EMPIRICAL ETHICS AND MORAL FORMATION OF BACHELOR DEGREE NURSING STUDENTS

EMPIRICAL ETHICS AND MORAL FORMATION OF BACHELOR DEGREE NURSING STUDENTS Results of two years of practice research in nursing ethics (2009-2010 and 2010-2011) Bart Cusveller PhD, Professor of Nursing Ethics Ria den Hertog MScN, Senior Lecturer in Nursing School of Health Care, Christian University of Applied Sciences Ede, The Netherlands Background In 2009, the Christian University for Applied Sciences in Ede, The Netherlands, started its research group or lectoraat in nursing ethics. The group s aim is to engage in practiceoriented scholarship focused on nurses abilities to address good care issues within their own work processes and meetings. Its results contribute to the moral quality of nursing care, that is, through empirical ethics the research group produces knowledge to be integrated in bachelor nursing students moral formation. 1 Problem Research shows that the institutional context is usually central in nurses experience of moral distress. 2 According to the Centre for Ethics and Health (a body advising the Dutch government) professionals in health care do not wrestle so much with the nature of good care, as with how to provide good care within the organizational conditions. By and large, nurses indicate to know what it means to provide good care. With regard to actually providing it, however, they experience obstacles in the complexity and dynamics of their daily work setting. Aim In The Netherlands, the professional nursing profile distinguishes between three domains in its responsibilities: tasks related to being a professional, to providing direct patient care, and to working within an organization. 3 Nurses indicate to experience moral issues mostly related to the last. 4 They enter practice with a commitment to provide professional care for the patient, but are inclined to adapt to the institutional context. Studies of nursing students suggest that they might develop more awareness and self-direction in morally sensitive situations. 5 In order to educate nurses in moral sensitivity and reflection, and in order to strengthen their abilities to influence the institutional context, the nursing ethics research group studies what helps them and what hinders them in this respect. Concepts Regarding the conceptual framework of this research, competencies can be considered as the integrated sets of knowledge, attitudes and skills needed to perform successfully in a clinical situation or to provide a suitable solution to a clinical problem. 6 The concept of professional responsibility is understood to cover the binding expectations of (a) nurses personal qualities, (b) systematic conduct and interventions, and (c) outcomes of practice. 7 In other words, providing good care requires a good professional (person), implementing good procedures (process), and serving patients interests well (product). 8 Professional ethicists may coin these the professional virtues that the nurses embody, professional norms that the nurses uphold, and professional values that the nurses aim to realize. 9 Crucial to this is the focus on nurses competencies on the shop floor, hence the need of daily addressing the moral aspect of their own work processes and meetings. This may take 1

place in hand-over, staff meetings, or team consultation, in which reflection on one s contribution to good nursing care is on the agenda. This rather informal sense of ethics rounds, reflection or deliberation is to be distinguished from the competencies for participating in the more formal ethics committees or consultations on ethical dilemmas in the technical sense of the word. 10 Ethics committees and consultations are a highly specific form of addressing moral issues, requiring specific competencies, which the national professional profile also mentions. 11 Question Nurses need competencies to address moral aspects of their daily caring practice. In The Netherlands these are laid down in a competency profile in bachelor nursing programs and collectively accepted as terms of references. With an eye to moral formation, this competency profile needs further elaboration and application. Hence our leading research question is: which competencies do nurses need to address moral aspects of good care effectively within the organizational context of their practice? In the first two years of the nursing ethics research group this main research question was divided into the following five guiding questions (Table 1): 12 1. What obstacles do (student) nurses experience in providing good care? Table 1: Guiding questions 2. Which aspects of professional responsibility (person/virtues, process/norms, product/values) are possible obstacles within the organizational context? 3. Which competencies do nurses need to reflect on, discuss and use on obstacles to providing good care? 4. How can a nursing program educate bachelor students to reflect on, discuss and use on obstacles to provide good care? 5. How can nurses in clinical practice be empowered to reflect on, discuss and use on obstacles to provide good care? Design Over the course of two years, fourth-year bachelor nurses graduated on knowledge integration projects. Several institutions in health care provided questions from clinical practice, which were selected for our research group on the basis of their thematic relationship with competences for reflection on good care. Existing procedures for knowledge integration projects within the curriculum were followed, with the support of educators with a master s degree in nursing science. The aim was to analyse the projects afterwards for common data on reflection on good care. Method The majority of projects involved semi-structured interviews with nursing students, nurses, and other health care professionals, with topic lists based on literature reviews. In a few projects the size of the population required surveys, although still small in scale, counting as qualitative research. Educators fostered a quality level that would allow publication in a Dutch language professional journal. The use of tape recording was required, as was verbatim reporting, open coding and qualitative analysis as described in Baarda et al s book. 13 After two years the results of the knowledge integration papers were collated in a grid based on the guiding research questions in Table 1. Outcomes were analysed qualitatively after open coding. Common themes in the results were grouped together, leaving out labels mentioned only once. 2

