I recently participated in a panel discussion on a controversial topic related to aging and health care. The complex issues of practice that were discussed had moral, ethical, and public policy components. The panel members came from a variety of backgrounds and perspectives that facilitated lively and, at times, opposing dialogue. The audience members represented multiple disciplines, but most of them were graduate and undergraduate nursing students and faculty. Two aspects of the evening were disturbing. First, the audience seemed to be searching for, and found quite appealing, positions that were simple and linear, and which neatly polarized the issues. Second, many audience members accepted most readily the positions of the loudest, most dominant voice. These observations suggest that nurses need to develop more sophisticated analytical skills.
If any quality can be generalized to older adults, it is that they are a heterogenous group. Aging is a fluid and multidimensional dynamic. Simple solutions to practice issues, therefore, are not to be expected. In addition, the changing landscape of health care encourages disciplines to have an illness-cure mentality. This contradicts the most fundamental view nurses hold of the holistic nature of humans. The holistic human is interrelated with other systems, such as family, environment, and culture. Each person can thus be understood only as both a whole separate entity and as a part of other systems. The parts of the system are interdependent and influence each other. Nurses establish a trust with their patients that includes not trivializing or marginalizing their experiences or perspective. If we do not seek to understand the practice problem from a context-driven and experiential perspective, we may be left with either an overly simple or completely distorted explanation. Quick solutions and rigid categorizations, though appealing in some respects, may distort reality more than reveal it. We may only be able to truly solve practice problems by accepting the multicausal, multidimensional nature of our discipline.
Many of the issues confronting gerontological nursing have a clear moral or ethical component, and this also makes simple solutions unlikely. It would be nice to have a moral barometer or a computer we could turn to when difficult practice problems arise. Perhaps the audience the night of the panel discussion was simply looking for an authority figure to make certain that which is so unclear. But nurses should know better. We must have the courage to develop and use our intellectual and moral imagination.
The arena for moral dialogue has changed and become less certain. More and more we hear these issues being discussed by journalists, scientists, and attorneys. Morality used to be passed down to us by religious leaders and parents. There was some comfort in this paternalistic order, and one could certainly argue that the world would be a better place if we more frequently sought wisdom from these sources. It is time for nurses, however, to be mature partners with others in the dialogue and debate over gerontological health care issues. To do this, we must become more skilled at evaluating, synthesizing, and critiquing knowledge from a variety of sources and experiences. Analysis emphasizes the study of parts and how they are related and organized. Synthesis is the putting together of the parts to determine a structure not previously elucidated. Evaluation is making judgments of value for a purpose or solution. The process of becoming a more analytic person involves both finding your own voice as well as trusting that voice. Analytical and critical consideration of ethical dilemmas in nursing should be an important part of nursing curricula. Exemplars from nursing practice can help identify problems of concern to nursing as well as ways of solving these problems.
The action or lack of action by gerontological nurses affects older adults. Our discipline cannot avoid journeying onto the rough road of moral issues. Whose position is right? What standard will guide our practice? What is the process for deciding? It seems a reasonable place to start is to strive to figure out what actions by the nurse/health care system hurt, disengage, humiliate, or diminish the older adult. In the film version of Neil Simon's play "Chapter Two," Marsha Mason's character asks her husband after one of their more brutal arguments, "Why do we hurt each other so much?" NO-W, there's a question. Perhaps morality is a continuing conversation about how to keep from hurting one another.
We must also be careful not to be mesmerized by the loudest or seemingly most passionate voice. Conviction of ideas can become moral arrogance. The route to a moral health care system, it seems, involves more, not less, dialogue, disagreement, and debate. A gerontological nurse with intellectual and moral imagination will formulate positions by weighing all sides of an issue, and seeking out divergent opinions.
As students of the human condition, nurses have unique insights that can add both enlightenment and pragmatism to the analytic arena. We need to continue to deepen our understanding of the human experience of health and illness. Developing, testing, and promoting nursing interventions that offer restorative power to our patient's mind, body, and/or spirit is imperative.
Just as older adults are dynamic, so too is the health care system that serves this population. There are several forks in the road. Which path should we choose? The destination is unclear, but we need to actively take the journey on a road that cannot be straight and undoubtedly will require some bridge-building.