Ethics education for nursing students traditionally has used a medical model instead of a nursing model. Nurses and physicians may not experience the same ethical problems and their perspectives on these problems may difïer. A model for teaching nursing ethics must address the social role of nursing as a profession and the nurse-client relationship (Bishop & Scudder, 1990; Fry, 1989). Increasingly, nurse educators realize the importance of teaching nursing ethics rather than medical ethics to nursing students (Hilliard, 1990).
Nursing programs use four general models or a combination of these models for ethics education: a few hours of ethics content in a nursing course; integration of ethics content into all nursing courses (Ryden, Duckett, Crisham, Caplan, & Schmitz, 1989); an ethics course taught by nursing faculty; and an ethics course taught outside the nursing department. Often, these models do not address nursing ethics.
The authors developed a model that has been used successfully for four years to teach nursing ethics in a baccalaureate nursing program. Nursing students take a required philosophy course in ethical theory. In class and clinical discussions, faculty members present increasingly complex ethical problems and help students to resolve these problems in a professional manner that affirms and develops their integrity. First-semester seniors participate in a half-day seminar on nursing ethics developed and presented by a nurse ethicist. By this time, senior students have experienced a variety of clinical nursing situations and are able to apply the seminar content to specific ethical problems in nursing.
Before adding the nursing ethics seminar to the curriculum, faculty members presented one hour of ethics content in each of three nursing courses. The focus on a nursing practice area did not sufficiently promote students' knowledge and enthusiasm about nursing ethics. Each nursing practice area became an organizing framework for students. In contrast, the seminar encourages students to view nursing ethics as a comprehensive framework that guides all of nursing.
The nursing ethics seminar provides philosophical approaches that help to resolve ethical problems in nursing. Often, nursing students ask for right answers to ethical problems. Because ethics is complex and not an exact science, the seminar does not furnish right answers or a single approach. The seminar differentiates nursing ethics from medical ethics, thus adding clarity to nursing's philosophical foundation.
During the seminar, the nurse ethicist describes ethical problems in nursing, discusses the caring and justice perspectives for resolving ethical problems, presents the Caring and Justice Nursing Ethical Theory (Cameron, 1990) and helps the students to apply the theory. This article describes the nursing ethics seminar and strategies for helping students to grapple effectively with ethical problems in nursing.
Nursing Ethics Seminar
Ethical problems in nursing
An ethical problem is a situation involving conflict about the right thing to do. Ethical problems focus on ethics, a branch of philosophy that is concerned with morality and moral judgments. William Frankena (1973) defined morality as a social system of regulation that exists before and after the individual who is inducted into it and becomes more or less of a participant in it. Ethical problems range from societal problems such as how to distribute scarce health care resources to individual problems such as Kate's conflict about what to say to Jane in the following nursing practice situation.
Jane Thompson, age 75, is hospitalized for a broken hip; she has a history of depression. Kate, Jane's nurse, learns that Jane's son, Ted, killed himself two days earlier. Jane's family members don't want her to know about Ted's death for a few days. They are concerned that she might become depressed, which could interfere with her recovery. Jane's physician writes an order saying that the hospital staff should not tell her about her son's death. When Jane doesn't hear from Ted, she expresses concern to Kate, who feels conflict about what to say to her. Kate is experiencing an ethical problem.
Ethical inquiry occurs on three levels: descriptive ethics, normative ethics, and metaethics. Descriptive ethics describes ethical behavior and formulates theories of human nature (Frankena, 1973). By describing her conflict about what to say to Jane, Kate engages in descriptive ethics. An example of a descriptive ethics theory is Kohlberg's theory of moral development (1983), used in most nursing ethics research.
Normative ethics attempts to answer questions about what is right and good. Normative ethical theories take the position that some actions are morally superior to other actions. Kate engages in normative ethics when she debates how she is going to resolve her ethical problem and why. Three normative ethical theories are Frankena's Mixed Deontologica! Theory of Obligation (1973), Action-Guides of Beauchamp and Childress (1989), and Thiroux's Universal Ethical Principles.