Results I: General data In these two years of practice-oriented studies, 67 fourth-year bachelor nursing students and seven educators were involved in 20 knowledge integration projects. Questions came from diverse fields, ranging from mental health, home care, hospital care and sectorgeneric projects. A total number of 231 respondents were interviewed in 15 projects. In five projects the surveys involved a total of 340 responses. Other methods were occasionally included, such as document research (patient files), participating observation, and expert interviews. Quantitative data in Table 2 have been supplied to indicate size. Table 2: General data Students Tutors Area Method Respondents 67 Bachelor Nursing 7 Nursing Educators 7 Acute Care 6 Home Care 5 Generic 4 Mental Health 18 Literature Reviews 15 Interviews 5 Surveys 2 Expert Interviews 2 Document Research 1 Observation Study Interviews: 167 Nurses 32 Nursing Students 32 Other Professionals/Educator Surveys: 238 Nursing Students 36 Nurses 66 Other Professionals/Educators Document Research: 131 Patient Files Observation: 36 Nurses Expert Interviews: 11 Educators Results II: Research questions Question 1: Obstacles In terms of obstacles in the provision and reflection on good care, it was confirmed that it is often difficult for (student) nurses to be good professionals in relation to the organizational context. There are several examples. (Student) nurses refer to themselves where their own expertise and professional view is concerned. They also point out some respondents show a reserved, a headstrong or a possesive attitude and a lack of relational skills, arguably causing them to inaccurately or individually interpret a given situation. Good care is sometimes also said to be troubled by a lack of (clear) procedure; the (student) nurses own contribution is not clear or not recognized, and ways of collectively addressing issues are absent or poorly carried out. This arguably leads nurses to inaccurately or individually interpret and apply a given intervention. Lack of expertise and view (17) Table 3: Question 1 3

Lack of clear procedures (16) Role ambiguity (13) Complex, limited or rigid organization (13) Ambiguous attitude of (student) nurses to situations and interventions (12) Lack of (intra-disciplinary) coordination of (inter-disciplinary) collaboration (11) Relational skills (vis-à-vis patients, colleagues, other disciplines) (6) Question 2: Factors Regarding the elements of professional responsibility, the 20 projects indicate without exception that providing and reflecting on good care is often troubled by weaknesses in the personal qualities or professional virtues of the (student) nurse. Predominantly these are deficiencies in knowledge and expertise, in engaged and responsible attitudes, and in relational and communicative skills. Thus tuning-in to the people involved and reinforcing clinical decision-making is at risk. In addition to personal qualities (professional virtues) respondents pointed out the importance of principles for procedures and collaboration, preferably laid down in a structure of guidelines (professional norms) making clear the use and the conditions of the primary caring process. A minority of projects refers to obstacles in professional values, meaning the desired outcomes or patient interests, mentioning differences in professional perspectives on what a patient really needs. A small number of studies indicates that joint communication of the patient and nursing values is necessary for good care. Person/virtue (20): - Well-grounded (17) - Firm, positive, flexible attitude (12) - Relational/empathy towards patient (6) - Communication towards (6) - Responsible (5) - Reflective (4) Process/norms (17): - Cooperation/coordination (11) - Working in a methodical way (9) - Conditions (7) - Clear structure (6) - Open structure/participation (4) Product/values (10): - Goal oriented/perspective on what is really needed (9) - Consensus/teamwork (3) Table 4: Question 2 Question 3: Competencies 4

