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Multiple loyalty conflicts in nursing Lamb, Ruth M. 1985

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MULTIPLE LOYALTY CONFLICTS IN NURSING By RUTH M. LAMB B.A., The University of British Columbia, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing We accept this thesis as conforming to the required standard THE(UNIVERSITY OF BRITISH COLUMBIA June 1985 Q Ruth M. Lamb, 1985 In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representative. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada, V6T 1W5 Abstract MULTIPLE LOYALTY CONFLICTS IN NURSING The International Council of Nurses [ICN] Code for Nurses clearly states that the registered nurse's f i r s t obligation is to the patient (ICN, 1973). But, in the c l i n i c a l setting, multiple loyalties or obligations to the patient, family, physician, employing agency, professional standards, and personal ethical beliefs may conflict. Given the diversity of obligation in nursing practice and the ever expanding array of l i f e sustaining technologies and techniques, a problem arises for nurses when they attempt to employ c l i n i c a l guidelines offered by the ICN Code. Therefore, in order to ascertain how nurses uphold patient autonomy when responding to conflicts in the empirical setting and to delineate the patterns of reasoning which contribute to the actual response as well as to the preferred response, a qualitative grounded theory methodology was selected. This exploratory approach provided evidence that when conflict occurs, perceptions of relevancy on both a cognitive and affective level, influence the nurses' response. Often nurses with apparently equal cognitive capabilities on a moral developmental level perceived conflict of loyalty situations in vastly different ways and thereby responded with a range of behavior that went from exemplary care, which supported patient autonomy, to unsafe care, which completely denied patients their autonomy. An inductively derived substantive theory outlines this variance in care. The manner in which patient autonomy i s u p h e l d i n m u l t i p l e l o y a l t y c o n f l i c t s c a n be e x p r e s s e d on a t h r e e d i m e n s i o n a l c a t e g o r i c a l b a s i s w i t h p e r c e p t i o n s o f i m p o s e d , bounded and v o l i t i o n a l r e l e v a n c e c o n j o i n e d w i t h t h r e e l e v e l s o f c o g n i t i v e m o r a l d e v e l o p m e n t , i n c l u d i n g b o t h d e s c r i p t i v e and n o r m a t i v e e x p l a n a t i o n s o f c o n f l i c t r e s o l u t i o n . P r i n c i p l e s and t h e i r s u p p o r t i n g r u l e s f o r n u r s i n g a c t i o n d e r i v e d f r o m e a c h c a t e g o r y e m p h a s i z e t h e l i t t l e r e s e a r c h e d b u t c o m p l e x r e l a t i o n s h i p b e t w e e n m o r a l c o g n i t i o n s , p e r c e p t i o n s and a f f e c t i v e v a l u i n g . iv Table of Contents Page Abstract i i List of Tables v i i Lis t of Figures v i i i Acknowledgement ix Chapter One: Introduction 1 Background to the Study 1 Problem Statement 4 Purpose of the Study 4 Methodological Perspective 5 Research Design ' 5 Thesis Organization 8 Chapter Two: Conceptual Framework 10 Introduction 10 Obligations in Nursing 11 Ethical Principles in Nursing 13 Ethical Decision Making 16 Theory of Cognitive Moral Development 19 Summary 23 .V Page Chapter Three: Research Design 26 Introduction . . 26 Methodology 27 Selection of Participants 27 Data Collection 28 Data Analysis and Interpretation 30 Ethical Concerns 31 Limitations to the Study 32 Summary 32 Chapter Four: Data Analysis 34 Introduction 34 Part One Multiple Loyalty Conflicts 34 Substantive Concepts 35 Theoretical Integration 38 Part Two Imposed Relevance 40 Theme: Anger . 41 Theme: Resentment 55 Theme: Revenge 62 Comparative Critique 69 v i Page Bounded Relevance 73 Theme: Relationship versus Role Responsibility . . . . 75 Comparative Critique . 83 Theme: Nursing Rights versus Physician Rights 86 Theme: Nursing Rights versus Institutional Rights . . . 97 Theme: Nursing Responsibility and the Right of the Patient to Die with Dignity 103 Theme: Individual Rights versus Societal Responsibility 119 Comparative Critique 127 Volitional Relevance 134 Theme: Cooperation 135 Theme: Accountability 145 Comparative Critique 156 Summary 160 Chapter Five: Grounded Theory 162 Introduction 162 Theoretical Purpose 162 Conceptual Clarification . . . . . . 163 Theoretical Perspective 165 Propositional Statements 165 Theoretical Narrative 167 Principled Determinants for Action 173 Summary 174 v i i Page Chapter Six: Summary, Conclusions, Implications and Recommendations 177 Summary 177 Conclusions 181 Implications and Recommendations 182 Nursing Education 183 Nursing Practice 186 Nursing Administration 192 Nursing Research 197 References 199 Appendix A: Canadian Nurses Association Standards for Nursing Practice 205 Appendix B: International Council of Nurses Code for Nurses 207 Appendix C: Letter of Introduction 210 Appendix D: Consent Form 212 v i i i L ist of Tables Page Table 1. Principled Determinants for Action 175 ix List of Figures Page Figure 1. Ethical decision making model 24 Figure 2. Structural components of cognitive comparisons . . 25 Figure 3. Structural components of cognitive and affective comparisons 39 Figure 4. Multiple loyalty conflict: Cognitive-affective interface 166 X Acknowledgements I would like to thank Professor Helen Elfert, my thesis chairman, and Professor Kathleen Simpson for their willingness to offer guidance and encouragement. In addition, my appreciation extends to Mary Vorvis who, with care, typed the manuscript and to Professor Ray Thompson, the external reader, who made a careful and objective study of the thesis and contributed to reaffirming i t s f i n a l form. Finally, with deep gratitude I thank my husband and children whose ab i l i t y to be independent, cooperative and sharing provided me with the freedom to pursue a valued professional goal. 1 Chapter One: Introduction Background to the Study The International Council of Nurses [ICN] Code for Nurses clearly states that the registered nurse's f i r s t obligation i s to the patient (ICN, 1973). But, in the c l i n i c a l setting, multiple loyalties or obligations to the patient, family, physician, employing agency may conflict with professional standards and personal ethical beliefs. Given the diversity of obligation in nursing practice and the ever expanding array of l i f e sustaining technologies and techniques, a problem arises for nurses when they attempt to employ the c l i n i c a l guidelines offered by the ICN Code. O'Rourke (1983) believes that basic consciousness raising endeavors are needed i f the ICN Code is to be truly implemented in nursing practice. Davis (1980) concurs and notes that nurses need s k i l l s in identifying the ethical dimensions of their practice, plus the confidence to act on well reasoned decisions which are based on ethical principles. Schlotfeldt (1981) maintains that i n order to assess and enhance the general health status, health assets, and health potentials of human beings, and thereby support the dignity and rights of those we care for, nurses require a sharper conceptual focus in seven areas—one of these being the accurate selection of s c i e n t i f i c , humanistic, and ethical content. Systematic inquiry into this area, she argues, w i l l promote increased feelings of accountability and 2 autonomy within the nursing profession. Gortner (1974) builds on this idea; she stresses the fact that intellectual freedom and individual self direction "are at the very heart of accountable practice" (p. 767) and that these attributes require sound decision making s k i l l s . To this end, nursing has evolved an ethical code that places heavy emphasis on the accountability of the nurse for quality of care and on her duty to act as a patient advocate. The ICN Code, i t s e l f , is founded on basic normative standards and consists of a set of rules from which the nursing profession establishes i t s duties and obligations (Beauchamp & Childress, 1979). However, i t is the ethical principles inherent in these standards which must be referred to in the problematic cases where loyalties conflict, for example, when invasive therapies interfere with upholding the dignity of the individual. Specifically, the concept of autonomy—liberty of action based on informed choice (Storch, 1982) , i s addressed in this case. Patient autonomy is a component of the ethical principle of autonomy and i t s meaning is grounded in the ICN Code of ethics. This principle follows from the ICN Code's directive to promote patient rights and to uphold patient dignity by respecting the beliefs, values and customs of each individual (ICN, 1973). It endorses the ethical aspect of professional nursing practice by referring to the responsibility and trust which has been invested in the nursing profession by society. When i t is adhered to i t leads to decisions that meet the requirement of s c i e n t i f i c 3 accountability, promotes a sense of autonomy and contributes to the humanitarian and caring dimension of nursing. Thus, principles provide nurses with a way of organizing the raw data of experience (Davis, 1982), and the principle of autonomy, as i t is addressed in the concept of patient autonomy, provides a focus for this study as ethical issues in nursing practice are discussed. But, quality decisions require more than conceptual focus: c r i t i c a l thinking based on a certain pattern of reasoning is essential. To this point, Kohlberg (1981) developed a theory of cognitive moral development. One assumption of this theory i s that the quality of a decision outcome can be determined by identifying the pattern of reasoning with which the individual j u s t i f i e s the decision (Kohlberg, 1981). Kohlberg links specific reasoning patterns to levels and stages of moral development. He cites three levels which incorporate six stages through which people can progress. Each stage provides the individual with a more comprehensive perspective on the effect of society on individual rights. Thus, to actually understand the modes of thinking that contribute to resolution of conflict of loyalty decisions, i t is necessary to explore the patterns of reasoning that underlie the outcome; plus, in order to assess the effect of the contextual nature of the situation and to see i f patterns of reasoning are affected, i t is necessary to expand the exploration to include a rationale for a preferred outcome. 4 Problem Statement This study focuses on: multiple loyalty conflicts which involve problems pertaining to patient autonomy and explores the underlying patterns of reasoning which serve to substantiate rationales for both the actual and the preferred decision outcome. Definition of Terms  Multiple Loyalty Conflict Any incongruence of demand or desire between the patient, family, physician, employing agency, personal ethical beliefs and professional ethical standards of the individual registered nurse. Patient Autonomy The patient's right (or the incompetent patient's surrogate) to have beliefs and values respected when making informed choices for action. Patterns of Reasoning The level and stage of cognitive moral development as defined by Kohlberg's theory of cognitive moral development. Decision Outcome The conflict resolution including both the actual and the preferred outcome. Purpose of the Study The purpose of this study is to identify the patterns of reasoning which registered nurses use to resolve multiple loyalty conflicts involving patient autonomy, and to compare this reasoning 5 with the pattern of reasoning that depict a preferred outcome. The purpose includes the following objectives: 1. Identification of multiple loyalty conflicts involving patient autonomy. 2. Outlining of pertinent data related to the decision making process. 3. Discovery of concepts, categories, and themes that are grounded in data. 4. Analysis of the substantive conceptual scheme in relation to the theory of cognitive moral development. 5. Comparative analysis of the rationale for the decision outcome and the pattern of reasoning which supports a preferred outcome. 6. Development of a grounded theory perspective of the problem. Methodological Perspective Research Design A qualitative, grounded theory methodology suitably f i t s the exploration of decision making processes when the purpose i s to generate concepts which explain action. This design choice is based on the fact that l i t t l e is known about how the ethical dimension of the reasoning process relates to action and, thereby, to modes of resolving multiple loyalty conflicts in nursing. This design calls for a ten step process: (a) setting out a general problem area; (2) gathering relevant empirical data; (c) comparing the data; 6 (d) formulating concepts; (e) organizing concepts; (f) developing core concepts into an explanatory framework; (g) c r i t i c a l l y comparing the empirically derived concepts in the framework with those in the literature; (h) reducing the number of concepts; (i) refining the conceptual definitions; and, f i n a l l y , (j) developing an abstract theoretical perspective. Three studies which deal with the general topic area are particularly relevant to this study, two are by Ketefian (1981a, 1981b) and one is by Crisham (1980). Ketefian (1981a) focused on the relationship between c r i t i c a l thinking, educational preparation, and level of moral judgment in relation to a selected group of 79 registered nurses. She found that c r i t i c a l thinking and educational preparation together predict greater variance in moral judgment than either variable alone. She contends that i t is necessary to develop valid and reliable tools for measuring the resulting moral behavior among nurses and to investigate the exact nature of the relationship between thinking, judgment, and behavior. Later that same year, Ketefian, u t i l i z i n g the same sample, completed another study (1981b). Here, she attempted to ascertain the relation between moral reasoning as i t is related to ideal versus r e a l i s t i c behavior. Yet, while noting that this area of study requires further methodological consideration, Ketefian does discover what she terms "distressing" knowledge about the relationship between 7 what nurses value and how they believe they would respond in reality; she believes that the bureaucracy may be at fault by forcing the nurse to accept the values of the organization. Of a similar nature is a study by Crisham (1980). She compared nursing responses to both general moral dilemmas as well as to specific nursing related moral dilemmas. Plus, she analyzed responses in relation to such variables as education, experience, and familiarity with the specific dilemma. In doing this, she found that the level of education and familiarity with dilemmas tended to lead toward more principled thinking, but that the moral judgment scores of staff nurses were lower than those of pre nursing students. This discrepancy, Crisham postulates, could be due to hospital milieu effects on nursing practice. Hence, she concludes with the statement that in order to advance knowledge of moral judgment, i t is necessary to c l a r i f y "situational pressures", conflicting claims and contexts of professional dilemmas, and to further investigate the interaction of these milieu effects (p. 110). In a l l , the three studies establish that there is concern about nurses and their a b i l i t y to make ethical decisions. While variables such as c r i t i c a l thinking a b i l i t y and educational level were cited as having a significant but not large influence on the decision making a b i l i t y of a nurse, there was really no causal or predictive information forthcoming. However, as mentioned, Crisham's study did note a possibly important intervening variable—the hospital milieu or, perhaps we could say, the bureaucratic milieu. 8 Ketefian and Crisham have identified an area most worthy of study. Their findings raise more questions and in general direct research back to the reassessment of milieu effects. In order to truly assess the contextual nature of the problem, a qualitative exploratory approach is needed; this approach explores the registered nurse's view of the substantive situation. Concepts and themes which are grounded in the nurse's subjective world view may help identify as yet unknown variables which w i l l add to what is already known about patterns of reasoning in conflict situations of an ethical nature. Thesis Organization Chapter One is designed to provide a basic overview of the study. Chapters Two and Three present a more detailed conceptual framework and a complete discussion of the research design. Analysis of data follows in Chapter Four. Part One of this chapter l i s t s the range of multiple loyalty conflict situations that were brought forward by the respondents. In addition, i t identifies dimensions of the major substantive concepts and provides a refinement of concepts based on collateral literature. The grounded conceptual schema i s then integrated into Kohlberg's theoretical framework. Keeping the integrated substantive and theoretical perspective in mind, Part Two continues the analysis by identifying thematic issues for each category of the framework and by u t i l i z i n g concrete examples to explain the varying patterns of reasoning. Again, literature is 9 used as a c r i t i c a l , comparative resource. Chapter Five, providing a more abstract rendition of the data, presents a grounded theoretical perspective which attempts to account for discrepancies in patterns of reasoning. A brief summary of the study, a l i s t of conclusions and a discussion of implications and recommendations pertinent to the four key areas of nursing education, practice, administration, and research follows in Chapter Six. 10 Chapter Two: Conceptual Framework Introduction The purpose of the conceptual framework is to interrelate the facts, concepts, principles, and theories which underpin the research problem and, consequently, support the purpose of the study. Many of the ideas u t i l i z e d in this study come from other disciplines because ethical concerns in health care reach into such areas as philosophy, psychology, and education. In particular, reference w i l l be made to Beauchamp and Childress (1979), Cassel (1983), and Veatch (1976), a l l modern philosophers. Background philosophical insight is provided by Kant and M i l l , two 18th and 19th century philosophers who were instrumental in developing theoretical perspectives pertaining to contemporary ethical thought and action. In addition, psychology and education are represented by Kohlberg (1981). His contribution to the understanding of moral development and ethical thought took another step forward as research findings which pointed to patterns of reasoning became discernible. The conceptual framework requires a synthesis of thought from various areas; however, each conceptual and theoretical focus is ut i l i z e d to stress the central importance of the concept patient autonomy and i t s c r i t i c a l relationship to present day nursing practice. The framework, in following an inductive expansion, f i r s t l y , presents an outline of the obligations in nursing; secondly, i t grounds these obligations in a higher order ethical principle; 11 then, discusses how nursing obligation requires ethical decision making; and, f i n a l l y , places ethical decision making into the context of cognitive moral development theory. A brief summary at the end of the chapter ties the conceptual framework together schematically and prepares one for the manner in which the data is analyzed. Obligations in Nursing Inherent in nursing is respect for l i f e , dignity, and the rights of the individual. These tenets are upheld in the Nurses (Registered) Act (1979) , the CNA Standards for Nursing Practice (1980), and are outlined in the ICN Code for Nurses (1973). These three documents provide an interface for justice, standards, and duties, and delineate the role of the registered nurse. While this study focuses on the ethical implications of nursing practice as formulated by the ICN Code for Nurses, ethical guidelines are founded within a legislated and professionally defined context. For example, the nursing practice act, formally a product of the provincial legislative body, functions to regulate the scope and intent of practice for registered nurses in British Columbia. The overall aims of the Act is to protect the interests of the citizens of this province. The constitution and bylaws, sublegislation for the purposes of carrying out the Act, speak to societal values. Nurses are to "further the standards of nursing practice" and "to engage in activities that are conducive to the health and welfare 12 of the public and the welfare of nursing and a l l i e d professions" (Nurses [Registered] Act, 1979, p. 1). This statement not only j u s t i f i e s nursing's raison d'etre and is v i t a l to our philosophical basis for caring, i t also stipulates that there are parameters on which to base criminal and c i v i l l i a b i l i t y . Nurses, in fact, have legally been given a mandate—a right to practice. These general statements are supported in a more specific fashion in the CNA Standards for Nursing Practice (1980). This document outlines four standards which help c l a r i f y areas of nursing accountability while taking into account the independent, interdependent, and dependent functions of nurses (see Appendix A). It clearly stipulates that nurses "direct their energies toward the promotion, maintenance and restoration of health, the prevention of il l n e s s , the alleviation of suffering and the ensuring of a peaceful death when l i f e can no longer be sustained" (CNA, 1980, p. v). The ICN Code of ethics functions as a further guide for accountable action (see Appendix B). It provides rules for action which are designed to protect the patient and represents an articulated statement of role morality as seen by the members of the profession (Beauchamp & Childress, 1979). However, while nursing has evolved an ethical code that places emphasis on the accountability of the nurse for quality of patient care and on the duty to act as a patient advocate, conflicts are occurring. Nurses are caught by competing demands which require opposing courses of 13 action and the rules do not provide adequate guidance. For example, an adolescent g i r l with a terminal illness asks the nurse i f she is dying, but her father does not want her to know, yet the nurse believes she is mature enough to cope with the knowledge. Or, immediately after the nurse witnesses a patient sign his surgical consent form, he turns and with fear in his voice, states he may have made the wrong decision and may not know enough about the surgery and, furthermore, the nurse knows that the patient is a poor candidate for surgery and that he was not told of the high risk of stroke that accompanies such an operative procedure. In such cases, i t is clear that the nurse's obligations are in conflict. With such conflicting loyalties, how can obligations be met? Davis (1980) states that an understanding of the ethical principles which underlie the ICN Code w i l l help the nurse organize the data, conceptualize the experience, and, thereby, be able to articulate a more thoughtful stance. Ethical Principles in Nursing Thus, there is a need to formulate a principled context to nursing practice by becoming somewhat more general and looking at the principled base of the ICN Code. While several ethical principles underlie the ICN Code, one is of particular importance for this study: the principle of autonomy. This principle i s rooted in ideas relating to freedom of choice backed by personal responsibility for action. 14 Kant in 1785 wrote about the notion of self-legislation in accordance with rationally chosen moral principles. His contention was that when these principles were selected with thought given to their universality and generalizability and, further, when considered ends in themselves, they would lead to right and humanitarian action (Aune, 1979). It is evident that Kant strongly favored a principle of autonomy and saw a need to enjoin action with autonomy. In theory he actually proposed that the principle of autonomy must be a necessary condition for moral judgment (Paton, 1964). Yet, while Kant favored the idea, M i l l , in 1863, adopted a more empirical bent. M i l l (1910/1977) believed that different persons required different conditions for their healthy development and advocated the need for individual diversity, originality, and self determination, insofar as they do not interfere with the rights of others and, as a consequence, promote an overall good for the greatest number in society. Once again, then, liberty of action comes to the forefront: the freedom to choose rationally remains a central ingredient for both philosophers. In the ICN Code, the principle of autonomy is evident in the statement supporting the individuals' right to act on their own values according to their own beliefs (ICN, 1973). These directions give the nurse the right to promote the individual's a b i l i t y to "set goals and make decisions" (ICN, 1973). Secondly, i t points to the individual's right to information. For as Cassell (1983) 15 notes, autonomy i s impossible without the information on which to base action. To have a free choice, one must know what choices are available. Finally, the nurse must consider the patient's right to the truth, and according to Veatch (1976), i t is the individual's right and obligation to have the truth. He notes that "rarely i s withholding information potentially useful or meaningful to the patient to be condoned" (p. 248). Although there are rare times, he admits, when this contingency must be taken into account; nevertheless, the justification for nondisclosure rests with the person who withholds. This point of view i s soundly upheld by the President's Commission (1983) in their latest document on ethical, medical, and legal issues in health care. The Commission states that rarely " i s incapacity absolute," hence, individual decision making capacity should be examined in each situation; furthermore, the c r i t e r i a for assessment should be based on lay person c r i t e r i a (i.e., one asks whether a lay person would judge the individual to have reasonable a b i l i t y and understanding) (p. 123). Evidently, after thoroughly considering ethics and health care, the Commission believes that the principle of autonomy holds prime value in our society today. A principle that has such force behind i t cannot and must not be set aside. Yet, with the ever present and expanding array of technologies and techniques available in health care, very complex human situations arise. How can nurses follow this principle so 16 that legal and ethical directives are upheld? Arsokar (1982) believes that nurses are challenged as never beforehand that they must c r i t i c a l l y examine the moral dimensions of decision making. She stresses that the process of ethical inquiry must include principled thinking, reflective decision making, and strategies for action, a l l performed within a s p i r i t of compassion and with the knowledge that nurses are members of a profession f u l f i l l i n g a social contract. Ethical Decision Making One goal of ethical inquiry is the promotion of accountable behavior where accountable means that one is responsible and answerable for one's actions (Fenner, 1980). In order to make accountable decisions, Fenner contends that nurses must have the a b i l i t y to control their practice within appropriate set boundaries. Herein l i e s the problem—the need for a more explicit refinement of the legal and ethical boundaries of nursing practice. Arsokar (1982), when she brings up the contentious issue of mind sets, seems to capture the essence of at least part of the problem. She identifies three views of nursing mind sets and notes how each view has implications for ethical practice and conflict resolution. Either mind sets are directed f i r s t l y by the medical model, secondly by the institution's commodity view, or thirdly by the patient advocacy perspective. The defining boundaries for nursing practice are often dependent on how individual nurses view each mind set. 17 When nurses view themselves through the medical model, they often see themselves as having a solely dependent role and functioning as "a safe sounding board" for others (Arsokar, 1982, pp. 24-25). At this point, they may be totally unaware that they are involved in a situation requiring nursing consideration of ethical elements. Similarly, when nurses view themselves as part of an institution which promotes health care as a commodity with efficiency and productivity to the foreground, they may feel primarily responsible to the administrative hierarchy: right and wrong may be dictated by institutional goals and policies that have not had active nursing input. Finally, i f the nurse sees patients' needs as primary without critiquing the relevance of the need, societal resources can be depleted and professional integrity lost (Arsokar, 1982). Arsokar goes on to say that each mind set leads to a certain view of correct action which may not, in fact, meet c r i t e r i a necessary for professional and ethical nursing practice. When professional ethics are not upheld, the nurse is vulnerable to reprimand, censure, suspension, or even loss of licensure, i f the Association takes action (Arsokar & Davis, 1978). What is more, in some cases, basic safe practice is in jeopardy and a nurse can be found either directly or vicariously liable by the courts. True professional practice implies a higher order of obligation—an order which encompasses principled decision making founded on professional standards and ethical values (O'Rourke, 18 1983). It is only when this is possible that the scope of nursing practice encompasses the three dimensional focus with independent, interdependent, and dependent elements of practice given appropriate consideration. Actualizing the three dimensional nature of nursing practice requires the abi l i t y to think c r i t i c a l l y about complex ethical and human problems. In considering how this is to be done, a nursing theorist, Curtin (1979) developed a model for decision making which incorporates seven categories for data: background information, ethical components, ethical agents, options, application of principles, resolutions, and actions. These categories provide for the elucidation of situation and ethical factors as well as providing for comparisons with societal sanctions and legal constraints as necessary. With this model, the decision making process can then be ensured to encompass a f u l l exposition of the problem, consideration of several options, and a thoughtful resolution prior to action—decision making becomes a very systematic process. Ethical principles, when used in conjunction with the model, provide specific guidance and help the nurse differentiate between more and less appropriate solutions. Indeed, in conflict situations, i t is even more necessary to use the model efficiently i n order to cope with both intrapersonal, interpersonal, and interprofessional differences as well as to resolve the issue. Furthermore, while the model should be used efficiently, effective use, in the sense of the quality of reflective thought 19 u t i l i z e d , i s also necessary i f e t h i c a l guidelines are to be upheld. Because, as Janis (1982) notes, when i n d i v i d u a l s are confronted with choices between complex multivalued a l t e r n a t i v e s , many w i l l simply avoid the "unpleasant cognitive and emotional work" involved i n the decision process (p. 5). E f f e c t i v e model use, then, requires c a r e f u l thought and an assessment of such thought can be made by a study of cognitive moral development theory. Theory of Cognitive Moral Development In constructing a comprehensive explanation of cognitive moral development, Kohlberg looked to the patterns of reasoning with which i n d i v i d u a l s j u s t i f y a d e c i s i o n (Hersch, M i l l e r , & F i e l d i n g , 1980). He discusses s p e c i f i c patterns of reasoning through which people can progress and organizes the patterns into three l e v e l s each having two stages (Hersch, P a o l i t t o , & Reimer, 1979). Levels and stages can be understood as follows. Levels of moral judgment are general ways of defining what i s r i g h t and are supported by a c e r t a i n viewpoint or s o c i a l perspective (Duska & Whelan, 1975). Stages, more concrete e n t i t i e s , depict the q u a l i t y of organized p o s s i b i l i t i e s and underlying thought patterns that characterize the reasoning process at a given time (Hersch, P a o l i t t o , & Reimer, 1979). Kohlberg claims that stages form an inv a r i a n t sequence or order i n development with thought patterns i n the higher stages showing increasing cognitive d i f f e r e n t i a t i o n and i n t e g r a t i o n (Duska & Whelan, 1975). Consider now how Kohlberg has f i t the two concepts of l e v e l 20 and stage together. A person at the f i r s t level, the preconventional level, approaches a moral issue from an individualistic point of view with concern for concrete consequences. Stage one and two f a l l within this level. Stage one, heteronomous morality, focuses on right as being blind obedience to rules and authority; one does what is right to avoid punishment. In stage two, with individualism, instrumental purpose and exchange in the foreground, right i s defined as following rules when they are to one's concrete immediate interest. Right is relative. Deals are accepted. One does what is right to meet one's own needs while recognizing others have needs. People at level two are at the conventional level. They approach a moral problem from a member-of-society perspective and the concern is to be a good role-occupant while protecting society's and one's own interests. Stage three and four are encompassed at this level. Stage three people rely on mutual interpersonal expectations, relationships, and interpersonal conformity. Right is trying to liv e up to what is expected. In trying to be a good person in one's own eyes and those of others, people desire to maintain rules and authority that support stereotypical good behavior. This point of view follows the Golden Rule and trust, loyalty, respect, and gratitude are important. Stage four is the social system and conscience stage, here people seek to f u l f i l duties to which they have agreed and to uphold laws unless they conflict with other social duties. The aim is to keep the institution going so to avoid breakdown in the social system. Here, individual actions are 21 considered in terms of their place in the system; right is ensuring that one meets one's defined obligations as roles and rules dictate. A person at the last level, the postconventional level, or principled level, approaches a moral conflict from a prior-to-society perspective. This perspective encompasses seeing beyond the laws and given norms of self and society in order to seek principled stances. Stage five and six are represented here. Stage five bases action on the idea of social contract or u t i l i t y and individual rights. People at this stage recognize that others may have different values and that some values may be relative to a group. However, nonrelative values such as the right to l i f e and liberty are upheld consistently. In essence, right is adhering to the social contract because i t s aim is to promote the welfare of a l l . Stage six, the f i n a l stage, refers to rational commitment to universal ethical principles. At this stage, people follow self chosen ethical principles. These principles pertain to justice, equality of human rights, and respect for the dignity of human beings as individuals; right is seeing people are ends in themselves and always treating them as such (Hersch et a l . , 1979) . It is this inquiry into reasoning about ethical and moral issues that has become the hallmark of Kohlberg's work. He notes that significant differences in the maturity of the reasoning process becomes apparent when individuals substantiate their judgment or actions with reasons (Duska & Whelan, 1975). Thus, 22 Kohlberg places major emphasis on the level and stage of reasoning utilized when an action or endpoint is being justified. Bearing the above points in mind, i t is of pertinence to this study to note that Kohlberg's theory has been c r i t i c i z e d . Three authors in particular warrant examination. F i r s t , Hersch et a l . (1979) and Sullivan (1977) believe that Kohlberg has paid too l i t t l e attention to the emotional side of reasoning and, consequently, to the relationship between knowing what is principled, right, or just, and acting on their knowledge. They both refer to individually perceived risks embedded in situational factors and to the various rational motivations involved in these cases. In addition, Gilligan (1983), in agreement, states that thought and action are inherently dialectical processes, with one intimately affecting the other: thought and action fuse within the contextual nature of the situation so that judgments often depend on the way the problem is framed. In fact, Gilligan (1982) is interested in the relational aspects of decisions made by women. She notes how different forms of self definition in women—forms based on connectedness and interrelationships—can shift individual focus from what i s right to what i s the most caring. Thus, women, she says, are pulled between compassion and autonomy. Interestingly, Kohlberg (1981) has responded to this critique by concluding that yes, i t is necessary to inquire into the process 2 3 of moral judgment and decision making that underlies action within a set context. He says that in order to do this, actual experiences must be delved into such that the individual's practical pattern of reasoning can be el i c i t e d . Here, moral choice and action occur within the context of a social group. Moreover, Kohlberg now notes., that the social group can have a profound influence on the emotions and motives of the decision maker. Action at this time may be more a function of what is enforced by the group than of the individual's stage of moral development. This latter form of decision and action, one based on real world performance, i s called descriptive ethics: one cites what actually occurs. Reference to normative ethics is made when what should have happened, or what one would have preferred, is e l i c i t e d . Obviously, what is needed in nursing is a closer view of both descriptive and normative ethics in multiple loyalty conflict situations. This view encompasses the dichotomy between facts and values; between real world pragmatics and ideal world prescriptions. Summary In review, i t w i l l be helpful i f the key factors which provide structure for the conceptual framework are integrated schematically. This can be done by diagraming Curtin's decision model and adding both descriptive and normative elements that f i t with the theory of cognitive moral development. Figure 1 provides a review to the researcher's analytic use of Curtin's (1978) model. Each category is now specific to this study and functions as a tool for data gathering. Background Information Issue: multiple loyalty conflict factors pertinent to case example Ethical Component Ethical principle: autonomy, the patient's right to choice Pertinent legal sanctions Ethical Agents Agents: those involved in the decision Options Options: alternatives preferred by health care team Resolution U t i l i z a t i o n of principles / or facts ACTION Pertinent societal expectations Figure 1. Ethical decision making model. From "A Proposed Model for C r i t i c a l Ethical Analysis" by Leah Curtin, 1978, Nursing Forum, 17 (1), p. 15. Adapted by permission. 