Senior Lecturer in Nursing
University of Canberra, ACT
This paper argues that lack of clarity by nurses on what is important about their practice leads to lack of dignity for patients and increasing feelings of moral distress by nurses. The central assumption of the paper is that values influence decision-making. When nurses make clinical decisions, these decisions are influenced by what the nurse considers to be important. The process of valuing is usually implicit and the effects of valuing may be invisible to the nurse. Cancer nurses may uncritically adopt the dominant biomedical view of health that exists in Australian cancer care to the detriment of patient well being. However, through critical reflection on clinical decisions, nurses can reveal to themselves what they value in clinical practice and develop the ethical arguments to support their decisions.
Values underpin an individual’s perception of reality and derive from abstract ideals about ways of behaving or one’s goals in life. Values reflect an individual’s beliefs about the relative importance of universally accepted principles and are mechanisms used by the individual for choosing acceptable alternatives and for identifying the right actions in a situation1. Values are revealed in what we say and what we do – our choices reveal what is important to us as human beings.
Values development in nursing begins in pre-registration education. Students are indoctrinated into a ‘normative ethic’ for nursing. It is here that the objective knowledge and truth underpinning most curricula is value laden but invisible. Rarely are students invited to subject the ethic to rigorous philosophic analysis leading to a group of professionals unable to defend their values when they are called into question2. Nurses in general do not analyse their professional actions, but adopt a prescribed professional role, thereby fulfilling a prescriptive social stereotype3. The following syllogism illustrates:
“The situation is X. In situations like X, a good nurse does Y. I am a good nurse. Therefore I shall do Y” 4.
This stereotype works well within a biomedical, prescriptive philosophy where practice decisions are based on the best available scientific evidence. However, as Thorne4 notes:
“When we see the cancer field as limited to biomedical science explanations, we reveal our ignorance about significant questions that are being raised in the public domain…. the prevalence of existential experiences and questions forces us to understand that cancer is an experience of living, breathing, questioning human beings, not simply a biologic malfunction“5.
Nurses who apply Glen’s3 syllogism in daily practice decisions find themselves struggling to justify their decisions from an ethical perspective6. The biomedical view of cancer care limits the human potential of the nurse-person relationship by dehumanising the person and creating moral distress for the nurse. The challenge for nurses in the cancer care setting is to recognise the potentially negative effects of the biomedical view and implement strategies that address the issues raised.
The contemporary approaches to cancer treatment are informed by the dominant biomedical view of health. In this view, cancer, as a disease, is something apart from the person that ‘attacks’ the person7. The human body is conceptualised as a machine in need of repair8. High health care costs (really disease costs) can be attributed to technology, or ‘magic bullets’, in the form of advanced surgical techniques, more potent drugs, and advanced radiation physics. These technological advancements are the ‘tools’ used by doctors to repair and restore the body and they share common qualities. They are expensive, are geared to treatment, aggressively attack disease, and produce many iatrogenic effects.
The dehumanising potential of cancer treatments is illustrated in the woman with breast cancer who may experience:
The physical effects of treatment can be compounded by the attitude of health professionals. In providing a personal account, Sauri9 suggests that appropriate behaviour, on the part of professionals, is of the utmost importance, emphasising that the professional’s words, attitudes and gestures are branded upon the vulnerable patient’s mind. This personal account is supported by research done by Kralik, Koch and Wotton who could group patients’ experiences of nursing care into two categories: engagement and detachment10.
“Defensive attitudes create in professionals a kind of armour-plating that prevents them relating to the patient’s emotions [detached]. This translates into a relationship that is distant, cold, aseptic and, most definitely dehumanised”9.
In the biomedical view of health, the role of the nurse is limited to the technical skills associated with administering the treatment and prevention or management of any iatrogenic effects. In this climate, nurses are challenged to develop evidence, preferably using randomised controlled trials and based on probabilities, to support their clinical decision making.
“While nurses clearly need to be guided by the most up to date knowledge, especially in hospital settings, to allow clinical tasks to be performed with skill and consistency, the nurse-patient process is not data-based. Rather, [nursing] is a human-based engagement that must be guided by human values and theoretical principles of relevance to human engagement”11.