In terms of competencies, each of the 20 projects mentions the importance of nurses ability to keep daily care issues in tune with colleagues, other professionals and patients, and of keeping one s own expertise updated. Inconsistency in the working procedures and methods is one thing, but diversity due to unconfident, headstrong or poorly supported procedures is quite another. Here the ability to influence the organization and assume one s own professional role is crucial. Keeping in tune with colleagues (20) Reinforcing one s expertise (20) Keeping in tune with other professionals (11) Keeping in tune with patients (9) Influencing the organization (9) Reinforcing one s professional role (6) Table 5: Question 3 Question 4: Education With regard to the question what a nursing program may contribute to these competencies, a majority of the projects bring up reinforcing professional knowledge and a professional perspective on good care. The curriculum s practice and competence-oriented character should be developed and its structure and transparency improved for students. A substantial number of projects refer to the nurses professional roles and attitudes as a neglected area of the students formation. Reinforcing professional knowledge and professional perspective (13) Practice and competence-oriented curriculum (10) Clarification of the program s structure (10) Reinforcing the nurses professional role and attitude (8) Reinforcing relational and communication skills (4) Table 6: Question 4 Question 5: Practice Organizations or institutions play an important role in creating the preconditions and facilities (the means, methods and measures) for good care and reflection on good care. Respondents in our projects indicate that the strengthening of the desired working climate, role clarity, and support for employees would be welcome. Reinforcement of employees expertise is also one of the aspects organizations should look into. Other conditions for provision and reflection on good care are clear communication lines, frequent work conferences, and objective methods and procedures. Creating good working climate, role clarity, and support for employees (12) Clarification of organizational structures (7) Clear communication and consultation lines (7) Table 7: Question 5 5

Improving expertise (7) Implementing unambiguous care plans (6) Clarification of views on good care (3) Discussion: theory What are the patterns to be discerned in two years of practice-oriented research on the research groups thematic focus on the nurses ability to address explicitly the desired achievements of nursing care? One pattern is that (student) nurses indicate that much depends on their personal qualities and the arrangement of procedures and cooperation processes. As the CEG study indicated, they see a substantial part of the obstacles in providing reflection on good care in their relationship to the organizational context, not so much in care itself. Respondents reported to value reinforcement of their expertise, knowledge of good caring and professional behaviour, whether or not initiated by themselves, education, profession or employer. Their aim is not to be able to be the exclusive owners of the caring process, but to be able to guide the caring process to be in tune with patients, colleagues, other professionals and management. Much is to be gained here as (student) nurses report shyness. With respect to the focus on nurses abilities to reflect on good care, the findings lead to a more precise formulation of the things nurses should be able to reflect on. The review suggests a twofold distinction, between the content (working methodically) and the relationships (being in tune with everyone involved) of the caring process. Put differently, there is the dimension of the way their expertise is guaranteed and the way tuning with other stakeholders is warranted? Call this the methodical and the relational dimension. In our projects, both dimensions show an inside and an outside perspective: extremes constraining good care and also reflection on good care. The inside perspective on the methodical dimension is in the individual behaviour of the nurse, deciding everything for herself or himself (from whatever motive). The outside perspective on the methodical dimension is the collective behaviour of the nurse, relying entirely on collectives (in which the individual nurse is the outsider). The inside perspective on the relational dimension is in the nurse acting as the exclusive owner of the caring process. The outside perspective is in the patient as the exclusive owner of the caring process (making the nurse the outsider). Philosopher Richard Sennett addresses how the institutions of health care - especially the burden of so-called paper work -- inhibit the professional discretion of nurses and doctors to move between these inside and outside perspectives. The demands to express quality (good work or good care) in terms of units of time and performance rob the care providers of the time and space they need to move between - what Sennett calls - problem finding and problem solving. Apart from pruning their professional competences, the result is that they are not expected to explore complexities of the body that escape quantitative scores. 14 This may be precisely what is important to the condition of the patient. In terms of personal qualities and management of procedures, the review suggests that the challenge for (student) nurses is to move back and forth between both dimensions: care needs to be in tune with both colleagues and patients; and care has to be checked against one s own expertise and the demands of others. Nurse ethicist Derek Sellman recently developed two concepts that might fit these qualities: the professional virtue of trustworthiness (relational dimension) and open-mindedness (methodical dimension). 15 Professional wisdom is needed to keep the two dimensions together, so to speak. Thus, patterns in our projects reflect issues of good care in the nursing literature. Discussion: method 6