25 Features that are essential to the study problem are added to a more refined view of the f i n a l two categories of the model in Figure 2. Here, i t can be seen how and where Kohlberg's theory i s applied and, in fact, how i t has been extended to include a comparison of rationales for normative and descriptive resolution processes and their correlative outcomes. Resolution: Descriptive Perspective Action: Performed Preconventional Stage I Stage II Conventional Stage III Stage IV Postconventional Stage V Stage VI Actual Outcome Resolution: Normative Perspective Action: Preferred Level and Stage Prescriptive Outcome Figure 2. Structural components of cognitive comparisons. The overall concern of the study is with reasoning and the patterns that come forth when a registered nurse is faced with multiple loyalty conflicts. The decision model is used as a data collection tool and the concept of patient autonomy i s used because of i t s central meaning to nursing and because of i t s direct relevance to moral and ethical issues. 26 Chapter Three: Research Design Introduction A qualitative grounded theory approach is most appropriate when the researcher intends to explore an area in which l i t t l e prior knowledge has been found (Diers, 1979). While to date no studies have been identified that pertain to the multiple loyalty problem i t s e l f , studies such as those by Ketefian (1981a, 1981b) and Crisham (1980) refer to the ethical area of nursing practice. These studies support the need for further research into the nurse's subjective experiences when ethical conflicts arise. Once individual subjective experiences of conflict within the social situation are obtained, i t is in keeping with grounded theory methodology to identify variables which explain action. These variables can then be clustered into substantive concepts: concepts embedded in the experiences themselves. In other words, abstractions are sought (Diers, 1979; Glaser, 1978). This means that important aspects of the decision process in multiple loyalty conflicts are analyzed so that the concepts and subsequent themes are woven out of pragmatic examples of real world situations. These concepts, according to Glaser, not only f i t the data, they must be interrelated in such a manner that the main contextual problems emerge. Thus, the conceptual level of the conflict situation is raised in a truly inductive fashion because the core concepts are grounded in data. The core concepts and evolving themes are then 27 looked at In relation to Kohlberg's cognitive moral development theory and, correlatively, compared to other appropriate literature sources. The aim is to develop a theoretical construct which describes the contextual nature of reasoning in multiple loyalty conflicts. In order to activate this design, particular methodological steps were taken. An explication of each step w i l l further elucidate the research process. Methodology Selection of Participants Eleven registered nurses were selected from a large urban area in British Columbia. Criteria for selection were based on (a) the respondent's a b i l i t y to speak English fluently, to provide for clarity in communication; (b) the timing of graduation being prior to the summer of 1983, to guard against data due to the i n i t i a l reality shock of the new graduate; and (c) a working schedule of at least half-time, to ensure adequate patient contact time. The respondents were selected via a method of intraprofessional referral: given the sensitive nature of the data required, i t was fe l t that intraprofessional referrals would ensure protection of privacy and alleviate any anxiety the registered nurse may feel i f his or her comments were in any way associated with a particular institution or agency. In order to do this, information was circulated informally through colleagues who provided the investigator with the name and address or phone number of nurses whom they had approached. 28 A l e t t e r of introduction was then sent to the nurse who responded by mail or phone i f w i l l i n g to p a r t i c i p a t e (see Appendix C). This method of s e l e c t i o n i s congruent with a combination of two methods suggested by Diers (1979). The f i r s t method i s c a l l e d purposive sampling. Here, respondents who "represent" the topic being studied are selected ( i . e . , nurses interested i n partaking i n a study about multiple l o y a l t y c o n f l i c t s i n nursing). Secondly, nominated sampling, a way of asking for names of appropriate i n d i v i d u a l s to include i n the study, was used. Of the eleven respondents, s i x had t h e i r diploma i n nursing, four t h e i r baccalaureate i n nursing, and one a master's degree i n nursing. Of i n t e r e s t , each nurse demonstrated the need for continual learning, a l l had taken either degree or nondegree courses for personal and p r o f e s s i o n a l growth reasons. The average age was t h i r t y with a range of twenty-four years to the m i d - f i f t i e s . A l l nurses worked f u l l t i m e . Experience ranged from three years to thirty-one years with an average of t h i r t e e n years. Eight nurses worked i n ho s p i t a l s and three i n community health centres. In the h o s p i t a l s e t t i n g , four respondents were s t a f f nurses, one a head nurse, two as s i s t a n t head nurses, and one was an assistant d i r e c t o r of nursing. In the community, one nurse worked i n long term care and the other two i n the prevention program. Data C o l l e c t i o n Two, one to one and one-half hour, semi-structured, in-depth 29 interviews were conducted with six of the respondents and one, two hour interview with the remaining five. Each interview was audiotaped and then transcribed. In keeping with the methodology, theoretical sampling was employed (Glaser, 1978). This form of sampling entails the transcription, analysis and coding of each interview so that pertinent categories of concepts and themes can emerge prior to the next interview. Memos were written and designed to elaborate upon ideas in relation to the evolving structure. Then, in subsequent interviews, data were elicited which either confirmed, denied, encouraged revision, or helped to saturate the evolving categories or concepts. Continual comparison of the similarities and differences in content between the various interviews helped to determine the structural conditions of the evolving categories, relevant boundaries were delimited and, as Glaser and Strauss (1967) suggest, conceptual gaps wereLmade more evident. Each interview had a goal. The f i r s t served as an introduction to the research process and to gain a small amount of demographic information as well as to e l i c i t information relative to the nurse's understanding of ethical principles. Examples of multiple loyalty conflict situations in nursing practice were then sought and the general decision procedure outlined along the lines of the Curtin model. Then, as noted, the interview was transcribed and analyzed. The second interview served to c l a r i f y any questions that had arisen (by either the respondent or the researcher) and to seek pertinent, 30 more in-depth data that would help to identify the level and stage of moral reasoning used in the resolution phase of the decision process. Concomitantly, data pertaining to the reasoning the nurse used to state what should have been done or what would have been preferred was e l i c i t e d , and any discrepancies between reasons for the performed action versus those for a preferred alternative were noted. Following the twelfth interview with the i n i t i a l six nurses, certain conceptual patterns and ways of responding to conflicts arose and by that time much of the required data was obtained in a two-hour interview. Therefore, single two-hour interviews were conducted with the remaining respondents. Data Analysis and Interpretation Inductive and deductive methods were utilized in the data analysis and interpretation. Inductively, significant substantive quotes were noted and particularly descriptive events demarked for future use in identifying and "sensitizing" the chosen categories (Glaser & Strauss, 1968, p. 24). Deductive methods were uti l i z e d both to compare and contrast inductive results to various concepts and theories already in the literature, as well as to determine how the emerging concepts and themes related to the rationale for the study, or as Glaser and Strauss note, to assess the relevance of the beginning "foothold concepts" (p. 45). However, as Glaser's (1978) warning was heeded, a balance between the two logics was maintained, with the deductive in the service of the inductive. 31 The continual comparing of the grounded material with the more abstract deductive tended to force the investigator to generate categories and concepts, and to explore their properties, interactions and limitations u n t i l saturation of conceptual categories occurred (i.e., no additional data was found which contributed further to the categories) (Glaser, 1978). At this point, a way of thinking about the reasoning process involved in the conflict situation, which was grounded in data, emerged. This type of analysis incorporated a continual referral to and assessment of patterns of reasoning as detailed in cognitive moral development theory. In addition, core concepts were sought from within the data concepts that would provide a view to the nurse's subjective experience at the time. It was thought that experiences would contribute to some extent to reasoning ab i l i t y ; hence, Crisham's concern with milieu effect was addressed, and as Kohlberg's critiques and then Kohlberg, himself, admitted, the contextual nature of the situation did contribute to variations in reasoning patterns. Ethical Concerns The rights of the research subject were upheld, confidentially safeguarded, and permission to withdraw from the study at any time, granted. Subjects were also informed that they may refuse to answer any questions. Information which elaborated on these concerns was provided in an introductory letter and a signature acknowledging consent was required before data collection began (see Appendix D). 32 Potential risks which had i n i t i a l l y been foreseen related to the affective domain. For example, i t was f e l t that feelings of sadness, frustration, or anger, might have arisen as nurses discussed conflicts in their practice. It was f e l t necessary to observe for such emotions and to acknowledge them should they arise; moreover, time was then to be set aside for the subject to verbalize feelings associated with the issue i f they so desired. Limitations to the Study Concerns related to study limitations are threefold: F i r s t , eleven respondents provided adequate data for category development and description of themes, however, a larger sample would have aided further descriptive refinement within each theme; secondly, selection by the method of intraprofessional referral could possibly have provided a biased sample as only those nurses who have problems with the ethical decision process responded; f i n a l l y , the goal of the interviews was to u t i l i z e open-ended questions to promote in-depth discussion, nevertheless, the investigator may not have made sensitive enough discriminations between pertinent and nonpertient data. With these considerations in mind, the generalizability of the findings is limited. Summary An exploratory grounded theory design proved to be effective and concepts and themes which described nursing responses to multiple loyalty conflict were derived from the data. Reviews of pertinent 33 l i t e r a t u r e a i d e d i n c l a r i f y i n g v a r i o u s p r o p e r t i e s o f e a c h c o n c e p t u a l d i m e n s i o n and h e l p e d t i e s u b s t a n t i v e c o n c e p t s t o f o r m a l t h e o r y . A l t h o u g h t h e s a m p l e was s m a l l and t h e r e b y g e n e r a l i z a b i l i t y i s r e d u c e d , a d e q u a t e d a t a was g a t h e r e d r e s u l t i n g i n a g r o u n d e d t h e o r e t i c a l p e r s p e c t i v e . 34 Chapter Four: Data Analysis Introduction The purpose of this chapter is to demonstrate how a substantially derived framework of core concepts, categories and themes relates to and describes factors from the empirical data. F i r s t l y , types of multiple loyalty conflict are identified; secondly, the substantive concepts are outlined and linked to cognitive moral development theory. Each dimension of the main concept i s then defined, supported by themes and quotes and fi n a l l y compared to pertinent concepts and theories in the literature. Part One Multiple Loyalty Conflicts Many varieties of conflicts were noted by the registered nurses as they corelated their views on conflict of loyalty situations with their beliefs about patient autonomy. Situations described by the respondents included (a) intrapersonal conflicts with personal-professional ambivalence (i.e., the nurse agreed to a resolution which created some sort of inner personal turmoil); (b) intraprofessional d i f f i c u l t i e s between nurses (i.e., a nurse views time with the patient as important whereas nursing administration bases priority on productivity and efficiency); (c) interprofessional problems with physicians and social workers (i.e., conflicts between domains of practice); (d) ambiguities arising between duties to the institution versus those to the profession i t s e l f (i.e., institutional policy 35 statements which do not support high standards for nursing); (e) awkward situations with overbearing or uninterested family members (i.e., dealing with relatives who demand certain therapies without consulting their family member, or conversely, coping with family members who do not assist a more dependent member when i t i s necessary). In many instances, the conflict was based on a question that lay just beneath the surface of the problem: What is an appropriate, f a i r and just balance between the individual's right to autonomy, the individual's duty to be a responsible citizen versus the reciprocal rights and duties of a responsible society toward i t s citizens? It is the individual nurse's answer to this question that often seem to contribute to how the conflict is resolved (i.e., to what, within the nursing range of responsibilities, was permitted to happen). Substantive Concepts An analysis of data shows that nurses tried to resolve multiple loyalty conflicts by seeking ways to promote patient autonomy, however, varying perceptions of relevance hindered their efforts. And the whole idea of perceived relevance, the study's major substantive concept, li e s within the notion of individual perception of self and the importance of one's person in a particular situation. The data suggest a three-part categorical breakdown of perceived relevance. This breakdown is based on the respondent's perception of self in the conflict, which contributed to how important nursing input was 36 perceived to be, to how the nurse chose to cope with the situation and to how the nurse would have preferred to have coped with i t . Evidence to support this categorical outline became noticeable both when the respondents tried to express what they did at the time of the conflict and when they attempted to explain why they made the choice they did. A definite three-dimensional operationalized schema of self interpretation evolved as subjective interpretations provided similar reasons for action even when the content of the conflict situation differed. The dimensions are categorized as follows: The f i r s t is based on the perception of inequality or disparity in professional contribution, a second on the limitation or restriction inherent in a complex conflict situation which takes place within an institutional framework, the third on the perception of equality and feelings of accountability. Substantial support for part of this conceptual schema has been found in the writings of one author in particular, Alfred Schutz (1970). He attempted to synthesize ideas from the sociologist Weber and the philosopher Husserl in order to provide a framework which would support a meaningful construction of social reality or, in other words, phenomenological sociology. Schutz's (1970) writings are found to support the basic idea of this study as he firmly believes that consciousness is tied to concrete experiences. He is concerned with how individuals attach subjective meanings to particular experiences. To Schutz, perception of what 37 is in fact relevant is based on what i s expected or what has become typical in the situation. He defines perceived relevance as the importance ascribed by an individual to aspects of specific situations when the individual's multifarious interests and involvements are considered. These interests relate to domains of relevance. While Schutz l i s t s several such domains, two are pertinent to this study. The f i r s t is that of imposed relevance. This means that a particular way of viewing a situation i s forced or urged on another. The second domain of value is that of volitional relevance whereby freedom to choose how to view a situation is granted. Schutz's perspective provides valuable assistance not only in supporting the need to study subjective interpretations of experience, but also in helping to cl a r i f y the meaning and to give the labelling of two of the substantive categories: relevance based on inequality now refers to imposed relevance and that based on equality is now volitional relevance. The middle category w i l l be called bounded relevance. Operational definitions, based on a deductive refinement of the inductively discovered concepts, are as follows: Perceived relevance. The view of self as i t pertains to the subjective interpretation of the multiple loyalty conflict situation. 1. Imposed relevance. The perception of inequality based on a set of firmly held expectations. 2 . Bounded relevance. The perception of limitations based on the need to maintain relationships or uphold rules. 38 3. Volitional relevance. The perception of equality expressed as the right to participate and to make choices congruent with self chosen ethical principles. The subjective interpretation of conflict in a concrete situation results in a certain perception of what is relevant followed by the need to resolve the issue in some way and to act. However, when one steps back and reviews the situation, the need to become objective and to seek a more ideal solution is natural. This perspective provides a normative view. In such cases, the subjective world view takes on a lesser importance and pure, abstract, more objective cognition becomes primary. Hence, in order to view thought forms of the descriptive and the normative views together, the three-dimensional nature of the core substantive concept is integrated into the framework of cognitive moral development theory. This inclusion provides a comparative view of the theoretical and the contextual descriptive nature of multiple loyalty conflicts. Theoretical Integration In order to understand how pragmatic real world phenomena can be integrated with cognitive moral development theory on a two-level, descriptive and normative basis, i t is f i r s t necessary to explain the manner in which the linkage occurs. As the study began i t was unclear just how this theory to practice link would occur. It was not clear just how deeply subjective interpretations would affect patterns of reasoning which contribute to normative viewpoints. For example, Flaherty (1981) notes how nurses have traditionally 39 based arguments for or against action on emotive elements. Hence, i t was thought that nurses would not be objective and there would be less of a gap between the structure of descriptive and. normative reasoning than proved to be true. However, respondents were consistently rational and objective when asked to provide a preferred resolution and outcome in conflict situations. In short, when asked for descriptive details, affect and emotion intertwined with cognitive factors. But when responding to questions that e l i c i t e d normative aspects of thought, the nurses' patterns of reasoning were grounded in the cognitive domain. Bearing this factor in mind, i t soon became evident that the phenomenologically experienced conflict situations could be better understood by u t i l i z i n g the three-dimensional substantive concepts along with the theory of cognitive moral development to discuss the descriptive case examples and then refer singularity to cognitive moral development categories to outline the normative view. Figure 3 outlines this relationship. Perceived Relevance: Descriptive Analysis Preconventional Conventional Pos tconventional Stage I, II 1. Imposed Relevance Stage III, IV 2. Bounded Relevance Stage V, VI 3. Volitional Relevance Themes: Themes: Themes: Normative Analysis Level and Stage Figure 3. Structural components of cognitive and affective comparisons. 40 Part Two A. Imposed Relevance At the preconventional level the nurses f e l t that a selected set of rules and facts were imposed on them and that there was a strong positive correlation between their personal-professional welfare and obedience to these impositions. While nurses had one view of what supporting patient autonomy actually meant to them, they f e l t forced to compromise their beliefs to the point of consciously agreeing to u t i l i z e patterns of reasoning congruent with Stage I and II thinking. Needless to say, loyalties were torn and ambivalence expressed. Themes for this category f e l l uniformly under the heading of one major principle: The nurses perceived that blind obedience to rule was the most relevant factor for a l l decisions. Promotion of patient autonomy, while at times attained subversively, became a third priority: f i r s t priority went to obeying rules (both overt and covert); second priority to self protection; and third, to the patient. Themes of anger, resentment, and revenge followed as nurses tried to cope with a highly compromised sense of professional integrity. In the examination of specific cases i t can be seen how patterns of reasoning reflect each of the above three themes and how the patterns of reasoning change when objective consideration is given to how patient autonomy could have been promoted. Several of the worst examples of unprofessional behavior and 41 most blatant neglect of patient welfare occurred when professional relevance is placed secondary while unjust rules of "correct" behavior take precedence. The f i r s t episode occurred in a c r i t i c a l care unit. It depicts the theme of anger and shows how the nurse could not protect her patient's right to adequate medical treatment. Theme: Anger  Case #1 Descriptive analysis. A patient had a severe cardiac conduction problem and was in need of an AV sequential pacemaker. At present the ventricle needed pacing; however, i t was f e l t that before long the atrium would need pacing as well. A surgeon who has a reputation for drinking was called in. The patient was informed of the conduction problem and consented to having an AV sequential pacemaker installed. The surgeon arrived in the operating room inebriated. Although he had performed surgery in that operating room before, he could not find the theatre. R: He apparently was smelling of alcohol . . . one of the OR nurses had to lead the doctor to the operating room. And this was witnessed by the representative from the company who spoke to me about i t because he was quite upset. At this time the pacemaker representative also told the nurse that he had asked to go into the theatre with the surgeon so he could explain how this newer pacemaker worked—this is the usual procedure when new equipment comes on the market. The surgeon refused. This nurse, who was now caring for the patient, knew that i n i t i a l l y the leads to the pacemaker had been connected up backwards 42 and the patient had to return to the operating room within 24 hours for another anaesthetic. Yet, s t i l l the a t r i a l lead was not connected up properly. So on the third day the director of the unit had to decide whether the patient should have a third surgery or whether the a t r i a l lead should be shut off. R: What the director decided to do was to turn off the a t r i a l portion and just leave the patient with a ventrical pacemaker, so what i t means is that she has a wire in her heart that i s functionless and that i f she ever needs a t r i a l pacing they w i l l have to operate again and put in a new a t r i a l lead and i t is just not a happy situation because i t is a pacemaker that costs a lot of money. I: What is a lot? R: Twenty thousand dollars. The conflict between promoting the rights of the patient and dealing with a set of facts that state, the physician is right, proved most d i f f i c u l t . Not only did a nurse lead the inebriated physician to the operating theatre, but also the c r i t i c a l care nurses noted that he was "smelling of alcohol" and reported this to the head nurse. I: It was reported that the man was inebriated two times? R: Yes. I encouraged the representative of the pacemaker company to t e l l her this. I: It was the representative of the pacemaker company that had to t e l l the director of the unit? R: That's right. I: Not the operating room nurses? R: No. And also the director basically said, after the pacemaker representative l e f t the unit, " I ' l l never use 43 these pacemakers again, there must be something wrong with them." But there's nothing wrong with his pacemaker. What's wrong i s the person the director has putting them i n — t h e director just won't admit that! I: The director won't admit i t but the pacemaker representative did say that the surgeon was inebriated? R: Yes, he did. I: And the response was to deny the fact?" R: Hmm. I: Just deny it? R: Yes, just nothing. And i n the meantime we had documented this for the head nurse, right, that he had come i n — I: Documented, how? R: We have a report that i s called a nursing practice form. I: Okay. R: And i t was given to the coordinator who ripped i t up. I: The nursing coordinator? Why did she rip i t up? R: Because she said that the solution recommended was inappropriate. I: What about another form then? R: Well, apparently, i t was going to be followed up but we've had no—no one has ever come back to us and said that i t was looked into. I: But the point is that the formal complaint was torn up. R: That's right. . . . This form i s a nursing practice form. . . . We are actually reporting medical practice, and we have no real form in our hospital to report medical practice. I: Do you think you should have one? R: I think so, yes. I think not to be vindictive or anything, but I think there are times when nurses witness things that 44 are c l e a r l y negligent or incompetent or we see a physician p r a c t i c i n g under the influence of drugs or alcohol and we have no protection. Because who do we complain to? I t ' s hard to complain to the medical d i r e c t o r who i s not there to see things. I t ' s your word against the physicians. You can't complain to the physician's a s s o c i a t i o n because again i t ' s t h e i r word against your's. . . . I think sometimes that there i s a r e a l moral and e t h i c a l issue i n terms of there are l o t s of times when I f e e l l i k e I would l i k e to t e l l t h e i r patients and t h e i r f a m i l i e s . I: T e l l them what? R: That they have suffered grievously at the hands of an incompetent physician. Their physicians have admitted error. I: To? R: To another physician. But, they won't t e l l the pati e n t s , so the patient goes home never knowing how his case was screwed up. But we can't do that. I t ' s unethical for us to do that, to go and t e l l a family, you know, t h i s doctor r e a l l y screwed you around. So here we have anger directed at the system which protects such behavior, and sorrow because when patients i d e a l l y could be warned the p r e v a i l i n g r u l e makes such a warning unethical. When asked what she would have preferred to see happen, t h i s nurse stated that a proper form should be devised and, as w e l l , the operating room nurse should have c a l l e d the nursing supervisor to come attend to the surgeon. Plus, of course, further action was demanded of the head nurse. Because of th i s and s i m i l a r a c t i v i t y , the morale i n t h e i r unit i s low and nurses face continual c o n f l i c t when they attempt to deal with i t . R: Nurses have discussed the problem at length and have discussed i t with the head nurse who has attempted to discuss i t with the d i r e c t o r involved. But i t doesn't— there i s no r e s o l u t i o n because t h i s physician hasn't a 45 terribly high regard for nurses. And I mean, we have a new head nurse almost every year because of this. This means there is obvious conflict,,you know, really obvious. And the fact that the physician doesn't see this as a problem is a problem. I: What would you prefer? Is there any route to resolving this that you can see? R: Yes, I think there is a route but i t is not an immediate short term answer. It's a very long term route and I think i t relates to nursing i t s e l f as a profession, you know, . . . about nurses being women and how they express themselves, how they communicate because they are women, how they exercise their judgment within the power structure, how they try to affect change and f a i l because they don't go about i t properly. I think i t has to do with the cred i b i l i t y that our profession has not established for i t s e l f because we are not recognized as having a body of knowledge that is independent from medicine or being a discipline that is independent from medicine. And I don't mean independent a l l the time because some of our functions are interdependent, but, you know, just being an entity of it s own. I think the fact that nursing has no power in many health care systems, power to be involved in significant decision making, we're always affected dramatically by decisions but we are not usually at the hub of the decision making process and that involves nurses becoming more p o l i t i c a l and getting more control of the decision making process that affects their lives so dramatically. Boards of Directors of hospitals seldom have nurses on them, yet what are hospitals for i f not for nursing? . . . Hospitals should function for nurses and nurses should be the prime decision makers. She goes on to say that rarely do Boards of Directors show adequate representation. R: Two of the main interests in the hospital, the consumer and the nurse, are not represented—that has a great impact when i t comes to allocation of funds and when i t comes down to even just the respect that is accorded the nurses in the hospital and the respect that is accorded the patients or users of the hospital. I: So you are saying that a whole attitude change is necessary before nursing could have something to say to that physician director? 46 R: Yes , because as i t i s r i g h t now i n our h o s p i t a l , the medical people can interview for s e l e c t i o n of people for nurs ing p o s i t i o n s but the nurses don ' t interv iew for s e l e c t i o n of medical people for medical p o s i t i o n s , so there i s a c l e a r s u p e r i o r i t y s i t u a t i o n set up where one has c o n t r o l over the other , where one a f fect s very much the l i f e of another without r e a l l y having a great knowledge of what the other even does. You know, I th ink there are a few doctors who know what nurses r e a l l y do. The same th ing appl ies at the p o l i t i c a l l e v e l , but much higher i n our government where you have hea l th care planners who p lan hea l th care but don ' t take the advice of the people i n hea l th care a l l that w e l l . You get the white paper on hea l th care that was generated by the H a l l Commission. How long ago was that and yet we haven' t r e a l l y seen any concrete evidence that there i s a change i n our p o l i t i c a l a l l o c a t i o n of funds i n hea l th care to preventat ive work, or to community work, where there i s even a de s i r e to save money by a l l o c a t i n g funds to le s s c o s t l y forms of treatment. And I'm t a l k i n g about a l l h o l i s t i c th ings , a l l preventat ive programs, or us ing nurses as an access to the hea l th care system. C l e a r l y , the lobby i s i n from other groups which prevent th i s from happening. So nurses are not represented w e l l enough at the government l e v e l and by saying that the d i r e c t o r of our p r o f e s s i o n a l a s soc i a t ion meets with the M i n i s t e r of Heal th twice a year to discuss c e r t a i n issues causes despair for me, i t ' s not even funny. I t gives me despair because what that means i s that we are not an a c t i v e p a r t i c i p a n t i n the d e c i s i o n making process . I : That i s r e a l l y an i n t e r e s t i n g answer because what you've done i s you've taken the problem r i g h t i n your u n i t and you've b u i l t i t in to the broader h o s p i t a l s and the broader p r o v i n c i a l p o l i t i c a l scene to the n a t i o n a l scene. So that kind of problem i s r e a l l y , I gather, a t y p i c a l one i n nursing? R: We've ju s t had a s t a f f meeting about the morale i n our u n i t l a t e l y because i t i s very low and I might add that tha t ' s not unusual . I : In your u n i t — R: I t ' s not unusual i n my h o s p i t a l . I th ink the morale i s genera l ly low among nurses r e a l l y , the ones that I know are not happy wi th the pro fes s ion for one reason or another and most of them s ta te that i t i s not the job per se that makes them unhappy, i t ' s the condi t ions and the communication 47 and a l l those other externals that are a part of your job and a f fec t your l i f e dramat ica l ly at work. I ju s t sor t of laugh when my head nurse says that we are going to so lve the problems of morale at our s t a f f meeting because we don' t have any c o n t r o l over the things that get us down; you know, I think t h a t ' s i t r e a l l y . I th ink there i s a c e r t a i n amount of your own a t t i t u d e you can have c o n t r o l over and to be f a i r , you can be p o s i t i v e and t ry and struggle for be t ter working condi t ions and so on, but , on the other s ide of that c o i n , when you are already g i v i n g so much of y o u r s e l f , there i s not a l o t l e f t to have to dea l wi th a l l those externa l s tresses too. The externa l s tresses are the ones I think that are r e a l l y hacking away at nurs ing r i g h t now. I t ' s making i t a less de s i r ab le p ro fe s s ion . I t ' s making the nurses leave . I t ' s making nurses not come i n , you know, p o t e n t i a l nurses , because i t ' s a job i n which you don ' t have any c o n t r o l over your own d e s t i n y , almost. You ' re there and you ' re at the beck and c a l l of the system and your l i f e i s not your own. You know, even your o f f duty l i f e i s not your own because y o u ' r e subject to c a l lback and the working hours are so t e r r i b l e with s h i f t work. Having to work ro ta t ions of seven or e ight days .o r , worse y e t , regress ing to twelve-hour s h i f t s which—the labor movement has s truggled for years to get people out of sweatshop work hours of twelve hours a day. down to decent work hours. Nurses have regressed to that out of s e l f defence so that they could have some time of f away from t h e i r job . I t shouldn ' t have to be that way and I th ink that the fact that i t i s allowed to happen bespeaks f i r s t of a l l of the respect the nurses have for themselves and, secondly, to the respect that soc ie ty has for nurses . And so with a l l these ex te rna l s , how can the nurse have c o n t r o l over her working s i tua t ion? I : So you think that i t i s hopeless , almost, to change the morale? R: Yes , I do. I th ink that the best that a nurse that I work with can do today i s she can say, " I am going to go to work and when I'm at work I'm going to do the best job I can do for my pat ient s and hope that nobody gets i n my way." And i f somebody s a i d , d id you have a good day or a bad day, to me, a good day i s when I am allowed to go to work and do my job as I see i t without ge t t ing has s led . Normative a n a l y s i s . This nurse i n a most eloquent monologue voices the i s sue most c l e a r l y . What should or could have been done 48 i s backed up by Stage VI thinking. This nurse is aware of the rights of consumers and of nurses. She is aware of the social contract nurses have made via the nursing Act and expressed in the nursing Code and Standards of Care document. She sees the need for nurses to promote and protect their rights so that, in turn, the rights of the patient can be upheld. A certain u t i l i t a r i a n perspective, a tra i t of Stage V reasoning is. noted when she states those who ought to benefit by the health care system are the consumers. This, she says, includes us a l l ; therefore, the health care system should benefit the consumer f i r s t . She pleads for fai r and beneficial practices. But caught by the relevances of the milieu situation she not only continues to care for a patient who has an inebriated surgeon, she is unable to do anything when the nurses' complaint is torn up and the surgeon returns to perform the second surgery. Pragmatic concerns based on self interest led to a pattern of reasoning at the time that is classified as Stage I because the nurse did not want to deal with the wrath of a controlling authoritative director. The second case, depicting similar reasoning, brings up an example of how severe the pull on loyalties can be when tension exists between promoting what a patient desires and protecting oneself i n an unsupportive environment. Case #2 Descriptive analysis. This incident occurred when a nurse from another agency was observing a caesarean birth in a health care 49 institution. Background factors revolve around the desire of the prospective parents to see their baby's birth: the woman had requested an epidural anaesthetic and the physicians involved had agreed. Prior to the actual i n i t i a t i o n of the anaesthetic several facts which would influence this case require mentioning. The obstetrician was to be thirty minutes late. With this in mind, the general practitioner "who was in a hurry" continually urged the anaesthetist to administer the epidural. The anaesthetist firmly refused stating that i t was against hospital policy to administer epidurals before the obstetrician was in the theatre. R: So we were about