How does a non-licensed caregiver deal with a client's request to hasten her death? Does a non-licensed aide have a right to know that the client is HIV-positive? If caregivers witness abuse of the mentally challenged person in a long-term care facility, should they report the incident, and to whom? If a homecare aide is asked to perform duties for which one is not trained, what should the individual do? These questions reflect some of the ethical dilemmas confronting nonlicensed caregivers. Each of these situations presents a controversial issue where support for opposing positions could be identified. A Homecare/Special care aide (nonlicensed caregiver) is exposed to these situations not only as a student, but also as an employee working in a special care facility or a private home.
Students in non-licensed caregiver programs need guidance in learning how to deal effectively with ethical issues. Case (1994) emphasized the importance of decision-making skills on the part of the non-licensed caregiver. Caregivers must decide what information to report and to whom to report it. They must also choose appropriate responses to interpersonal situations involving clients, their families, and health care personnel (p. 101).
A strategy to address ethical decision-making by a non-licensed caregiver is structured controversy. This strategy has an advantage of making students examine an issue and reach a common decision with others who have different opinions. It promotes critical thinking and creativity in decision-making. This article explores several definitions of critical thinking, and defines and outlines the process of implementing structured controversy in ethical decision-making. Structured controversy was used with non-licensed caregivers in a clinical setting to provide information on ethics and ethical decision-making. The adaptation of this teaching strategy to the needs of these learners will be described. Thompson and Thompson's (1985) ten steps to ethical decision-making were used to assist the students in the process of decision-making.
The literature review was broad, as it focused on critical thinking, structured controversy, and ethical decision-making. These issues are usually not dealt with in an education program for non-licensed caregivers, however they were adapted to the needs of non-licensed caregivers in their education program.
DEFINITIONS OF CRITICAL THINKING
A non-licensed caregiver must understand the whole concept of critical flunking because it is an essential component in ethical decision-making. Focusing on all aspects of a dilemma assist the caregiver in making a decision based on the needs of individuals involved.
There are many definitions of critical thinking in the literature. Case (1994) defined critical thinking as "a process and cognitive skill that we apply to identify and define problems and opportunities for improvement; to generate, examine, and evaluate alternatives; to reach conclusions and decisions, and to create and use criteria for evaluating our decisions" (p. 101).
Brigham (1993) stated that experts in critical thinking cannot agree on a definition, but what was more important is that nurse educators study the various definitions and develop a definition they can integrate and implement in their curriculum (p. 50).
Jones and Brown (1993) stated that critical thinking is "interactive, process-oriented, and a rational activity that uses structure as a means rather than an end. Ever present is the understanding that knowledge is limited, beliefs change, and conclusions are temporary" (p. 72). It is important to note that for many situations there is no single way of thinking.
All of these authors support the use of a strategy to promote critical thinking. One such strategy is structured controversy which is an interactive, process-oriented, cognitive, rational activity that demonstrated the understanding that conclusions are based on circumstances present at any given time (Pederson, 1992). Structured controversy promoted critical thinking in ethical decisionmaking by generating ideas, examining options and evaluating alternatives to reach a decision.
Bevis (1993) stated that critical thinking involved an "intellectual growth goal for nurses":
To be truly critical thinkers, we must be willing to go mentally naked; to be naked for the moment of inquiry and reflection; to be naked of our life-amassed conditioning, our familiar precepts, our world view, in short, of all our acquired views, to view die thing and examine the idea, once again through innocence, but an innocence sophisticated in its pursuit of uncovering the true nature of the lived reality (as opposed to supposed unreality) ( p. 104).
Learning is a "collaborative journey" where the learner is an equal partner with others in the process. The persons may not agree but must be committed to investigative, thoughtful questing conversation" (p. 105). Once again structured controversy in ethical decision-making required active participation of the non-licensed caregiver, where the learner exerted their own intellectual powers, and was an equal partner with others in the process of making an appropriate decision.