For this review it was assumed that the respondents came from one homogenous population, although there are differences related to work experience and setting. Even so, all projects have been selected on the basis of clinical relevance for the nursing profession, which gives all projects something important in common. Two years of practice-oriented research also shows how bachelor students and educators in nursing programs conducted their knowledge-integration programs. In the discussion sections of each of the 20 separate projects students question their research skills. They particularly mention interview skills (n= 13), conceptual clarity (n= 4) and analytical skills (n= 3). If this says anything about nursing students in general, it seems that nursing programs would do well to strengthen education in research skills. There is also the question of the small scale of each separate project. Even when the projects together form a completely randomized sample, students find it difficult to ascertain how the sample represents the population (n= 9). This could be improved by repeating the same studies. Conclusion In a review of 20 small-scale knowledge-integration projects the authors conducted a qualitative analysis and conceptual framework of two years of practice-oriented research. The importance was to find patterns in student nurses professional behaviour through empirical ethics in order to educate them better in reflection on good care. From a bigger net with a big mesh the research group can proceed to smaller nets with a smaller mesh. The research question of later projects may now focus on competencies in two dimensions of good care, i.e. the relational and the methodical dimension of (reflecting on) the caring process. Research continues into the relationship between the organizational context and reflection on good care. Health care institutions continue to provide new research questions pertinent to the same research agenda: how to implement quality indicators, small scale teams, or self-managing teams in nursing. Through connecting knowledge-integration projects by students and curriculum innovation by educators with such questions from clinical practice, the research group produces new knowledge for professional education and professional practice. Acknowledgements The authors wish to thank Auke Bos MScN and Martin te Lintel Hekkert MScN, the members of the research group during the projects reported here. We also thank the organizers and participants of the third international Faith and Nursing symposium at Trinity Western University in Langley BC, Canada (May 10-12, 2012), and the Good Work conference, University of Humanistic Studies, Utrecht, The Netherlands (October 17, 2012). References 1 B. Cusveller, Wat je van verpleegkundigen mag verwachten (lectorale rede), Verpleegkunde 2010/1 (p. 32-35). 2 A. Struijs, S. van de Vathorst, Morele dilemma s van verpleegkundigen en verzorgenden, Den Haag: CEG (RVZ), 2009. 3 E. Leistra, S. Liefhebber, H. Hens, M. Geomini, Beroepsprofiel van verpleegkundigen. Maarssen: Elsevier gezondheidszorg, Utrecht: NIZW; Utrecht: LCVV, 1999. 4 J. den Uil, B. Cusveller, Ontwikkeling van competenties voor ethisch overleg onder hboverpleegkundigen, Verpleegkunde 2011/3 (p. 4-12). 5 G. Hunink, R. van Leeuwen, M. Jansen, H. Jochemsen, Moral issues in mentoring sessions, Nursing Ethics 2009/4 (p. 486 ff). 6 J. Cluitmans, Aan de slag met competenties, Nuenen: Onderwijsadviesbureau Dekkers, 2002 (p. 31-32). 7

7 A. Roelens, Ethische besluitvorming voor de verpleegkunde: naar een geïntegreerd model, Verpleegkunde 1995/4 (p. 220-232). 8 H. Jochemsen, R. Kuiper, B. de Muijnck, Een theorie over praktijken, Amsterdam: Buijten & Schipperheijn, 2006. 9 B. Cusveller, Met zorg verbonden, Amsterdam: Buijten & Schipperheijn, 2004. 10 B. Cusveller, Nurses serving on clinical ethics committees: A qualitative exploration of a competency profile, Nursing Ethics 2012/3 (p. 431 ff.). 11 A. Pool, C. Pool-Tromp, F. Veltman-van Vugt, S. Vogel, Met het oog op de toekomst, Maarssen: Elsevier Gezondheidszorg, 2001. 12 H. Sikking, B. Cusveller, Aanvraag Lectoraat Verpleegkundige beroepsethiek, Ede: Christelijke Hogeschool Ede, 2008 (interne notitie). 13 D. Baarda, M. de Goede, J. Teunissen, Basisboek kwalitatief onderzoek, Groningen: Wolters- Noordhoff, 2005 (tweede, geheel herziene druk). 14 R. Sennett, The Craftsman, London: Penguin Books, 2008 15 D. Sellman, What makes a good nurse, London, Jessica Kingsley Publishers, 2011. 8