ten minutes late and we got a phone c a l l that the obstetrician was on his way but i t would be ten or fifteen minutes yet. And so again the family physician kept pressuring, "come on, give her the epidural, let i t take effect so that as soon as the obstetrician comes we can get in there." This was kind of on the sidelines because the woman was awake and the husband was there as well. So the anaesthetist kind of ignored him and then said, "No, I w i l l not do that." So eventually the obstetrician arrived and she was given the epidural right away. Well, i t was either slow to take effect or i t wasn't taking effect, so they gave her a second dose of the epidural in about ten minutes when they realized nothing was happening. And they were, both doctors were, the obstetrician and the family physician, were s t i l l in a hurry so without waiting to see i f the second epidural was going to work, or had worked, they incised her! I: Incised her? R: Incised her and she is awake and feeling and screaming with pain. And the c l i n i c a l nurse pops her head in the door to see what was going on and she whipped the husband out the door right away when she heard the screaming. And then a l l I could hear was both doctors saying, "Get her out, get her out, quick, quick, quick." So the anaesthetist then administered the mask to give her the general anaesthetic. And as she was going under she was s t i l l screaming at them, 50 "No, no, I want to be awake, wai t , wa i t , I want to see my baby b o r n . " And she was out. I : Even when she was i n a l l that p a i n , she was s t i l l say ing , " w a i t , I want to see my baby"? R: " I want to be awake, I can stand the p a i n , I want to be awake." . . . She d i d n ' t r e a l i z e that they were doing a very wrong th ing . But I d id and so d id everybody i n the room. And I was abso lute ly h o r r i f i e d . I was ju s t s i c k to my stomach and I watched the nurses and I cou ldn ' t understand why the nurses were, you know, why they d i d n ' t say to the o b s t e t r i c i a n , "no , wait ten minutes , " or even to the anaes thet i s t , "wait ten minutes to see i f the epidurals w i l l work . " Why they d i d n ' t say, "no , s t o p . " But i t was l i k e a conspiracy almost. I : To go along wi th the doctors? R: Yes , the doctors had the power and everybody e l se went along with i t . I was ju s t so angry and jus t so confused and l i v i d . The doctors were so cold and i n a hurry . I was r e a l l y shaky a f ter i t was a l l over and I thought—my e t h i c a l sense s a i d , " I should t e l l th i s couple that what went on i s t o t a l l y u n e t h i c a l . " This nurse d i d not do t h i s . She reported the inc ident to the nurse c l i n i c i a n at the i n s t i t u t i o n . She reported i t to her immediate supervisor and to the two supervisors above the f i r s t one. F i n a l l y , the nurs ing d i r e c t o r of the agency where she was employed had her w r i t e a l e t t e r with the d e t a i l s and send i t to the i n s t i t u t i o n i n quest ion. Before th i s l e t t e r was sent , (a) the nurse had to rewr i te the l e t t e r severa l times to " so f ten the tone" of i t ; (b) the medical d i r e c t o r of the agency had to review i t and suggested that the Col lege of Phys ic ians and Surgeons be n o t i f i e d , but the Col lege refused to speak to the p h y s i c i a n s ; moreover, (c) the l e t t e r was not addressed to the adminis trator or d i r e c t o r of nurs ing but to 51 the c l i n i c a l nursing s p e c i a l i s t of the u n i t . An answer concerning followup was never received. This nurse i s angry and s t i l l somewhat h o r r i f i e d as she r e l a t e s the event three years l a t e r . When asked what she would have preferred, she made t h i s statement. R: I wish my thoughts and emotions had been together enough so that I would have spoken up and sai d , "Stop," you know, "Why do you want to cut her when you haven't waited for the epidural to take e f f e c t ? " I wish I could have been c o l l e c t e d enough to say that r i g h t then. I would c e r t a i n l y have caused a commotion and I probably would have been thrown out. I believe that t h i s husband and wife read books, asked questions and knew what they wanted. Well, I handled i t the proper bureaucratic way, but I am s t i l l angry. This nurse did check several times over a number of months to see i f mother and baby were f i n e . They were. Normative analysis. In t h i s case as w e l l , r i g h t became Stage 1 b l i n d obedience to authority because the nurse's intent was to avoid punishment. She knew she would not be supported i f she had taken a pr o f e s s i o n a l stance. Several i m p l i c i t rules were obeyed here: (a) do not i n t e r f e r e with the physicians even i f your " e t h i c a l sense" t e l l s you to; (b) do not inform patients of t h e i r r i g h t to q u a l i t y care i f i t has not been maintained. The nurse f e l t unequal. Numerous very powerful i m p l i c i t guidelines directed her behavior. Nevertheless, with opportunity to r e f l e c t , Stage V thinking i s evident. She f e l t a duty and an o b l i g a t i o n to uphold the r i g h t s and hopes of the expectant mother and father. She f e l t that they 52 had made an informed choice and that their decision should have been respected. In the next case, right becomes: relative; instrumentally speaking, the nurse has to get along with others on the health care team. She perceives herself as unequal but capable of at least trying to organize a degree of fair exchange in the sense that, although unequal, she is a needed participant. On this basis, she tries to provide support for families in need. Case #3 Descriptive analysis. A member of a family was dying. The nurse was making rounds with the family doctor, "who just comes in and out of the situation and is not heavily involved in i t . " He said, "Don't t e l l the family [he is dying], they are not ready for this yet." R: We nurses have seen the family every day for the last two weeks and they are si t t i n g there in absolute anguish wondering what is going on. I recommended that the not-tel l i n g approach is not very feasible, but my statement was ignored. They [the doctors] don't pick up on anything they don't want to pick up on. People who shirk these kinds of responsibilities shirk them a l l along the way— they won't pick up on these things. I: What happened to the family? R: Hmm. I: Would someone t e l l them, a doctor, a nurse, or would they be l e f t longer? R: Oh, easily. Their anguish affects nursing a lot more than i t does some aspects of medicine. I: How does i t affect them? R: How, in that the family practitioner, at most, may see this 53 family three minutes a week. We nurses see the f a m i l y — i n a twelve-hour s h i f t you see them for s i x hours. Each case being d i f f e r e n t you know. Did we l e t t h i s family s i t i n anguish? Yes we d i d . Again though, i f the family comes i n and asks the appropriate quest ions , you can introduce subjects which w i l l a l l e v i a t e some of t h e i r anguish. I : What kinds of subjects would you introduce? R: Hmm. Are you wondering why he i s n ' t breathing on h i s own? You know, i s t h i s something that concerns you? By t h e i r responses y o u ' l l know i f they want a simple answer or an indepth answer—you s t a r t out simply and meet t h e i r needs. I : Why would you introduce such questions? R: I t i s so obvious. They are there and they look to you. They present themselves i n a s ta te of anxiety and worry and horror at what i s happening. You are there looking a f ter t h e i r family member and f e e l qu i te respons ib le for what i s happening. I : For the fami ly , too, you mean?" R: You f e e l respons ib le for the pa t ient and the cond i t ion he i s i n . I mean—this i s a person who i s s i g n i f i c a n t to someone e l s e . I don ' t see them as separate. In t h i s case, the nurse perceived the family had a need to know; neverthe les s , t e l l i n g becomes a covert quest ioning and answering process . The nurse exclaims i n anger, "Why go through h e l l when you don ' t have t o ! " "When simple knowledge and understanding w i l l put you at ease for a b i t , I think th i s i s the l ea s t people deserve . " The nurse in terpre ted what was r i g h t by how the family responded to vague h i n t s she gave and the p h y s i c i a n in terpre ted r i g h t from information gleaned i n short weekly v i s i t s . When asked what she would p r e f e r , t h i s nurse made the fo l lowing response. R: I th ink , genera l ly speaking, nurses should represent the human f ac to r . Nurses are the " s t a te of the a r t . " We are 54 the ones that encourage the medical personnel to be more human. Seeing doctors as a support system for nurses hasn ' t been one of the things I 've observed or with the p a t i e n t s . For example, to recognize that t h i s pa t i ent i s a human being with a family wi th problems with needs for interact ion—we present th i s to the doctors who care about i t . I : You choose who you present i t to? R: Oh, abso lu te ly . Some are too busy. There are l o t s of times when that r e a l l y i s t rue , too. I t ' s ju s t that those who r e a l l y care go through a l o t more anguish about being too busy than the others who w i l l d e l i b e r a t e l y be too busy. But the nurse needs support i f she i s to remain humane and empathetic and to dea l wi th her f e e l i n g s . I see abso lute ly no support for the nurse i n that r o l e . I th ink that i s j u s t b l u n t l y i t . You b r i n g with you, as a nurse, what you are , whatever your h i s t o r y has been. There were some nurs ing i n s t r u c t o r s who had the capaci ty to encourage the element of humanity. Though, i t a l so comes wi th growing up, experiencing a l o t of things y o u r s e l f . Perceptions change. I t ' s through growth. And as the humane aspect grows I think the q u a l i t y of nurs ing grows too. Normative a n a l y s i s . Stage II patterns of reasoning are evident here as the nurse explains how she copes with th i s kind of c o n f l i c t . She arranges a quest ion and answer sess ion with the questions geared to subt ly tes t the family to see how she can best meet t h e i r needs for information—how she can best r e l i e v e t h e i r anguish due to not knowing. But the nurse i s angry about t h i s because she r e a l i z e s how chance and luck are r e f l e c t e d i n how a family i s t rea ted . She a l so notes that , "Many nurses withdraw from th i s dilemma by not becoming over ly involved i n the human f a c t o r . " She says that th i s nurse "does her. work, provides cursory news of the days without i n v i t i n g anything e l s e — t h i s keeps her emotionally s t a b l e . " Nevertheless , i n her statement of preference , she speaks wi th Stage IV 55 patterns of reasoning. She be l i eve s that nurses should remain humane helpers seeing pat ients as human beings i n need of sustenance, support and informat ion . Desirous of mainta ining the system wi th nurses who can provide such care , she asks for support for nurses . Each case represents a typology of inc ident s which depic t the dependent and unequal nature of the nurse ' s percept ion of her r o l e . These nurses responded with anger. At times, though, t h i s same percept ion of i n e q u a l i t y i n relevance led to the themes of resentment and the presence of f ee l ings of indignant d i sp lea sure . Theme: Resentment Prov id ing an example of how resentment forms, th i s nurse ou t l ine s the steps i n the process . She has observed what happens wi th s t a f f nurses who i n i t i a l l y t ry to promote what they b e l i e v e i s necessary for t h e i r p a t i e n t s , yet are defeated by the system. Moreover, th i s nurse h e r s e l f , though on a broader l e v e l , voices resentment. She be l i eves that nurses must l ea rn to funct ion as pro fes s iona l s before they w i l l be able to a s s i s t pa t ient s to vo i ce t h e i r own dec i s ions or provide adequate care for the dependent p a t i e n t . Case #4 D e s c r i p t i v e ana lys i s R: Nurses say to me, " C a l l t h i s phys i c i an for me." I say, "Why?" The response i s i n v a r i a b l y , " I don ' t want to c a l l t h i s p h y s i c i a n because the l a s t time I c a l l e d , he was mean." The nurses seek about u n t i l they can f ind someone to c a l l for them. I : Is i t because they f e e l they 've been mistreated at some point? 56 R: They feel they have been. Of course i t depends on the emotional maturity of the people [nurses] involved. I: In other words you need people who are mature and w i l l continue to c a l l . R: Yes. When asked i f these other nurses w i l l c a l l , she answered, R: Oh, they'll make the c a l l i f they absolutely have to, but i t ' s not made with a good tone of voice. Do you know what I'm saying? I: Are they almost setting themselves up because they are resentful? R: They are ready for him to y e l l . A lot of nurses bear grudges because the nurses may make a suggestion and the doctor basically tosses away a suggestion which shouldn't be a suggestion—it should be prudent medical treatment at this point in time. And as far as I know, he has no reason to do that. That's the kind of thing that prevents nurses from taking the risk the second time. I think that's why a lot of things get l e f t . At times, she mentions, nurses w i l l put their request i n writing. R: I try to get them to sign their notes, sometimes they don't, but i t then certainly has a degree of anonymity to i t which offers them a comfort zone. I: So a comfort zone comes from writing an anonymous note. R: So he can throw i t away—it's not as embarrassing to them. I: To the nurse? R: Yes. I: In general, when that happens, do the physicians just not want nursing input, or is i t that they don't agree with the suggestion? R: It depends on the physician. There are some who do not want nursing input. They are the paternalistic Gods and they know what to do. And there are some who wouldn't know a good suggestion when they hear i t . And we do have 57 a f a i r number of family p r a c t i t i o n e r s who f a l l under that category—some because they have been p r a c t i c i n g for too long without keeping up. I : Are you say ing , that because they have not kept up, they wouldn't recognize a good suggestion? R: Yes. When i t i s something that i s r e a l l y going to in f luence pa t i ent care , I go the medical management team. This team has the a b i l i t y to put pressure on doctors . I : They l i s t e n to nursing? R: Yes, and we u sua l ly get the kind of r e s u l t s we want i n 24 hours.because I th ink a l o t of times when a family p h y s i c i a n i s phoned by the team, they know they've done i t . I t ' s not because we haven' t ta lked to them. I t ' s not because we've gone r i g h t over t h e i r heads. We've probably been asking them for a week or so for something and we're not ge t t ing anywhere. I : But, p r e v i o u s l y , you mentioned the backlash that can occur? R: I t w i l l i f the doctor goes running down to the nurs ing admin i s t r a t ion , to the coordinator or a s s i s t ant d i r e c t o r s . I think they often see t h e i r jobs as being to p laca te . I th ink nurs ing admini s t ra t ion should be less w i l l i n g to p lacate the doctors and should be more w i l l i n g to f ind out what i s happening on t h e i r u n i t s . In f a c t , I do not go to nurs ing for support for my d e c i s i o n making, I go to a r e a l l y good group of phys i c i ans . But i n the end, you have r e s p o n s i b i l i t y to your se l f so that you can go home and s leep at n i g h t . I : That i s your p r i o r i t y ? R: That has to be the u l t imate p r i o r i t y . The u l t imate p r i o r i t y i s that you c a l l the shots the best way you can. You do what i s the most r i g h t at any given po int i n time according to your percept ion and according to the facts that you have. I : Because you f e e l that l i v i n g with yourse l f i s most important? R: I th ink that i n the end, tha t ' s got to be what i t comes down to . Because other people are a l l going to go t h e i r own way and l i v e t h e i r own l i f e and i f they leave you a battered wreck, they don ' t care . . . . In nur s ing , though, emphasis must be put on pa t i ent safety and nurs ing competence 58 with pat ients given as much d e c i s i o n making power as p o s s i b l e . But nurses are indoc t r ina ted in to the medical profess ion—nurses fol low doc tor ' s orders . I think some of our nurs ing leaders are very small minded—which makes me f e e l sad. Nursing should be taking quantum leaps . Nursing should be knocking down some of the boundaries— making i t an absolute pro fe s s ion . Nurses are not going to do that under the present system. They are not going to do that unless they are w i l l i n g to take on some of the hass le of change. I : Do you think nurses are w i l l i n g to do thi s? R: W e l l , I c e r t a i n l y th ink some of the higher l e v e l nurs ing adminis trators are not . We are an unaccepted pro fe s s ion . Part of i t i s because we are women, part of i t i s because of the nature of the work we do, i t i s n u r t u r i n g . And that i s t r a d i t i o n a l l y seen as a woman's kind of ro le—we're j u s t not accepted as p ro fe s s iona l s . S t i l l , i t ' s great for nurses to want autonomy, i t ' s great for nurses to say a l l these things—but they do not want to l i v e up to the expectations of i t — s o i t f r ightens a good many nurses. I think tha t ' s why I see two groups of people [nurses] a r i s i n g because there i s a group that w i l l not cope with pro fe s s iona l i sm, and that group w i l l be at the bedside i n the end. They won't have to th ink and they won't have anything to do except o r d e r s — t h e y ' l l j u s t do. The r e s p o n s i b i l i t y won't be on them. I t w i l l be on someone e l se . Normative a n a l y s i s . A n a l y s i s , i n th i s case, proves somewhat complex as the nurse i s funct ioning at a much higher l e v e l of reasoning than some of her s t a f f . Nevertheless , th i s example of s t a f f nurse behavior provides i n s i g h t in to how resentment forms. These nurses have t r i e d to promote high standards of care for t h e i r p a t i e n t s . They ju s t become u n w i l l i n g to cope wi th derogatory remarks and ignored or torn-up suggest ions. With t y p i c a l Stage II reasoning, they attempted a f a i r exchange and, i n f a c t , continue to do so to a p o i n t ; however, they serve t h e i r own needs by l eav ing a l o t of 59 things, by not following through to the physician. They bear grudges, form resentment and, at times, make phone calls with a tone of voice that suggests they already know they w i l l be treated unprofessionally. There is a perception of inequality. Similarly, on a broader level, this nurse shows resentment towards the nursing administrators and nursing leaders. She believes, for example, that the nursing administrators placate: again, this i s a Stage II pattern of behavior as i t seeks instrumental gains and deals are made. Showing signs of Stage VI patterns of reasoning, this nurse has definite principles of fairness and justice which guide her behavior. Also, she is quite adament that the status quo within nursing should change. She wants to see the rights and values of patients respected as well as the nursing profession evolve to a point where not only is i t respected, but also i t can freely promote the rights of the patients. One further example of the theme resentment is evidence as one. nurse t e l l s how nurses "constantly make compromises with their own ethical stand." In the succeeding case, the advocate for an incompetent patient, his wife, could probably have benefitted from nursing support (i.e., an informed nurse would have been able to discuss her husband's condition and alternate options for care with her). Case #5 Descriptive analysis. The background for this case involves an elderly dying gentleman and a physician's suggestion to the patient's wife that tube feeding be stopped. 60 R: The man was unconscious, had no b r a i n and we were keeping him a l i v e for what? The p a t i e n t ' s wife became outraged and compared i t to Dachau. I: She i s outraged at the d o c t o r ' s suggestion? R: There was a time when the doctor would never th ink of making a suggestion l i k e that . I : Where does the nurse stand i n th i s case? R: E x a c t l y , what i f the woman had decided the doctor was r i g h t and the doctor could d i scont inue the feeding tubes and stop feeding the pat ient? I : I f you were i n that s i t u a t i o n , how would you handle i t ? R: I ' d have to th ink about i t . Death i s not the worst th ing that could happen to that man. He had died a long time ago s o c i a l l y speaking. I : So i n th i s case, you say, nurses would have to r e a l l y th ink about i t ? R: The nurses d i d n ' t think about i t . I : Oh, the nurses d i d n ' t th ink about i t ? R: Hmmhmm. I : What d id they do? R: The nurses, j u s t for s e l f p r o t e c t i o n , do not come to terms with anything u n t i l the problem i s a c t u a l l y t h e i r ' s . I : Right there , on the u n i t , i n a d o c t o r ' s order? R: I f the doctor had taken the tube out and s a i d , "Don ' t feed him anymore," then, we would have had to dea l wi th i t . But whi le he was s t i l l asking the wi fe , i t was not our problem. When asked what the nurses would have done had the order been w r i t t e n , she f e l t that they might have gone to the h o s p i t a l lawyer or refused to look a f ter the p a t i e n t . But most l i k e l y they would have "deferred to the d o c t o r ' s o r d e r . " 61 R: Nurses are always constrained by doc tor ' s order . . . . For ins tance , th i s doctor d id not consult wi th nurses and . . . d i d n ' t ask anyone e l se how they f e l t about i t . I : Do you f e e l the nurses should have been part of that dec i s ion? R: I b e l i e v e that dec i s ions l i k e that are s o c i e t y ' s d e c i s i o n s . They are not the prerogat ive of a p ro fe s s ion . And as far as the law goes, i t r e f l e c t s s o c i e t y ' s dec i s ions and i t i s dangerous not to observe the l e t t e r of the law. And I th ink the tube feeding i s n ' t covered by t h i s . I : So there would have been a r e a l dilemma for you i f the wi fe had agreed to have the tube removed? R: Yes . . . because I would have seen i t as a dangerous precedent. That wi thhold ing food or other kinds of care would become common p r a c t i c e for whomever i t i s determined i s unable to l i v e a complete l i f e . What i f there are disagreements here? Instead of going to S i b e r i a , you get your l i f e support system removed. I : But r i g h t now, for th i s p a t i e n t , i f the order had been w r i t t e n , do you know how you would have dea l t wi th i t ? R: No, I don ' t know how I would have dea l t wi th i t . Deal ing with au thor i ty f igures l i k e doctors— The nurse was asked i f th i s au thor i ty hindered support of pa t i ent autonomy, o r , i n t h i s case, the autonomy of the wi fe . She r e p l i e d , R: D e f i n i t e l y . We don ' t have the autonomy of the medical pro fes s ion to counter i f we disagree or i f we f e e l that there i s c o n f l i c t between the p a t i e n t ' s autonomy and the d o c t o r ' s order . The nursevwould have to chal lenge the medical profes s ion and that i s hard to do. I : I t ' s d e f i n i t e l y a f e e l i n g that i t would be a challenge? R: D e f i n i t e l y . I : Not sort of a cooperative d i s c u s s i o n , a team approach? R: I don ' t think so, nurses a ren ' t c a l l e d on to discuss th ings . Nurses are given d o c t o r ' s orders . 62 Normative analysis. Although Stage IV reasoning is evident in the preferred approach, this nurse admits confusion over the issue of tube feeding and would have most likely followed the doctor's order even i f he had ordered that a l l feedings stop. Stage I reasoning is evident because this nurse perceived herself as unequal; she f e l t the authority of the physician could override her protestations. Yet she was very clear in her statement concerning what ought to take precedence. Society's sanction and legal stipulations are needed to provide guidelines. With certain Stage IV reasoning, she acknowledges the need for people in general to face the issue, for legal parameters to be set, and then for the health care system to adopt these guidelines with more than one profession in control of the outcome. This view is geared to protecting and maintaining consistently high standards of care within the health care institutions. In these examples i t is evident that resentment builds when nurses feel that they are faced with situations that emphasize their inequality and are, in addition, unfair. When these conditions become exacerbated, the need to retaliate comes forward and is expressed in the theme of revenge. Theme: Revenge Revenge or the need to avenge or retaliate in kind and degree is identified as the main theme in two rather extreme examples. In the f i r s t case, the nurse had to cope with something she perceived was highly unjust which caused her to feel the need for revenge. 63 Her percept ion of i n e q u a l i t y led her to view h e r s e l f as he lp le s s i n a t r a g i c s i t u a t i o n . Case //6 D e s c r i p t i v e a n a l y s i s . This p a r t i c u l a r inc ident involves a young woman who was unaware of aspects of her medical h i s t o r y . The medical and nurs ing s t a f f , however, were cognizant of her complete medical h i s t o r y . R: [This woman] had had a breast removed s i x years before for cancer and was [now] coming i n for a hysterectomy for cancer b e l i e v i n g i t to be a recurrence of her f i r s t cancer. In a c t u a l i t y i t [the breast removal] was a mistake by the medical p ro fe s s iona l who had removed the breas t . I : You mean, i t wasn't a cancerous breast? R: I t never was cancerous. But because i t was a traumatic th ing for her , she was t o l d i t was cancerous. This was a l l i n her h i s t o r y and i t was her u ter ine cancer that was a primary. I t was not secondary as she thought. So what are [-nurses ] doing i n that s i tua t ion? Do you leave w e l l enough alone? Now where does the nurse ' s duty l i e ? Are you going to make her mad for a l l those years , or are you going to forget about i t so she can get on with her business of l i c k i n g th i s cancer? . . . But you see, i f i t was me, I would want to know. I ' d want to be mad and I ' d want to have f i r s t choice of a s u i t . That might help me l i c k my second cancer—revenge. I : Did she f e e l , t h i s being a secondary, that she was worse or be t ter off . . . because i t was a secondary [to her]? R: You can only ju s t imagine what you would do. I would sue the whole place i f I found out they had been keeping th i s from me. I : Has she ever found out? R: No. But to t e l l her , for ins tance , that her breast cancer hadn' t been cancer and the doctor made a mistake when he hadn't even done a biopsy—he jus t lopped her breast o f f and then d id a b iopsy . 64 This nurse had i n i t i a l l y spoken of opportunities to be untruthful when unable to uphold the patient's right to know. So the interviewer asked, I: So you were having to act, in a sense, you had to be untruthful? R: Well, I think nurses have to remember that they have a vested interest in the institution of healing and when truthfulness comes in the way of that institution, then there i s going to. be hard choices to make and they [nurses] w i l l probably side with the institution that is providing them with a job, or credibility. I: You feel in your nursing practice that you would have to do that? R: Uh huh, . . . to a limit. I suppose everybody's got their limit. I: Could you imagine where your limit would be drawn? R: Well, I'm saying that this i s one instance—I didn't t e l l her her history. I: You were protecting her? R: She could have f e l t betrayed i f she had known at this p o i n t — i t was being kept from her. I rationalized [that] i t was good for her not to know and i t was good for me not to t e l l her t h a t — i t was clear incompetence; I: And you were okay with that? R: I lived with i t . I: Did you feel that the institution and the physician approach takes precedence? R: Definitely. I: You have no doubts? R: No. This nurse was asked how she would like to deal with patient histories. 65 R: I would l i k e to have the chart at the p a t i e n t ' s bedside. They would see a l l reports as they come i n and then decide who they would l i k e to discuss them w i t h . There are too many secrets with phys i c i ans . Very often h i s t o r i e s that are known to the s t a f f are unknown to the pa t i en t s . But she adds, R: I see pat ients wanting to be taken care of . I see them very happy to r e l i n q u i s h t h e i r r e s p o n s i b i l i t i e s . They a c t u a l l y r e s i s t autonomy. R: Yet as pat ients become more autonomous, then nurses are more free to c r e a t i v e l y help them become autonomous. I : In your p r a c t i c e , you ' re not seeing pat ients demanding r i g h t s , demanding information? R: I of fer them : the i r r i g h t s . I say, "You t e l l the doctor what you want to know. Wri te i t on a p iece of paper . " They say, " O h , he ' s so busy. I don ' t want to bother h i m . " They are a f r a i d that i f they s ta te t h e i r r i g h t s , the doctor w i l l not want to work wi th them. They be l i eve compliance i s the answer to care , to be good, to make sure they have care. Normative a n a l y s i s . This i s another example of a nurse p e r c e i v i n g nurs ing relevance as unequal . Others decided that the inc ident should be covered up so that the pa t i en t "wouldn't f e e l be t rayed . " There was no long term concern with the p a t i e n t ' s p sycho log i ca l s tate and the meaning to her of what she be l ieves i s a second cancer, nor was there concern with her r i g h t to know and the r e l i e f that may have gone with knowing she hadn' t had cancer of the breas t . Yes , perhaps she would f e e l sorrow over the l o s s , but also r e l i e f that i t was not malignant. P l u s , as the nurse remarked, monetary compensation may have afforded much needed f i n a n c i a l support. This nurse cooperated, she feared repercussions so she r a t i o n a l i z e d the s i t u a t i o n away and followed a path congruent with Stage I reasoning. The super ior 66 power of the a u t h o r i t i e s overruled i n the m i l i e u s i t u a t i o n . Nevertheless, on r e f l e c t i o n and away from the s i t u a t i o n , while ready for revenge, t h i s nurse voiced concerns congruent with Stage V reasoning. She f e l t patients should be informed and should accept some personal r e s p o n s i b i l i t y i n caring for themselves; thus, even i f they chose not to be informed, the l i b e r t y to become so ought to be a v a i l a b l e (e.g., the chart at the bedside), and the l i b e r t y to sue i f genuine damage has been done ought also to be the patient's choice. The next case involves a nurse who, i n t r y i n g to uphold the r i g h t s of her patient, a c t u a l l y took a form of revenge. Case #7 Descriptive a n a l y s i s . In t h i s case, a 45 year old woman was dying of cancer. R: She had cancer of the lung and she was i n such need of oxygen that she was going a b i t crazy. . . . One of the surgeons decided he was going to do a lung biopsy. The anaesthetist said he would not anaesthetize anyone i n that condition because he would not be able to get them o f f the r e s p i r a t o r . And she had been without anything to eat or drink for two days while they were arguing about t h i s . I: Did she have an intravenous? R: No. I t was j u s t — " s h e ' s going to have surgery and NPO." So I'm worrying about t h i s and two days was my l i m i t for l e t t i n g her go . The surgeon and the anaesthetist were s i t t i n g i n the nursing s t a t i o n arguing. S o — I: Arguing about? R: The surgeon wanted to do the operation, the anaesthetist sai d , "No, I'm not going to." And another doctor was i n there and everyone was putting i n t h e i r two cents. So I went down to see her, she was s i t t i n g up t a l k i n g and d e l i r i o u s . . . . She was very hungry, her mouth was s t i c k i n g 67 together and a l l t h i s — a n d she was begging for water. . . . So, instead of going up to these doctors and saying, "make up your mind or I'm going to feed her r i g h t now," I j u s t did i t . You know, I c h o s e — w e l l , as I'm thinking back on i t now, i t was the r e a c t i o n of a c h i l d . You know, you j u s t don't think about i t , you j u s t disobey. So I took i n a load of j e l l o and j u i c e and gave i t to her. I didn't say anything to the doctors. Then the doctors went i n to have one more look at her and saw her eating and they came back . fuming and screaming, "Who gave her something to eat?" And, of course, I s a i d , "Well, I d i d . " They didn't b e l i e v e anyone would admit to i t r i g h t away, so i t took them back two steps. "Ah, why did you do that?" And I s a i d , "She was hungry and she hasn't eaten for two days." But I should have gone further and s a i d , "Because you guys can't make up your minds—you don't ask her—you're not asking her family — y o u ' r e not t e l l i n g her the r i s k . " So the anaesthetist, I suppose, ei t h e r agreed to do i t , or he said he wouldn't, and they found someone who did. So she ended up being bumped to surgery the next day. I: Did she sign a consent? R: Now, I can't remember that. She could have signed i t before. And she probably wouldn't care what she signed. This guy wanted to go i n and do a lung biopsy, w e l l , I don't know why. So he went i n and got her lung b i o p s i e d — a n d they couldn't get her o f f the r e s p i r a t o r . That was a sad case. I was sorry about the whole thing and she c e r t a i n l y didn't have any input. I think the guy [the doctor] needed a case i n the operating room. And he was aggressive and pushy and he b u l l i e d the anaesthetist to the l i m i t and he got h i s way. And i t wouldn't matter i f she was NPO four days, he'd keep her NPO u n t i l he got h i s way. So he was furious when I fed her. I: What would you do tomorrow i f that happened? R: I'd make sure the patient knew what was going on. And i f the patient was d e l i r i o u s , as she had become—she couldn't have made a d e c i s i o n whether to go to the operating room or not. Then I would say, you have to involve the family. I: Why.would you choose to be more autonomous now? R: Well, I think that you have to go through the bad experiences to make your decisions. You know, you have to a c t u a l l y experience poor decisions to give you a f e e l i n g f or where 68 you ought to be. There i s n ' t any structured p o s i t i o n f o r nurses. They're on the fringes of everyone else's decisions. They're required to follow doctor's orders, you see. That's how we are trained. Yet on the other hand, we are t o l d to question orders we don't agree with. But you do that d i s c r e e t l y . I think that case haunted a l o t more people. The anaesthetist should have known that other people would have supported h i s decision. The nurses should have been i n on that decision. To point out how nonpersonal nurses a r e — t h e y were having t h e i r argument i n the nursing s t a t i o n [as i f ] we weren't there! I hadn't worked i t out i n my head [ f i r s t ] . I reacted, I didn't act. R: Part of the problem—I think a great part of the problem with these e t h i c a l dilemmas i s that there i s no place for nursing d e c i s i o n s — t h e r e r e a l l y i s n ' t . They can t e l l you there i s and there r e a l l y i s n ' t . The one making the decisions i s the d o c t o r — t h e patient either writes a consent or says no. And then you're the one supposed to coerce the patient into signing the consent i f you are a "good" nurse. I: Would you coerce now? R: Never, never. Normative a n a l y s i s . Issues of imposed relevance grounded i n the authority of others reinforced the perception of i n e q u a l i t y and r a d i c a l l y altered the nurse's b e l i e f i n q u a l i t y care i n th i s case. The nurse, as she states, did not know how to act so she reacted. In taking revenge, she t r i e d to be f a i r to the patient as we l l as to meet her own need to provide food and f l u i d to a dehydrated patient. She did not wish to follow the a u t h o r i t a t i v e point of view, yet was unable to make her preferred stand. She responded i n an admittedly c h i l d i s h Stage I I manner. She now, true to Stage IV patterns of reasoning, would take a firmer stance by s t a t i n g the nursing perspective and asking for the family to be brought i n and for a decision concerning hydration to be made. 69 Preconventional level approaches based on the perception of imposed relevance led to nurses viewing conflict issues from a very concrete individualistic perspective. The nursing concern balanced self interest with the expected consequences before any given action. In this way, untenable risks are avoided. Nevertheless, because the nurses were capable of conventional and postconventional thought and because i t was the contextual nature of the social situation that forced regression of thought, they suffered cognitive and affective repercussions. These repercussions are reflected in the themes of anger, resentment, and revenge. Let us now turn to the literature in order to incorporate insights gained from a deductive analysis. Comparative Critique Selected facts, concepts and theories from literature are used to develop an explanatory model which offers suggestions that w i l l help explain the gap between what, in fact, occurred in these cases and what, in the nurse's words, they believe ought to have occurred. In the examples evidence of a perception of imposed relevance and, consequently, inequality abounds. Inequality in status i s particularly noticed in such statements as, (a) "there is no place for nursing decisions," and (b) "nursing recommendations are tossed off." Perceptions such as these seem to cause nurses to develop mind sets that, as Arsokar (1982) states, make nurses feel that they are "primarily means to the ends of others" (p. 30). This 70 percept ion leads to the r o b o t - l i k e , moral ly passive behavior Davis (1983) speaks of . I t can be seen how these nurses d id accept t h e i r r o l e i n a r o b o t - l i k e way (at l ea s t on the surface) as they acquiesced to behaviors grounded i n Stage I and II patterns of reasoning that they, indeed, had trouble coping w i t h . These troubles were due to cogn i t ive dissonance and re su l ted i n the need to r a t i o n a l i z e or b o l s t e r themselves as they sought i n t e r n a l r epr i eve . However, these nurses could not f o o l themselves, t h e i r c o n f l i c t of l o y a l t y and the need to funct ion i n a p r o f e