In Frankena's Mixed Deontological Theory of Obligation (1973), one ought not to inflict evil or harm; one should prevent and remove evil or harm and do or promote good; one ought to treat people as equals in distributing good and evil equally among them.
The Action-Guides of Beauchamp and Childress (1989) add the theory of the right of self-government, and the theory that one ought to give all people their due.
In Thiroux's Universal Ethical Principles, life is revered; a person should strive to be a good human being and attempt to perform right actions; one should treat others fairly; one should engage in meaningful communication. All human beings have individual differences, and they should have the freedom to choose their own way and their own means of being moral.
Metaethics consists of analyzing meanings of ethical terms (Beauchamp & Childress, 1989). Kate engages in metaethics when she defines what she means by terms like "the right thing to do" and *a good person ."Another example of metaethics is when nurses debate the meaning of terms such as "good nurse* and "caring nurse."
According to nursing research, the most stressful part of nursing involves ethical problems. Findings indicate that the more stress nurses experience, the more burned out they become and the more they compromise their integrity. The more nurses compromise their integrity, the more stress they experience and the more burned out they become - a vicious cycle (Cameron, 1986; Duxbury, Armstrong, Drew, & Henly, 1984; Gray-Toft & Anderson, 1981; Jacobson, 1978; Jones, 1981; Oskins, 1979; Stone, Jebsen, Walk, & Belsham, 1984). These results suggest that nurses need to effectively resolve ethical problems in a manner that facilitates their personal integrity.
Caring and Justice
Nursing literature describes two current major perspectives for resolving ethical problems. One perspective called justice, or principled thinking, dominates medical ethics and focuses on abstract reasoning. Ethical theories using the justice perspective define people's duties or rights. Some justice theories address right consequences (consequentialism) and some address right action (deontology). Other justice theories rely on principles or action-guides arising from consequentialism and deontology.
The previously mentioned principlebased justice theories are frequently used in medicine and nursing. To resolve an ethical problem using one of these theories, nurses view the problem with a rational, impartial, impersonal stance. They apply the principles of the theory to the problem and arrange them hierarchically according to importance. Finally, they logically derive conclusions that lead to the problem's resolution.
Critics claim that the justice perspective is inadequate because it ignores caring and does not reflect the behavior of real human beings. People do not analyze ethical problems by isolating abstract principles but by looking at these problems in context, taking into account personal values (Blum, 1988). Kohlberg's moral development theory (1983) and other theories based on justice reflect a white male point of view that has little relevance to nurses, women, and people of color (Fry, 1989; Gilligan, 1982).
Nursing literature has proliferated with articles about caring, the second current major perspective for resolving ethical problems. Noddings (1984) defined caring as feeling as nearly as possible what the cared-for feels (a pre-act consciousness) and acting on that person's behalf in a concrete situation. Caring focuses on intuition and empathy rather than rationality. Some nursing theorists describe caring as the essence of nursing (Watson, 1990).
Critics claim that caring is inadequate for resolving complicated ethical problems. People may not agree on an intuitive approach. Few people are able to care for enemies and strangers. Caring may exploit nurses who traditionally have been expected to provide care in spite of inadequate compensation. Instead of encouraging a love of the good, caring may nurture a disproportionate love of one's own. A caring person could act wrongly because of an inability to analyze a problem with detachment (Cameron, 1991).
Although overlapping, caring and justice have distinguishing characteristics. Caring, associated with femininity, involves who one is. Justice, associated with masculinity, involves what one does. Caring is concrete, subjective, contemplative, particular, partial, and personal. Justice is abstract, objective, calculativa, general, impartial, and impersonal (Cameron, 1991).
