Tender, feeling, percepiive, conscious, alice, responsive, responsible, caring, spirited, discerning, observant, fastidious, empalhelic - these are words in the health care literature which signify desirable character traits. An accepted task of nurse educators is to develop such traits in their students.
But accepting the character traits as desirable is far from having the instructional where -with -a 11 to foster them in others. There are a number of educational pitfalls which are used as a sole means to develop these traits.
First, there is the values clarification trap. This technique assumes that we can sit in a classroom, apart from life's mainstream, talk to one another, and modify OUT attitudes, values, and behavior. Often, students do not have life experiences to share and the meaning and insight to clarify, and so the discussion becomes trivial and academic. This technique assumes that there are no value standards which we ought to impose on one another, no basis for accountability but that we are all free to choose, prize, cherish, and act without regard for others,
Second, there is another pitfall at the other end of the spectrum involving legalism. It is the Apollonian error wherein we exhuast ourselves pursuing the question "What is right?" We labor to discern detailed moral principles and standards of practice to meet all of the situations which emerge in health care. It is too often assumed that, if we are armed with the "correct principles," then correct behavior will follow. In medicine there is an Apollonian disposition that man is the maker, the controller. Scientists develop knowledge and knowing is power, rolling back life's mysteries and leading to "correct" (i.e., healing) action. But we often fail to ask whether value principles are akin to the empirical generalizations of medical research, and whether the moral life can be lived by consulting a "moral pharmacopoeia-" lr\ addition, legalistic principles linked to a theory of obligation can too readily become a matter of blind obethence to authority, on the one hand, or to a pharisaic legalism of binding duty, on the other.
Another pitfall is ideological. We grapple with the question "What is good for humankind?" trying to establish, once and for all, the terminal values of life- Once we have our answers, we impose them upon others as the Truth, dictating and judging. Our ideology limits our vision of other values and we tend to use others to serve our own purposes.
A Softer Path
Fortunately, there is a softer path to the development of those character traits deemed desirable. Instead of coming to the practice of health care armed with a theory of duty, clarified values, and a lofty set of demanding principles, we might come with a sense of social commitment and trustand with two questions:
To whom am I responsible?
For what am I responsible?
The focus is upon responsibility. We come to an ethical situation not with ready answers but with a desire to do what is fitting (responsible) in that situation. Living life with others is always an art. Art requires discerning what is happening (Who is suffering? How is that suffering created and manifest?, etc.) - and having the skill to do something about what is happening (alleviate the suffering). Art is always an expression of ourselves (the social commitment we have) and art communicates to others (our social trust and concern). The practice of ethical health care is like art in that it reflects our existence in a community of others who count on us and who sustain us. In this sense, ethical health care practice, like art, is a reflection of the gift relationship between practitioner and those who suffer in the community.
Building the desired character traits - ethical ones - is a matter of developing people who are responsible, and respond in a fitting manner to ethical dilemma s in real life situations.
The ability to take a self-conscious, selfcentered, preoccupied learner and to develop within the student the ability to listen, to hear, to observe, thereby to identify where another person is, how he is, and what he is, without introducing to him t he nurse's value set requires teachinglearning exercises of a noncognitive but affective nature.
Rather than begin this education with ethical principles and "value s clarification," we need, in a pluralistic society, where there are many values, rules, and ideals, to begin with a process of sensitizing. We, the educators, need to involve ourselves and our students in many different and unfamiliar experiences. Here the students' previous reality, with its beliefs, norms, and images, is not sufficient. In the process of sensitizing, the old mind se t is confronted with a new unfamiliar reality. The new experience challenges the student to make sense of what they see and to develop responsible ways to respond.
The following activities are suggestions for initiating the process of sensitizing. They are useful to raising the consciousness ("creating awareness") of different realities. . .to what is happening elsewhere, to human needs and suffering, and to challenge reflection on appropriate, fitting responses to those needs. The list of activities is not exhaustive - but hopefully will provoke the creativity of educators to similar possibilities in their own situations!
1 Volunteer ten hours at a Goodwill Industries or Salvation Army store recycling household goods and serving customers. Reflect upon what all of this activity by donors, workers, and customers means in the context of a community of "haves"and "have nots." Is this a true gift relationship, or are there societal defense mechanisms in play?
2. Apply for public assistance and linger about the office lobby observing clients. What does it take to get food stamps and other assistance? How do officials behave toward clients? How do clients behave (body Unguage, etc.)? How do clients refer to themselves? Interpret and compare the self-concepts of the officials and of the clients.
3. Go to a public health clinic. Linger about the Waiting room, observing clients and professionals. Request family planning assistance. What generalizations and value judgments can you make as a result of this experience?
4. Spend a night shift riding in a police car (urban or rural area). Reflect upon your concept of justice and reciprocity. Identify examples of helping, caring, social values, and responsibility.
5. Spend the weekend as a worker in a youth detention center. Reflect upon yourconcept of personhood and dignity. Examine value conflicts, absence of a sense of responsibility.
6. Try a weekend shift with an ambulance in an inner-city area. Reflect upon your conception of human needs. What are the obligations of the emergency staff from a staff perspective, from a client and family perspective?
7. Follow the school schedule for a disadvantaged rural or urban child for one day. Discern his junior or high school learning experiences. What is taught which is meaningful in terms of his/her life situation? Do linguistic barriers exist? How is he/she treated by school officials, teachers, and peers?
8. Participate and observe health classes in several high schools or junior high schools. Try a mix by socio-economic level, ethnicity/ race, and rural/urban. What useful learning takes place? What do students learn that is meaningful righi non· in their !ives?
