its importance in understanding the ethical domain of practice, in addition to its potential significance to a patient’s experience. This case-study involves a nursing academic and former colleague who had been diagnosed with breast cancer.3 My colleague kept a diary as she confronted and experienced biopsy, diagnosis, surgery, and prepared for radiotherapy. Her diary provides important insights into both the nurse-patient relationship, and nursing care, from the perspective of an informed patient.
Being ‘prepped’ consisted of having my breast, axilla, and back painted. The sensation was pleasant; the last pleasant sensation there would be for a breast that had, in its time, been appreciated by baby and lover alike. There was no avoiding the issue, this was what I was going to lose. The nurse and I didn’t talk. She didn’t fill the moment with idle chit chat or pseudo empathy, which I would have found offensive and would have demanded social responses from me that I would have struggled to make. The nurse treated the task and thus me and my soon to be no more breast, with respect. While sharing none of the horrors of pubic shaving, this preoperative preparation was an activity that called for high calibre nursing skills. I was very grateful for the way it was managed; it preserved my dignity, did not exacerbate an intrinsically distressing situation and gave me a sense of, literally, ‘being in good hands’. (CN)
The nurse described here is observant, respectful of her patient, competent, and “managed” the interaction with CN, and the required nursing intervention, in a calm, professional, and respectful manner. It seems reasonable to suggest that the above scenario portrays the “therapeutic” relationship described by Morse.
On return from theatre it was trained staff who washed me, made me comfortable, gave me iced water to drink while checking heart rate, blood pressure, oxygen saturation, drain, and wound. The sense of being completely cared for, when I was in that post anaesthesia dependency state was wonderfully comforting and reassuring. For a short while I was completely in their hands and their competence was very obvious. Each task done well reinforced the sense of that competence. So it was as important that the water from the face cloth didn’t run down my front as that the drain wasn’t pulled or the wound exposed, forcing me to look at it rather than letting me choose my moment. These demonstrations of hands-on competence created a climate of confidence in the nurses’ expertise. (CN)
Again, in this diary extract, CN describes examples of therapeutic relationships. The nurses remain nameless, part of the effective, competent, caring team. CN then goes on to describe the patient experience and the missed opportunities when that therapeutic engagement is lacking:
In contrast the first postoperative shower was the domain of the nursing assistant. Of course this cannot be combined with cardio-vascular monitoring in the way that bed-based care can be. And it is a low level activity, with the focus of concern on not letting the patient stumble, get scalded or the wound get wet. Even though at this level the task was completed competently and kindly, my sense, as a patient and as a nurse, is that this first postoperative shower is a key nursing activity, not one to be ‘given away’ to a nursing assistant. As a nurse I recognize the opportunity for proper monitoring of the wound and drain, and much more crucially of the patient’s psychological state. Is she afraid to look and, if so, how best should this be managed? Does she want to talk about it; get information, reassurance that her thoughts and feelings are normal? How does it feel, is hypo or hypersensitivity present, to what extent; how should it be accommodated while showering and dressing? These assessments can be more completely made in the shower than in the bed; and they can be inferred from the patient’s behaviour without the need for intrusive, insensitive, premature questioning. For the patient, the first post-op shower represents her most vulnerable moment, naked, only one breast, a huge wound, a drain, a newly improved view of one’s flabby bits. Not only is the patient confronting this sight for the first time, she is exposing herself to someone else’s view in, for many, a rehearsal of showing her husband or partner. That degree of vulnerability demands a professional’s response. It is the nurse, not her assistant, who has the biological, psychological and sociological knowledge that enables her to deal with the situation appropriately. (CN)
CN’s comments here have ethical as well as clinical relevance. Exposure of the patient to this first post-operative shower has ethical as well as clinical salience and shows a potential lack of ethical sensitivity in the delegation of this task to the care assistant. We then find, in CN’s account of her interactions with the Clinical Nurse Specialist in Oncology, an excellent description of Morse’s “connected” relationship:
E’s skill and respect for me as a patient were evident in a number of ways, on this occasion and on all succeeding occasions. I told her I was scared, I would have told anyone but she made it easy to say to her and her reaction, which was minimal, didn’t make me feel foolish. Her behaviour made it entirely clear that she had understood my terror and was reacting accordingly. E knew I was an academic before she met me, so her conversation during the biopsy, clearly designed to distract me, utilised that knowledge. She told me about her Master’s degree and the essay she stayed up all night word processing and which had got lost. The topic was familiar enough to hold my attention and to remind me of situations in which I was a competent ‘grown up’ person; thus boosting my self-esteem and confidence. I nearly passed out at one point. Her skill in dealing with that was very evident – position, comfort, maintaining the circumstances which allowed the biopsy to continue; afterwards a glass of really cold water; keeping someone with me when she had to go. And everything done in a way which allowed me to maintain my dignity. E’s behaviour during the biopsy established the basis for my total trust in her. This was vital when she became the person to communicate the confirmed diagnosis and the options for surgery. (CN)
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