Aristotle (1987), an ancient Greek philosopher, wrote that both moral virtue (excellent character) and intellectual virtue (contemplative and calculative reasoning) are essential for the good Ufe. Noddings (1990) acknowledged that justice may be needed in addition to caring. According to Frankena (1973), virtues/traits of character and duty/principles are not rivals but complementary aspects of the same morality. Davis (1989) stated that nurses need virtuous character and ethical principles.
Nurses can use caring or justice to resolve ethical problems. However, an integration of the two perspectives produces a more comprehensive, gender-undiflerentiated ethical theory. Both caring and justice perspectives may be needed for nurses to resolve complicated ethical problems on individual, institutional, professional, and societal levels. The Caring and Justice Nursing Ethical Theory (Cameron, 1990) suggests how nurses can apply a combination of the two perspectives to ethical problems in nursing.
Components of caring
Advocacy: How can I be an advocate? Advocacy means to support and defend the client's cause, without carrying out illegal or unethical requests. Gadow (1980) encouraged nurses to be existential advocates who help clients to clarify their values and to reach decisions that express these values. Besides advocating for individual clients, nurses need to be advocates for society (Fowler, 1989) and for themselves. Applying Aristotle's ethics (1987), virtuous nurses are generous but they do not give away resources that they need in order to live virtuous lives themselves.
Compassion: How can I be compassionate? Compassion means to view a person with empathy and to identify intellectually and emotionally with the person. Most nursing literature on caring focuses on compassion. The first author interviewed a nurse about her lived experience of caring for a client and analyzed the interview according to attributes and consequences of caring/ compassion. When caring occurred, the nurse said it felt like she was "clicking" with the client. The process of caring/ compassion was on a continuum. The more caring/compassionate the nurse, the more the client "clicked" with her and the more gratified the nurse felt (Cameron, 199OX
Virtue: How can I be virtuous? Virtue means to develop excellent character and living. According to Aristotle (1987), moral virtue is a disposition to choose the mean between excess and deficiency of a human behavior. Through education and habituation, nurses can develop dispositions to do what is right because the virtuous life is the happiest, most satisfying life. By behaving with integrity, nurses make ethical choices in conformity with their developed inner sense of rightness. They pursue excellence whether anyone else takes notice and encourage other people to be virtuous, too.
Values: How can I live up to my values? A value is a conception of what is desirable, ethically justified, and influential to behavior (Uustal, 1987). Because values directly influence actions, nurses need to clarify their values and help clients to do the same. By knowing their values, people can more easily sort through confusing ethical problems and act consistently on these values. People who clarify their values will be more likely to determine how ethical their values are.
Components of justice
Autonomy: What are realistic options, taking into account my autonomy and constraints? Autonomy means selfgovernance, the capacity for meaningful choice (Beauchamp & Childress, 1989). Without autonomy, one cannot be held responsible for one's behavior. Autonomy requires that nurses act in a manner that is sel£chosen and informed and provide clients with the opportunity to be selfgoverning themselves. Nurses cannot be simply autonomous for they are constrained by professional, legal, institutional, and personal codes (American Nurses Association, 1985). To make good ethical decisions, nurses need to identify these constraints and know how to act autonomously within them, taking responsibility for their actions when they choose to follow or not follow them.
Utility: What will bring about the most good for the most people? Utility means the action that maximizes the good and minimizes the bad. A consequentialist perspective, utility is based on act utilitarianism, an ethical theory developed by John Stuart Mill (Smart & Williams, 1985). To determine right action, nurses using utility compare the value of the consequences of individual actions. The more valuable the consequence of an action, the more valuable the action. The right action in a given circumstance is that action which, out of all possible alternatives available, maximizes the good and minimizes the bad for the most people involved.