9. Select one school district and visit the physical education classes from K to 12. What is physical education in those classes? What happens to children which relates to physical and mental health? How do you Feel about these experiences? Are you excited by the prospect of your children getting this physical education? Why?
10. Get involved in social activities in a Community, seeking opportunities to chat with various people about access to and quality of health care What sense of their health care expectations do you get? What evaluations of health care emerge from the discussion?
11 Select a variety of work situations and do one-day stints at each: sanitalion worker, camp counselor, school teacher, day-care worker, nurse aide, farm worker, stock clerk, newspaper deliverer, sales clerk. What kind of people did you meet? What conflicts arose? How did you resolve them?
12. Search out the community and participate in ethnically different entertainment: Polish festivals, soul music, etc. Interact with others in the audiences.
13. With several friends, who are "different" ethnically and age-wise, shop for health insurance in a variety of agencies. Go in one at a time, then come together at the end of the experience and compare notes.
14. Co to a home-care or surgical rental store, or attempt to rent/ purchase oxygen equipment. Identify the barriers and constraints. What concessions must the client make?
15. Spend an academic term tutoring students who need help. See how "needing help" affects one's personhood. Compare notes with colleagues tutoring other students.
16. Spend a week in a wheelchair. with one arm strapped down. Try to follow your regular schedule each day. What did you learn?
17. Compile a listing of volunteer service agencies in your neighborhood. Volunteer time to one agency for a semester. Record your impressions and feelings daily. At the end of the term, try to sum up your success and limitations in a few brief statement;.. Share them with others.
18. Do a "shopping spree" in an ethnic or lowincome neighborhood and in an affluent community. Try to repeat the effort m a small, rural grocery store. What price and stock differences did you see? What different social functions did the consumer "places" serve? What cultural differences were apparent? What does all of this say to health care professionals?
19. Spend Saturday evening (at least eight hoursl at the desk sergeant's place in a police station, in the waiting room of an emergency ward, or in a constable/magistrate's office. Observe the priorities and needs of clients, of the providers.
20. Be a participant/observer at a variety of religious services (e.g., Sunday or Friday worship, weddings. funerals) in vartous ethnic communities and various rehgtous traditions What differences in forms of expression, symbols, values. etc. were you able to discern7 Can you venture conc lotions about the implications of what you observed for ph ysical and mental health? for delivery of health care professional service?
21 Repeat item no. hut foist upon values - attitudes toward morality (how persons think they should interact, treat, and be responsible for others t What are the implicati onso f these moral dispos i titus for health rare? The health of the belt every? The believern' responsibility for others health?
22. Spend one hour observinga person in each of ten diff erent occupations fin ih etr workplaces I. Think about stress. Wha tvonr lusionscan you draw about the strees on each of the ten personsin their workplaces? How general can you make yottr conclusions abc,ut occupational stress?
23. Take a small town orur ban comm unity. Using the telephone book and a map, plot the opportunities for (11 Health Education. and 121 Health C:are. Compare th emapsv tb others' maps of different cow munities. If you knew only these two things about the communities, w'bat might you lot er about community differences and similarities?
24. In an urban area, spend eight hours ri ding the bus or subway. Capture the essence of th ecity and its people in youro h servatiotes. and in to your interactions with the city's many people. What does this io ttrney reveal abc,ut the pluralistic needs of the city's people for health care? What did you discover that has a betrtng on health care deli very?
25. Do the same for a more rural area, chatting with folks a rural bus stations.
26. Arrangeaone'week live-in with an ethnically different family, ma neighborhood distant frtem your own. Dis-cern difficult concerns, and styles regarding eating practic es, sleeping, family memb erro let. Reflect upon their meaning for personal health and health expectations and how people deal wtthdtseaseanddeath.
27. Spend a week working inapnson medical unit. What kinds of persons do you esperi - ence there? What goes an that fosters a tense of physical and mental health? What demeans tmage and self-esteem?
28. Spend severaldaysincriminal rourtobterving the conflicts inherent in several trials Visit the familyjjuvenile court, and discern the conflicts there. What do these conflitto have to do with your attitudes and competencies as a health-tare professional.
29. Observe the drivers' license renewal process What happens toimompeient readers? How do they feel? What in the health-care profession induces similar client feeling*?
30. Have a 'minority experience." Enroll in a class or community educational program where you are in an ethnic, religious, or racial minority. What is the significance (personal and social) of such an experience?
31. Spend one day in the health clinic of three schools, located in three diverse neighborhoods. What sorts of problems are dealt with? Which expected problems Jo not "appear?" What conclusions can you draw about health care in each of the communities, reflected in their school clinic? About health values, and knowledge of health?
32. Identify "fishing spots" for several localities 30 to 50 miles from where you live. Spend half a day quietly interacting with each group Identify their priorities, needs, and health care viewpoints.
33. Spend a week at the local animal shelter putting unwanted animals "to sleep." Reflect on your feelings and deeds Draw analogies between the animal control situation and any issues in health care delivery in Amenta, as il is and JS it might be
The emphasis upon sensitivity in the development of ethical health care practitioners is based upon the view that such practice is a vocation - a "calling" - notan occupation. The practitioner's relationship to others \s notthat of employer-employee, but of person to community. The notion of responsibility is inherent in this relationship. The relationship is marked by the reciprocal giving of gifts, yielding social commitments of trust and accountability to a community. The moral agent is the person who is sensitive to others' situations and needs, on the one hand, and who has the capacity to do something fitting to ease suffering and make a difference in the overall process of community life. Sensitivity to others is a first ingrethent, and the sensitivity experiences provided are a means to accomplish that first step with health care students.