s s i o n a l way never receded. Fes t inger (1962), the man who developed the theory of cogni t ive dissonance, s tates that when inconstancies stand out, people attempt to normalize them away; when they are unable to do t h i s , they experience p sycho log ica l discomfort which i s c a l l e d dissonance. In t r y i n g to reduce t h i s dissonance, people t ry to avoid s i t u a t i o n s that cause i t . This may w e l l be why one nurse s t a ted , "The nurses ju s t for s e l f p r o t e c t i o n , do not come to terms with anything u n t i l the problem i s a c t u a l l y t h e i r ' s , " and another s a i d , "A l o t of things get l e f t . " These a c t i v i t i e s , according to Fest inger (1962), lead to dissonance reduct ion because attempts are made to make the i s sue re levant . The theory of cogni t ive dissonance affords one explanat ion for the regres s ion i n patterns of reasoning due to m i l i e u e f f ec t s . Because, i n essence, th i s theory s tates that two elements are i n dissonance i f , cons ider ing these two alone, the obverse of :one element would fo l low from the other (Fes t inger , 1962) ( i . e . , fo l lowing physician orders promotes a standard of care which support patient autonomy). To Festinger (1962), dissonance arises from (a) logical inconsistency, as just cited; (b) disagreement over cultural mores; (c) one specific opinion taken over general opinions; and (d) past experience. While a l l four factors may contribute to nursing's conflict, perhaps the f i r s t one is most evident in this study. Additionally, Festinger (1962) adds that the more valued the issue, the greater the dissonance created. In the same sense as imposed relevancy, Festinger (1962) speaks of forced compliance. Forced compliance also rests on reward or punishment. He notes that once compliance is exhibited, there is a noncorrespondence between overt behavior and private opinion. The need is then to reduce the tensions aroused by increasing the number of consonant relations. This is certainly the techniques chosen by the nurses as they avoided risks and followed orders or dodged issues. The nursing administrators, in placating, also were trying to decrease dissonant relationships. Caught in an attempt to increase consonant relations, nurses partook of what Janis (1982) calls defense avoidance strategies. In outlining a model of conflict resolution in decision making, Janis (1982) notes that i t is common for people to use this negative strategy. It also helps decrease personal dissonance. Janis cites two techniques which f a l l under this strategy: rationalization and buffering. When people are unable to resolve conflicts, they 72 try to convince themselves that they could do no more, or that they did their best and need not do anything more. Evidence of this behavior is noted as: (a) the nurse rationalized that i t was better the lady did not know of her nonmalignant breast, (b) the incident of the nurse checking on the caesarean birth, and (c) the nurse who saw the report on the inebriated physician torn up. In other circumstances, these nurses may have done more but their perception of inequality, in these cases, held them back. Such behavior occurs when paternalistic leanings overshadow the rights of others to speak out. These leanings decrease feelings of dignity and self worth and lead to decreased motivation. Chaska (1983, p. 482) says that people then feel as i f they are "things" or "objects" for instrumental use: human freedom is consequently limited. A sense of control i s negated. Nurses were unable to promote the kind of patient care they believed in, they were unable to provide circumstances for their patients in which the patients themselves could take control. Various elements in the milieu situation and features from within the nurse herself led to a perception of inequality and, consequently, to the belief that others make decrees and nurses follow. Preconventional levels of reasoning compounded by feelings of fear and inadequacy undermined higher level standards to the point that egocentric self preservative values took precedence over accountable behavior. Nurses who could function well at conventional 73 and postconventional l e v e l s found themselves angry, r e s e n t f u l , and revengeful, yet unable to change the present s i t u a t i o n . B. Bounded Relevance Nurses who faced multiple l o y a l t y c o n f l i c t s with conventional l e v e l patterns of reasoning, f e l t that t h e i r r i g h t to function as a p r o f e s s i o n a l was l i m i t e d or r e s t r i c t e d by bounds inherent i n the structure of the health care system. Conceptualizing such a complex and, indeed, perplexing category required an approach that presents the issues involved i n such a way that elements e s s e n t i a l to the controversy can be examined. Often i t seemed that any action taken by the nurse would have an unfavorable outcome because i t would lead to compromising one of the involved p a r t i e s . C o n f l i c t s , at times, reached true dilemma proportions as nurses were pulled between various commitments. For example, some f e l t obliged to meet professional standards and to maintain a sense of t r u s t and respect with the patient, yet p o l i c i e s promulgated by the i n s t i t u t i o n and treatment decisions set by the physician forced a weakening of t h i s commitment. Or, secondly, when looking at the i n t e r e s t s of each group involved (e.g., the physicians, the i n s t i t u t i o n , the patient and family), the nurse became unsure of whose values should have p r i o r i t y . This brought up c o n f l i c t s pertaining to questions concerning q u a l i t y of care backed by ambivalence which was created as l o y a l t i e s were torn. In general, l e g a l standards of care are upheld ( i . e . , the minimal safe standard) i n each c o n f l i c t of i n t e r e s t s i t u a t i o n . Nevertheless , the espoused standards of care that i n s t i t u t i o n s present i n t h e i r miss ion statements a l lude to care that surpasses minimal standards. Words such as exemplary care , or p r o v i s i o n of high q u a l i t y s e r v i c e s , are commonly inc luded . S i m i l a r l y , terms with equatable meanings ex i s t i n the Standards of Care Document and Code for Nurses. Not s u r p r i s i n g l y , nurses who u t i l i z e Stage I I I or Stage IV patterns of reasoning, based on a member-of-society perspect ive which s tresses the importance of e i t h e r maintaining r e l a t i o n s h i p s or upholding s o c i a l s t r u c t u r e s , s truggle with d iv ided l o y a l t i e s . C o n f l i c t ex i s t s between what the nurses consider r i g h t or ju s t ac t ion and what they consider respons ible ac t ion given nur s ing ' s confined r o l e . This ambiguous p o s i t i o n led to themes which are grounded i n i ssues that can be expressed as dilemmas. Stage II I c o n f l i c t s revolve around the one main theme of r e l a t i o n s h i p s versus r o l e r e s p o n s i b i l i t y . Stage IV l o y a l t y c o n f l i c t s contained four main themes: nurs ing r i g h t s versus phys i c i an r i g h t s , nurs ing r i g h t s versus i n s t i t u t i o n a l r i g h t s , nurs ing r e s p o n s i b i l i t y and the r i g h t of the pa t ient to d ie with d i g n i t y , and i n d i v i d u a l r i g h t s versus s o c i e t a l r e s p o n s i b i l i t y . The f i r s t theme to be discussed w i l l deal wi th the nurs ing need to maintain r e l a t i o n s h i p s and to meet the expectations of others versus a need to perform respons ib ly w i t h i n the nurs ing r o l e . 75 Theme: Relationship versus Role R e s p o n s i b i l i t y  Case #8 Descriptive analysis. In t h i s case, the nurse believes i n "the concept of the patient being an i n d i v i d u a l with r i g h t s of h i s own." Given t h i s b e l i e f , she had d i f f i c u l t y coping with a s i t u a t i o n i n which a patient was not given adequate information concerning the r i s k s involved p r i o r to a s u r g i c a l procedure. She was asked how she would further define her idea of patient r i g h t s . R: The r i g h t [ i n t h i s case] would r e l a t e to h i s r i g h t to p a r t i c i p a t e i n the dec i s i o n and to make the f i n a l choice with regards to anything that r e l a t e s to h i s health. But you come up with c o n f l i c t s because, while nurses are supposed to have a r e s p o n s i b i l i t y to provide teaching, to provide information, so many of the s i t u a t i o n s i n which we f i n d ourselves we don't r e a l l y have the control to do that properly. For example, the l e g a l consent form says the patient must be informed by the physician, and no matter what kind of information I give them the l e g a l system i s set up that i t r e a l l y depends on what the physician t e l l s them as that being the l e g a l basis f o r choice. I: So do you f i n d that you are witnessing a consent form and patients are not informed? R: Yes. Or not as informed as you would l i k e to see them. I: How do you know they aren't informed? R: Because sometimes—not sometimes—often you l i s t e n to the doctors explain things to them and you can t e l l what the physician i s giving them i s a biased point of view. Maybe not o f f e r i n g a l l the a l t e r n a t i v e s , maybe not pointing out to the patient a l l the r i s k s involved with the treatment they are about to accept, and then the patient signs the form because he fe e l s helpless. He f e e l s s i c k . He has to take the doctor's advice and have t h i s treatment because, for some reason, he respects the physician too much to ask f o r , maybe, a second opinion. And then, a f t e r he has signed the consent and the physician has l e f t , then, he s t i l l 76 has l o t s and lo t s of quest ions , and l o t s of doubts, and worries about whether he i s doing the r i g h t t h i n g , which he then v e r b a l i z e s to you, the nurse. I : And what do you, the nurse, do about that? R: W e l l , sometimes you can go back to the phys i c i an and say, " I don ' t be l i eve that the pa t ient s t i l l r e a l l y understands ." Then, i f he takes you s e r i o u s l y or not and w i l l take the time to go back to the pa t ient i s a r e a l , i n d i v i d u a l th ing for each p h y s i c i a n . Or you can encourage the pat ient to t a lk again wi th the p h y s i c i a n , but u sua l ly by that point they have consented to the treatment and i t i s already booked, and u s u a l l y i t i s rushed ahead and there ' s not that k ind of time element to allow the pa t ient to discuss i t again thoroughly. Or e l s e , because of the way he i n t e r a c t s wi th h i s p h y s i c i a n , he doesn ' t f e e l comfortable quest ioning the p h y s i c i a n ' s informat ion to d i g deeper for more information to get a l l h i s worries out of the way. Maybe he w i l l f e e l s i l l y or something l i k e that . I : Can you think of a pat ient? R: Mmhmm. I can think of a pa t ient who had an abdominal aneurism. . . . [He] had [a 5 cm] aneurism . . . and there was a time when vascular surgeons would say that i f an aneurism was greater than 5 cm, then they would have to operate, and i f i t was l e s se r than [5 cm], they wouldn't have to . But these days i t seems the c r i t e r i a have changed so that i t depends on the ra te of growth. I f the phys i c i an sees a person one year and i t ' s 4 cm and the next year they see him and i t ' s seven, then the ra te of growth would i n d i c a t e that i t w i l l rupture soon. So, based on the rate of growth, they w i l l decide to operate. Now, t h i s was a man who had many r i s k f a c t o r s : he was a d i a b e t i c person; he had heart d i sease , had had previous M i s , had problems with heart f a i l u r e ; and he r e a l l y wasn't an optimum candidate for t h i s surgery. He had already had one previous s troke and the r i s k of stroke with aneurism surgery i s very h i g h . His rate of growth hadn' t r e a l l y been that high and so h i s 5 cm aneurism might have stayed for awhile without ruptur ing and h i s present q u a l i t y of l i f e was not that good because he was incapac i ta ted by h i s heart d i sease . I : Could he do anything on h i s own? R: He could do things on h i s own. I was going to say that h i s q u a l i t y of l i f e was not that good, but i t was s t i l l decent 77 enough, you know. He needed biannual admissions for card iac problems, but otherwise at home he was independent. He l i v e d with h i s wife and so on, and I remember that when we were d i scus s ing h i s surgery for the purposes of consent, the surgeon involved r e a l l y d i d n ' t expla in to him to my s a t i s f a c t i o n anyway, and I'm not sure how important that i s i n the whole process that everyone e l se i n the room be s a t i s f i e d that you have got enough in format ion , but I j u s t thought at the time that the surgeon d id not exp la in to t h i s man the s i g n i f i c a n c e of h i s own personal r i s k . And, for sure , I f e l t he d i d n ' t at a l l expla in to the man the r i s k of CVA and how high i t was. I : He d i d n ' t mention i t at a l l ? R: Not at a l l , not as a f a c t o r , and the man went to the tab le and had a massive stroke and never d id recover . And I th ink that the way the informat ion was presented to him, he f e l t that he probably had no choice but to have the surgery. I : So he had a 5 cm aneurism, do you know the ra te of growth over the l a s t 12 months? R: His aneurism had i n i t i a l l y been diagnosed about 10 years previous to that and at that time i t was about a 3 cm aneurism, but i n 10 years i t had grown 2 cm. I : His l i f e expectancy was l i m i t e d anyway, perhaps, with the condit ions you mentioned. R: Yes , most d e f i n i t e l y . You know, a d i a b e t i c wi th heart problems has severe l i m i t s to l i f e expectancy. And I th ink that he didn't—maybe he would have opted to have the surgery anyway. But I th ink that i f someone had t o l d him that the chances were about 75% that he would probably have another s t roke , that r i s k s are that h igh and might severe ly incapac i t a te him, i f they had explained to him the r e a l l y s i g n i f i c a n t r i s k of put t ing somebody wi th that k ind of heart disease on the t ab l e , then he might not have had the surgery. To me the expression of the danger ju s t d i d n ' t seem to be e x p l i c i t enough. I : So, you would have pre ferred the surgeon had taken time to s i t and l e t him calm down and then explained the facts and r i s k s and even the percentage r i s k of l o s i n g h i s l i f e ? Is that what you would have preferred to happen? 7 8 R: Yes. I: And was he offered any other alternative? R: No, he wasn't. The whole discussion was predicated by the surgeon's statement that he f e l t that he should have t h i s surgery; he had been consulted by the c a r d i o l o g i s t and he f e l t he should have t h i s surgery. I: Can you just hypothesize on why, why the surgeon at that p a r t i c u l a r time was worried about the aneurism? R: No, I can't. I: But with a l l your experience, you can't see why the focus at point, p a r t i c u l a r l y when he had been admitted for another reason? R: No, I didn't r e a l l y understand i t at a l l at the time a c t u a l l y . I: So how do you fe e l ? R: Well, sad, I.guess. I don't f e e l responsible but I f e e l sad. I: Why do you not f e e l responsible? R: Because i t i s not up to me, i t ' s not my d e c i s i o n , i t ' s not my r e s p o n s i b i l i t y to give that information to him, and, while I may f e e l that i t i s my moral and.ethical r e s p o n s i b i l i t y , i t has no l e g a l bearing on whether or not he should have had the surgery and the outcome was beyond my co n t r o l . I: So he was taking i t on f a i t h that the very best suggestions were coming f o r t h , would you say that was correct? R: Yes, patients have an ordinate and, I think, sometimes undeserved amount of t r u s t i n t h e i r physicians, and so, i f t h i s c a r d i o l o g i s t , who had managed his l i f e , I mean b a s i c a l l y managed his l i f e for about 10 years and had kept him a l i v e despite h i s heart disease for 10 years, had recommended that a surgeon see him and then the surgeon comes and sees him and says that i t i s h i s opinion that he should have the surgery, I think that i t would take the most strongwilled person I know to say to t h i s man, "Well, j u s t a minute, I want another opinion," or "I don't think 79 so, I j u s t want to go on the way I am," because they a lso run the r i s k of i n c u r r i n g the anger of t h e i r phys ic ians which r e a l i s t i c a l l y does have a bear ing on how they w i l l be managed i n the future . I t would be n ice to say that i t wouldn't but , i n f a c t , I think quest ioning phys ic ians often does. I : I t does what? R: I t has the e f fect of having the p h y s i c i a n ' s a t t i tude towards you as a pa t ient change. You see qui te often i n conversations wi th phys ic ians where pat ients have not been 100% compliant , say, to a regime of treatment that the phys i c i an w i l l refuse to see them therea f ter , or sees them but grudgingly, or sees them wi th very negative comments, and that w i l l co lor the way they t rea t them, I th ink , from then on. I : So have you seen that kind of thing happening where a phys i c i an i s begrudgingly t r e a t i n g a pa t ient i n the unit? R: Yes . Normative a n a l y s i s . Stage I I I patterns of reasoning d i r e c t e d th i s nurse i n t h i s p a r t i c u l a r case. She focused on how important i t was for th i s pa t ient to maintain h i s p o s i t i v e r e l a t i o n s h i p with a phys i c i an who had v i r t u a l l y kept him a l i v e for the past 10 years . Concomitantly, the nurse was aware of what can happen to pat ients who ask for second op in ions , or who refuse c e r t a i n modes of treatment. On the other hand, she recognized that on an e t h i c a l and moral l e v e l a l l was not w e l l , although l e g a l l y she acted w i t h i n what she f e l t to be the correc t standard. However, i n s t a t i n g that she would prefer a knowledgable p a t i e n t , one who can make a l l f i n a l d e c i s i o n s , she c e r t a i n l y espouses Stage V reasoning. What i s more, another t y p i c a l t r a i t of Stage V i s an awareness of the mora l - l ega l gaps i n points of view plus the r e a l i z a t i o n that these points of view are 80 d i f f i c u l t to integrate. The nurse f e l t h e l p l e s s , morally and e t h i c a l l y speaking. She could not break what she perceived to be a l i m i t a t i o n inherent i n the health care system nor did she under the circumstances want to r i s k the patient-physician r e l a t i o n s h i p or, i n f a c t , her own r e l a t i o n s h i p with the physician. As another nurse states, We have to work with those physicians, we have to get along with them. And the other thing i s , we can't take r e s p o n s i b i l i t y for jeopardizing that doctor-patient r e l a t i o n s h i p . This nurse went on to say that, The physician i s s t i l l the one who they are going to go to when they're s i c k , and you can't destroy that t r u s t . So nursing has to do whatever i t can within the constraints of whatever the s i t u a t i o n might be. Nursing i s bound by medicine—and that's what holds nursing back i n a l l s i t u a t i o n s . We are forced to work within the bounds of medical constraints. Case #9 Descriptive analysis. Once again, r e l a t i o n s h i p needs come to the foreground as a public health nurse and a school-based team, fi n d i n g l i t t l e help within the system but guided by deep feel i n g s of empathy for a c h i l d , continue to seek a r e l a t i o n s h i p with the mother of an abused c h i l d . Nevertheless, a question a r i s e s : What p r i o r i t y should be given to a f r u s t r a t i n g and long drawn out, time consuming, r e c a l c i t r a n t case? This nurse sadly comments that i n t h i s p a r t i c u l a r case some .. members of the school-based team have given up. They have decided, she says, that the c h i l d w i l l become a " s t r e e t c h i l d " . However, 81 some of the team continue to try to gain a p o s i t i v e r e l a t i o n s h i p with the mother, who, as th i s nurse remarks, R: Is i n her own c r i s i s with an a l c o h o l i c husband who beats her and who i s i n and out of j a i l . She cannot make a deci s i o n f o r her c h i l d — s h e i s unable to make decisions for h e r s e l f . And with the Minis t r y of Human Resources [MHR], i f the parent refuses resources, everything i s l e f t . But her c h i l d has been sexually abused three times over one period of time, yet the MHR mandate f or abuse and apprehension i s so s t r i c t that you have to have so many c r i t e r i a met before t h i s c h i l d can be removed from her environment. Plus there are so few good foster homes. There i s a bandaid approach to working with the family. But often they have had so many huge problems over the years that not much happens. We are a l l very fr u s t r a t e d with society as a whole re resources for th i s c h i l d . I: How old i s the g i r l ? R: About ten. . . . For t h i s c h i l d we have proof of the three occasions, but the c h i l d i s getting p h y s i c a l care and she i s not i n danger of continued contact with the people. But there i s n ' t a ph y s i c a l l i m i t set on the c h i l d at home. I: So she can wander? R: Oh, yes. Plus she i s a behavior problem. A st r e e t k id almost. There has been loss of control and no parental guidelines for years. But, you see, the Court knows that t h i s c h i l d has been assaulted three times. They have fact s about i t . The other fa c t i s she i s p h y s i c a l l y cared for at home, though there are no l i m i t s put on her. The Court knows she i s acting o u t — b u t they did not have any grounds to make MHR the c h i l d ' s parent. And only i f MHR i s the c h i l d ' s parent can they arrange to get the c h i l d sexual counselling. On three occasions the mom was asked to give permission for t h i s . One time she agreed. Mother and c h i l d were sent to a p s y c h i a t r i s t i n town. But he i s a very busy man and they had one session together. The c h i l d refused to ta l k about sexual issues with him so he dismissed the case. I: He expected her to ta l k i n one session? R: Yes. He dismissed the case because the l i t t l e g i r l didn't want to t a l k about i t . But when she was ready to ta l k about 82 i t , he would see her again. But to me, any person, whether a c h i l d or an adult, needs to gain some tr u s t with another person and know them over a period of time before they would ever t a l k about such personal emotional issues. Now, at school she fe e l s safe. She l i k e s the s t a f f . I t ' s the i d e a l place. But when she goes home and on weekends and holidays, she's back into a chaotic family l i f e . The nurse goes on to say that now, over a year l a t e r , they are s t i l l t r y i n g to reform a r e l a t i o n s h i p with the mother. She says, "MHR i s the prime worker and they have done the best they c a n — t h e i r hands are t i e d by t h e i r mandate and the law." The nurse says that they w i l l continue with the mother i n hopes that i n time she w i l l seek counselling for h e r s e l f and her c h i l d . She says that over a year l a t e r some members of the school-based team, while f e e l i n g bound by the rules and regulations of the bureaucracy, are s t i l l t r y i n g to seek a p o s i t i v e r e s o l u t i o n . They f e e l the c h i l d "deserves more." When asked how the school-based team was going to handle the s i t u a t i o n , she responded that the team was going to t r y to work around the s i t u a t i o n . They were going to see i f a p s y c h i a t r i s t would come to the school to counsel on a one-to-one or a group b a s i s , or family services would maybe s t a r t up a group for sexually abused children. This approach, apparently, can be taken whether the mom agrees or not because i t i s sponsored by the school. The nurse was asked to comment on the l a t e s t idea. R: I think i t ' s okay. I think i t ' s great. MHR are doing t h e i r best, but as long as t h e i r hands are t i e d . . . those of us on the team that are more emotional about t h i s keep pushing. 83 I: Which side do you prefer? R: I'm more for pushing and doing things f o r people even i f i t i s a l i t t l e under the table. I believe i n people accepting r e s p o n s i b i l i t y f o r themselves and I wish we could push that with these c l i e n t s — i t ' s a slow process. But i t ' s a f i g h t with the s o c i e t a l b u r e a u c r a c i e s — t h e r e are so many one has to coordinate with. Normative analysis. The remaining group of interested team members seemed to base t h e i r stand on a t h i r d person perspective. For example, they seemed to consider norms of society as w e l l as the feel i n g s that they perceive the c h i l d might have. Relationship and caring for another was primary and i s common to Stage I I I patterns of reasoning. A l t e r n a t i v e l y , when given a chance to comment on what she would prefer and, i n f a c t , the team might i n s t i g a t e , t h i s nurse adopted a Stage V pattern of reasoning. She was w i l l i n g to go forward with a plan even i f i t "was a l i t t l e under the table." The rules within the system were unsatisfactory for her i n th i s case. Again, the l e g a l stance did not l i v e up to the moral o b l i g a t i o n f e l t by several members of the school-based team. Comparative C r i t i q u e Conventional l e v e l Stage I I I patterns of reasoning focus on the meaningful nature of r e l a t i o n s h i p s . When conventional patterns of reasoning are examined from within the perspective of bounded relevance, nurses were faced with c o n f l i c t s of l o y a l t y that, at times, took on the force of a dilemma. Yet, choices had to be made. In examining how choices were made, we w i l l review pertinent facts from selected cases while providing an abstract r e n d i t i o n of what the o r i s t s have to contribute. 84 In the case examples depicting Stage III thinking i t i s evident that the nurse f e l t conflict of loyalty when witnessing a patient giving consent while inadequately informed: the concept of patient rights was not upheld. But a belief in the value of a positive and trusting doctor-patient relationship backed by the assumption that she wasn't legally responsible for the patient's lack of knowledge, kept her silent. Her basic assumption is questionable because, as Fiesta (1983) remarks, the hospital and i t s nurses can be held liable i f they knew there had not been adequate disclosure in cases of informed consent. In the second case, the "emotional" and very time-consuming need to find treatment for a l i t t l e g i r l kept several members of the school-based team hoping that they could form a relationship with the child's mother so both mother and child would get counselling. (It may have been the same need for relationship that kept them from challenging the psychiatrist's hasty decision.) Concern for another which is rooted in caring remains foremost: empathy with the other brings in an emotional relationship-promoting component. The conflict in each instance was recognized for what i t was, yet the need to maintain the human connection Gilligan (1982) speaks of i s paramount. Women, she says, believe that "fractures in human relationships must be mended" (p. 207). Correlatively, in the f i r s t case, the nurse did not want to sever the doctor-patient connection because she believed the connection was more important than the high risk of stroke and perhaps death that the inadequately informed patient faced. The nurse did feel a certain degree of 85 cognitive dissonance but to some degree i t was reduced because she placed such a high value on maintaining the r e l a t i o n s h i p . I t came p r i o r to her need to uphold Stage V values depicting f a i r and b e n e f i c i a l p r a c t i c e s . With t h i s i n mind, according to Festinger (1962), the magnitude of the dissonance i s reduced. A l t e r n a t i v e l y , i t i s possible that dissonance i s lessened i f the nurse either consciously or unconsciously decreased the importance placed on Stage V concepts thereby increasing the attractiveness of r e l a t i o n s h i p . I f t h i s i s true, then Janis's i n t e r p r e t a t i o n of defense avoidance techniques i n c o n f l i c t theory can at le a s t p a r t i a l l y explain the value placed on r e l a t i o n s h i p . However, i t i s not known i f t h i s l a t t e r process was u t i l i z e d ; o v e r t l y , i t appears that value i s placed on r e l a t i o n s h i p . A formulation that places r e l a t i o n s h i p p r i o r to justness and fa i r n e s s , G i l l i g a n contends, may seem naive and co g n i t i v e l y immature; nevertheless, i t i s l o g i c a l to assume that the r e s t o r a t i v e a c t i v i t y of care, communication and connection between patients and health care professionals i s an addit i v e factor i n the healing process. In f a c t , both stress how h e l p f u l and often c r u c i a l l y important the human interpersonal component i s : humane and thoughtful caring sustains and fosters hope i n those who are unwell. I n t e r e s t i n g l y , out of the m i l i e u context each nurse was capable of Stage V patterns of reasoning: they were conversant with the e f f e c t of l e g a l parameters and were cognizant of the moral implications of t h e i r actions. Nevertheless, i n the s o c i a l s i t u a t i o n t h e i r concept 86 of value focused on the need for r e l a t i o n s h i p and r i g h t ac t ion become equatable with r e l a t i o n s h i p maintenance. In perce iv ing that nurs ing relevance was l i m i t e d , t h e i r concept of moral worth as i t r e l a te s to n u r s i n g ' s r i g h t to r e l a t i o n s h i p with the pat ient d iminished. Stage V perspect ives were abdicated. Act ions which could have promoted pro fe s s iona l nurs ing standards as w e l l as a sense of nurse-pat ient t rus t were set a s ide . As we progress to the Stage IV reasoning, i t can be noted that i d e n t i f i e d themes are grounded i n a more cogni t ive r a t i o n a l foo t ing versus the more a f f e c t i v e perspect ive ju s t d iscussed. In the fo l lowing cases, d i screpancies wi th e i t h e r s o c i a l or p r o f e s s i o n a l goals or value systems occur. In many ins tances , the in f luence of modern technology in t rudes . Clashes of l o y a l t y are often caused by the i n a b i l i t y of some members of the hea l th care team to t r u l y see the human be ing—technolog ica l gadgetry or test r e s u l t s become powerful ly overwhelming. The f i r s t theme w i l l contend with the r i g h t of the nurse to meet defined ob l i ga t ions to the pat ient versus the r i g h t of the phys i c i an to spec i fy the nature of the treatment. Theme: Nursing Rights versus Phys i c i an Rights Case #10 D e s c r i p t i v e a n a l y s i s . The ensuing case provides i n s i g h t in to a p s y c h i a t r i c nurse ' s percept ion of the l i m i t a t i o n s set for nurses and her way of coping with them. " P a t i e n t autonomy should be encouraged," she remarks. 87 R: Patients should be able to maintain t h e i r i n d i v i d u a l i t y — t h e i r i d e n t i t y — a n d be treated by health care professionals with the respect that i s due them as i n d i v i d u a l s and to be able to operate as i n d i v i d u a l s . . . . So that, I be l i e v e , involves r e s p o n s i b i l i t y on behalf of the health care professionals as w e l l as r e s p o n s i b i l i t y on behalf of the patient. She believes that nurses i n psychiatry must help patients: R: Maintain as much autonomy as possib l e , make decisions f o r themselves, and i t i s very hard to do that because a l o t of times these patients look to us to make decisions for them. But [problems] h i t home the most when I see p s y c h i a t r i s t s behaving very p a t e r n a l i s t i c a l l y to patients and I f i n d that quite d i s r e s p e c t f u l . I could see that s i t t i n g i n a recent interview with a patient who was a [pr o f e s s i o n a l ] . I: She was a female? R: Yes, and her p s y c h i a t r i s t , a f a i r l y young male, e s s e n t i a l l y sat there and to l d her that she should do these things because he i s a p s y c h i a t r i s t and knows better, and that i s pretty w e l l exactly what he said. I: So she had no options offered her? R: Well, she could have chosen other options but he said, you know, i f you want to get better, you know, you would l i s t e n to me because I have a l l t h i s t r a i n i n g and, therefore, I'm supposedly learned and i f you want help dealing with your emotions that you can't handle, you w i l l do A, B, C, and D. Very dogmatic. I: So he a c t u a l l y gave her A, B, C, and D. In that case. And what did the patient do? R: She c r i e d i n front of him and said she f e l t t o t a l l y l o s t and helpless and couldn't r e l a t e to that [his suggestions], I: Was she going to do A, B, C, and D? R: I don't think so. I think she said she f e l t she couldn't do those things, she wasn't capable of i t . I: So what happened then? 88 R: He just sort o f — I can reca l l the setting, too. She was sitting on the bed and there is a desk in v.the room over here and he came in and sat on the desk, so she's down there and he's sort of up here looking down. I: And where were you? R: And I was sitting in a chair over in the corner and I recall getting quite distressed at this. Not only—I f e l t he was quite cold in his approach and I wasn't too familiar with this particular psychiatrist. I had known him for as long as he worked here which was a couple of years. But I hadn't actually sat in and done interviews with him so, you know, I wasn't familiar with his style, so this came as a b i t of a surprise to me. I didn't find i t particularly warming to me but I thought, well, I ' l l just s i t here and see what's happening and, you know, maybe he has something different going with this woman and I don't know. I f e l t i t was quite distressing because this woman became a lot more distressed as he went along and i t didn't seem to me that he was getting anywhere. So fi n a l l y I pointed this out and said, "this doesn't seem to be helping us," and I don't think there was any huge resolution from.that interview. Because I f e l t dissatisfied with i t , I thought I better check i t out afterwards. So, then, I sat down and talked with the psychiatrist and tried to find out, you know, the background. Maybe she [the patient] had been very d i f f i c u l t to deal with and this was sort of the.last route he had to take. I did feel good in that I checked i t out and found out that in my judgment he was just lousy, that's a l l , and wasn't being helpful at a l l . And I, actually, was quite open. I told him that's what I thought. A lot of the other staff f e l t the same way. And we [the nurses] tried to alter our plan with this woman. I: How old was she? R: She was in her young twenties. I: And you took the step of altering the plan with the patient without his A, B, C, and D? R: Yes. It didn't particularly involve doing whatever i t was he s a i d — I can't re c a l l now, I wish I could, i t would help. It seems to me f a i r l y typical though, when you are working in psychiatry on a team basis, we don't a l l agree a l l the time. And also on the ward I work on, the nurses do most of the work in terms of the amount of time which is spent in interacting with patients. 89 I: So do you set up a plan that doesn't need a physican order then, and you actually do therapy and you don't need physician involvement? R: Yes, we t e l l him what we are doing. And, basically, probably they don't really care what you do as long as they are not violently objected to i t . You have to realize that there are some psychiatrists that are a lot more involved with the work than others are. I: So this is a psychiatrist who didn't particularly have to be involved, he didn't mind? R: No. I: So you were free to make your own plan. Well, how did i t work when you made a plan with her? R: Well, I would say she was discharged improved. She was a very d i f f i c u l t person to work with, you know, that sounds judgmental but everybody found her very d i f f i c u l t . She herself acknowledged a great deal of d i f f i c u l t y in feeling that she was making improvement in the things that were bothering her. . '.  .. She had tried to k i l l herself . . . but wasn't injured that badly. . . . She herself f e l t she couldn't explain why or rationalize i t or talk about i t to any huge depth. It-was just that she did i t and i t was over with and she won't do i t again. I: Do you feel that the nurses made any real progress with her? R: I'd like to think that we made progress. I think we related with her much better in that I f e l t that there was more of a connection—that she f e l t understood with us and that she f e l t by being understood, better able to open up and try to identify some of the things that were really bothering her. I: Did she have a plan when she went home then? R: Yes. I: Was she able to plan something she could contribute to? R: Yes. I: And that was due to her nurse making that plan with her? R: Yes, we worked on a plan. As a matter of fact, we got a card from her not too long ago. 90 Normative analysis. This nurse i n c h a r a c t e r i s t i c Stage IV reasoning was quite clear on where she stood within the system. She was also aware of her nursing o b l i g a t i o n s . After having to undergo an unpleasant interview s i t u a t i o n , she questioned the physician about his approach and then, w e l l within her r i g h t s as a nurse, she helped the patient devise a care plan which would be e f f e c t i v e . The physician had the r i g h t to veto the nursing plan but chose not to. S t i l l , i n t h i s kind of s i t u a t i o n , i t i s worth noting, p a r e n t h e t i c a l l y , how often a responsible nursing plan i s vetoed and, i n such cases, what l i t t l e r i g h t the nurse has to proceed as her judgment d i c t a t e s . Further, even though the plan of care proceeded, i t i s l i k e l y that the patient had to overcome fee l i n g s of powerlessness enhanced by the i n i t i a l therapy session. Loyalty, once the physician's r a t i o n a l e was assessed, went to the patient; nevertheless, i n the i n i t i a l interview, the nurse was unclear about where her primary l o y a l t y should be directed. S i m i l a r l y , i n the succeeding example, nurses' r i g h t s are i n f r i n g e d upon and, i n t h i s case, to the point of at l e a s t v i c a r i o u s l i a b i l i t y and, at the most, d i r e c t l i a b i l i t y . Case / / l l D e s c r i p t i v e analysis. The s e t t i n g again i s i n psychiatry. This nurse believes that the philosophy of her u n i t , s u c c i n c t l y put, states: The road to health i s paved by people taking r e s p o n s i b i l i t y for themselves and part of that r e s p o n s i b i l i t y involves recognizing when they should be i n h o s p i t a l . In other words, acknowledging that they have a problem that they want to do something about. 