NURSING ETHICS – ISSUE 10.2 (2003)
Contents, Editorial & Editorial Comment for Issue 10.2 (2003) Contents Editorial Editorial comment J Storch Articles Ethical considerations in international nursing research: a report from the International Centre for Nursing Ethics Working Group for the Study of Ethical Issues in International Nursing Research The ethics of the caring conversation L Fredriksson, K Eriksson Integrity in the care of elderly people, as narrated by female physicians A Nordam, V Sörlie, R Förde Differences in ethical attitudes between registered nurses and medical students R Elder, J Price, G Williams Commentary on: Differences in ethical attitudes between registered nurses and medical students: Ethics, gender, disciplines and the social division of labour J Liaschenko Moral agency in nursing: „Seeing value in the work, and believing that I make a difference‟ EJ Pask Ethical issues following the disclosure of a terminal illness: Danish and Norwegian hospice nurses‟ reflections M Lorensen, AJ Davis, E Konishi, E Haugen-Bunch Conflicts of interests; experiences of close relatives of patients suffering from amyotrophic lateral sclerosis I Bolmsjö, Göran Hermerén „No suicide contracts‟ and informed consent: an analysis of ethical issues TL Farrow, AJ O’Brien Reflections on the health workers‟ strike at Malawi‟s major tertiary hospital, QECH, Blantyre 2001: a case study AS Muula, A Phiri Codes Code of conduct for NHS Managers Interview with Glenda Wildschut Book reviews Daniels N, Sabin JE, Setting limits fairly: Can we learn to share medical resources? (reviewer: T Meulenbergs) Ubel PA, Pricing life: why it‟s time for health care rationing (reviewer: W Mohr) Chiarella M, The legal and professional status of nursing (reviewer: B Dimond) Cox CL, Reyes-Hughes A eds., Clinical effectiveness in practice (reviewer: M Shaha) Bartter K ed., Ethical issues in advanced nursing practice (revieweer: M Shaha) Maehle A-H, Geyer-Kordesch J eds., Historical and philosophical perspectives on biomedical ethics: from paternalism to autonomy? (reviewer: T Meulenbergs) Schefter K, Weil es um die Menschen geht; als Krankenshcwester in Afghanistan (reviewer: V Tschudin) News/Calendar of Events
Editorial 10.2 Verena Tschudin It is clearly important to set standards in international research. The leading article in this issue aims to set such standards and is written by the Working Group for the Study of Ethical Issues in international Nursing Research, chaired by Douglas Olsen. This is the first time that the International Centre for Nursing Ethics (ICNE) is collectively publishing an article. intention of. The same group is also conducting research about international research in nursing, with this article as the guiding document for good practice. It sees this as a flagship article for ICNE, and is encouraging its use among students and anyone carrying out research that cuts across different nations and cultures. The unifying theme of this issue is a demand to „listen to us!‟ from the less powerful. This is a recurring theme in this journal, of course. Lennart Fredriksson and Katie Eriksson outline what is needed of nurses in the relationship with patients for this to be a reciprocal relationship. The principles outlined as being necessary for ethical research make it clear that research is done „with‟ people, not „on‟ subjects Ann Nordam and her colleagues describe the integrity needed by female physicians to continue in their work in the care of elderly people. This is often seen as a „Cinderella service‟, but is perhaps the service that will grow most in the future. It needs therefore to have, and be seen to have, equal status with all the other in-patient services. Ruth Elder, John Price and Gail Williams describe the differences in the ethical attitudes between registered nurses and medical students and suggest that the two professions should learn together to share ethical values: sharing each other‟s values is vital. Elizabeth Pask listened to her students and so helped to affirm their work through the stories they told of having made a difference to their patients‟ lives. Margarethe Lorensen and her co-authors also listened to what colleagues in a different discipline found when they were in difficult care situations. Their stories need to be heard for their psychological well-being, and for practice to be values and also improved. Ingrid Bolmsjö and Göran Hermerén heard the stories of relatives of patients suffering from a wasting disease. When medicine has no means of curing or even ameliorating a disease, the person who carries this burden can easily be forgotten. The stories of their carers are therefore all the more important. Tony Farrow and Anthony O‟Brien listened to what their clients said to a treatment that seems not only impossible but ethically questionable, and are publishing their findings in an effort to alleviate further suffering. Adamson Muula and A Phiri describe a strike by health care workers in one of the world‟s poorest countries, and the poor outcome of the strike because the powerful did not listen well enough to the less powerful.
