Much attention has been focused on identifying what nursing is, and on conveying to others what is unique about nurses and nursing. The nursing profession is currently struggling to define itself as it deals with both internal and external pressures. Bandman and Bandman (1988) suggest that because of the existing confusion, this is an auspicious time to use critical thinking and logic to examine assumptions, beliefs, goals, and values that characterize nursing. Furthermore, as Paul (1985) points out, critical thinking can transform students into active participants in their own intellectual growth. Nurse educators, therefore, need to encourage the use of critical thinking in order to stimulate both personal and professional growth.
Bandman and Bandman (1988, p. 5) define critical thinking as "the rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs, and actions." According to these authors, students can begin applying critical thinking skills in the examination of controversial ideas by appealing to rational standards. For nurses, these standards include scientific inquiry through use of the nursing process, problemsolving, decision-making, and reasoning.
Siegel (1985) cites three imperatives for teaching critical thinking: (1) facilitating the student's self-sufficiency and autonomy, (2) empowering the student to control his or her own destiny, and (3) promoting rationality as the use of reasons. Teaching methods must, therefore, encompass more than didactic methods in order for nursing students to learn the application of critical thinking skills to relevant issues. Teachers need to identify and use strategies that stimulate questioning, inquiry, curiosity, and consideration of valid alternatives.
Acquired immune deficiency syndrome (AIDS) has been described as "not a doctors' disease, but a nurses' disease," since it is nursing care that these patients need most (Fitzhugh & Shubin, 1988). The nurse assigned to care for a patient with AIDS must deal with the issues of the coramunicability of the disease, the prognosis of those suffering from it, and the lack of prospect for a cure. Further, the nurse may be obliged to confront and deal with personal feelings and beliefs concerning homosexuality and substance abuse, which are common causes of the disease. Personal risks and values must be weighed against a nursing code of ethics, which mandates that individuals receive respectful care regardless of the nature of their health problem.
Of interest is a study by Lester and Beard (1988), which explored the knowledge, fears, and beliefs about AIDS held by baccalaureate nursing students. The researchers found that while 96% of those surveyed believed that AIDS patients are entitled to the same care as any other patient, nearly half of the students (49%) stated they preferred not to provide that care. The fact that this dilemma may exist not only for students but also for faculty was noted by Steele (1986). Steele observed that value systems held by students and faculty may be incongruent with caring for AIDS patiente. She encouraged the use of value clarification exercises as a mechanism for resolving this conflict.
Schools of nursing are now challenged to assist students in dealing with these controversial issues. Students need to be prepared to make decisions, such as those regarding the provision of nursing care to AIDS patients, based on the application of critical thinking skills rather than on impulsive reactions to an emotionally charged situation. This article describes a teaching strategy that incorporates Siegel's (1985) imperatives for teaching critical thinking while challenging nursing students to confront the issue of providing care to patients with AIDS.
Students involved in two classes of a senior-level course titled "Issues in Nursing" in a baccalaureate nursing program participated in the teaching/learning activity. Within the context of the two-credithour course, students are challenged to analyze issues related to professionalism, history, legal and ethical decision-making, economics, and politics. In addition, the documents that provide the foundations for professional nursing practice are reviewed and discussed.
To stimulate the process of critical thinking, students were assigned to write a two-page paper responding to the following question: Should nurses be required to administer care to AIDS patients? They were also requested to draw from courserelated materials in order to provide rationale to support their positions. The papers, assigned during the last three weeks of the semester, were graded on a ??-point scale and were weighted as a quiz grade. Grading was based on evidence of a clear position statement as well as documentation of at least one theoretically based rationale supporting the stance. Students had a week to write their papers. The class discussed the responses and rationales once the papers had been turned in and graded.
The diversity found in the students' responses to the question of whether nurses should be required to administer care to AIDS patients reflects the complexities surrounding this issue and reinforces the need for nurses to be able to think critically when faced with such dilemmas. A total of 40 female students (36 generic and 4 registered nurse students) completed the assignment. A review of the students' responses to the question revealed that the majority (75%) of the students thought that nurses should be required to administer care to AIDS patients. Of these 30 students, 28 were generic students. Six students ( 15%) said that nurses should not have to provide care to patients with AIDS, and the remaining four (10%) communicated ambivalent feelings. Each of these last two categories contained one registered nurse student.