91 That philosophy i s f i n e when a l l l e g a l proceedings concerning h o s p i t a l admission are followed. But this nurse has been caught with a d i f f i c u l t issue: she i s expected to provide nursing care f o r patients who have neither signed a consent nor been committed. She says, R: I came to work a f t e r days o f f and there i s a patient who has been there for 24 hours that has neither a: signed consent nor been committed—and I ju s t make i t very clear to the medical people involved and any supervisory people around that I am ..not doing anything with the person because they are not here v o l u n t a r i l y and they are not committed. I: How can they be there without any kind of consent then? R: I t happens a l o t i n psychiatry, I'm sure. . . . You see thi s a l o t with ambivalent p e r s o n a l i t i e s . I: You mean they won't sign, yet t h e y ' l l stay? R: Yes. They won't sign, yet t h e y ' l l stay. Well, I t e l l them, "Look, i f you are not w i l l i n g to sign, w e l l leave." And they don't leave. I: W i l l they sign f o r you, then? R: No, not ne c e s s a r i l y , no. . . . And i t i s not up to nurses to write committal papers, they can only be written by medical personnel; however, we are often l e f t holding the bag. . . . Well, two weekends ago, I was working nights. I came on and there was an e l d e r l y woman who had been admitted, I b e l i e v e , on the advice of her GP. She had been at home, not eating, refusing to eat as a matter of fa c t , had been i n the emergency department once to have her e l e c t r o l y t e s r e s t a b i l i z e d and to be rehydrated and went home, immediately deteriorated and came back i n by ambulance and was admitted d i r e c t l y to the p s y c h i a t r i c ward. She refused to eat or drink anything, refused to accept any form of s e l f care, and, i n f a c t , she required t o t a l care. She was incontinent i n bed and had to have an IV started. I r e a l i z e d — I think I was there the second night she was there. I started work and she was neither committed nor had signed a consent. As f a r as my understanding of the l e g a l procedure goes, the doctors, the h o s p i t a l , a l l sorts of people, could have been charged with assault f o r the procedures they had i n s t i t u t e d on that woman without t h e i r 92 being consent or committal. I was quite angry about that because I don't l i k e being placed i n a p o s i t i o n of jeopardy and I also think i t v i o l a t e s her r i g h t s . I: So, what did you do then? R: So, I t o l d the nursing supervisor, I t o l d a l l the other s t a f f I worked with, and informed the doctor on c a l l , the p s y c h i a t r i s t who was covering the ward, that, you know, something needed to be done about t h i s . I guess what angered me was that i t took somebody coming to work on a Friday night whereas the woman had been there two days and i t should have come to somebody's attention, p a r t i c u l a r l y her doctor's, the p s y c h i a t r i s t on the ward. I: Is t h i s an example, then, of consent being more or l e s s ignored? R: Well, i t becomes a matter of s e t t i n g p r i o r i t i e s and I think, unfortunately, a few basic things get missed i n the p r i o r i t i e s , since obviously somebody has made a judgment that t h i s woman i s not competent and needs our help r i g h t away or she i s going to die. Now, i f she was l e f t i n her apartment, she would have died. And, therefore, she had to come i n . I: Did she a c t u a l l y get committed? R: Yes, she got committed that day, the day that I reported i t . I: Is t h i s the thing you mean where nurses get caught holding the bag? I t seems that nurses are doing a f a i r amount of actual assessment that makes a r e a l d i f f e r e n c e . R: Oh, I think so. I can r e c a l l again on the c r i s i s ward where they would get people i n more acute phases and get a l o t more acting-out behavior which required immediate intervention such as IM i n j e c t i o n s of major t r a n q u i l i z e r s . We frequently would be asked to i n j e c t people who had not signed consent or been committed. Fortunately, I worked with a very good team of nurses who made t h e i r stand pretty c l e a r on that. But we had to do i t quite c o l l e c t i v e l y . I: What was your stand? R: The stand was that we say to the p s y c h i a t r i s t s that, you know, I'm not going to give that i n j e c t i o n to that person u n t i l something i s done as far as them either giving an 93 informed consent or you getting them committed. Because i t was a v i o l a t i o n of t h e i r r i g h t s . And I guess i t wasn't so much an e t h i c a l dilemma because I could c e r t a i n l y appreciate that they probably needed that medication and, i n f a c t , i t ' s almost c r u e l to deny i t to them because they are i n a great deal of d i s t r e s s i f they are h i t t i n g out or i n such a degree of d i s t r e s s that they don't know r e a l l y or don't appreciate the nature of t h e i r actions. So they r e a l l y need i t , but I mean the laws are there to protect them as w e l l . 1 think that what was probably annoying about that i s the p s y c h i a t r i s t who was d i r e c t o r of that unit seemed to be very f l i p p a n t and sort of slack i n employing those p r i n c i p l e s . He was sort of making sweeping generalizations l i k e , "Well, I ' l l cover you a l l i n a court of law i f i t should come to that," and I said , "Well, thank you, but I prefer to cover myself." You know, I j u s t — i t r e a l l y was a case where we had to stand up. Normative analysis. This nurse stood up for her r i g h t s as they are s t i p u l a t e d within the system and sanctioned by the law. This pattern of reasoning exemplifies Stage IV thought. She refused to continue providing service u n t i l patients and s t a f f a l i k e were protected for both e t h i c a l and l e g a l reasons. Where at a l l possible, she prefers that patients decide on t h e i r care. When th i s i s not possible, commitment i s . The physician has the r i g h t to commit a patient; i t i s her b e l i e f that he also has the o b l i g a t i o n to do so i f a consent i s not signed. Patient r i g h t s are then upheld and nurses and physicians a l i k e have met defined o b l i g a t i o n s . Our f i n a l case under the theme of nursing r i g h t s versus physician r i g h t s has to do with nursing's r i g h t to information which can a s s i s t i n the understanding of a d i s r u p t i v e patient. Case #12 Descri p t i v e analysis. A lack of pertinent information i n th i s case added f u e l to what was already an unpleasant s i t u a t i o n . The incident takes place i n a unit c o n s i s t i n g of mainly e l d e r l y people. 94 R: One phys i c i an admitted a young 17 year o ld g i r l with p e l v i c inflammatory disease [PID]. And to say that she was a major behavior problem was put t ing i t m i l d l y . She was the worst one I have ever had to encounter. She was v e r b a l l y abusive to the nurses . They cou ldn ' t do anything with her . And she kept using the famous four l e t t e r word. She kept her cur ta ins drawn. She was i n a four bed room with three e l d e r l y ladies—one was dy ing . The ward was ful l—we had no place to put her . And she was a s t r ee t k i d , and s t ree t -wise . I don ' t know how.long she had been on the s t r ee t . . . . We were not managing her w e l l , and we were not coping w e l l wi th her . These k ids are hard to love— they are very hard to l o v e . And i t i s very d i f f i c u l t as a head nurse to support your nurses when they are being v e r b a l l y abused. They get fed up and they d i d n ' t get the emotional support they needed. I thought that there should be some place e l se for a 17 year o ld to be put . She'd come to the nurs ing s t a t i o n and have major tantrums. I d i d n ' t think the woman who was dying should end her l a s t couple of days hear ing that . So we phoned the p h y s i c i a n and mentioned we were having problems managing t h i s c h i l d and would l i k e to consul t . . . . So we had a meeting. . . . One of the things that d i s t re s sed me, and I regret now not taking i t up further [ in the meeting] , was the fact that from a s o c i a l work aide we had learned that th i s g i r l had been sexual ly assaulted by her father or her s tepfather as a c h i l d and she—the nurses ' a t t i tudes changed toward the g i r l . Oh, i s n ' t that t e r r i b l e — t h a t ' s why she ' s l i k e t h i s . And, oh, what a t e r r i b l e l i f e , you know. And t h e i r approach to her changed. And dur ing the conference, I brought up to the phys i c i an how—the problem she was causing on the ward—that she was very d i s r u p t i v e . And that we were f i n d i n g i t hard to keep her on the ward. Yet the g i r l was i l l w i th PID. And I suggested that the C h i l d r e n ' s Adolescent Uni t be t r i e d because the nurses there know how to dea l with adolescents . Although not . a l l adolescents are l i k e her . . . . The doctor hadn't heard of the adolescent u n i t . R: The doctor wasn't in te re s ted but I encouraged her to look in to the adolescent u n i t . The re s t of the conference involved the doctor de sc r ib ing the process of PID and noted that there i s something we can ' t say. This i s why I wish I ' d taken the doctor up, but i t wasn't r i g h t for that d i scus s ion—or that kind of confronta t ion . And the fact that some awful th ing had happened i n t h i s g i r l ' s l i f e that the doctor r e a l l y cou ldn ' t discuss with us. And I was upset at that statement, r e a l l y upset. And i n some ways I wish I ' d taken up on that statement r i g h t there and then and s a i d , 95 "you expect us to give her good care , yet a p r o f e s s i o n a l s o c i a l work aide i s given that information and jus t happened to l e t i t drop [to the nurses ] . And we are denied that , how can we care for th i s person?" I would c e r t a i n l y , i f we had a pa t i ent l i k e that i n again with that k ind of behavior , I would c a l l the doctor on i t . She d id get in to the adolescent u n i t . I : But you noted that when the nurses a c t u a l l y found out that there might be some cause, or some explanatory reason for such behavior , that they could then approach her d i f f e r e n t l y , or d id they f e e l d i f f e r e n t l y ? R: Oh, yes . Yes, and when they were c a l l e d names they d i d n ' t f e e l i t was so personal—they r e a l i z e d that there was a reason for i t . I : So sharing— R: Sharing that information i s very important. And i f i t i s denied the nurs ing s ta f f—I f e e l that as p ro fe s s iona l nurses , that we should be given that information to bet ter understand and care for a person. You know our profes s ion holds sacred and dear, to us c o n f i d e n t i a l in format ion . And I wondered where th i s doctor thought ha l f of us had been. I : This conference d id have i t s ef fect? R: I t d id have i t s e f f e c t , yes . I : Is that what you p r e f e r r e d , what happened? R: Yes , I d i d , for the sakes of the other pat ients too. I : And for the g i r l ? R: Yes. I t i s i n t e r e s t i n g to note that sometime l a t e r another p h y s i c i a n , one who chose to work wi th the nurses , admitted a g i r l wi th a s i m i l a r problem to the u n i t . The nurse comments that they could care about her , could understand her behavior be t t e r , and could t a l k to her . R: She was managed w e l l . Her phys i c i an was f rus t ra ted with the system because he was t r y i n g to get help for her . He thought she had p o t e n t i a l . 96 I : When she got out? R: He sa id she was for tunate , they 'd found a good fos ter home and the foster parents were w i l l i n g to pay themselves to get her counsel ing i f she would go. The phys i c i an had conned a psychologi s t who s p e c i a l i z e s i n sexual assault to take her on at a cut p r i c e . And we were lucky to have the support of that p h y s i c i a n . Normative a n a l y s i s . This nurse ' s thought i s representat ive of Stage IV pa t tern of reasoning. She works w i t h i n the system: she only asks for more cooperation and cons idera t ion so that pat ients can rece ive maximum understanding. She gives two exce l l en t examples of the d i f f e rence that can occur when hea l th profes s iona l s work i n unison to a s s i s t t h e i r p a t i e n t s . In the f i r s t case, she perceived a l ack of p ro fe s s iona l re levance , and thereby f e l t l i m i t e d i n what she could say to the p h y s i c i a n ; i n the second ins tance , she was a col league. She now fee l s a l i t t l e more prepared to work w i t h i n the system for change and w i l l challenge the unsharing phys i c i an i f necessary i n the future . Just as nurses f e e l bound by phys i c i an r i g h t s when they perceive a c o n f l i c t of i n t e r e s t or l o y a l t y s i t u a t i o n , they a l so can f e e l bound by the r i g h t s of the i n s t i t u t i o n . In a l l cases, the des i re i s not to undermine the i n s t i t u t i o n , but to b r i n g forward concerns p e r t a i n i n g to p o l i c y i s sues . C o n f l i c t s often revolve around d i f f e r i n g views on one ques t ion : what are the c h a r a c t e r i s t i c s of sound i n s t i t u t i o n a l p o l i c i e s which r e f l e c t f a i r and ju s t deal ings on a p o l i t i c a l , economic and i n t e r d i s c i p l i n a r y l e v e l , such that the consumer's r i g h t s and the nurses ' r e s p o n s i b i l i t i e s are protected and promoted? Let us examine cases i n which expression of t h i s theme i s evident . 97 Theme: Nursing Rights versus I n s t i t u t i o n a l Rights  Case #13 Descriptive analysis. The dilemma f or th i s nurse i s prompted by concerns r e l a t i n g to the economic pressures the health care system i s undergoing at present and the t o l l r e s t r a i n t i s taking on the qu a l i t y of patient care. She compares the cost of maintaining l i f e when a patient has l i t t l e or no hope of s u r v i v a l with the loss incurred at the other end of the system ( i . e . , for patients who w i l l survive but require adequate nursing time and teaching to upgrade t h e i r l e v e l of functioning). This nurse speaks of patients who are i n multisystem f a i l u r e and i n the terminal phase of a chronic disease being maintained at great cost to a system that i s "severely strained f i n a n c i a l l y . " Yet, she says: R: We've j u s t come through a year and a half of being cut i n the h o s p i t a l budget—so they have cut nurses. Cut to the point that you are looking a f t e r — l o o k i n g a f t e r two v e n t i l a t e d patients with various intravenous d r i p s . Plus, you r e l i e v e other nurses when they go on breaks and take on more patients. An impossible t a s k — i m p o s s i b l e q u a l i t y . And we are l i e d to, t o l d a l l kinds of gross things. I t i s ju s t amazing what money w i l l make human beings do! But they w i l l . We a c t u a l l y f e l t and saw the c a l i b r e of actual c r i t i c a l care j u s t take skids and a l l the people j u s t making excuses for t h i s . I: People meaning? R: Nursing, nursing administrators t e l l i n g us that we were disorganized, we were t h i s , we were that. In the end they had to face the f a c t s . In the end we had to resolve the problem. We resolved i t by documenting and documenting and documenting. And i t i s gross. . . . Eventually, nursing administration did do something about i t by closing 98 beds. But i t took them a year . I t took them a year to do that and i t took them blaming us , and not being support ive of us. I t was not u n t i l we s tar ted w r i t i n g things down and the a r t i c l e s i n the paper s tar ted ge t t ing a b i t d icey that they s tar ted taking steps. So I don ' t give them any c r e d i t for moral f o r t i t u d e whatever. They had to be threatened before they would see that . A simple s o l u t i o n . I don' t blame the p r o v i n c i a l government. We can ' t a f ford any more, we have to make changes from now on. Now I th ink that nurs ing i s u sua l ly synonymous with female and I th ink that means we get the short end of the s t i c k . . . I don ' t think we're ge t t ing a f a i r share of the money. I th ink the s t a f f i n g has to be maintained but the need to cut costs has to be considered, but not at our expense. I : Not at nur s ing ' s expense. A l l that documentation, I suppose, brought i n the i ssue of l e g a l l i a b i l i t y . . . . And then the nurs ing administrators supported you. R: Now they w i l l say otherwise. They w i l l say they've been doing th i s but the facts are there . And when they got t h e i r courage up, there was h e l l to pay for that for the nurs ing admin i s t ra t ion . I : What kind of—I don ' t know what that means? R: W e l l , what that means, because i n our ICU open heart surgery, which i s sanctioned by the p r o v i n c i a l government, had to be cut . The government i s saying you can double your open hear t s . In doubling the open hearts—the lo ser s—oh, they are doing people who have a l o t less chance of making i t than they used to . That means our ICU beds are f i l l e d wi th a l o t of very i l l , open heart pat ients who should quest ionably have had the surgery in.the f i r s t p l ace . Ah, but then we have closed beds and they can ' t do the open heart surgery, they don ' t get money, and the surgeons are up there screaming because they are not doing the correct number of surgeries a day. I : Screaming at nursing? R: Screaming at anyone who w i l l l i s t e n . But i t a l l comes back to because nurs ing closed those beds. And the fact i s that there i s no comprehension that you need nurses to look a f ter these people. I : But nurs ing under a f a i r amount of duress supported the s t a f f nurses and q u a l i t y of care? 99 R: Yes , w e l l , yes , I th ink out of fear . I : Out of fear? R: Things haven't changed at a l l , have they? I : I t ' s unfortunate because nurs ing could work with nurs ing . R: Support. I : I f we a l l work together , we are s tronger . R: That ' s r i g h t . She goes on to say that the pressure created by inadequate s t a f f i n g and s i cker pat ients creates " a change over of s t a f f about every two years—just at the point when c r i t i c a l care nurses get t h e i r most u s e f u l , they l e a v e . " I : The nurses leave? R: Yes . W e l l , they burn out for a l o t of reasons. But for one t h i n g , there i s no i n t e r e s t i n keeping—in worrying about how you can keep nurses from burning out. You have to keep that k ind of experienced person there . Everyone e l se i s going to have to l ea rn i t again. I : There i s no support to keep you there a f ter two years when you f i n a l l y have mature people? R: No, and yet I'm not keen on l e a v i n g . You see because what I gained—I gained so p a i n f u l l y not ju s t through one experience but through an accumulation of experiences. And having reached that l e v e l of maturity and knowledge where you think you can r e a l l y be e f f e c t i v e plus teach others as w e l l . You can be an example and encourage others to have humane responses. She says how important i t i s that nurses be cons idered, for s h i f t s to be s p l i t , for leave of absences without pay to be a v a i l a b l e , so nurses can re-energ ize . R: Except i t i s not very important , you see. The system i s more important than the c a l i b r e of the people there . Who 100 i s concerned that there i s a turnover every two years? . . . Nursing administrators should stand on t h e i r pro fes s iona l i sm and then say back what they are going to do. Why do they l e t us s t ruggle and t ry and document and go through moral h e l l ? I mean, why don' t they a n t i c i p a t e problems before they happen? Everyone e l se can—they could have too. I : So i t seems from what you are saying that i t was the grass roots nurses who i n s t i g a t e d the change? R: That ' s r i g h t . I t ' s i r r i t a t i n g that i t has to be t h i s way. That ' s not what I expect from a d m i n i s t r a t o r s — i f that i s what you are going .to be, then there has to be some kind of l i a i s o n where adminis trators represent me. I honest ly don ' t f e e l that there i s anyone represent ing the grass roots nurse anywhere. Normative ana ly s i s . Thinking congruent with Stage IV patterns of reasoning i s voiced through t h i s d ia logue . This nurse i s aware of what her p ro fe s s iona l dut ies and r e s p o n s i b i l i t i e s are. She a lso cares for c r i t i c a l l y i l l , extremely dependent pat ients—she i s t h e i r advocate. An unsupported advocate. Although t r y i n g to perform at a q u a l i t y l e v e l , wanting to f u l f i l l dut ies to which she be l ieves nurses have a r i g h t to f u l f i l l — d u t i e s which are encompassed i n the ro le s and ru les soc ie ty has set for nursing—she i s c o n t i n u a l l y f rus t ra ted by bureaucrat ic p o l i c y . Such p o l i c y places c r i t i c a l care nurses i n s i t u a t i o n s of "moral h e l l . " I t i s l i t t l e wonder these h i g h l y experienced nurses leave i n two years . They are unable to l i v e up to t h e i r mandate to the p u b l i c they are there to serve. The i n s t i t u t i o n has the r i g h t to make economic d e c i s i o n s : i t i s the form the d e c i s i o n takes that causes c o n f l i c t of l o y a l t y and nurs ing burnout. Unable to f u l f i l l dut ies agreed to as a nurse and f e e l i n g 101 vulnerable and open to l i a b i l i t y , the nurse phoned the RNABC for guidance and then began documenting at-risk situations—these nurses followed a legitimate route to force the issue. The next case is somewhat similar as i t refers to how funding allocation affects nursing. Case #14 Descriptive analysis. Time spent with patients remains a c r i t i c a l issue, this nurse speaks of being "barely able to do basic [nursing] functions much less take time to be creative with patients." R: I personally think that this i s really important, that you are not just there as an observer of the patient or a recorder of data and that patient welfare is your responsibility more so than anyone else. I have accepted as a day-to-day fact that what you do at the bedside is important. We are the ones that get the pain medication and a l l that coordinated, make sure they get adequate analgesia, that they are comfortable, that things that are making them uncomfortable are dealt with, and that dangerous turns in their condition are treated. It i s not that the medical staff doesn't care, but their bent is completely different and they don't spend the time —they don't watch what these people go through. The patient lying there c r i t i c a l l y i l l in bed, even i f they don't remember the experience in most cases, i f they survive, they are completely dependent on nursing care for everything and that includes the type of medical care they receive as well. I: If you want your patient to be comfortable, you have to say something and challenge the fact that there is not enough ordered or the wrong combination of orders? R: Exactly, and I accept that as the norm so I don't consider that irresponsible on the physician's part, I consider that nursing i n i t i a t i v e . I: Do the physicians consider that a norm? R: Yes. I: So they expect the nurses to evaluate their orders in a sense and update what needs it? 102 R: I think they are a l i t t l e too dependent on i t . But because a l o t of s t a f f are new, they never had the opportunity to l ea rn to p r i o r i z e work—they are ju s t thrown i n . I : Can the q u a l i t y of medical care be r e f l e c t e d by the q u a l i t y of nurs ing care? R: Yes , exac t ly . This nurse says she prefers to work with the nurs ing adminis trators and other members of the hea l th care team by making headway through consi s tent per s i s t ance , diplomacy, documentation, and being f i rm but reasonable. And they have made some headway, she says. R: You don ' t get everything you want, but wi th a u n i f i e d , i n t e l l i g e n t vo ice you can make ga ins . You document inc ident s not to b r ing the medical people up on the carpet but to l e t them know you are aware. You have to be qui te f i rm and set your l i m i t s wi th these people. I think they don' t understand pat ient s as nurses do. They are not watching the pa t ient su f fe r . I think i f they were, they would be more aware of the need for care—the human aspect of the i s sue . In s e l f defense, they ignore i t . I : Why? R: Because of the absolute awesome r e s p o n s i b i l i t y they have towards the pa t ient and the r e s u l t , i f there are complicat ions to the treatment. Normative a n a l y s i s . Supporting the pa t ient and pro tec t ing the dependent, c r i t i c a l l y i l l pa t ient remain p r i o r i t y ob jec t ives for th i s nurse. With Stage IV patterns of reasoning, she places her view w i t h i n the system's perspect ive . I t i s obvious that to her , medicine has more say i n who gets what throughout the bureaucrat ic s t ruc ture ; moreover, she recognizes the i n s t i t u t i o n ' s r i g h t to make funding d e c i s i o n s . Nevertheless , undaunted, she descr ibes what nurses can do. She perceives that nurs ing can work w i t h i n the system as i t i s 103 today by s e t t i n g f i rm standards and being cons i s t en t ly p e r s i s t e n t and with a c e r t a i n diplomacy, documenting instances that run counter to pa t ient safety or q u a l i t y care. In t h e i r in terv iews , both of these nurses spoke about the need to promote the p a t i e n t ' s r i g h t s and to spend time with the pat ients working with them so they can a t t a i n an optimal l e v e l of func t ion ing . They c i t e d what happens when nurs ing funds are cut . Underlying the second case, and d i r e c t l y s tated i n the f i r s t , i s the need to look at where money i s being spent and how. The next theme to be presented looks at one aspect of t h i s i s sue whi le concentrat ing on the p a t i e n t ' s r i g h t to a d i g n i f i e d death. Theme: Nursing R e s p o n s i b i l i t y and the Right  of the Pat ient to Die with D ign i ty This area i s one that i s f u l l of controversy i n hea l th care today. To r e i t e r a t e , t h i s study i s not designed to advocate an approach to care , nor i s i t designed to lay blame on any one group or pro fe s s ion . We a l l contr ibute to our soc i e ty . We are a l l respons ible for what happens. Fur ther , the top ic of death i s s t i l l shrouded with mystique and to some extent fear i n soc ie ty today; there fore , i t i s not s u r p r i s i n g that many of the most heart rendering and complex c o n f l i c t s i n the hea l th care system today, p e r t a i n to values and b e l i e f s associated with the treatment or nontreatment of those who are t e rmina l ly i l l . The fo l lowing case examples o f fer nurs ing perspect ives on the i s sue . These perspect ives are steeped 104 in perceptions of helplessness due to the nurse's feeling of bounded relevance. Although a l l involved, physician, nurse and family alike, are doing their utmost as i t is defined from within their own perceptions, to care for those who are dying, nurses feel their responsibilities to the patient are often compromised to the detriment of patient and nurse. In general, each case presents an individual who is dying, who has l i t t l e hope of survival beyond a brief time span, i f at a l l . F u l l treatment is undertaken. The nurses, a l l maintaining Stage IV patterns of reasoning in the actual conflict situation, are placed in extreme conflict of loyalty positions. They honor the autonomy of the individual who is undergoing treatment and who has suffered almost complete loss of autonomy; conversely, they honor the system which, in these cases, supports a rule which states: treat at a l l cost, treat as long as anything is treatable. Case #15 Descriptive analysis. The patient is a man in his sixties. He is cared for by a nurse who believes patient autonomy can be upheld, even in the c r i t i c a l care unit by, R: Finding a way to communicate with the patient, by involving the family in the care—finding out what the individual is l i k e — t h a t helps a great deal, i t gives the patient some right to decision making. I: Can patients actually make a decision then? R: Some can . . . the ideal situation is where someone who had a terminal illness could decide—they would be informed of a l l the options and treatments available to them. 105 I: Does that happen often? R: I f i n d that [hospital] i s very, very aggressive. I: What does very aggressive mean? R: Very aggressive means they w i l l maintain extraordinary means to support l i f e i n patients where the prognosis i s poor with great p h y s i c a l s u f f e r i n g to the patient. I: The prognosis poor and at great p h y s i c a l s u f f e r i n g — h a s the patient been asked? R: No. I: Has the family been asked generally? R: Most of the time. But sometimes that i s disregarded based on the aggressive philosophy of the medical unit. . . . They w i l l maintain l i f e as long as there i s an i n f e c t i o n present, as long as there i s some sign of sepsis because that i s a "t r e a t a b l e " cause. In r e a l l i f e i t i s not, but p h i l o s o p h i c a l l y i t i s . So we give them another a n t i b i o t i c and extend t h e i r l i f e u n t i l they have had t h e i r course of a n t i b i o t i c s for 3 or 4 days depending on the drug. I: So that might be a time for decision making, when the course of a n t i b i o t i c s has ended? R: Decisions are made but they are often prolonged. Not long ago we had a cancer patient i n our ICU. He had leukemia, he was intubated and v e n t i l a t e d and he l i v e d , h o r r i b l y , for s i x weeks. I: What does h o r r i b l y mean? R: H o r r i b l y means that he was s e p t i c — h e was a human p e t r i e d i s h — h e was immunosuppressed, he was bleeding a c t i v e l y , because of h i s sepsis he was t h i r d spaced. The t o t a l parenteral n u t r i t i o n [TPN] , the d i a l y s i s and everything to keep him going caused f l u c t u a t i o n s i n blood sugar and e l e c t r o l y t e imbalances, sores, i n f e c t i o n s , s c l e r a l edema, he couldn't close h i s eyes. I: This was for s i x weeks and then what happened to him? R: He died. 106 I : To your knowledge, was he ever asked, at any time, what he would l i k e ? R: To my knowledge I don ' t th ink i t was ever discussed wi th him but i t was discussed with h i s family and they wanted . aggressive treatment. I : Even when they saw what the aggressive treatment was doing? R: There was some problem wi th the fami ly . They d i d n ' t get a long. They had d i f f e r e n t op in ions . I f you have ever seen someone l i k e that ! I : I haven' t seen anybody qui te l i k e that . R: I have seen a l o t of people l i k e that . I : I think I would have found i t d i f f i c u l t . R: He looked hideous, h i s consciousness would f luc tua te and he withdrew. Pa t ient s ju s t withdraw, they don ' t want to be there and I th ink that was the case with him. . . . I n i t i a l l y , i t s tar ted out, w e l l we w i l l see, w e ' l l t ry a few th ings , but i t ju s t kept on going and d i d n ' t stop. I : So, i n i t i a l l y , the in tent i s a good one, w i l l buy him some t ime, yet there i s no c r i t e r i a to stop t i l l the end. What would you consider a more i d e a l approach? R: A c t u a l l y , I th ink they should have discont inued treatment and done th i s e a r l i e r . He wasn't even kept comfortable because of h i s low BP and sep t i c shock and the need for cont inua l n e u r o l o g i c a l assessments. I : So would one p r i o r i t y be comfort? R: In th i s s i t u a t i o n . I : Why would you prefer invas ive treatment to stop and comfort measures to s tar t ? R: Because I thought causing a l l that pain and discomfort was not going to gain him anything. To me i t was unnecessary a f ter a c e r t a i n po in t . I : Do you f i n d that that happens o f ten , that i n i t i a l l y i n an ICU the in tent i s r e a l l y admirable, but somewhere along the l i n e i t s l i p s and s t a r t s d e t e r i o r a t i n g in to something that i s a mess b a s i c a l l y ? Is that common or not? 107 R: That i s a common occurrence. I : How are you affected? R: You have to endure c e r t a i n things and you make i t through, i t i s not pleasant . When asked what condi t ions deter th i s from happening, the nurse noted that at times pat ients w i l l put what they pre fer i n w r i t i n g , or w i l l t e l l a family member. However, she also noted . that sometimes pat ients f e e l i t i s the end when i t i s n ' t . In these ins tances , she s t re s se s , pat ients need to be t o l d that they can recover for a per iod of time. When asked what she would p r e f e r , she again stated that pat ients must be informed and then be permitted to make t h e i r choices . P l u s , she wanted a p r i o r i t y put on comfort and invas ive treatment measures stopped at an appropriate time. Normative a n a l y s i s . This nurse , i n accepting the system she works under, "endures" some of the negative features of i t . Caring for a dying pa t ient who i s s u f f e r i n g grea t ly whi le aggressive treatment measures are employed i s d i f f i c u l t . I t must in f luence the burn out and h igh turnover of nurses i n c r i t i c a l care u n i t s . As a previous nurse noted, "We are there to see the pat ient s u f f e r . " In t y p i c a l Stage IV reasoning, t h i s nurse would pref er that a more equi table s tate of a f f a i r s be set up w i t h i n the system. She recommends (a) that pat ients be informed and given a choice of treatment, and (b) that assessment points be i n s t i g a t e d so aggressive treatment can cease when i t i s c l ea r to a l l involved there i s no hope of recovery. 108 Nevertheless, in stating this, the interests of each constitutive group are to be considered as social and moral agreement is sought. Case #16 Descriptive analysis. Another c r i t i c a l care nurse stresses the need for the health care team to see patients as human beings with a right to autonomy and for the patient to understand the economic strains of the system. She says nurses would like to make recommendations but nursing input is limited. She is referring to a case involving a sixty year old alcoholic male, R: Who had drank himself into total body rot. His wife had gone and his business had gone—both for the past ten years. And every system he had was in a state of degeneration. Now, as far as I'm concerned, what we did for that man was purely experimental which is immoral. He obviously had nothing to live for—he had to work very hard to do that much destruction to himself. I: How do you see what nursing and medicine did to him was experimental? R: Just that they bothered to keep him alive. I: Just bothered at a l l , just to see i f i t worked, you're saying? R: Yes, to see what we could do. I mean, they did not perceive i t this way. Medicine didn't t h i n k — l e t us practice here. But that's because their eyes—-they had blinkers on. There are stat i s t i c s about system breakdown. When you get into your fourth nonfunctioning system the fata l i t y rate is 90%. Well, he didn't have any systems that were working. He didn't have anybody to care about him. He didn't have any future to get into. I don't know why i t i s , I look at i t and i t i s so obvious. Yet I'm working with a l l these wonderfully dedicated people who don't see i t that way. And for my own peace of mind—I don't stress myself in those circumstances. I mean I'm not going to make those moral decisions. But in order to keep my sanity and my perspective, I c a l l this an experiment. A l i t t l e b i t of ignorance, a l i t t l e b i t of not wanting to see—or whatever—and I hope 109 that what I am doing w i l l have something going for i t i n the name of an experiment. I : You want to see the good i n i t ? R: W e l l , to make some excuse for what I'm doing th ink ing that I c a n ' t r e a l l y f ind a good reason. Otherwise, why should I do what anybody's saying? So, I guess, maybe that experiment i s my view of j u s t i f y i n g why I carry on. I don ' t want to see t h i s . I don ' t want to see th i s pat ient the way they ' re seeing him. You know, I l i k e the view I 've got. The view I 've got makes a l o t more sense to me than t h e i r view. So by put t ing i n j u s t i f i c a t i o n — o n e I can handle—I can keep my own point of view and s t i l l funct ion i n t h i s environment without too much of a loss to myself . The loss to myself would be what would bother me—I don' t want to s t a r t th inking i n terms of—the way these people are th ink ing that t h i s i s a case of t o t a l body breakdown, l e t ' s see— I: But you do know that i t i s hopeless? R: Yes. I : How long , i n c i d e n t a l l y , d id that man go for? R: Probably two to three weeks. I : In the ICU? R: Yes. I : And then what happened? R: He d i ed . I : Then he d i e d . So two or three weeks of s t a f f , drugs, equipment, t ime, e t c . — R: Doing the whole th ing . I mean, h i t t i n g everything you could pos s ib ly do. You know, d i a l y s i s , TPN, everything abso lute ly pos s ib le to meet a l l these needs. We weren't n e u r o l o g i c a l l y ge t t ing anything but , " tha t could come back cou ldn ' t i t a f ter everything e l se goes?" I : Is t h i s mode of th ink ing qui te common i n ICUs? R: I think i t ' s not thought about, I don' t th ink medicine thinks about i t . I'm not qui te sure how they use t h e i r c r i t e r i a . 