Nursing: Yesterday. Today. Forever
Hanging in our conference room is a picture with the caption shown above, namely, “Nursing: Yesterday. Today. Forever”. In this picture there are two rooms, one commands the foreground of the picture and the other we see only through a doorway. In the foreground a middle aged man lies in a quilt-covered bed with wooden headboard, a bandage on his head, his mouth open as if speaking. A candle lights the darkness and sits on a small wooden table with a bowl and a glass. Beside the bed is a nurse who appears to be listening to the patient. She wears a red cross veil, blue uniform and white bib and apron. The patient looks peaceful: the nurse looks attentive and compassionate. Through the open doorway we see a hospital room that is bright and modern. It features a bed with side rails and substantial equipment, including intravenous stands and monitors. A patient lies in that bed, as well. Her head is elevated and her gaze is to the nurse in blue pant-suit uniform who stands beside the bed. In this scene, too, the patient appears to be talking and the nurse attentively listening. There are many thoughts stimulated by this dual scene. The most striking message, underscored by the title, is the one suggesting that nursing is needed for every age and in every age. Nursing, yesterday, today and forever? Do we believe it? Does society believe it? If that belief is widespread, as I hope it might be, why have we failed so miserably in ensuring that well qualified nurses will continue to be the essential care-givers of tomorrow. Do we see this as having anything to do with ethics? If you believe that the “care nurses provide has direct and significant outcomes for patients, clients and families the system is designed to serve” (1), then the nursing shortage is an ethical issue of major proportions.
The cause of the nursing shortage is complex and may have slightly different root causes in various countries; but there are commonalities as well. Reports recently released in Canada (2), for example, cite the nursing shortage as having three main causes: an actual shortage caused by too few nursing education seats and an aging workforce retiring; an inability to maximize the productivity of nurses due to high overtime, part-time work, high absenteeism, etc.; and insufficient funds to hire the number of nurses needed to provide care. There are startling figures in one of these reports. For example, it is estimated that Canadian RNs work overtime hours each week that are roughly equivalent to 7000 full-time jobs per year, that the lost time due to RN illness and injury is equivalent of almost 9000 full time nursing jobs, and that converting the time of nurses working part time (involuntarily) to full time nursing positions would add the equivalent of 2592 nursing positions per year (1). Should we be morally distressed by these statistics? Should administrators and governments at all levels feel morally responsible for these shameful statistics? For some years now, the importance of evidence-based decision-making has been touted as essential for change in policy and practice. The reports referred to above, along with reports in other provinces, other countries, and those emanating from national and international nursing organizations, have supplied a substantial volume of researchbased evidence for many years. In the case of nursing health human resource planning, will this matter? Does it matter that nurses are compelled to work such a substantial amount of overtime? That they are called in on days off and not permitted to take holidays due to shortage of nursing staff? That nurses become ill and injured due, in part, to their heavy workloads? That they daily experience moral distress because they are not able to provide the safe, competent, ethical care they were prepared to give? Most professional associations have attempted to assist nurses in a number of ways, for example, by revising codes of ethics and preparing other ethics documents to advise them about how to deal with requests for mandatory overtime, short staffing, working with limited resources, supervising unregulated health care workers, and the many problems nurses face as a result of the nursing shortage. This is well and good. These actions alone may be like bandaging a wound without treating it. And patients, families and communities continue to be compromised by the failure of governments to pay attention to the “unnatural disaster” of the nursing shortage. In large part this shortage can be traced back to the long term effect of drastic health care cutbacks in the late 1980s and the 1990s. With little or no thought for the future, the numbers of nurses in nursing workplaces were reduced and attempts were made to re-engineer and re-structure nursing work in health facilities into a predictable “factory style system”. The high rate of unsuccessful re-structuring attempts might be attributable to the failure to appreciate the complex nature of healthcare delivery (3). Without more full time jobs, to utilize fully the existing nurses and to attract students seeking a career in nursing, there can be little hope of relief for those nurses currently working overtime to staff health facilities and programmes. I suggest that we need to begin to frame these matters more publicly as serious ethical issues that require moral courage and moral commitment on the part of leaders in nursing and in health care, and all political leaders. Acting on the evidence is critical, now! Such action is a moral obligation for all who profess to value safe, competent and ethical patient care. References 1. Health Canada (2002). Our health, our future: Creating quality workplaces for Canadian nurses. Final Report of the Canadian Nursing Advisory Committee. Ottawa: Author. 2. Health Canada (2002); Canadian Nurses Association (2002. Planning for the future: Nursing human resource projections. Ottawa: Author. 3. Beyers, M. (2001). Nursing workforce: A perspective for now and the future. JONA‟s Healthcare Law, Ethics and Regulation. 3(4), 109-113.