Students demonstrated the ability to examine ideas, beliefs, and principles in writing a position statement and in generating rationales for their positions. They drew from a variety of resources to support the provision of care to AIDS patients, including the American Nurses Association (ANA) Code of Ethics (1985), the American Hospital Association (AHA) Patients' BuI of Rights (1975), definitions of nursing, the Nightingale Pledge, the state's Nursing Practice Act, and ethical theories and principles. Many of these were cited in concert with one another to further substantiate the position taken. Interestingly, the six students (15%) in the sample who did not think nurses should be required to provide care for AIDS patients also cited the ANA Code of Ethics and the AHA Patients' Bill of Rights as rationale for their decisions.
Those nurses supporting the nurse's responsibility for providing care to AIDS patients quoted the statement in the ANA Code of Ethics that "The nurse provides services with respect for human dignity and the uniqueness of the client unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems" (ANA, 1985). Students who believed that nurses should not be required to administer care cited the Code's statement that the nurse has not only a right but a responsibility to refuse to administer care if he or she does not feel personally competent to do so. This statement was interpreted broadly by these students to encompass both clinical and emotional competence.
Further, the AHA Patients' Bill of Rights statement that "patients have a right to considerate and respectful care* (AHA, 1975) was used by students both to support the nurse's responsibility to provide care to AIDS patients and to validate the nurse's right to refuse to administer care. The point was made by those supporting provision of care that this right is not contingent on the patient's diagnosis. On the other hand, those taking the stand that nurses had the right to refuse to provide such care emphasized the emotionally charged, controversial nature of AIDS care. They expressed concern that forcing a nurse to care for an AIDS patient, when to do so conflicts with the nurse's personal values, would likely compromise the nurse's ability to relate to the patient in a considerate and respectful manner.
The four students (10%) who conveyed ambivalent feelings about whether nurses should be required to administer care to AIDS patients also cited the ANA Code of Ethics and the AHA Patients' Bill of Rights as support for the provision of care and as justification for the nurse's right to refuse to provide care. Their indecisiveness emphasizes the multitude of factors that must be taken into consideration when nurses are confronted with dilemmas such those surrounding AIDS care.
Nurses are currently being faced with difficult decisions in the provision of health care that do not always have definitive, clear-cut answers. It is, therefore, vital that they know how to examine ideas and information rationally from a variety of sources and perspectives in approaching the decision-making process. Critical thinking skills must be taught and reinforced during the educational process to equip nurses to meet these challenges. Providing students the opportunity to apply critical thinking skills in addressing a relevant health care issue proved to be an interesting and instructive teaching/learning strategy. Also, the class discussion of responses to the question of whether nurses should be required to administer care to AIDS patients further stimulated the critical thinking process as students were challenged to consider perspectives other than their own.
- American Hospital Association's Patients' Bill of Rights (1975). Chicago: Author.
- American Nurses Association. (1985). Code for nurses with interpretive statements. Kansas City, MO: Author.
- Bandman, E.L., & Sandman, B. (1988). Critical thinking in nursing. Norwalk, CT: Appleton & Lange.
- Fitzhugh, Z.A., & Shubin, S. (1988). Caring for A.I.D.S. patients: The stress will be on you. Nursing 88, 19(10), 43-47.
- Lester, L.B., & Beard, B.J. (1988). Nursing students' attitude toward AIDS. Journal of Nursing Education, 27, 399-404.
- Paul, R.W. (1985). The critical thinking movement. National Forum, 65(1), 32.
- Siegel, H. (1985). Educating reason: Critical thinking, informal logic and the philosophy of education, Part Two. Philosophical questions underlying education for critical thinking. Informal Logic, 7(2 and 3), 69-81.
- Steele, S.M. (1986). AIDS: Clarifying values to close in on ethical questions. Nursing and Health Care, 7, 146-148.