110 They are ju s t wound up to save l i v e s r i g h t . And they ju s t —somehow they don ' t look at the surroundings, they don ' t make judgments because they don ' t have to . They ju s t go i n and put t h e i r heart and sou l in to doing t h i s job. I don ' t th ink they see i t on this—we're not going to save th i s man's l i f e anyway—but l e t ' s see what we can l ea rn from i t . I don ' t think t h a t ' s t h e i r conscious thought process at a l l . And I use that one when I have to , when I r e a l l y f e e l that I shouldn ' t be doing t h i s . I guess i t ' s because I am e x q u i s i t e l y aware of the p r i c e t h a t ' s paid on the other end of the system—like nurses on the medical wards who are not given an opportunity to d e l i v e r hea l th care or nurs ing care that they would be able to do had they been given some honest support. Here we have money d r a i n i n g out. She sees reason for nurses to be i n c o n f l i c t and to be i n s e n s i t i v e . R: Why be s e n s i t i v e and burn your se l f out i n three months t r y i n g to be a human being when the system i s not set up for you to be that way? I : What ought to happen? R: I ' ve come through an era where people were se lec ted codes —and i t was obvious that i t was the nurses who were dec id ing that someone who was 7 5 years o ld and s e n i l e — somehow the thought of c a l l i n g a code on him never occurred to us. This dec i s i on d i d n ' t f e e l uncomfortable at the time. Now i t [ c a l l i n g codes] i s jus t done as a matter of form. I f ind i t a p p a l l i n g . I j u s t can ' t understand i t . . . . There i s a c ry ing need for somebody to s t a r t s e t t i n g up an e th ic s committee because we simply—the Hea l th Care System cannot handle everyone going through an ICU. I mean, they scream about the costs of these units—we have s t a f f i n g problems because they are not prepared to s t a f f them. There are a l l kinds of p h i l o s o p h i c a l questions I am prepared to tackle wi th t h i s but w i l l stand i n judgment of people who won't tackle them. To think that we should save a l i f e at a l l cost i s wrong. I t i s very i d e a l and would be nice—we cannot do i t because we do not have the funds to do i t . And when we think we do have the funds, we are robbing the other end of the sca le . I t can ' t be done. So some kind of compromise must be made and that means some have to be t o l d yes and some t o l d no. . . . I ju s t think people make choices and why should I i n t e r f e r e with your choice? I mean, i f your choice i s to dr ink your se l f in to o b l i v i o n — t h e n , so you know the consequences, so why should I jump i n to save you? I l l I : So you are saying i n a sense that , why should we as a s o c i e t y , I gather you might be meaning, support someone i n an ongoing s tate of a lcohol i sm w e l l i n to o ld age when t h e i r systems are going and they are going to have to be c h r o n i c a l l y maintained i n c r i t i c a l care units? R: Yes. Yes , the whole time. . . . We don ' t have an end anymore, tha t ' s not e n t i r e l y true but , i s that any be t t e r than having a d i g n i f i e d end three years e a r l i e r ? I : So t h i s l o y a l t y problem, i f I'm looking at i t c o r r e c t l y , t h i s time you would be supporting a sens ib le system versus maintenance of l i f e at a l l cost?" R: E x a c t l y . Normative a n a l y s i s . I t i s evident that the nurse looked at pat ient choice from a two-dimensional v iewpoint . F i r s t , she be l i eves pat ients should be considered and asked what treatment they pre fer— e s p e c i a l l y i n the terminal phase of chronic i l l n e s s . Secondly, she thinks that soc ie ty must set c r i t e r i a for treatment which places some r e s p o n s i b i l i t y on the consumer on a l i f e s t y l e ba s i s . In wanting the system to funct ion o p t i m a l l y , she fears the costs incurred when those who are i n the end stage of a chronic i l l n e s s are given maximal treatment. This lessens the care given to those who w i l l survive and may need exce l l en t nurs ing care ( e . g . , to provide l i f e s t y l e counse l l ing to help the pa t i ent accept r e s p o n s i b i l i t y for s e l f ) . M o r a l l y , she i s aghast at the way choices for treatment are made. Yet she s e l e c t s , as i s congruent wi th Stage IV patterns of reasoning, to work w i t h i n the system but suggests that a review committee such as an e th ic s committee could provide guidance on treatment i s sues . At present , pe rce iv ing nurs ing ' s l ack of relevance and, there fore , 112 inab i l i t y to provide responsible nursing input, she rationalizes, calling the worse cases experiments done for the sake of gaining knowledge. Case #17 Descriptive analysis. Correlatively, similar problems occur on the children's units. This nurse believes i t is important to look at the family as a unit, to inform them and then let them make decisions on treatment options. R: Most children are not autonomous, and especially the premature infant, he is not autonomous at a l l ; in fact, there i s nothing autonomous about him, he can't even breathe on his own most times, his l i t t l e heart beat is about a l l he's got going for him. Though when you have chronically i l l children, I find they start to make decisions younger, they seem mature, become more sophisticated, and they w i l l make rational decisions, like I don't want anymore, I've had enough. But often a child is l e f t , no decision is made and the legal side of the issue enters because: R: If you stop treatment on this child and he dies, are you going to be legally responsible, you are ethically responsible? We have had children in our ICU where there is no hope that the child is going to l i v e , grow, or do anything, is semi-comatose, probably uncomfortable, certainly unhappy i f he has enough intelligence to feel those sorts of emotions, and the parents say we want you to treat and they show up every month or two and say, "We want you to treat," and you feel this child—we are not doing anything for this child except prolonging the agony. We did this with one child, since he was a newborn, for a l i t t l e over a year. He was a severely limited hydrocephalic child and the parents knew the prognosis. And there was a feeling that i f we didn't maintain his l i f e to the best of our a b i l i t y , that there was a danger of a lawsuit. . . . This case was very d i f f i c u l t to look after. You had to r e a l l y — t h e head nurse found i t very frustrating because the child would take the lower priority of everyone, he 113 would be ignored i n rounds, because b a s i c a l l y there wasn't a change and you had to force the phys i c i an to come and look at him. Nurses d i d n ' t l i k e looking af ter the c h i l d , they d i d n ' t f e e l they could do anything use fu l or worthwhile. He was semi-comatose or comatose and on a v e n t i l a t o r . I f we stopped aggressive treatment, he would die—removal of therapy would k i l l him. I : What do you think i s a pre ferable approach? R: I guess that people would be w i l l i n g to s i t and discuss the case and make dec i s ions at points along the i l l n e s s . For ins tance , i n i t i a l l y ask ing : Is aggressive therapy worth i t ? And then, somewhere along at another stage again ask: Where are we going? What can we expect? Plus — i n v o l v e the parents . I : There i s a point where nurses and phys ic ians can agree that hope decreases s i g n i f i c a n t l y ? R: Yes. And there i s a tremendous s t r a i n on the family when they have a c h i l d wi th a long term chronic i l l n e s s . I have seen f ami l i e s break up and other s i b l i n g s su f fe r , and I often wonder i f th i s [aggressive treatment] i s the r i g h t thing to do . . . but I know the c h i l d r e n who used to be mirac le c h i l d r e n , now grow up as normal c h i l d r e n . So I guess we have to walk that l i n e . I f we don ' t push the f r o n t i e r s , we won't make any advances. Normative a n a l y s i s . Improving the funct ion of the hea l th care system and improving the q u a l i t y of l i f e of the c r i t i c a l l y and c h r o n i c a l l y i l l c h i l d concerns t h i s nurse deeply. She wants to see f ami l i e s drawn in to the d e c i s i o n making and even the young c h i l d l i s t e n e d to . She wants to see treatment dec i s ions assessed at appropriate time per iods . A l l of the suggestions t y p i f y a Stage IV pat tern of reasoning that seeks to enhance and maintain the hea l th care system while concurrent ly looking at the q u a l i t y of l i f e of the i l l c h i l d and i t s fami ly . Since th i s nurse can def ine some of the drawbacks i n the present system, i t seems only reasonable to suggest she could p lay a re spons ib le r o l e i n t h e i r c o r r e c t i o n . 114 Case #18 D e s c r i p t i v e a n a l y s i s . L u c i d , yet c r i t i c a l l y i l l pa t ients often know when they don ' t want treatment, s tates t h i s nurse. She i s speaking of one example of t h i s , a f i f t y year o l d profess ional .man "who l i v e d a couple of months i n multisystem fa i lu re—he d id not want to continue l i v i n g . " I : He l e t you know? R: He l e t them know, but medicine cou ldn ' t face i t emotional ly —to l e t him go. He extubated himsel f about four times. I : Did he succeed? R: No. He d id extubate himsel f but he was reintubated i n each case. I : Was he l u c i d when he extubated himself? R: He was h e a v i l y sedated and had to be re s t ra ined even though he was l u c i d . I t was a h o r r i b l e s i t u a t i o n . He was on the v e n t i l a t o r with aggressive treatment u n t i l he f i n a l l y died — i t took him a month. I t broke the heart of every reasonable person that came in to contact wi th him. I t was an emotional t h i n g . The senior medical person i n charge refused to d i scont inue treatment. But nurs ing s t a f f , res idents and in terns don ' t have the power to get court orders or d i scont inue aggressive measures—but a l l were upset about i t . I : Does the emotional s ide come i n often do you th ink , i n the unwil l ingness to l e t people go? R: Sometimes, but not o f ten , because the philosophy i s to t r e a t . I f someone has b r a i n damage and they can CAT scan and do EEGs, dec i s ions are a l o t eas ier to make. I : So people get removed from r e s p i r a t o r s , e t c . , once the b r a i n i s dead? R: Bra in death i s p r e t t y w e l l accepted, but there have been cases where l i f e support has not been discont inued because of family wishes. 115 I: How long could this go for? R: Six months. I: A brain dead person can be kept alive for six months i f the family wishes? R: In this case, the family was nice enough, but they pushed this case and pushed i t with a threat of lawsuit. This man started to grow things, he smelled. He was just lying there without a neuron in his head. At the end of six months, he arrested and wasn't resuscitated. I: What would the ideal be for the f i f t y year old man? R: The ideal situation would be that he, with his terminal il l n e s s , could decide. He would be informed of options and treatments available f i r s t . Normative analysis. Day upon day, nurses looked after this man whom this nurse f e l t wanted to be l e f t to die. Residents and other nurses agreed with this; nevertheless, a l l of these people perceived the bounds of their influence—they could not do anything but continue treatment. Loyalty to the man and observance of his fu t i l e attempts to extubate himself proved heartrending. A l l were helpless. Desirous of improving the system by working within i t , this nurse espousing Stage IV patterns of reasoning, wants to improve the way in which the system meets i t s obligation to the patient. Case #19 Descriptive analysis. Another nurse, accentuating the bounds forced onto the nursing role, draws our attention to the problem that can occur when technology ceases to be a tool and becomes the medical decision maker. 116 R: I have had a s i t u a t i o n where I watched i n agony as a pa t i ent died and i t was ju s t h o r r i b l e . This man, a post cardiac arres t was one of the worst s i t u a t i o n s I have come up against and he was l u c i d . I had known him for a per iod of a week, he was intubated . His status was too unstable for him to come of f the v e n t i l a t o r . I then went of f [duty] and when I came back there were reports back which the phys ic ians thought showed, hemodynamically, that he had no cardiac output, that he b a s i c a l l y had no heart l e f t and h i s prognosis was grave. The doctors ta lked to the family who were exhausted, and they wanted to d i scont inue the treatment. They expected him to die r i g h t away and he d i d n ' t . I : They withdrew the re sp i ra tor ? R: Yes , plus the Dopamine. [But] he d id f i n e . He had a wavering s tate of consciousness. The medical s t a f f cou ldn ' t get i t together about how aggressive they wanted to be wi th t h i s guy. Then he was put back on the v e n t i l a t o r . His pressure d i d n ' t f a l l . He had only a few slow [heart] beats . The res t was normal. No one requested turning down the v e n t i l a t o r . Yet here I am carry ing on, g i v i n g morphine as ordered and V a l i u m . I was g iv ing large doses of morphine and V a l i u m every hour with booster shots of both. I : The man w a s s trong obvious ly . R: Tha t ' s what got me. Look at a l l I gave him—he w a s s t i l l s truggl ing—you or I? I was ge t t ing r e a l l y s tressed at t h i s time. I c a l l e d out and grabbed a res ident and a senior nurse and s a i d , " I want something done. " .What d i d , t h e y want me to do? Was I f a c i l i t a t i n g t h i s for the f a m i l y ' s benef i t? At one point the pa t ient r e a l l y fought the v e n t i l a t o r . He was s t rong . We gave him more morphine— I was r e a l l y d i s t raught . I was c ry ing inwardly because the family was at the bedside , everyone had expected him to d i e . Even when the v e n t i l a t o r was turned down he would s t a r t to f i g h t . I t was h o r r i b l e to watch. F i n a l l y I made the family leave the room and made the res ident come i n wi th me and p u l l e d the c u r t a i n s . We turned off the v e n t i l a t o r , he was s t i l l intubated and he was gasping and s tar ted to s t rugg le , he moved h i s hands and h i s arms and I was r e a l l y , r e a l l y upset. He was gasping and choking— we underestimated h i s a b i l i t y to compensate. I : Did the res ident show any d i s t re s s ? R: He could have come e a r l i e r , because I had approached him numerous times during the day and I don ' t think he understood 117 or h i s a t t en t ion was on other th ings , but he was support ive i n an emotional sense to me at the end he stayed with me. But I had to be r e a l l y a s ser t ive to have him there . I : What could have been done? R: In re trospect and with h i n d s i g h t , I would have given him a T-piece without morphine to see how he would do. I : Was he ever, at any time, part of the decis ion? R: I think he was l e f t out of the d e c i s i o n because he would have periods of being f a i r l y l i g h t n e u r o l o g i c a l l y and then go r i g h t back down. I made the res ident stay with me because I d i d n ' t want the r e s p o n s i b i l i t y of g iv ing a l l that morphine on my own. I t was not c lear cut , per sona l ly I don ' t f e e l he was sure not to surv ive . U l t i m a t e l y , he would have run in to t rouble on the ward i n two days, twelve hours and I don ' t know that for sure. That i s the only d i s c o n t i n u a t i o n of treatment I have ever seen based on cardiac s ta tus . I : Pure ly hemodynamic s ta tus . R: He should have had the v e n t i l a t o r and the drugs discont inued s lowly over three or four days g i v i n g him time to accommodate and then on to the next t h i n g . I t was poor ly coordinated, i t was extremly p a i n f u l for me, p a i n f u l for him. I : P a i n f u l for the pat ient? R: I'm sure i t was. I : What d id the medical s t a f f or the nurs ing s t a f f do? Was there anything done to a l l e v i a t e that from happening again? R: I t was an i s o l a t e d i n c i d e n t , but I d id t a l k to the head nurse about i t . I was very upset about i t . I approached a l l my higher-ups about i t during the course of the day and they had t rouble p inning down the medical s t a f f . I : What would you do now i f that kind of th ing happened again? R: I wouldn't wait as long going back and f o r t h to them [doctors ] . I would be more aggressive. I : What would your aggression include? 118 R: Approaching the doctors and being very f i r m , and i f they say I w i l l deal wi th i t l a t e r , then I would say th i s man was su f f e r ing and then I w i l l t e l l them I'm going to document and n o t i f y the s t a f f man. I t i s not that I want to absolve myself of the r e s p o n s i b i l i t y as much as make sure they are aware and accountable. I : Would you go as far as re fus ing to be the nurse for that pat ient i f there was no change i n the procedure or are you sure there would be a change? R: I am p r e t t y sure there would be a change, that i t would be dea l t w i t h . I would hate to use that k ind of th ing but to emphasize the point that I was uncomfortable, then I would say I don ' t want the r e s p o n s i b i l i t y and I'm sure i t would not go any further than than because once you d id that , and they had to assume the r e s p o n s i b i l i t y themselves, and a f ter you document your re luctance to be involved i n that s i t u a t i o n , they would have to dea l wi th i t at that p o i n t . I : So you think i t would be dea l t wi th prov id ing you kept at i t , even more a s se r t ive than l a s t time? R: I wouldn't l e t i t go, part of i t was inexper ience . Normative a n a l y s i s . Stage IV patterns of reasoning were upheld i n the c o n f l i c t s i t u a t i o n , yet evidence of Stage VI th ink ing appears when the nurse provides informat ion on what should have happened and what she would p re fe r . Right becomes a matter of conscience, a matter of what ought to happen i n such cases. The pat ient warrants a f a i r t r i a l even i f h i s s u r v i v a l i s l i m i t e d . The disease process w i l l d i c t a t e the outcome, not a drug. This nurse was quite adament when she descr ibed what she would do now. On p r i n c i p l e she would act and see that another form of care was provided. Before cont inu ing , i t bears not ing that , although t h i s inc ident had occurred months p r e v i o u s l y , t h i s nurse remained deeply affected by the wrong she be l i eved had been committed: she be l i eved that due to inexper ience , 119 she had acted contrary to her own p r i n c i p l e s and, furthermore, contrary to p r i n c i p l e s of j u s t i c e which protect the d i g n i t y and r i g h t s of the p a t i e n t . Not only how to provide respons ib le nurs ing care but also how to ensure our hea l th care system i s respons ib le to the p u b l i c i t serves are c r u c i a l questions today. A l s o , the r i g h t s and r e s p o n s i b i l i t i e s of the i n d i v i d u a l require assessment. Both system and i n d i v i d u a l must f ind a way of working together i n harmony i f high q u a l i t y , e f f e c t i v e and e f f i c i e n t hea l th care methods are to p r e v a i l . The f i n a l theme w i t h i n the category d e p i c t i n g Stage IV reasoning concerns i n d i v i d u a l r i g h t s and the r e l a t i o n s h i p of these r i g h t s to s o c i e t a l r e s p o n s i b i l i t i e s . Theme: I n d i v i d u a l Rights versus S o c i e t a l R e s p o n s i b i l i t y Nurses f ind themselves caught wi th d iverg ing l o y a l t i e s when they attempt to d i s c r imina te between the r i g h t s of the i n d i v i d u a l and the pos s ib le l i m i t s of s o c i e t a l r e s p o n s i b i l i t y to that i n d i v i d u a l . Because s o c i a l p o l i c y and the h e a l t h care system i t s e l f haven' t defined the p o s i t i o n c l e a r l y and s ince the system often places p r i o r i t y on a r b i t r a r y or unsubstantiated p r i n c i p l e s for treatment, i t i s d i f f i c u l t for the nurse to balance discrepant claims when those of the i n d i v i d u a l c o n f l i c t wi th what seems, i n genera l , i n the best i n t e r e s t of a j u s t , e f f e c t i v e and e f f i c i e n t l y run system. Cases verge between examples where i n d i v i d u a l s demand too much of a s t ra ined system to examples that depict a system which i s unable to set l i m i t s . 120 Case #20 D e s c r i p t i v e a n a l y s i s . In th i s example, the nurse speaks of the long term care program and the serv ices that were promised pa t i en t s . She s tates that i n i t i a l l y , for p o l i t i c a l reasons, seniors were promised too much but that now i t i s f e l t that seniors should take more r e s p o n s i b i l i t y for themselves and that f ami l i e s can contr ibute more. When asked i f f ami l i e s contr ibute or seek options p r i o r to c a l l i n g the long term care s e r v i c e , she comments: R: Oh, not u s u a l l y , o c c a s i o n a l l y but not u s u a l l y . I : So the tendency i s to c a l l f o r help p r i o r to looking for options? R: Yes , though people are l e a rn ing and becoming more knowledgable. I th ink the p u b l i c do not have enough knowledge. There are those that w i l l go [and seek a l t e r n a t i v e s on t h e i r own] but there i s a c e r t a i n group of people who f e e l i t i s owed to them and they want someone e l se to take over. So there are two groups. My experience i s that those who r e a l l y need our serv ices are the ones who s truggle and do i t on t h e i r own because they have always been independent and regardless of t h e i r s i t u a t i o n , h e a l t h , s o c i a l or otherwise, t h e y ' l l work at i t u n t i l they jus t— I : But with some there i s a re s i s tance to i d e n t i f y the problem? R: E i t h e r re s i s tance or not knowing how to . I : This i s where nurs ing comes in? R: Yes. I : So once the problem i s i d e n t i f i e d , you a c t u a l l y see people become more autonomous? R: Oh, yes . Oh, yes , i t i s d e l i g h t f u l to work wi th those c l i e n t s . I : So they help you work with them? 121 R: Oh, yes , i t i s fabulous. I r e a l l y enjoy i t . But to have that—to encourage that happening i n our heal th care system we have to s t a r t ea r ly i n educating groups of people. And I have given ta lks to seniors on t h i s . A tremendous group of people but for some reason because of the s l o t that seniors have been put i n , they f e e l that other people have to make the dec i s ions for them. My whole emphasis was that they have to do things for themself—they are qui te capable. They have l o t s to of fer the community and everybody e l se . But they put the d e c i s i o n o f f to another. Now our r e a l goal i n the Heal th Department i s to have them doing for themselves. And dec id ing for themselves. Normative a n a l y s i s . Remaining w i t h i n a system's per spec t ive , th i s nurse i s showing how much she values the input of the sen ior s . While i t seems she could be v o i c i n g Stage V values of people , she places her b e l i e f w i t h i n the Stage IV context because she i s r e i t e r a t i n g a p o l i c y that has come down through the hea l th care system w i t h i n the l a s t year . In t r y i n g to help th i s seniors group to plan s o c i a l and hea l th re l a ted a c t i v i t i e s for the coming year , she found the seniors unable to take c o n t r o l . She f e l t part of the problem was due to s o c i a l i z a t i o n and part due to how the long term care program i s set up and who sets i t up, even w i t h i n her own agency. She would l i k e to see nurses managing the problem because they are the ones with the s k i l l s to assess and in tegra te p h y s i c a l , p sycho log i ca l and s o c i o l o g i c a l data i n t o a care p lan that b u i l d s on the i n d i v i d u a l ' s s trengths . She speaks of the waste involved i n time and funds because of c o n f l i c t s between s o c i a l workers, phys io therap i s t s and nurses as they a l l do assessments when nurses are the only ones "who have a broad education i n the three key areas, who know how to use a s c i e n t i f i c method and 122 how to plan i n accordance." In cases where nurses are not i n the management p o s i t i o n , she sees defensiveness b u i l d between pro fe s s iona l s . She says: R: Other d i s c i p l i n e s do not understand when i t i s a nurs ing problem—they don ' t have the knowledge. They tend to cover everything so they give l o t s of ass i s tance but don ' t r e a l l y i d e n t i f y s p e c i f i c problems. Not to be c r i t i c a l , but that i s the way one would operate i f he or she d i d n ' t understand. So there i s a waste of money because assessments a ren ' t done s c i e n t i f i c a l l y plus they work toward making the c l i e n t dependent forever . Consequently, there i s conf l i c t—nurse s have to be very ca re fu l because i t becomes very threatening fo r non nurses . Often when nurses want to make recommendations i n a multiproblem case we. are ju s t not heard—it i s j u s t too threatening for them. A l s o , there are nurs ing consultants who could help out but they have no author i ty to see recommendations are c a r r i e d out. This case presents a good example of a nurse who values reasonable hea l th care p o l i c y , who can de l inea te the problem and can provide ideas for re so lu t ions but i s unable to because of the way p o l i c y i s set w i t h i n the bureaucracy. The next case provides an exce l l en t example of the r i g h t s the i n d i v i d u a l s b e l i e v e they have and how t h i s b e l i e f places a s t r a i n on the hea l th care system as w e l l as p l ac ing the nurse i n a d i f f i c u l t p o s i t i o n . Case //21 D e s c r i p t i v e ana lys i s R: Many problems a r i s e when f ami l i e s w i l l not l e t t h e i r e l d e r l y parents make dec i s ions for themselves. Then I get the pressure from the family that I have to go i n and do something —put them i n a home. I : Does that happen? 123 R: Oh, every day. I had an awful time with one yesterday. I t ' s so f r u s t r a t i n g . And the problem i s that we do not have the time to s i t down with the f ami l i e s and help them work i t out—to work through t h e i r own g u i l t and counsel them. I : Is i t u sua l ly based on g u i l t ? R: Yes, i t ' s u sua l ly based on g u i l t . I : What kind of s i t u a t i o n d i d you run into? The nurse went on to o u t l i n e a s i t u a t i o n that af fected an e l d e r l y married l ady . R: She had stresses because of m a r i t a l problems as I assessed i t . But i n terms of her general hea l th p h y s i c a l l y , there were no major problems. And her son and the doctor had i n s i s t e d that we do an assessment because she was going to need a l o t of care and he lp . The problem came out that the woman f e l t depressed but that there were m a r i t a l problems. The nurse suggested she get some support and counse l l ing f i r s t for h e r s e l f and then for both of them. The nurse sa id that she would make a r e f e r r a l or suggest to her doctor that he make a r e f e r r a l to a mental hea l th team or p s y c h i a t r i s t , whatever she would prefer and the doctor would agree w i t h . When the nurse l e f t that day she be l i eved that "no one was paying a t t en t ion to the r e a l problem." R: They were responding to what she wanted which was to be cared f o r , taken care of . And people were rushing around to f ind ways to respond to th i s wish instead of f i n d i n g out why she was wanting to be so dependent. The next t h i s nurse heard was that the lady was h o s p i t a l i z e d and then returned home with a request for homemaker s e r v i c e s . Before long the son phoned, "adament that she be placed r i g h t away." 124 R: So I s a i d , "How d i d you come to that conclus ion?" " W e l l , " he s a i d , "she jus t c an ' t stay there anymore. So you have to get her to a home." And I s a i d , " W e l l , are there other hea l th problems that would warrant her being placed? How i s her p h y s i c a l hea l th? " "Oh , p h y s i c a l l y she 's f i n e , " he answered, " i t ' s j u s t o ld age and she needs to be i n a home." I : How old was she? R: E a r l y sevent ies . And so I s a i d , "Old age i s not c r i t e r i a for placement." Then I s a i d , " I ' d l i k e to ask you another ques t ion . Have you discussed t h i s with your mother?" He hummed and hawed and d i d n ' t answer. So I s a i d , "Is th i s agreeable to her?" He responded, " W e l l , she has to go! There ' s nothing e l se can be done, she has to go . " I s a i d , "For what reason?" " W e l l , " he s a i d , " the doctor says she has to get out of that environment, she could go to X h o s p i t a l . " The son responded wi th threats such as, "What are you going to do, j u s t l e t her d i e ? " "You people are ju s t going to l e t her d i e ? " R: I f e e l there i s a c r i s i s i n terms of her r e l a t i o n s h i p and that i s not being dea l t with—the r e a l problem i s the marriage. On d i scus s ing t h i s problem with the coord inator , we thought of the assessment centre which has a team approach to care . So I thought, I ' l l mention that to the son to see i f I can get past the doctor and get her the help she needs or that I perceive she needs. So when the son c a l l e d back he was t o l d t h i s . He responded that she was going in to h o s p i t a l . He had got a doctor to send her in to the h o s p i t a l . I : So what happened, i n essence, was, I gather, a prolonging of the problem? R: I f I had had the time and he [the son] was agreeable, I would have l i k e d to have met with him to help him come to r e a l i z e what was happening i n the r e l a t i o n s h i p and to give him some d i r e c t i o n and counsel on how he could work wi th her and support her rather than take f u l l r e s p o n s i b i l i t y . But i t was apparent to me that he was f e e l i n g very g u i l t y and was t r y i n g to t rans fer the g u i l t . . . . I f e l t that he was going through a l o t and i f I could have helped him i d e n t i f y h i s own fee l ings about what was happening, then perhaps r e a l work could have begun. I : So you would have preferred to have had him come i n and address the whole i ssue and take time to do th i s ? 125 R: Yes. I th ink that he was not even aware of h i s f ee l ings of g u i l t and r e s p o n s i b i l i t y nor that he was t r a n s f e r r i n g and p r o j e c t i n g th i s onto the hea l th care system. He was ju s t being defensive. Normative a n a l y s i s . This long term care nurse i n taking the perspect ive of the whole system i s us ing Stage IV reasoning. Her goal i s to help the system funct ion more e f f e c t i v e l y and e f f i c i e n t l y whi le a lso a s s i s t i n g the son's mother to come to terms with her hea l th s t a te . She be l ieved that the son could help i n t h i s ; however, the problem was ju s t being prolonged at cost to the system. The nurse was l i m i t e d i n what she could do. She wanted to d i r e c t the woman to the hea l th care assessment team; neverthe les s , doctor and son d i rec ted the mother to the h o s p i t a l . The nurse d id not succeed i n p l a c i n g r e s p o n s i b i l i t y for problem so lv ing (with ass istance) back to the son and mother because her input was bounded by both r e s t r a i n t s on time and au thor i ty . As i n the fo l lowing case, the hea l th care system i s abused. Case #22 D e s c r i p t i v e a n a l y s i s . People use the system, s tates another nurse, because the "mental hea l th system feeds i t s e l f so much." She says, R: People become dependent on the system and t h i s drains the system, drains everybody that they work w i t h . They may go through ten p s y c h i a t r i s t s being on each p s y c h i a t r i s t ' s caseload four years , then say ing , " I can ' t have you anymore." She says people become " p s y c h i a t r i c j u n k i e s . " R: The system i s r e a l l y s t ra ined and i t j u s t cannot continue to provide for t h i s . I can think of r i g h t now on the ward 126 we have a good example of people for want of a bet ter word I ' l l ju s t c a l l vaguely n e u r o t i c . They are not people with thought d i sorders at a l l . They are people who at one time were func t iona l i n d i v i d u a l s i n t h e i r l i f e . I : But they are not now? R: No. As a matter of fact there are three middle aged women, a l l h i gh ly f u n c t i o n a l at one time. One was qui te wealthy at one point but now she i s l i v i n g on welfare and another i s supposedly d i sab led although the degree of her p h y s i c a l d i s a b i l i t y i s very questionable—as i s the t h i r d one. She has been checked out by medicine and they say there i s nothing wrong and shipped her over to psychia t ry which i s r e a l l y a blow to her because i t sort of impl ies she i s l y i n g — t r y i n g to get something for nothing. But as part of her i n a b i l i t y to deal with l i f e she has been hanging around the h o s p i t a l . Whenever we approach discharge for any of the three , each one comes up with a new c r i s i s and new problems. One has used up her f r iends and they say she r e a l l y can ' t come stay wi th them. They are t i r e d of t h i s dependent i n d i v i d u a l . So she i s now at f i f t y , dependent on the system. So there i s a c o n f l i c t there , the system provides but how much should i t provide? I : What would you prefer happen to that woman? R: I think the system i s p rov id ing too much, yes. I t has become countertherapeutic to provide for th i s woman. I t ' s qu i te hard not to get angry at people l i k e t h i s because part of my own—I think i t ' s p ro fe s s iona l and c l i n i c a l judgment as w e l l as. my personal b e l i e f — t h a t she i s abdicat ing her personal r e s p o n s i b i l i t y to h e r s e l f for whatever reason. So you try to incorporate that in to your c l i n i c a l p i c t u r e of her . But at what point do we extend concern and t ry and formulate treatment and at what po int do we say, look , i t i s time you got your act together and looked a f ter y o u r s e l f . I : Is there any l e g a l reason why she cou ldn ' t be discharged? R: None I am aware of . I don ' t know i f i t ' s l e g a l so much as c l i n i c a l l y e th ica l—people l i k e th i s often say, "You know, I might k i l l myself i f you don ' t look a f ter me." Very f r a n k l y , as someone working with these people, I f e e l put i n a double bind with that k ind of thing l o t s of times. I : What would you prefer? 127 R: That people be helped to maintain t h e i r i n d i v i d u a l i t y , t h e i r i d e n t i t y and be treated by the hea l th care profes s iona l s wi th the respect that i s due them as i n d i v i d u a l s and be able to operate as i n d i v i d u a l s . There i s a r e s p o n s i b i l i t y on behal f of the hea l th care people to inform the p a t i e n t , to give them as much information as they need. But I think the pat ients have some r e s p o n s i b i l i t y to maintain and seek help for themselves. I say that i n l i g h t of the fact that I see a l o t of people that are i n the p o s i t i o n of doing s e l f de s t ruc t ive things . I recognize that we are there to help them maintain and promote h e a l t h i e r ways of coping wi th l i f e but , you know, you a l so see people who endless ly seek ways of des t roying themselves. I f e e l that there i s only so far that a hea l th care p r o f e s s i o n a l can go i n that respect . You know, t ry as you might, people are going to k i l l themselves no matter what. Normative a n a l y s i s . Loya l ty c o n f l i c t here r e l a t e s to dec i s ions p e r t a i n i n g to ju s t how much help do people deserve when they are i n h o s p i t a l to be treated but i t seems that they are also mal inger ing . In one sense t h i s nurse c r i t i c i z e s the system because- i t " feeds" i t s e l f she says. On the other hand, people requi re r e s p e c t f u l treatment. In t y p i c a l Stage IV reasoning, the nurse seeks to maintain the hea l th care system, to encourage optimal funct ioning of i n s t i t u t i o n s w h i l e , at the same time, t r u l y he lp ing people become more autonomous yet l e t t i n g them choose not to i n a way that does not d ra in the system. Stage IV patterns of reasoning i n m u l t i p l e l o y a l t y c o n f l i c t s i t u a t i o n s l ed to the i d e n t i f i c a t i o n of four themes. In each theme nurs ing problems r e l a t i n g to pa t ient autonomy are descr ibed . Let us now place these problems i n j u x t a p o s i t i o n with those descr ibed i n the l i t e r a t u r e . Comparative C r i t i q u e Given the form of s o c i a l i z a t i o n which i s present i n the hea l th care system and the type of p o l i c y dec i s ions made i n i n s t i t u t i o n s , 128 nurses perceive that t h e i r r i g h t to p r a c t i c e as profes s iona l s i s bounded by cons t r a in t s . Y e t , to an overwhelming degree, these same nurses would l i k e to see the hea l th care system funct ion e f f e c t i v e l y and e f f i c i e n t l y w i t h i n a f a i r and jus t framework. C o n f l i c t s for nurs ing as depicted i n these cases r e f l e c t conventional th inking at Stage IV s ince each nurse advocates maintenance of the hea l th care system, a l b e i t a more equitable one. However, when preferred so lu t ions are e l i c i t e d , evidence of Stage V and Stage VI th ink ing emerges; never the les s , the nurses ' main aim was to per fect the funct ioning of the hea l th care system. In c i t i n g c o n f l i c t of l o y a l t y areas under the theme of phys i c i an versus nurse and the theme of nurs ing r i g h t s versus i n s t i t u t i o n a l r i g h t s , i t becomes evident how pa t ient autonomy can be compromised when confusion regarding primary l o y a l t i e s , l e g a l r i g h t s , i n s u f f i c i e n t information or inadequate s t a f f i n g a r i s e s . Nurses do, as the nurs ing standards document s t a te s , have a dependent funct ion . And i t i s , i n the main, i n t e r p r e t a t i o n . o f th i s dependent funct ion that ra i se s many of the key quest ions . For example, how does th i s funct ion i n t e r r e l a t e with nurs ing ob l iga t ions? The answer provided i n these cases revert s to a focus on encouraging the informed pat ient to p a r t i c i p a t e i n dec i s ions and, as a c o r o l l a r y , to improving organiza t ion w i t h i n the hea l th care system so that w i t h i n a set of reasonable c r i t e r i a , pa t ient s can make t h e i r own choices regarding care . Only then can nurses who already have a mandate to promote pa t ient autonomy t r u l y f u l f i l l t h e i r p ro fe s s iona l o b l i g a t i o n s . 