Barker’s11 view is supported by Curtin who states that the goals of nursing are not scientific; they are moral and are based on the seeking of good12. Therefore, nursing actions are subject to judgement, influenced by values, as well as scientific evidence.
There is mounting evidence that the values learned by nurses are not consistent with the values of the health system. Kelly13 found that senior baccalaureate nursing students in the United Kingdom valued ‘respect for the patient’ and ‘caring about little things’. Little things included getting out the mirror so patients can see themselves, fixing their water so they can reach it, and worrying about someone’s dentures or the cat they left at home. She found that this same group also valued ‘fitting in’ and ‘going along’. These students felt that their values would be in conflict with common hospital practice and saw themselves as powerless.
The finding of powerlessness, is a theme reinforced by another study completed in the USA14. Over 300 neonatal nurses were surveyed and it was found that those nurses working in large tertiary centres believed the nurse-patient relationship becomes secondary to physicians’ orders, institutional policies, and other external forces14. In a survey of Australian cancer nurses, it was found that 74% agreed that sometimes hospital policy or practice standards conflict with what the patient needs15.
The result is a conflict between what the nurse should be doing, learned at nursing school, known as espoused values (sometimes reflected in a formal code of ethics or conduct), and what they are actually doing in the clinical area, values-in-use3. This conflict can result in moral distress, defined as when the nurse knows the right course of action but constraints make it impossible to pursue the right course of action16. Hamric15 describes institutional constraints such as lack of time, lack of supervisory support, physician power, institutional policy, and legal limits.
Two main issues that lead to moral distress for nurses are (1) the clash between professional, corporate, and societal definitions of adequacy of care16,17 and (2) nurses’ belief that they value patient autonomy more highly than physicians do17. Moral distress produces painful feelings, that can range from a feeling that something is wrong to anger and frustration. Over time, moral distress can escalate to feelings of depression, anguish, and moral outrage15. Moral distress in nurses is an important issue for consideration in cancer care as there is increasing evidence to suggest that moral distress is a powerful factor in nurses’ decisions about remaining in practice18,19,20.
Clinical nurses are challenged to consider and articulate how they view health and what is most important when they deliver nursing care. Reflecting on clinical experiences through journalling is one way to unravel the value assumptions that inform clinical decisions and choices. Asking oneself questions about an incident such as: What was important to me at the time? What may have been important to others in the situation? How do I know that the decision was right (theory)? Would my colleagues (nursing and medical) share this view? Why or why not?
Nurses must identify the theory used to make morally defensible clinical decisions and choices, recognise the contextual nature of value judgements, and develop the art of practical deliberation with colleagues to improve practice3. This process is more than knowing and understanding the nursing process or routinely implementing institutional policies derived from evidence. The evidence-based movement has an important place. However by focussing on evidence alone, legitimised through a biomedical view, the nurse risks creating a dehumanising experience for patients and missing the rare or unlikely responses that are rendered invisible in empirical research.
“Technological evidence is important but should not distract [nurses] from the need to explore the world of the person or family, through the nurse-person process. It is within such exploration that we shall find out what exactly is happening, to this person, at this particular time, and what meaning they construct out of the experience. That is not evidence – that is truth: the truth of individual experience, often ephemeral, but always true at the time of knowing. Such ‘personal truths’ are very different from the probabilistic assumptions of evidence, which risk blinding us to the rare or unlikely” 11.
The development of critical thought and critical spirit is essential for nurses to formulate logical, but tentative, personal views on contentious health issues. Clear formulation of one’s values helps guide day to day practice. Educational strategies include attending short courses on bioethical theory and requiring mentors for less experienced nurses. Understanding of bioethical theory would assist nurses to articulate the rationale behind clinical decisions and choices. Less experienced nurses, new to the cancer area, would benefit from being mentored by an experienced clinician who can facilitate the reflective process. Such strategies have the potential to increase critical thinking skills in nurses.
Research into the role of values in clinical decision making by cancer nurses is urgently required. Contemporary demands for evidence based decision-making leaves little scope for understanding the unique experiences of human beings. Nursing is a nurse-person process, with outcomes that are context dependent rather than empirically derived. If the biomedical view of health continues to dominate, there is serious risk to the human nature of the nurse-person relationship resulting in persons not choosing treatment due to perceived lack of dignity and more nurses leaving the profession due to moral distress.
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