Woods (1993) stated that the need for critical thinking skills has never been more important than at this time when the health worker's role is expanding to home and community care. Not only is the role of the professional expanding but there is an increasing demand for the nonprofessional health worker in inhome care situations. Critical thinking development is personal and is influenced by individual experiences. The learner must possess cognitive thinking ability to use the self as basis of building a relationship with a client. This awareness of self involves feelings, beliefs, values, and attitudes. Growth in affective competency assists the student's ability to be empathetic. Non-licensed caregivers must possess knowledge and skill in ethical decision-making. The use of structured controversy with guidance from Thompson and Thompson's ten steps to ethical decision-making provided the necessary structure for this process to occur.
STRUCTURED CONTROVERSY TO PROMOTE CRITICAL THINKING
How can critical thinking be encouraged in the practical setting? Johnson and Johnson (1988) advocated critical thinking througji "structured controversy." "Through controlled argumentation, students can broaden their perspectives, learn material more thoroughly, and make better decisions" (p. 58). The purpose of the controversy must be defined as an issue or problem to be solved, not as a win-lose situation. Students must value and respect one another, feel safe enough to challenge each others' ideas and reasoning, keep an open mind, and be willing to change their conclusions if their opponents present persuasive arguments.
Smith, Johnson and Johnson (1981) defined controversy as existing when one person's ideas, information, conclusions, theories, or opinions are incompatible with those of another person, and the two seek to reach an agreement (p. 651). The use of structured controversy promoted supportive, caring, and accepting relationships with peers, as well as continued motivation to learn about the issue involved.
Pederson, Duckett, and Geoffrey (1990) described the use of structured controversy in helping students deal with difficult ethical situations and the effectiveness of this approach in promoting ethical decision-making. There are five basic phases of the process beginning with the plan of positions, presentation of these positions, argumentation with opponents, reversal and argumentation of new positions, to formulation of consensus (p. 151).
The importance of providing the student with a theory base in ethics as well as opportunity to practice ethical decision-making was supported by the literature. Fromer (1980) stated that each day students are confronted with ethical dilemmas, but these are often ignored because they are not recognized for what they are (p. 604). Providing non-licensed caregivers with ethical theory as well as a strategy such as structured controversy assisted them in ethical decision-making. Ethical issues will never disappear. With technological advances that have been made, increased consumer awareness, as well as patient rights' advocates, ethical issues are more prevalent than ever. They may be painful to confront at times, but health workers do not have the luxury of ignoring them or thinking they will be solved by others.
Thompson and Thompson (1989) stated that if ethical practice was to be more than a catch phrase, ethics must be integrated into a curriculum (p. 84). To apply ethics, one must learn how to reason morally, identify ethical issues, and make ethical decisions. The teacher's role is to help learners tolerate disagreement and ambiguity, to respect others, and to disagree without personal attack. Group discussion is essential for assessing the level of understanding of theory (p. 85).
Yeo (1991) supported the fact that there are three basic areas of ethical knowledge an individual possesses to function effectively as a caregiver. These include: a) moral beliefs and values, b) codes, policies, legal implications, c) knowledge of six basic ethical concepts which included: beneficence; autonomy or self-determination; tmthfulness; confidentiality; justice; and integrity. These ethical concepts provided a guide for formulating ethical issues for discussion.
MODIFICATIONS AND IMPLEMENTATION OF PROJECT
Most of the literature reviewed was based on needs of nursing students. This project was implemented for Homecare/Special care aide students so modifications had to be made in the strategies used. The educational background of the students was varied. Students were high school graduates (one had grade X) and none had any formal education in ethics, ethical decision-making, or values clarification. Because moral decision-making is not addressed in non-licensed curriculum, a handout covering this basic ethical information was distributed and reviewed. Guidelines for the process of structured controversy and Thompson and Thompson's (1985) ten steps to ethical decision-making were included in this handout. Journaling, specific to ethical issues identified in the practicum was also introduced, as a strategy to promote critical flunking.
Brown and Sorrel (1993) advocated the use of clinical journals to enhance critical thinking. The journal provides "guided opportunities for the student to think on paper, reflecting on their own perception or understanding of the situation they encountered in practicum" (p. 16).