129 Without a s t ructure that supports t h i s , nurses encounter dilemma s i t u a t i o n s . The ambiguity and accompanying i n c o m p a t i b i l i t y between what nurses b e l i e v e i s r i g h t and what they know i s necessary i n these cases creates l o y a l t y c o n f l i c t s . This type of problem cons t i tu te s a moral dilemma. Langham (1977) s tates that th i s i s because c o n f l i c t s a r i s e over what i s considered f a i r or j u s t : value pos i t ions and b e l i e f systems c lash as d i f f e r i n g paradigms of hea l th care v i e for p o s i t i o n . Then, the s o c i a l i z e d expectations of others towards nurses and of nurses towards themselves, lead to a percept ion of bounded relevance which can contr ibute to what one nurse c a l l s "moral h e l l " . Nurses leave . The profes s ion i s depleted , often of i t s most able ind iv idua l s—those who advocate pat ient autonomy. Davis (1982) has seen t h i s happen and c a l l s i t burnout. One way to a l l e v i a t e t h i s , she contends, i s to reason through the often profoundly emotional laden dilemmas from w i t h i n an organized p ro fe s s iona l context . This concerned r a t i o n a l approach i s v i t a l . C o r r e l a t i v e l y , i t can lead to c l ea re r ideas on how to obta in adequate pa t ient in format ion , how to document pa t ient care or s t a f f i n g problems, and on how to assess l e g a l i s sues . For ins tance , some act ions can lead to culpable ignorance, defined by Smith (1983) as a de f i c i ency i n knowledge one should have or ought to have at hand. Other act ions can lead to negl igent conduct whereby l ack of nurs ing knowledge can lead to l e g a l l i a b i l i t y . And nurs ing r e s p o n s i b i l i t i e s are increas ing to the p o i n t , s tates F i e s t a ( 1 9 3 3 ) , that nurses w i l l more often be held l i a b l e . P l u s , l i a b i l i t y r e s p o n s i b i l i t y , contends Freedman ( 1 9 8 0 ) , 130 is born in the chain of command by the last person who consumates the harm or, she goes on to say, to the last person who had a clear chance to prevent harm. Realizing this, one respondent noted that she did not want to be covered by a vague general statement made by another professional—she wanted to be accountable for her own actions. Fiesta (1983) stresses that although hospitals and other hierarchical organizations can be held liable for the acts of their employees, nurses w i l l have to become more legally accountable in.the future. The nurses' objectives are clear: their broad and deep grounding in empathy for the patient is evident; their desire to develop a sense of community and cooperative team work similar to the needs expressed by Gilligan, is ever present; plus, they are cognizant of the concrete need to provide comprehensive and equitable health care. Nevertheless, conflicting claims often lead to contrary objectives. Further examples of how and why this happens are also apparent in the theme based on the right of the patient to die with dignity. The case examples, sadly, show how the dying seem to become objects and thereby helpless recipients of rules that state: treat as long as anything is treatable; or, treat i f the technology is available. Accordingly, these beliefs lead to a denial of relationship, an ignoring of patient choice and a lack of humane caring. Taussig (1980) accedes to this view when he speaks of the "horror story of hospitals" (p. 9). He calls them combat zones where disputes occur over power, definitions of il l n e s s , and degrees of incapacity. Control, he says, is wrested from the patient: their status is 131 defined for them after they are compartmentalized into a disease state; hence, there is no mutuality, no interacting partner. Nurses, often unable to change the object status of the patient, do as one respondent did, she rationalized calling the treatment of a dying man an experiment. Roy (1981) believes that death has become an interdisciplinary event. He contends that death should be deprofessionalized and the dying person should be encouraged "to be the master of his own fate" (p. 17). It is evident in the case examples that the patients and their families are not given a satisfactory explanation of the problem, of the alternatives for treatment or nontreatment, or of the prognosis. They have l i t t l e opportunity to voice their needs based on their beliefs and values and have l i t t l e chance of being permitted to die with dignity. Wojak (1978) states that dying patients deserve a time of tranquility, a time to accept their fate and that machinery should not be allowed to interfere with the progress of death. He goes on to say that the hospital's healing mission has been obscured and the breakdown of trust on which healing depends deepened. Now, patient consent is muted. And "consent," he says, " has always been the bedrock of ethical medicine" (p. 1). Additionally, physical suffering and informed consent aside, when the cost factor arises, nurses are aware of the tremendous financial expense associated with prolonging a l i f e (sometimes for weeks or even months) using numerous highly invasive l i f e support techniques and therapies when a patient is in multisystem failure and i s on a dying trajectory. 132 Admittedly, there are no objective standards for decision making on issues of treatment or nontreatment and there is a strong desire to save lives among health care professionals. But, saving lives, today and saving lives twenty years ago are vastly different concepts as w i l l be that of saving lives ten years hence. It is true that health care professionals should never abandon care, yet as Riga (1981) asks: When can medical treatment cease and care for the dying begin? Likewise: How can f a i r and just objective standards be set forth? These questions can only be answered from the standpoint of social and public policy decisions. Given this statement, i t can be argued that policy reflects social value; therefore, what is happening in health care is a logical outcome of present day beliefs and values. This i s true to a point. Nevertheless, changes are occurring and these are noted by nurses in the f i n a l theme of individual rights versus societal responsibility. Here, nurses identified cases in which the health care system has been abused because i t has been set up so that i t could be abused. Furthermore, now that there is a more general awareness of economic issues, social values which decry f i s c a l irresponsibility are coming to the fore. With these factors in mind, i t can be.seen how old values are being questioned, and, as Kaplan (1974) notes, social philosophies do change and these changes get translated into public policy. He reiterates the stand taken by the nurses which supports patient autonomy and dignity by stressing the need to assist, care for and support the worth of the individual, to 133 provide for freedom of treatment choice and, f i n a l l y , to be aware of the social implications of the policies we create and how we use them. This is exactly what the nurses ask. They want workable c l i n i c a l guidelines that take into account the extraordinary complex task of considering the values of a l l persons involved so that the integrity of each is respected. With conventional level thinking, the pressures created by perceptions of bounded relevance gave rise to dissonance which resulted in the nurses' desire to promote positive change in the health care system. The type of cognitive dissonance experienced by the nurses in this category did not lead to strong negative emotions nor, as Festinger (1962) states may happen, to an acceptance of the status quo. It did lead to nurses consistently attempting to maintain safe high quality nursing care. Nevertheless, a lack of legal awareness and an inability to enact certain changes in the bureaucracy did lead to evidence of some of the defense avoidance behaviors of which Janis (1982) speaks. Behaviors such as rationalization, shifting of responsibility to others and denial of awareness of risks and losses for patients are present. In a few instances, several of the behaviors led to post decisional regret and, in one case, to a renewed commitment to principled thinking. Let us now turn to case examples of multiple loyalty conflict which depict principled thinking at a postconventional level. 134 C. V o l i t i o n a l Relevance At the postconventional l e v e l of reasoning, nurses perceived themselves to be equal members of the hea l th care team and resolved l o y a l t y c o n f l i c t s i n ways that maintained e t h i c a l and l e g a l standards. They f e l t committed to supporting the competent p a t i e n t ' s r i g h t to choose treatment or nontreatment measures. Concomitantly, wi th incompetent p a t i e n t s , nurses sought the advice of the fami ly . C o n f l i c t s were resolved i n p o s i t i v e ways, hence negative a f f e c t i v e repercussions were avoided as were the dilemmatic s i t u a t i o n s that faced nurses who f e l t r e s t r i c t e d by the need to conform to avoid d i sapprova l whi le mainta ining r e l a t i o n s h i p s , or to avoid the censure of au thor i ty f igures i n the bureaucrat ic s t ruc ture . A n a l y t i c a l l y , themes depicted i n th i s category express p r i n c i p l e s founded on the in te r f ace between j u s t i c e , standards, and d u t i e s , as they are encompassed i n the r o l e of the reg i s t e red nurse. The fo l lowing two p r i n c i p l e s are c o n s i s t e n t l y upheld : f i r s t , the competent and informed i n d i v i d u a l has the r i g h t to choose treatment measures congruent with h i s or her value system as long as others are not harmed and soc i e ty i n general i s b e n e f i t t e d ; secondly, the reg i s t e red nurse has the r i g h t to f u l f i l l e g a l and e t h i c a l dut ies as espoused by the major p r o f e s s i o n a l documents and upheld by h i s or her own p r i n c i p l e s of a c t i o n . Needless to say, themes of cooperation and a c c o u n t a b i l i t y are most evident . The nurse cooperates with the p a t i e n t , the f ami ly , and wi th other members of the hea l th care team. Nurses are accountable 135 to the patient and family, to regulations within the bureaucracy which promote f a i r and just procedures, and to themselves as autonomous professionals. When faced with conflicts of loyalty, nurses using Stage V pattern of reasoning gave priority to basic human rights and thereby to the values and beliefs espoused by their patients or their families. Nurses whose patterns of reasoning were backed by Stage VI thought showed an awareness of ethical principles. For example, they f e l t assured of the components of their role while at the same time being cognizant of the principle of justice and c r i t e r i a for fairness. In each case nurses took pride in their behavior and f e l t they were f u l f i l l i n g the nursing mandate. Let us now turn to the theme of cooperation and then, in conclusion, to the theme of accountability. Theme: Cooperation Case #23 Descriptive analysis. In this case, the nurse was working with a couple of young women who had Tuberculosis [TB] and were not anxious to be treated for i t . She had to delicately balance the rights of the patients with the need of a society to protect i t s e l f . But she says, "I tried to establish a thoroughly positive attitude toward them and work through negotiation." R: Negotiation pays off and I would say that maybe 75% of the time i t pays off. Many times their own values got in the way of treatment. Tuberculosis has a really bad, dirty—you know—they f e l t infectious or they feel they are undesirable. Their friends stay away from them and cast them out. Plus they did not like a schedule. 136 I: They don't want to be scheduled? R: Yes. If they choose to come in that is fine. But they don't choose to come in for their p i l l s . And not being able to choose that with some freedom i s really a hassle for them. It is a street value. S t i l l they look for a doctor or nurse who w i l l treat them as a human being. And I do think that people need to be treated with some dignity even in their misbehaving. I: How do you treat them with dignity in their misbehaving? R: Well, i f they come in angry, I deal with their anger. If they come in drunk, then my experience is that there is absolutely no point in getting into an argument with someone who is drunk. So with dignity, just say, "Why not come back tomorrow?" And say i t quietly, away from the rest of the people in the c l i n i c , so they can walk out feeling that they are s t i l l intact and okay. It's just that we are not going to deal with them when they are like that. I don't let myself become victimized by argumentative responses. I: Why not? R: Because I think i t w i l l just promote i t happening again. You know, I think society would just like to sweep this sort of person under the rug, just get r i d of the problem, i t ' s an eyesore. I: It seems there's a problem already—these people already have a tenuous thread with the health care system. R: Yes, they are just as li k e l y to wander off with their TB and never have i t checked. And you know, as in this case, even their partner doesn't want them to come in. Tuberculosis is relatively slow moving and an insidious sort of process. For example, in this case, two women were together, one having TB. The other woman wouldn't let her come in for her medications. But then the other one got TB and they both came in together. With support and counselling, they have 90-100% attendance. So, unless you deal cooperatively with the other significant person in the patient's l i f e , there can be a problem. These people w i l l not come i f they feel threatened or any lessening of their ego. They need humor, cooperation, and cajoling a b i t . Also, i f you are not up front with them, they w i l l not come back. So, i f I know I'm going to admit one of my patients to a hospital, I w i l l phone and see who is on c a l l and on what days, and so I only send my patients in on certain days. 137 I : You a c t u a l l y p lan what doctor w i l l see them? R: Sure. I f ind the appropriate hoops and jump through them. I have one doctor I owe many favors to . He has taken on many of my p a t i e n t s . I : He w i l l do a h i s t o r y and an admission for you? R: Yes and take the pat ient on for the dura t ion . I t ' s marvel lous . I : Do your pat ients know you do th i s for them? R: No. I : No. Do they have a clue that they get s p e c i a l treatment? They must sense i t . R: Some of them do because they get in to snags and I go beyond what may b e — i f s p e c i a l needs come up, I work around the ru le s without ge t t ing in to t rouble . I : Why w i l l you do that? R: I l i k e to promote the pa t i en t . The pat ient has a r i g h t to ask quest ions , to ask for good s e r v i c e , and for q u a l i t y s e r v i c e . I w i l l negot iate to an extent for my pat ient s but then I expect them to fol low through. I know that some of them get minimal care . Part of i t i s ju s t c a r i n g . L i k e these women, when you no t i ce something i s wrong you o f fer to help out by t a l k i n g to doctors and s o c i a l workers for them. See they get admitted i f they need to . I d id th i s wi th the f i r s t woman to get TB and now she comes i n r e g u l a r l y and takes i r o n and mul t iv i t amin p i l l s plus her TB p i l l s . She i s t r y i n g to get w e l l . She i s o f f other drugs and a l c o h o l at present . But a l l th i s took work, work with her and work with her partner . I have counsel led them and seen a decrease i n t h e i r s e l f de s t ruc t ive behavior . I : Is cooperat ing, then, what you preferred to do i n t h i s case? R: Yes . I gave them choices of a l t e r n a t i v e s and counsel led them about t h e i r problems and they picked up on i t . I : Do you think the fact that you went the extra m i l e , i t seems, has contr ibuted to t h e i r t rus t i n you as a hea l th care worker? 138 R: Oh, yes, definitely. I: So you see a bond? They made quite a few positive choices for their health. R: Yes and i t was such a small effort on my p a r t — j u s t to do that l i t t l e b i t extra. Then I reap the benefits for the nine months of their treatment. You know, they w i l l keep coming in. Their thank you comes out in their behavior. Working in this job has really made i t very clear to me that you have to be in touch with these people before you can work with them. So the fact that I turn in statis t i c s and say that my patients are averaging out to be in 85% of the time is a good stroke in i t s e l f . Other cli n i c s average 30% for successful treatment. But to be able to walk down the street and have my clients stop and chat with me and not feel worried about i t for any reason—I like that. You have to get over the barriers with these multiproblem people. Normative analysis. Getting over the barriers in this case required the nurse's willingness to work with two women who would just as rather not be treated for TB. However, cooperation was possible and common benefit accrued. Not only did this nurse have a clear perception of her own equality and the importance of her role within the health care team, she also had a firm grasp of how important the street values were for her patients. In typical Stage V reasoning, she upheld a societal value, for example, freedom from infectious diseases, while at the same time doing so from within a cooperative framework that her patients could understand. As she notes, conflict i s frequent and often the patient's need to be treated is slight, therefore, to resolve the conflict she bends a few institutional rules and succeeds in resolving the issue in a positive manner: obligations to the needs of society and loyalty to patient perspective are advanced. 139 In the next case, there i s no need to bend i n s t i t u t i o n a l ru le s but there i s a need to f ind a success fu l way to work with a pa t ient who accepts treatment whi le r e b e l l i n g against i t . Case #24 D e s c r i p t i v e a n a l y s i s . In t h i s example, the nurse discusses a young woman who has a severe eat ing d i sorder . While d e s i r i n g to l i v e and, i n f a c t , earning a l u c r a t i v e l i v i n g , t h i s woman followed an "extremely entrenched way of l i f e which included r e s t r i c t i v e eat ing and vomit ing" and placed h e r s e l f i n severe e l e c t r o l y t e imbalance. R: I sometimes wonder what i s normal i n society—we are c e r t a i n l y i n a p o s i t i o n to judge people. You know, some e c c e n t r i c people f i t i n qui te w e l l . But here we have th i s person who i s e c c e n t r i c , does w e l l , but has severe weight l o s s . She's here but do we feed her against her w i l l ? We used to force feed people. Now we manage a l i t t l e bet ter but s t i l l have to , at t imes, threaten that we w i l l put tubes down and force feed. Though we have never done th i s against a p a t i e n t ' s w i l l . They e i ther agree or they eat. But by then they are not f u l l y r a t iona l—they are s t a rv ing and have a temporary organic b r a i n syndrome due to n u t r i t i o n a l d e f i c i t s . How can she be r a t i o n a l when she says she i s e ighty pounds and i s f ine? But now, we have a more p o s i t i v e f e e l i n g about what we are doing—we work with the pa t ient i n a way that i s a c o l l a b o r a t i v e e f f o r t . We work with them against th i s i l l n e s s and say, "Now, how best can we help you?" Before , we almost had b a t t l e d with them—we forced them to eat , fattened them up and sent them home. Then, they immediately went to t h e i r o ld behaviors . Now we are less r i g i d and le s s anxious and t ry to understand what i s behind the problem. This g i r l was one of the toughest ones I 've had. We worked wi th her , f i n d i n g ways that she was w i l l i n g to cooperate and we are supported by the p s y c h i a t r i s t s on our un i t as w e l l . They recognize the nurs ing knowledge i n t h i s area. With th i s g i r l we looked at things i n view of her h i s t o r y and I ' d l i k e to th ink we o f fer hope. We asked her i f we could make t h i s h o s p i t a l i z a t i o n d i f f e r e n t . We d i d n ' t set up the usual behavior mod i f i ca t ion program and the usual r e s t r i c t i o n s . She was asked to contribute—we put the c o n t r o l i n her b a l l p a r k . 140 I : What happened? R: She l e f t i n a couple of months. She d id improve. She vomited le s s and had normalized her eat ing behaviors a l o t — I be l i eve we worked with her . She maintained her i n d i v i d u a l i t y and was treated with respect . We a l l worked for her good and t r i e d to promote h e a l t h i e r ways for her to cope with her l i f e . Normative a n a l y s i s . Cooperation and a more f l e x i b l e a t t i t u d e on the part of the nurse i n th i s case made her f e e l she had found a more appropriate form of c o l l a b o r a t i o n i n treatment. I t i s obvious that she hated the older method of threats and b a t t l i n g over meals. The reason she pre ferred t h i s uni ted approach i s couched i n statements that are true to Stage V reasoning because emphasis i s put on the p a t i e n t ' s choice and the treatment p lan i s devised from the p a t i e n t ' s per spect ive . Pragmat i ca l ly , the nurse r e a l i z e s that t h i s form of planning w i l l be more l i k e l y to f i t in to the woman's o v e r a l l l i f e s t y l e thereby being maintained on discharge . I d e a l l y , the nurse recognized that with the new approach her personal c o n f l i c t caused by an avers ion to f o r c i n g people to perform c e r t a i n behaviors was a l l e v i a t e d . From cooperating with pa t ient s who on some l e v e l must cohere with s o c i e t a l standards to cooperating wi th the s e l f d e s t r u c t i v e , we now turn to cooperating wi th those who ask us to cooperate wi th them. Case #25 D e s c r i p t i v e a n a l y s i s . This middle aged man with cancer of the lung had a thoracotomy and ended up with very sc lerosed lungs. As a consequence of t h i s , he required cont inua l r e s p i r a t o r y as s i s tance . 141 R: He was sent to us on a v e n t i l a t o r . He was l u c i d , h e l p f u l , and had a l o v e l y , support ive fami ly . S t i l l , he asked repeatedly to have v e n t i l a t o r removed. He had a course of treatment with us that l a s ted longer than he wanted i t to . He then had another lung biopsy . His lungs were completely s c l e r o s e d — i t was confirmed that he would never come of f the v e n t i l a t o r . I n i t i a l l y , i n another h o s p i t a l , he had made h i s wishes known. He d id not want to be maintained for the res t of h i s l i f e on a v e n t i l a t o r . He had already wanted to be taken of f the v e n t i l a t o r . He a lso knew that he would ra ther come of f the v e n t i l a t o r now than to d ie of lung cancer i n a short w h i l e . I : How d id t h i s a f fect you? R: The nurses communicated concerns and were pa t ient advocates. A c t u a l l y , I had a good rapport with h i s wi fe . The family supported h i s d e c i s i o n . We p e r s i s t e d . We l e t the [health care] team know what the pa t ient and the family wanted. P l u s , i t helped because the pa t ient was f a i r l y l u c i d and a lso he made h i s wishes known i n w r i t i n g though i t wasn't an o f f i c i a l document he had w r i t t e n . The nurses coordinated , f a c i l i t a t e d , and supported what the pat ient wanted. This i s something that i s encouraged i n our h o s p i t a l by the nurs ing admin i s t ra t ion . I : You are saying that you f e e l encouragement a l l the way down the admini s t ra t ive l i n e for communicating with pat ients and support ing t h e i r wishes? R: Yes , there have been improvements i n nurs ing c o n d i t i o n s — i t i s a r e a l i t y . We are a l l t r y i n g to work for the welfare of the p a t i e n t . Our goal i s to ensure q u a l i t y care. So we look at both nurs ing and medical standards. And, wi th the support of our head nurse , who plays an i n t e r e s t i n g d ip lomat ic r o l e , we do speak out when medical standards are f au l ty as w e l l . A f te r severa l weeks, the r e s p i r a t o r was f i n a l l y removed and the gentleman had h i s request respected. The family accepted and supported the d e c i s i o n at each step along the way. Normative a n a l y s i s . A man who took the i n i t i a t i v e , who wrote out h i s wishes , and who had a support ive fami ly , asked for as s i s tance . 142 He knew the quality of l i f e he could expect and chose to forego l i f e sustaining treatment. One component in his successful request lay in nursing action that advocated for his right to make such a choice. The nurse understood her patient's request and by gaining rapport with his wife determined that the family concurred with his wish as well. Then, over a matter of weeks, believing her contribution to be v i t a l , the nurse advocated for the family's position. Giving credence to Stage V patterns of reasoning, the nurse cooperated with a family who knew what they wanted, yet required additional support to attain i t . What could have continued as a conflict was resolved appropriately. The nurse's perception of equal relevance as a member of the health care team and her belief in the value of patient choice helped her become an influential patient advocate and, in a matter of weeks, a successful one. The next form of cooperation entails a more multidisciplinary structure. Our f i r s t case is resolved in a team conference. Case #26 Descriptive analysis. This case took communicating s k i l l s , strategy, and planning on the part of a head nurse who wanted to resolve conflict between staff on her unit and who believes in "meaningful conferences" and in the right to die in comfort. R: We have an old man who is ninety. He came in with pneumonia. He won't eat. He won't drink. He won't take his p i l l s . He knows he's going to die, you see, and yet the physician was giving him intravenous ampicillin and 143 an intravenous d r i p . So the quest ion arose, th i s man i s not e a t ing , he i s not d r i n k i n g , and there i s a no-code order , what are we doing g i v i n g him a m p i c i l l i n ? The res idents were f r u s t r a t e d . At any r a t e , then h i s pneumonia would reso lve and he 'd be okay. Then i t would f l a i r up again and he 'd go back on the o ld a m p i c i l l i n . And I. s a i d , we need to t a l k about th i s because people had d i f f e r i n g views. So we asked the phys i c i an i f he would come to a conference. Now he i s not a phys i c i an who i s very open to suggest ion. But we t o l d him about the p a t i e n t . We t o l d him he wouldn't eat or d r ink or take h i s p i l l s . The re s ident explained that we cou ldn ' t understand why he was on and of f a m p i c i l l i n . The phys i c i an explained that he put him on a m p i c i l l i n because he thought i t would make him more comfortable. Then we discussed the IV. Did we want him to get dehydrated? We thrashed these topics around for awhile . Everyone put i n t h e i r view. E t h i c a l l y , we knew he was a no-code. However, our philosophy i n the u n i t i s to make a l l t e rmina l ly i l l pat ients as comfortable and pain free as we can—we want to help them towards an easy death. So I s a i d , i f the a m p i c i l l i n i s he lp ing him towards an easy death, then we are achieving our goa l . So the outcome from the phys i c i an was that as long as he had ve ins we should keep the IV going at 75 ml per hour. And i f the pneumonia seems to be making him uncomfortable, we w i l l g ive him a m p i c i l l i n . Now I know other phys ic ians would disagree . They would d i scont inue the a m p i c i l l i n and the IV. I : Do you f e e l t h i s pa t ient i s comfortable? R: Yes , I per sona l ly do. Though the g e r i a t r i c i a n went through the cardex today and s a i d , "Why don ' t they p u l l the IV?" I think that th i s i s one of those things you jus t can ' t r e so lve . I t i s an i n d i v i d u a l p h y s i c i a n ' s choice but we want to be part of i t . I : Do you f e e l that the p a t i e n t , with the IV out , could s t i l l d ie a comfortable death? R: W e l l , p e r s o n a l l y , I don ' t think so. They get a cracked mouth, a dry tongue, e tc . We f e e l that a slow d r i p , as long as there i s an open v e i n , i s appropr ia te . Once the v e i n i s gone, I do not be l i eve the pa t ient should be poked and poked. Nor do I b e l i e v e a cut down should be done. But an IV promotes pa t ient and family comfort. 144 Normative a n a l y s i s . Comfort above a l l , comes f i r s t for t h i s head nurse of a u n i t which rece ives many te rmina l ly i l l pa t i en t s . When she sensed c o n f l i c t over ju s t how th i s dying man should be t rea ted , she c a l l e d a conference. Interested team members plus the p a t i e n t ' s phys i c i an attended. The outcome of the conference upheld the philosophy of the unit—comfort f i r s t wi th treatment and nontreatment measures to be decided on th i s b a s i s . The conference achieved i t s aim, each team member knew how to approach d i s s en t ing others and knew that the man was dying with the minimum poss ib le pain and s u f f e r i n g . With Stage V reasoning, th i s nurse be l i eved that the pat ient had the r i g h t to d ie with d i g n i t y and that her un i t has a r i g h t to funct ion with minimum f r i c t i o n as they care for those who are dy ing . When the philosophy of the u n i t i s quest ioned, the cause of the c o n f l i c t requires examination. I t i s worthy of note that i n issues of p a l l i a t i v e care and dec i s ions on whether to t rea t or not to , or on what degree of treatment i s appropr ia te , nurses and doctors and often the family cooperated time and time again. Such cases were a l l c l e a r l y terminal and they were concerned with i n d i v i d u a l s on a general medical or s u r g i c a l u n i t . The c o n f l i c t u sua l ly i s i n i t i a t e d over, as i n th i s previous case, i ssues of comfort. A d d i t i o n a l l y , the key dispute i s genera l ly focused on hydrat ion although a n t i b i o t i c treatment i s mentioned qui te f requent ly . Turning now to our f i n a l theme, a c c o u n t a b i l i t y , i t can be seen 145 how nurses conceptual ized the complex i ssues involved i n such a manner that they could re so lve c o n f l i c t i n g l o y a l t i e s by s e t t i n g j u s t i f i a b l e p r i o r i t i e s and by framing the r i g h t s and r e s p o n s i b i l i t i e s of a l l p a r t i c i p a n t s such that moral and l e g a l standards are upheld. Each nurse perceived h e r s e l f as s i g n i f i c a n t b e l i e v i n g she had v o l i t i o n a l relevance or , i n other words, b e l i e v i n g she had an important c o n t r i b u t i o n to make to the matter at hand. Theme: A c c o u n t a b i l i t y  Case #27 D e s c r i p t i v e a n a l y s i s . A nurse who i s an advocate of f a i r p r a c t i c e and who i s aware of the f r i c t i o n between medicine and nurs ing at present says she had recent ly run i n t o a problem that stems from o l d assumptions on the part of phys i c i an and nurse. She says, R: I think that we [nurses and physic ians] have been brought up with the idea that phys ic ians are more knowledgeable than nurses. I don ' t think that i s nece s s a r i ly so. And I think the younger nurses have a d i f f e r e n t a t t i tude which i s making more f r i c t i o n . Nevertheless , s e t t i n g as ide her ideas about younger nurses , th i s nurse with over twenty years experience i s a l so standing up for what she be l ieves i s accountable p r a c t i c e . She t e l l s of an i n c i d e n t . R: I t was over a laboratory repor t . The head nurse looked at a lab report and the way the r e s u l t s were recorded i t looked as i f the pa t ient was put on a drug that he was not s e n s i t i v e to . So she spoke to the phys i c i an and he s a i d , no, i t was ju s t due to how the stamp was placed on the sheet. So she s a i d , f i n e , but had already mentioned the supposed problem to the p a t i e n t ' s nurse i n case she saw the phys i c i an f i r s t . So t h i s nurse a lso mentioned i t to the p h y s i c i a n . He rudely responded to the head nurse , " I wish nurses would s t i c k to n u r s i n g ! " Yet I know that th i s head nurse had 0 146 picked up on three diagnoses that the phys ic i an had missed i n one week. The phys i c i an was already f rus t ra ted with her . I : Can you t e l l me what happened? R: W e l l , the f i r s t time she asked him i f he would come and see h i s p a t i e n t , but he d i d n ' t accept the symptoms she reported . F i n a l l y , she had to say, "You w i l l come see t h i s pa t ient r i g h t now." Y e t , you know, he i s an exce l l ent p h y s i c i a n , i t was a human mistake. Pos s ib ly he was so rude as w e l l because he comes from a cu l ture where nurses are considered the handmaiden of the doctor . Yet she d id diagnose c o r r e c t l y and two of the pat ients were going in to congestive heart f a i l u r e . Some of these doctors think we are t r y i n g to take over medicine. And to people l i k e th i s phys i c i an I ju s t say, "Come of f i t , you know, you send us up north because none of you w i l l go and so you hand over medical functions to us; then we come out and you say, no, no, no, you can ' t do t h a t . " So I s a i d , " I t ' s about time you people made up your minds about what you want . " So nurses can r e a l l y be s tuck, and th i s does hold us back from teaching pat ients and even from recogniz ing a missed diagnosis and demanding a pa t ient be seen. We nurses have to resolve a l o t of c o n f l i c t s w i t h i n ourselves and a l o t of e t h i c a l i ssues w i t h i n ourse lves . We must take stands and demand to be part of the hea l th care team. So that i s what I do and say. Here, we demand conferences and they work. At f i r s t the doctors s a i d , " I don ' t know how to s t a r t these t h i n g s . " Or, "What do we need a conference fo r ? " But we taught them how to have one and what could be accomplished. Now they ask for them. S t i l l , as noted, the o ld assumptions d ie hard. Ye t , as th i s nurse s t res ses , there i s hope and once the idea of working together gets going, everyone benef i t s and, of course, most of a l l the pat ient because that i s , a f ter a l l , who the conference i s f o r . Normative a n a l y s i s . This nurse espouses Stage VI reasoning because she places emphasis on prov id ing jus t and f a i r treatment. She i s committed to prov id ing q u a l i t y and r e s p e c t f u l pa t i ent care and acts i n accordance with p r i n c i p l e s that promote such care . She recognizes the need for i n t e r d i s c i p l i n a r y conferences and sees that 147 they are commenced. What i s more, she f a c i l i t a t e s th i s new rout ine i n a mature and responsive way such that each team member fee l s h i s or her c o n t r i b u t i o n has va lue . She has proven that those nurses and phys ic ians who w i l l work together can work together w e l l . She has a lso proven that standing up and p o i n t i n g out d i screpancies can help destroy i l l u s i o n s as w e l l as b r i n g leg i t imacy to the act ions nurses are capable of performing. Another example of a need to deal with outworn assumptions was c a l l e d to mind by a nurse who sees a number of seniors on her u n i t . Case #28 D e s c r i p t i v e a n a l y s i s . Assumptions can be potent forces . They can a f fec t how we view those about us and, i n p a r t i c u l a r , they can a f fec t how we view the senior populat ion i n our soc i e ty . F i g h t i n g such viewpoints , t h i s nurse c o n s i s t e n t l y reminds other hea l th care profes s iona l s that the seniors are i n d i v i d u a l s and must be assessed and treated as such. R: This a c t u a l l y i s a laughable s t o r y , yet i t i s also s e r ious . We had a family phys i c i an who admitted a lady i n her n i n e t i e s . She came i n with a g a s t r o i n t e s t i n a l hemorrhage. This l a d y ' s mind was b r i g h t as a button and sharp as a whip. This was on a F r i d a y . Now her phys i c i an was p a r t i c u l a r l y fond of her and he was th inking of put t ing her i n the ICU. So he phoned the senior res ident i n ICU and asked him to come down and see her . And he comes in to the nurs ing s t a t i o n and looks at her chart . Then he says to the family p h y s i c i a n , "You d i d n ' t t e l l me she was o l d . " This upset the family p h y s i c i a n . So worrying about th i s lady he cance l led a weekend t r i p out of town. He d id go see her and of fer her ICU treatment i f she needed i t . She s a i d , " N o . " She sa id she d i d n ' t want to go to ICU and she d i d n ' t want to be r e s u s c i t a t e d . She s a i d , " I don ' t want to have a l l those wires on me, leave me here , I ' l l take my chances. N o . " 148 And she took her chances and is now getting better. So a few days later we had a man in his mid-eighties come in for investigation of vertigo and he suddenly stopped breathing. He didn't have a no-code order so we called a code. Well, the same senior resident arrived at the code. He says, "He's in his eighties and you c a l l a code! What kind of unit i s this!" And so on and on. . . . Well, we told him he wasn't a no-code so legally we had to c a l l one. We also reinforced the fact that the man was up and around and doing okay. "But, he's old," says the resident. So, a few days later we get a patient up from emergency. She had a transient ischemic attack plus she had a long term chronic ill n e s s . Nevertheless, a very good physician saw her in emergency, said she was stable, and sent her to our unit. She was also in her eighties. And—she arrested. Well, we called the code a n d — i t was the same guy! Oh, he was furious! We resuscitated her. He was beside himself! He then discussed the whole issue with the resident on the unit. Then, you won't believe this. We admitted a 102 year old man, his diagnosis was failure to thrive—he arrested on us. We called the code and i t was the same resident again. Then—again, "What kind of unit are you running? What is the meaning of this?" I don't think he ever forgave us, I think we have the worst reputation going. But, i f there isn't a no-code order, we must resuscitate. I: Did any of these people warrant a no-code order? R: Well, the lady from emergency probably did. But I don't necessarily think that the 102 year old man did. Who are we to say—he was getting around, quality of l i f e was there. Nevertheless, this other resident wanted to make dictates at certain ages. He didn't feel there was a point after a certain age. Families must be asked also. We are, in fact, asking more and more families now and the patient, too. This code-no-code issue is a dilemma for nurses now. Codes are stressful for nurses and they are rarely successful. We a l l wonder i f we could have done more. We don't talk i t over. It's a big ethical question. Nurses are nervous about i t — t h e y ' r e scared. We cannot let patients die unless the physician has written a no-code. We a l l need to be part of this. The patient doesn't need an anxious health care team. These patients need people around them who can relax, be themselves, and can care about them without constantly being on edge watching for symptoms that require a code to be called. Yet not a l l older people should be no-codes. 