Universalizability: Which action can I will for everyone else to do in a similar situation? Universalizability means what one can will to be a universal law. A deontological perspective, Universalizability focuses on the right action, independent of its consequences. Universalizability is based on Kant's ( 1986) Categorical Imperative, the Golden Rule without loopholes. The Golden Rule, "Do unto others as you would have them do unto you," allows mistreatment of other people if one does not mind being mistreated oneself. Universalizability forbids the loophole of mistreating other people on the grounds that one cannot rationally will to be mistreated oneself It permits doing what one can will for everyone else to do in a similar situation.
Fairness: What is the fair thing to do? Fairness means equal treatment, equality of consideration, equality before the law (Frankena, 1973). Using fairness, nurses deal with other people and themselves according to merits, needs, and abilities. Fairness does not assume that people are equal in their capacities. People are equal to the extent that they ought to receive proportionally the same contribution to the goodness of their lives, once a certain minimum has been achieved by all. No one can make other people's lives equally good or maintain their lives at the same level of goodness. Although all people are equally capable of some kind of good Ufe, some people are capable of better lives than others.
During the nursing ethics seminar, the nurse ethicist encourages students' participation in order to promote their personal experiential engagement with the ethical problems discussed. Students describe ethical problems that they have experienced and explain why these problems are ethical in nature. Students classify their responses as deontological or consequentialist when asked, "Is it all right to tell a lie that will bring about something good?"
While discussing values, students write brief) confidential responses to the following questions: (1) What is a good Ufe? (2) What is a good death? (3) What happens after death? Their answers provide them with an understanding of their values, which are important in resolving ethical problems.
The nurse ethicist encourages students to use "ethical listening" as an independent nursing intervention to help clients resolve ethical problems. Instead of offering advice or solutions, nurses need to encourage clients to articulate their sense of rightness, to reach their own ethical clarity, and to experience peace of mind.
Toward the end of the seminar, the students divide into small groups to discuss the following ethical problem:
Recently, Tom went home from the hospital where he was diagnosed with AIDS- You are a public health nurse who visits him twice a week to give him medications and treatments until he is well enough to go back to work. Tom confides to you that now he practices safe sex. He says that he has informed everyone with whom he had unsafe sex in the past, other than Greg, about his diagnosis and has encouraged them to be tested and use safe sex. Three years ago, he and Greg, who works at the same company that he does, had an affair. The men didn't use condoms.
Since then, Greg has avoided Tom and has spent his time with Katherine, whom he will marry in two months. Tom has decided not to tell Greg that he has AIDS because: he may not have been HW-positive at the time of the affair, he is angry about GrCg1S recent treatment of him, he does not want to jeopardize his job and health insurance, he does not want to embarrass Greg, and he does not want to ruin Greg's marriage plans.
You are concerned about Tom's confidentiaUty as well as the health of Greg, Katherine, and other people with whom they have been or will be involved. As Tom's nurse, what is your ethical problem? Using the Caring and Justice Nursing Ethical Theory, what is your resolution to this ethical problem?
Each small group analyzes the problem using the Caring and Justice Nursing Ethical Theory (Cameron, 1990) and develops a resolution that takes into account each component of the theory. When the components of caring and justice seem to be in conflict, creativity is needed to develop effective resolutions. In the large group, the students present their resolutions and rationale.
Two weeks after the nursing ethics seminar, seniors take their final examinations for the semester. Included in these examinations is an essay question about an ethical problem in nursing practice. Students are asked to apply the Caring and Justice Nursing Ethical Theory (Cameron, 1990) to the problem and to describe their resolution. A faculty member grades them on how well they articulate ethical reasoning and reach an appropriate resolution. Students' responses have indicated an enhanced ability to apply ethics content to nursing practice.
The model described in this article integrates a philosophy course in ethical theory, discussions about ethics in nursing courses and clinical experiences, and a nursing ethics seminar. This model facilitates the development of nursing graduates who behave with integrity, whose professional nursing practice reflects congruence between their values and actions (Chickering, 1978). Teaching nursing ethics instead of medical ethics provides a firm foundation for ethical decisionmaking in nursing practice.
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