There were eight students in the clinical group. The process was operationalized using the five phases of structured controversy outlined by Pederson, Duckett, and Geoffrey (1990), as well as the ten steps to Thompson and Thompson's (1985) bioethical decision-making model. Included are:
Step 1. Review the situation
Step 2. Gather additional information
Step 3. Identify the ethical issues
Step 4. Identify personal and professional values
Step 5. Identify the values of key individuals
Step 6. Identify the value conflicts, if any
Step 7. Determine who should decide
Step 8. Identify the range of actions and anticipated outcomes
Step 9. Decide on a course of action and carry it out
Step 10. Evaluate the results.
The project was implemented over a 3-week period during the mid-practicum of special care aide students in a long-term care facility. The program is divided into two semesters as well as a mid and a final practicum. The mid practicum occurs after completion of semester one, with final practicum occurring after semester two. Three weeks of each practicum is spent in a longterm care facility as well as 3 weeks in homecare.
There were several controversial issues chosen for discussion. These issues focused on ethical principles identified, and included: 1) Prejudice - care of a non-compliant client who was a substance abuser; 2) Confidentiality and truthfulness - an HIV-positive client who demanded confidentiality be maintained about his test results; 3) Autonomy - withdrawal of life support at the request of a mentally competent client; 4) Euthanasia, beneficence, and justice - a father killed his severely disabled daughter to save her from further surgery and pain; 5) Integrity -students cover up for the incompetence of a classmate; 6) Truth telling -in his last moments, an elderly dying man calls the caregiver his granddaughter; she doesn't correct him; 7) Breach of confidentiality and disclosure of information - a caregiver is talking loudly about a client, his illness and his fate at a bus stop.
These situations were presented at the time of the session. The students did not have time to research the issue. Presentation of issues the day before would have been an advantage, as the students would have additional time to formulate their arguments, and could then move into their roles in structured controversy more quickly.
The instructor introduced the ethical issue verbally as a case presentation, or as a video clip. Students were divided into two groups, and within those groups, into pairs. This encouraged active participation by each student. Within each group one pair supported the pro and one the con of an issue. The five phases as outlined by Pederson, Duckett, and Geoffrey (1990) were implemented. During Phase 1, the students planned and discussed their arguments with their partner. Phase 2, each pair of students then presented their arguments to the other pair. Phase 3, the students listened critically to the opposing pair's position and questioned their point of view. Phase 4, perspectives or positions were reversed, so that a pair that had argued for a position, now argued against it. They planned their arguments, and once again presented to the other pair. Phase 5, The total group dropped advocacy, reached a consensus and identified appropriate choices based on the strength of the arguments. To provide additional guidance in the process of ethical decision-making, Thompson and Thompson's ten steps to bioethical decision-making were used. Due to a shortage of time, for some of the issues only two groups were formed and four students would prepare the arguments for pro and con. This approach was effective, but the more vocal students participated more than the quieter ones.
As the students progressed through the various topic relating to ethical principles, there was evidence of increased depth and perception in making ethical decisions. Students went from stages of dualism where there is a real answer, to multiplism, where knowledge is relative and there may be more than one interpretation of an issue, to contextualism, where there are multiple positions and interpretations of any issue, but the position taken is dependent on context and some answers are better than others in a particular context (Bowers & McCarthy, 1993). This response was unpredicted as the time frame for implementation of the project was short (3 weeks).
Journals reflecting ethical issues encountered on the individual units or throughout the day, handling of the issues, as well as suggestions for alternate approaches were submitted daily.
This project was most useful to implement with the non-licensed caregivers. Several methods were used to evaluate the effectiveness of this project. The first method evaluated the student's understanding of the ten steps of the decision-making model and their application to a case situation. Thompson and Thompson (1989) stated that evaluation of ethical decisions provides feedback and reinforcement of the positive reasoning patterns. Quinn (1990) stated that ethical analysis, like other cognitive skills, improves with practice. Students need opportunity to apply the knowledge gained. The goal of ethics education should be to teach the student how to think more so than how to behave (p. 729). It was difficult to objectively evaluate the effectiveness of students' abilities to implement the decision-making process. Students indicated satisfaction in participating in the project as well as a greater awareness of ethics, ethical issues, and ethical decisionmaking.
Changes were also noted by educators. A video was presented dramatizing an ethical issue with two different outcomes, based on the course of action selected. Students who had participated in structured controversy showed depth and perception in analysis of the video. Students required very little guidance in identifying the ten steps of the decision-making process. Exarnination of a student's own values and beliefs helped them appreciate that their choices may depend on the particular circumstances at that time. No one correct answer will resolve the issue for everyone. Turner and Rufo (1992) stated that the most difficult step in ethical decision-making might be sorting out your own values and needs, and to step back and identify emotional aspects of the situation (p. 276).
The second method of evaluation involved the use of structured controversy in ethical decision-making. Students were interviewed individually and filled out a questionnaire. The results were very positive. Students reported that exploration of both pro and con sides of an issue stimulated critical thinking, as well as encouraged active participation of all students. The use of pairs and groups of four were equally effective. One disadvantage identified by the group of four was domination of the vocal students over the quiet ones. This could be minimized by restructuring the groups.
Students indicated that following this project they were more aware of a clienr/s rights, values, and beliefs as well as their own. They stated they were able to think more critically as a result of the sessions, and would feel more prepared in making an ethical decision and focusing on the pros and cons. Comments such as the following support this fact:
It has made me open my eyes and look at both sides.
I never really looked at both sides of the situation.. .it has allowed me to empathize with people on their views without having to compromise my beliefs or values.
Our sessions on ethics have helped me think more critically. It also got me thinking two sided rather than being so opinionated.
The three weeks have changed me completely. I learned no situation is black and white. You have to look at both sides of the issue and commit yourself to the decision that will be best for the people in volved... Not to judge until I've walked a mile in their shoes.
The journaling was also an effective strategy to promote critical thinking. The decision not to mark the journal for writing style, grammar, or spelling proved to be the right choice. This would have inhibited the critical thinking process with some of the students. It gave the students a chance through writing to reflect on their day, identify an ethical issue and explore pros and cons and possible ways of handling the situations.
The combination of the three strategies complemented each other. Together they were an effective approach to use in implementing ethical decision-making. Benefits of using structured controversy in ethical decision-making resulted in a greater understanding in the subject matter of ethics and ethical decisionmaking, stimulation of critical thinking, higher quality decision-making based on inspecting both sides of an issue, reflection on their own beliefs and prejudices, growth in moral reasoning, and an appreciation of others' points of view.
RECOMMENDATIONS FOR FUTURE IMPLEMENTATIONS OF THE PROCESS
Some recommendations to incorporate with future implementations of the project include:
1. Time factor; extending the project to 6 weeks would allow more time to internalize the process.
2. Incorporating ethical theory as part of the Homecare/Special care aide curriculum. This would provide students with some basic knowledge on ethics, ethical decision-making, values, and values clarification before implementing structured controversy. Providing the students with the issue the day before would allow them time to research the issue, and explore legal and ethical codes that may guide the decision.
3. Use of a self-learning modular approach to provide necessary ethical theory to students prior to implementation of structured controversy.
The results of the project indicate a significant positive change in students' perception of ethics, ethical issues, and ethical decisionmaking. Structured oentrovensy is an innovative strategy in education that assists students in dealing with ethical issues. The use of Thompson and Thompson's (1985) ten steps oí ethical dedsion-making as a guide in actually making decisions was also an effective tool providing clear direction to nonlicensed caregivers. To provide students with the necessary skills can only be a positive influence.
In many long-term care facilities non-licensed caregivers constitute 90% of the employed staff. It is this individual that spends most of the time with the client, and is often present when an ethical dilemma occurs. The client needs an advocate, and the caregiver must assume that role. However, this cannot occur without education; first of all to recognize the situation as an ethical dilemma, and secondly, to have the knowledge on how to handle the situation effectively.
All individuals, regardless of their level of functioning, deserve to be treated with respect and dignity. Non-licensed caregivers must learn to examine their own beliefs and values, appreciate and accept that others may have values that differ from theirs, and learn how to respect the values of others.
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