149 She adds that people must be viewed as i n d i v i d u a l s and one cannot always assume q u a l i t y of l i f e i s low i f someone i s of a c e r t a i n age. She can laugh now at the r e s i d e n t ' s assumption, yet because she sees many more seniors than he does, she can respect the r i g h t s they have to be i n d i v i d u a l l y assessed and asked what they p re fe r . She has i n i t i a t e d more and more family involvement on her u n i t and i s encouraging respons ible family input . Normative a n a l y s i s . Empathy and the a b i l i t y to see.through competing claims to the c e n t r a l i s sue helps th i s nurse focus on the inherent v a l u e . o f the i n d i v i d u a l and to ignore inappropr ia te assumptions. She, true to Stage VI t h i n k i n g , respects the i n d i v i d u a l . She i s working toward a r e s o l u t i o n to the code, no-code c o n f l i c t that places emphasis on q u a l i t y of l i f e so that i t i s ju s t for a l l invo lved . And, she s t res ses , we must communicate t h i s need to step forward to the nurses on the u n i t , then we w i l l have more cooperat ion. Because, she adds, "sometimes you have to have a conference jus t to defend your pro fes s iona l i sm and to defend your r i g h t s as a nurse as w e l l as your l e g a l r i g h t s . " The f i n a l two cases depict independent, accountable ac t ion by nurses who b e l i e v e they are s i g n i f i c a n t members of the hea l th care team. Their l o y a l t y i s to the p a t i e n t . They have set c l ea r p r o f e s s i o n a l gu ide l ines for themselves and can, i n c o n f l i c t s i t u a t i o n s , decide how to resolve issues i n ways that support pa t i en t s . 150 Case #29 Descriptive analysis. Because this nurse knew she had the knowledge and experience to identify hyperactivity and because she saw the young child creating havoc in the classroom frustrating teachers and causing disturbances at home, and since nothing was being done for the child, she decided to push for diagnosis and treatment. The push took two years worth of effort. She describes the ordeal. R: I believe in encouraging parents and children to help themselves with their problems. In this situation I identified a child who was having d i f f i c u l t y at home and in the classroom. So I talked to the parents and to me i t seemed we had a case of a classic hyperactive child. Over the next year I took the Mom literature and I also gave literature to the teacher and spoke with her. They both agreed that, yes, this child is hyperactive. So, then, I encouraged the mother to go to her family doctor and ask for a referral to either of two doctors who know a great deal about hyperactivity. Well, the family doctor didn't know the child that well and didn't take the parents seriously. So the school staff and myself sent him a letter about the child's behavior and asked him to refer her. So he did. But the problem was that this specialist did his assessment and then sent her to another specialist who did his assessment. And everything is l e f t there. Meanwhile the child's behavior i s wild every day at home and at school and nothing i s done. I: With two assessments? R: The assessments were done and reports were sent to the school. The f i r s t report diagnosed her as hyperactive but this specialist recommended that she go for psychological educational testing. So she then got educationally tested with the usual results that she functioned at this level for reading, this for writing, etc. However, the f i r s t specialist did not take responsibility for treating her nor did the second. So I got back to them both and said, "Thank you for your reports but what are you going to do about the child?" Both responded that treatment wasn't 151 t h e i r r e s p o n s i b i l i t y . So I went back to the family doctor. But he doesn't know anything about h y p e r a c t i v i t y or r i t a l i n or dexadrene. Nothing i s done! The c h i l d i s s t i l l w i l d! F i n a l l y , j u s t when I was getting my most fr u s t r a t e d and planning my next move, we hired a new p s y c h i a t r i s t at the health unit. He deals with c h i l d r e n and has had experience with hyperactive c h i l d r e n . So I take the case to him. We s t a r t a treatment program. Now over a year and a h a l f l a t e r , she i s s t a r t i n g on a treatment program and i t may take up to s i x months for her to r e a l l y notice the benefits so i t w i l l be over two years of e f f o r t before i n i t i a l r e s u l t s . And you know, the family was great. They made t r i p a f t e r t r i p to t h e i r physician. They picked up reports, they delivered them—they were excellent. But we a l l were not considered autonomous enough or knowledgeable enough by these s p e c i a l i s t s . Not the parents, not the school, and not myself. Plus the s p e c i a l i s t sees the c h i l d but the report doesn't get typed and mailed out for two months afte r that. Then, the c h i l d waits three months to see the second s p e c i a l i s t and that report takes another two to three months. And then each s p e c i a l i s t sends a report to the other but neither may send a report to the family doctor. Moreover, the parents only get a copy i f they push and become very a s s e r t i v e and they even have to push harder to get a copy sent to the school or the health nurse. I: And your goal was? R: To help the c h i l d c o n t r o l her r e s t l e s s behavior so that she could s i t for longer periods of time i n the classroom and be able to absorb more of what she should be learning. Plus to help her and her family at home with t h e i r problems with her restlessness and sleeplessness, etc. F i n a l l y , within the health u n i t , we have dealt with i t . The p s y c h i a t r i s t i s following her month by month and taking r e s p o n s i b i l i t y for p r e s c r i b i n g correct dosages of medication. I work with her and have been working with her both by bringing her books, reading with her, and mainly t a l k i n g with her about how she f e e l s and how she's doing t r y i n g to encourage her to understand her behavior a b i t . I used to see her weekly. I: So someone was there p u l l i n g for her and helping her. R: Y e s — i t took a l o t of educating on my part to teachers and parents. I coordinated the whole mess and r e a l l y t r i e d to ensure that the family maintained a good r e l a t i o n s h i p with t h e i r family doctor throughout t h i s . 152 I : That was qui te a nurs ing r o l e . R: Oh—huge! But I was convinced I was r i g h t . I : Just h y p o t h e t i c a l l y , i f you hadn't been so convinced, do you th ink you would have— R: Given up? Sure. I : I wasn't going to say given up but , would you have been a l i t t l e less f o r t h r i g h t i n pushing forward for the ch i ld? R: Sure. I would have jus t accepted that the s p e c i a l i s t s had more knowledge. And I guess I would have j u s t , probably gent ly , not connected wi th the family or would have gradual ly withdrawn f i g u r i n g i t had been handled. But t h i s i s one of the cases that has made me f e e l very good. I am a p r o f e s s i o n a l f r i end to that family and the c h i l d i s r e a l l y c l o s e . She knows the nurse i n the s choo l , she l i k e s her , and she v i s i t s her o f f i c e . The family have coped w e l l . There i s not much negative emotional aftermath for th i s c h i l d . I : With the knowledge and the l o y a l t y you f e l t to the c h i l d you met your ob l i ga t ions even through extremely f r u s t r a t i n g times. R: Yes, I had the whole community to deal w i t h . But, the key th ing too i s , that t h i s family was w i l l i n g to accept some of the r e s p o n s i b i l i t y once they had some d i r e c t i o n . We worked together for a p o s i t i v e goal—they wanted to see change as w e l l . Normative a n a l y s i s . This nurse showed Stage VI reasoning when she decided not to maintain a status quo w i t h i n the hea l th care system. She was more in tere s ted i n advancing the welfare of th i s c h i l d , the f ami ly , and the teachers i n the school . Once she knew she had home and school behind her , the nurse determined a f a i r way of reaching a more p o s i t i v e outcome for the c h i l d . The concluding case speaks again of the a b i l i t y of a nurse to analyze a s i t u a t i o n , to take independent a c t i o n , and to meet her ob l i ga t ions to pat ients i n an accountable manner. 153 Case #30 Descriptive analysis. Complaining at work is often a nurse's way of dealing with unsatisfactory work habits or incompetent behavior of other health care professionals states this nurse. However, when a physician could not provide logical s c i e n t i f i c support for a treatment measure he was using, this nurse took the matter in hand and formally did something about i t . R: Yes, we complain at work to each other. Generally, we have a session just to let off steam. I think there is validity in that. If you f i r s t of a l l let people let off steam, they can then become objective. Then we sometimes leave i t , or i f i t is causing problems for a patient we take i t further. And there are avenues to go through i f you feel strongly enough about quality of patient care. In this instance, I questioned the competency of a psychiatrist on staff. His level of functioning is poor at the best of times. Even patients have remarked over this to me which is a whole other dilemma. But I am quite open with patients, I t e l l them to t e l l their doctors and that they definitely have the right to request another psychiatrist. I feel comfortable doing that and I think i t is ethically sound. But this man is not accountable. He w i l l even hedge on ordering and say to us, "Just give what you want." Well I refuse and t e l l him that he is my consultant and that he must order. However, this issue has to do with a f a i r l y bizarre treatemnt approach he used. One that is unfounded within recognizable treatment parameters. Anyhow, he was using this one approach which was based on the patient receiving electroneural stimulation. He insisted that this stimulation would cure almost everything. You name i t , i t w i l l cure i t . Well, being a thinking individual, I think this is a b i t far fetched. And I was not the only one who thought this. Other staff did also, including the doctors. • Now he keeps on insisting that he wants to use this on a l l the patients on the ward—it was getting to the point where a l l his patients were wearing this apparatus. And i t was just too much out of 1984. And I don't feel comfortable using these things. Fi r s t of a l l , I don't know anything about them. If they are good or not. I mean, Lord knows, they may be the answer. I don't want to deny these people health i f i t is going to be helpful. But I wanted some 154 more informat ion on i t . And he wasn't forthcoming with any. He jus t sor t of threw of f these vague genera l i za t ions about how wonderful they were and I d i d n ' t f e e l I was ge t t ing any s a t i s f a c t i o n . I went to the head nurse who was f e e l i n g equal ly f ru s t r a ted . But she has not had a p o s i t i v e r e l a t i o n s h i p with the d i r e c t o r of our u n i t , a p s y c h i a t r i s t , and d i d n ' t th ink he would do anything about i t so she wasn't going to him. So I phoned the nurs ing p r a c t i c e consultants at the RNABC. She gave me exce l l ent advice on how to deal wi th complaining about a col league i n the work p lace that you f e e l i s not prov id ing adequate care . For ins tance , you don ' t complain about p e r s o n a l i t i e s , you complain about ac t ions . So from t h i s , I c l a r i f i e d my pro fe s s iona l concerns. Then I drafted a l e t t e r and sent i t to a number of people i n the department. I documented the problem, I asked for a response and I sa id that I would take further steps i f something wasn't done. Funny enough, others agreed with me. I : But they were l e t t i n g him do i t ? R: Yes , here and on other un i t s throughout the h o s p i t a l . They were l e t t i n g him do i t . No one was stopping him. And f i n a l l y , as a r e s u l t of my l e t t e r , he was to ld to s top. So for one and one-half years he was us ing t h i s apparatus. Af te r i t was over, three other doctors t o l d me they agreed he should stop us ing i t . I : Nobody knew i f i t was a s c i e n t i f i c a l l y substant iated treatment but you fol lowed through on i t ? R: Yes. But I d i d l ea rn something from w r i t i n g t h i s l e t t e r . Probably another time I would involve more of the nurses on the u n i t . They knew I was doing t h i s , but I would have l i k e d t h e i r support on paper. I : You would l i k e the group support and group strength? R: Yes. I : Did you get any negative feedback from your independent approach? R: No. I : From the p s y c h i a t r i s t himself? R: No. I ta lked to him about i t before I ever wrote the l e t t e r . I f e l t I was represent ing other nurses and other pa t i en t s . 155 He could give me no answers, no documentation and only responded wi th anger. In fact he even sa id things l i k e , "How o ld are you anyways?" And, "How long have you gone to school? " I f e l t I had t r i e d . And I f e l t good about my approach. I even f e e l be t ter about working with him now than I d id before . I f e e l that I am a l o t more open wi th him now and he knows that probably i f I do object to anything , I w i l L . b e qui te open about i t with him. But I have to be ca re fu l I don ' t cloud my view of him over t h i s . I shouldn ' t quest ion him where I wouldn't quest ion others ju s t because of t h i s . I t ry to be c l i n i c a l l y o b j e c t i v e . I: Do you think soc ie ty wants the nurse to do anything about instances l i k e th i s ? R: I haven' t given i t much thought. But I don' t l i k e working i n an unsafe work environment where c l i n i c a l l y unsound judgments are made. I guess I wouldn't have thought about that quest ion so much u n t i l the Grange Commission. But I do th ink nurses cover for doctors . I : Do you think soc ie ty expects nurses . to cover for doctors? R: No. I am not saying that soc ie ty expects nurses to cover for doctors , but I do th ink that nurses are an eas ier target because there i s s t i l l t h i s mystique about the doctor being a l l -knowing and a l l - s e e i n g and, there fore , capable of doing no wrong. Nurses are eas ier targets because there i s not a mystique surrounding nurses. I : But do you think soc ie ty expects nurses to: report unaccountable phys i c i an behavior? R: W e l l , I don ' t honest ly know what joe p u b l i c th inks . I: Do you think nurses expect i t of themselves then? R: I expect i f of myself . I expect to be accountable for sure. L i k e i n t h i s in s tance , I had no qualms. I was not going to fo l low h i s order . I was not w i l l i n g to do that and I could c l e a r l y i d e n t i f y that . There are a l o t of e t h i c a l i s sues where I work and a l o t of l e g a l facts to be aware of . I always want to be proud of what I do and what I document. We r e a l l y have a l o t of power i n these jobs , i t i s important to judge people c a r e f u l l y and document accurately—we have a great r e s p o n s i b i l i t y on behal f of the p a t i e n t . They deserve respect and they deserve t h e i r r i g h t s and t h e i r d i g n i t y . 156 Normative a n a l y s i s . This i s an example of a f u l l y autonomous accountable nurse who resolves c o n f l i c t i ssues at a Stage VI l e v e l . A cons i s tent view of what i s f a i r and of what i s ju s t comes forward. In c i t i n g the fact that she i s a th ink ing person who values ob jec t ive judgments, th i s nurse i s cognizant of the need for r a t i o n a l dec i s i on making which i s grounded by respect for the i n d i v i d u a l s she cares f o r . She sought an e t h i c a l l y ju s t s o l u t i o n to a c o n f l i c t that had troubled a number of people over time. She was ready to a c t u a l l y r e s i s t the status quo and to threaten to go beyond the i n i t i a l formal route of complaint . She, on p r i n c i p l e , knew how to i d e n t i f y and organize an e f f e c t i v e r e s o l u t i o n whi le aware that others were unable to act . In e f f e c t , a f ter the f a c t , others supported her act ions and openly t o l d her how they agreed with her . She responded to her own act ions with pride—she had been accountable to s e l f and to o thers . Comparative C r i t i q u e Nurses who perceived they had v o l i t i o n a l relevance or equa l i ty as a member of the hea l th care team resolved c o n f l i c t s of l o y a l t y us ing postconvent ional reasoning. They autonomously and c o n s i s t e n t l y ascerta ined what was r i g h t on the bas i s of community welfare or on the bas is of moral p r i n c i p l e . This p r i o r - t o - s o c i e t y perspect ive i s evident because although the nurses were cognizant of the ru le s of the i n s t i t u t i o n , they were w i l l i n g to bend them or go beyond them— commitment focused on a t t a i n i n g f a i r and jus t outcomes for t h e i r p a t i e n t s . Ego concerns were not c e n t r a l nor were concerns based on 157 maintaining the status quo. Each nurse functioned from within a widened more objective and rational perspective which gave rise to the themes.of cooperation and accountability. Cooperation with the physician was evident when nurses using Stage V reasoning resolved conflicts. Correlatively, the views of the patient, when possible, were sought and became an integral part of what can be termed a contractual relationship based on cooperation for the purpose of upholding the rights of the patient and the quality of nursing practice. Similar reasoning is evident in cases depicting the theme of accountability. Nurses seek to enhance the patient's right to self determination and to enhance the dignity of those who lack f u l l decision making power. The f i n a l two cases express Stage VI pattern reasoning. Here, nurses, maintaining a principle of justice, were willing to fight the system in order to find just and ethical solutions for their patients. Within each theme, postconventional reasoning combined with perceptions of volitional relevance provides an example of vigilant decision making. As Janis and Mann (1977) claim, the vigilant decision maker is flexible, seeks adequate information and is discriminately open minded. To them, the vigilant decision maker must also contend with multidimensional sets of values and resolve problems related to their own cognitions and attitudes, as well as social pressures from the milieu. In other words, social status or self esteem may be threatened. In the face of such considerations, 158 there is l i t t l e evidence that these nurses lacked in decision making capacity. They were able to identify a problem, f i l l in the needed background information, speak to those involved, and find a route which promoted a positive resolution. Hasty conclusions were not evident nor did pressure from others deter the process of resolution. Accordingly, decisions were made with confidence. Manifestations of cognitive dissonance did not occur and i t is reasonable to conclude that Festinger (1962) is right when he says cognitive conflict dissipates once internal harmony i s established. Harmony, occurs, he says, when there is a consistency and congruity among opinions, attitudes, knowledge and values. Nurses, reasoning at the postconventional level, were proud of their behavior, acted on principle, and showed no evidence of post decisional regret. They f u l f i l l e d the nursing role in a manner which f i t not only with their own beliefs about the role, but also in a manner that i s congruent with statements in the ICN Code and Standards of Care documents. These nurses "maintained the highest standards possible within the reality of the specific situation" (CNA, 1980), and they knew i t . Backed by the a b i l i t y to function at a postconventional level, supported by the perception that nursing input was of value, these nurses functioned autonomously. Ambivalence and ambiguity were either diminished or nonexistent. Legal and ethical obligations are met. Both contractual and fiduciary aspects of care founded on the understanding of the.right of the patient and 159 the duty and responsibility of the provider were coordinated. And this, of course, is a fundamental condition in the provider-patient relationship. What is more, for nursing, independent judgment and professional sophistication, contends Murchison, Nichols, and Hanson (1978), is a necessity. In fact, they claim that nursing has no dependent functions and that legal and ethical care can only go hand in hand with autonomous nursing practice. Given these two considerations, i t is clear to see that one way to achieve autonomous action under the present health care system is to function at the postconventional level placing value on principles which support the rights of the patient and the nurses own personal and professional integrity. These nurses, without f a i l , found positive resolutions to conflict: their fundamental soundness in decision making procedure is made more evident by the fact that others, even those in the conflict, supported the resolution. This latter consideration is a crucial one, states Dworkin (1978, p. 279), because in complex issues when rights are at risk, finding the better solution i s a complicated process and often the answer must be "discovered", then firmly j u s t i f i e d . Clearly Kohlberg's contention that postconventional reasoning promotes more adequate decision making and thereby higher quality problem resolution is supported (1981). Thus, the concept of patient autonomy takes on a c r i t i c a l value when i t is upheld on a principled level. Nevertheless, this level of conflict resolution only occurred 160 when the nurse perceived she had v o l i t i o n a l relevance or equa l i ty w i t h i n the s o c i a l context : a l inkage of cogn i t ion and a f fec t i s ev ident . How then i s the c a p a b i l i t y for r a t i o n a l thought inf luenced by sub jec t ive a f f e c t i v e factors? The answer to th i s quest ion as i t r e l a t e s to pos tconvent ional , conventional and preconventional patterns of reasoning w i l l be discussed next as the foregoing data i s placed w i t h i n a substantive grounded t h e o r e t i c a l framework. Summary The major substant ive concept, perceived re levance , with i t s three dimensional focus of imposed, bounded.and v o l i t i o n a l re levance , has been examined i n r e l a t i o n to the three major categories of Kohlberg ' s theory of moral development. The examination includes both d e s c r i p t i v e and normative aspects and the d i screpancies which occur between thought and ac t ion i n c o n f l i c t s i t u a t i o n s . Var i ab le s which contr ibuted to the percept ion of relevance w i t h i n the m i l i e u s i t u a t i o n af fected the manner i n which pa t ient autonomy was upheld. The most severe d i screpancies between thought and ac t ion occurred when c o n f l i c t s were resolved with preconvent ional patterns of reasoning that are backed by percept ions of imposed re levance . Themes of resentment, anger, and revenge dep ic t ing severe a f f e c t i v e s tress were common. V a r i a t i o n i n q u a l i t y of d e c i s i o n making proved widespread when c o n f l i c t s were resolved wi th convent ional l e v e l reasoning associated wi th perceptions of bounded re levance . As 161 nurses t r i e d to resolve the incongruency between requirements of p ro fe s s iona l behavior and the requirements of a system which they supported, they were confronted with the fo l lowing f i v e dilemmas: (a) r e l a t i o n s h i p versus r o l e r e s p o n s i b i l i t y ; (b) nurs ing r i ght s versus phys i c i an r i g h t s ; (c) nurs ing r i g h t s versus i n s t i t u t i o n a l r i g h t s ; (d) nurs ing r e s p o n s i b i l i t y and the r i g h t of the pat ient to d ie with d i g n i t y ; and (e) i n d i v i d u a l r i g h t s versus s o c i e t a l r e s p o n s i b i l i t y . Although safe standards of care are upheld, exemplary care i s not , nor are the nurses able to implement the nurs ing code to the degree they would pre fer . On the other hand, c o n f l i c t s resolved at the postconvent ional l e v e l concerning perceptions of v o l i t i o n a l relevance met c r i t e r i a f i t t i n g f u l l p ro fe s s iona l behavior . Qual i ty pa t ient care r e f l e c t i n g adherence to standards of care and the ICN Code i s evident as are themes dep ic t ing cooperation and a c c o u n t a b i l i t y . As can be seen, cont inua l comparing of instances of m u l t i p l e l o y a l t y c o n f l i c t as i t centered on the concept of pat ient autonomy led to an in terconnect ing r e l a t i o n s h i p between categories of cogni t ive moral development and categories of perceived relevance which i s more a f f e c t i v e l y founded. I t i s the outcome of t h i s i n t e r a c t i o n that re su l ted i n vary ing responses on the part of the nurses . Chapter F ive w i l l focus on th i s i n t e r r e l a t i o n s h i p by prov id ing a more abs t rac t , t h e o r e t i c a l l y or ientated d i s cus s ion of the process of c o n f l i c t r e s o l u t i o n . 162 Chapter Five: Grounded Theory Introduction The analysis of data in Chapter Four clearly grounds the most relevant properties of the core concepts integral to multiple loyalty conflict situations and explains the resultant behavior on a thematic basis. Concrete examples of real world reactions to conflict over patient autonomy are woven into each thematic expansion. In this manner indicators for the concepts and their expression in themes are clearly illustrated and form a basis for theory construction. The aim of this chapter is to develop the theoretical relationships among the major concepts. To f a c i l i t a t e a more comprehensive understanding of the substantive theory, a brief retrospective of the study purpose and an outline of definitions central to the theoretical perspective w i l l be presented prior to a structural schematic representation of the theory, the propositional statements and theoretical narrative. Following this, principled determinants for action and implicit rules for behavior that underlie the cognitive-affective interface embodied in the concept of perceived relevance, w i l l be described. The intent here is to take the empirical findings and to raise the discussion to a more abstract conceptual level. Theoretical Purpose A l l theoretical effort is focused on one goal (Chinn & Jacobs, 1983), the purpose of the study: to identify the patterns of reasoning which registered nurses use to resolve multiple loyalty conflicts 163 i n v o l v i n g patient autonomy and to compare t h i s reasoning with the patterns that depict a preferred outcome. Variables which a f f e c t the discrepancy or congruency between patterns of reasoning r e f l e c t i n g what a c t u a l l y happened i n the c o n f l i c t s i t u a t i o n and what the nurses would have preferred, on a normative l e v e l , to have happened were sought. The core explanatory concept, perceived relevance, with i t s three dimensional subcomponents and respective thematic properties came forward as the major v a r i a b l e i n the study. This core concept provides a foundation for a d e s c r i p t i o n of the d i a l e c t i c a l process that intimately a f f e c t s thought and action once the contextual nature of the s i t u a t i o n i s taken into account. A number of concepts interconnect within t h i s r e l a t i o n s h i p ; therefore, p r i o r to presenting a schematic view and n a r r a t i v e of the theory, a review of pertinent d e f i n i t i o n s i s appropriate. Conceptual C l a r i f i c a t i o n  M u l t i p l e Loyalty C o n f l i c t Any incongruency of demand or des i r e between patient, family physician, employing agency, personal e t h i c a l b e l i e f s and p r o f e s s i o n a l e t h i c a l standards of the i n d i v i d u a l registered nurse. Patterns of Reasoning The l e v e l and stage of cognitive moral development as defined by Kohlberg's theory of cognitive moral development. Decision Outcome The c o n f l i c t r e s o l u t i o n including both the actual and preferred outcome. 164 Perceived Relevance The view of self as i t pertains to the subjective interpretation of the multiple loyalty conflict situation. 1. Imposed relevance. The perception of inequality based on a set of firmly held expectations. 2. Bounded relevance. The perception of limitations based on the need to maintain relationships or uphold rules. 3. Volitional relevance. The perception of equality expressed as the right to participate and to make choices congruent with self chosen ethical principles. Patient Autonomy The patient's right (or the surrogate's right) to have beliefs and values respected when making informed choices for action. The concept of patient autonomy remained stable and congruent with the study definition. This focus comes forth clearly in such respondent statements as: 1. Patients should have as much control over their environment as possible. 2. A patient owns his or her body and has the right to refuse treatment and to discharge himself or herself from the hospital. 3. As long as i t is possible, l e t the patient choose. 4. We must recognize that the patient i s a human being and has opinions about what is going on. 5. We must support patient autonomy by finding ways to communicate with patients. 6. Patients need to be treated with the respect due them so they can maintain their individuality and identity. So within the bounds of the quest to examine patterns of reasoning and the relationship between reasoning and mode of conflict resolution, 165 factors related to perceived relevance and not to the definition of patient autonomy intervene. Now let us turn to the presentation of theory. Theoretical Perspective Each concept and i t s related subconcepts are part of a structure. The interrelationships can be expressed in propositions which "outline a systematic view of phenomena by designating specific interrelationships among concepts" (Chinn & Jacobs, 1983, p. 20). Figure 4 presents a structural or symbolic representation of empirical phenomena. Propositions pertinent to perceptions of relevance involving the cognitive and affective interface in multiple loyalty conflict situations are as follows. Propositional Statements Proposition 1: (i) In cases of multiple loyalty conflict, i f a nurse is capable of Stage IV or V reasoning and i f she perceives herself to have imposed relevance, then the conflict w i l l be resolved with Stage I or II patterns of reasoning. ( i i ) Under these conditions the emerging themes of resentment, anger, and revenge grounded in the affective domain lead to symptoms of severe cognitive dissonance and result in unsatisfactory patient care. Proposition 2: (i) In cases of multiple loyalty conflict, i f a nurse is capable of Stage IV, V, or VI reasoning and i f she perceives herself to have NORMATIVE DESCRIPTIVE LEVEL OF POTENTIAL PERCEPTION RESOLUTION OUTCOME COGNITIVE RESOLUTION STAGE IV AND V IMPOSED RELEVANCE STAGE I AND II THEM:: _r-__ 1- RESENTMENT 2. ANGER 3- REVENGE PRE CONVENTIONAL STAGE IV, V, VI PERCEIVED RELEVANCE BOUNDED , _ RELEVANCE "I- 5* STAGE III AND IV THEME: 1- RELATIONSHIP VS. ROLE RESPONSIBILITY 2. NURSING RIGHTS VS. PHYSICIAN RIGHTS 3. NURSING RIGHTS VS. INSTITUTIONAL RIGHTS 4- NURSING RESPONSIBILITY AND RIGHT OF THE PATIENT TO DIE WITH DIGNITY 5- INDIVIDUAL RIGHTS VS. SOCIAL RESPONSIBILITY CONVENTIONAL STAGE V AND VI VOLITIONAL RELEVANCE STAGE V • AND VI THEME: - O 1. COOPERATION 2. ACCOUNTABILITY POSTCONVENTIONAL FIGURE 4. MULTIPLE LOYALTY CONFLICT: COGNITIVE-AFFECTIVE INTERFACE 167 bounded re levance , then the c o n f l i c t w i l l be resolved with Stage I I I or IV patterns of reasoning. ( i i ) Under these condi t ions the emerging themes take on dilemmatic proport ions wi th losses noted i n the q u a l i t y of pa t i ent care . P r o p o s i t i o n 3: ( i ) In cases of m u l t i p l e l o y a l t y c o n f l i c t , i f a nurse i s capable of Stage V or VI reasoning and i f she perceives h e r s e l f to have v o l i t i o n a l re levance , then the c o n f l i c t w i l l be resolved with Stage V or VI patterns of reasoning. ( i i ) Under these condi t ions the emerging themes of cooperation and a c c o u n t a b i l i t y show a balance of cogni t ive and a f f e c t i v e c a p a b i l i t i e s such that nurs ing behavior leads to high q u a l i t y pa t i ent care . T h e o r e t i c a l Narra t ive The process determining the manner i n which the c o n f l i c t i s resolved res t s on the percept ion of re levance , and ac t ion occurs i n r e l a t i o n to whether relevance i s perceived as imposed, bounded, or v o l i t i o n a l . Each of these categories i s corre la ted with the l e v e l of cogni t ive moral development, which expresses the under ly ing reasoning c o n t r i b u t i n g to c o n f l i c t r e s o l u t i o n , and these categories are juxtaposed against a normative l e v e l of reasoning, which expresses thought under ly ing the pre ferred c o n f l i c t r e s o l u t i o n . The r e s u l t of the discrepancy i s expressed i n terms of themes which expand on the proper t i e s of the outcome respec t ive to each dimension of perceived re levance . 168 We now want to answer our study question and also the question in Chapter Four which asks: How is the capability for rational thought influenced by subjective affective factors? In other words: What are the underlying patterns of reasoning which serve to substantiate both the actual and preferred decision outcomes? It is evident in Figure 4 that while capable of taking a normative perspective of Stage IV and V certain respondents made choices which reflect Stage. I and II patterns of reasoning. Other respondents capable of Stage IV, V, or VI reasoning responded behaviorally with reasoning depicting Stage III and lower quality Stage IV thought. Nevertheless, conflicts were resolved positively and patient autonomy was upheld as was professional practice. A group of respondents who perceived that they had volitional relevance maintained Stage V or VI patterns of reasoning. Thought and action remained congruently connected. Our question i s not new. Piaget in the 1930s began, to a certain degree, asking about this relationship. Feffer in 1959, 1966, and 1970 reports on research in the area. Kohlberg (1981) addresses the question as do Shapiro and Weber (1981) who speak of the unsolved quandry. Selman (1980) reflects on the same problem. Zimilies (1981) captures the essence of the question well when he states that the construct of cognitive-affective interaction occupies, a strangely contradictory position in current psychological theory and experimentation, because the way in which thought and emotion influence each other has seldom been subject to systematic study 169 and is most d i f f i c u l t to research on a quantitative basis (Shapiro & Weber, 1981). What happened? Let's look f i r s t at the postconventional thinkers who did maintain their normative standard behaviorally. Although this study does not identify a f u l l range of internal and external variables that lead to perceptions of volitional relevance, one thing is clear. These nurses chose to claim equal status within the health care setting and f e l t that they could contribute to patient autonomy. Their behavior, founded on Stage V and VI patterns of reasoning and sustained by personal and professional standards, was consistently self-affirmed when pressures within the social situation forbode of negative consequences. How, then, does the perception of volitional relevance relate to these facts? We can hypothesize that personal standards for performance were strong enough to overcome contingent pressures within the milieu. The values espoused by the nurse u t i l i z i n g Stage V or VI reasoning were valued both cognitively and affectively to such a degree that even an expectancy of adverse situational consequences could not deter the nurse. Concomitantly, i t is also possible that the ideal of cooperation and accountability, attained with i n i t i a l risk, was a goal worth pursuing—that the incentive to reach this level of functioning professionally provided a considerable motivating force. In other words, the immediate positive, situational consequence of dropping the matter or ignoring the problem was not strong enough to deter action aimed at a longer 170 term, higher l e v e l goal for patient and for s e l f . We cannot know whether these statements are f a c t s . However, such a. p o s i t i o n i s congruent with the s o c i a l perspective embodying Stage V and VI reasoning because the more integrated into the personal-professional personality structure and the more valued t h i s l e v e l of reasoning i s , the more l i k e l y an i n d i v i d u a l would be to plan for and focus on behavior that would promote harmony between thought and action, or, more s p e c i f i c a l l y , focus on behavior that could r e s i s t subtle or not so subtle pressures i n the m i l i e u . F i n a l l y , we cannot know for c e r t a i n from the data what the nurse's incentive or motivation for maintaining postconventional thought patterns when faced with multiple l o y a l t y c o n f l i c t i s . We can only speculate about the r e l a t i o n s h i p between (a) how relevant a nurse perceives h e r s e l f ; (b) the l e v e l of cognitive moral reasoning she i s capable of; and (c) the degree of environmental support. Each respondent who resolved the c o n f l i c t with Stage V or VI patterns of reasoning experienced i n t e r d i s c i p l i n a r y cooperation within the work s e t t i n g , perceived her contribution to be valued and, on a professional l e v e l , valued responsible and accountable behavior. Correspondingly, s t i p u l a t i o n s within the Code and those substantiated within the Standards of Care were upheld to a remarkable degree. Next, l e t us turn to the c e n t r a l features embodied i n multiple l o y a l t y c o n f l i c t as i t i s represented at the conventional l e v e l with perceptions of bounded relevance. By d e f i n i t i o n , the reasoning 171 associated with conventional th ink ing centers on sus ta in ing ru les and regu la t ions . When such ru les and regula t ions and t h e i r supporting p o l i c y statements are vague, inappropr i a te , i n e f f e c t i v e or even d i s regarded , nurses were faced wi th c o n f l i c t s that took on dilemmatic proport ions . Although each nurse , when faced wi th a dilemma, appeared capable of Stage IV or higher patterns of reasoning and seemed to genuinely des i re to maintain d i r e c t i v e s from the Code and to funct ion congruently with p r i n c i p l e s supporting standards of care , a c e r t a i n unwil l ingness to take a stand became evident . This response d id not threaten the l e g a l standard of care . I t d i d threaten the q u a l i t y of care because the r e s u l t i n g ambivalence regarding ac t ion and ambiguous nature of p r i o r i t y i n l o y a l t y l e f t the nurses unsure of t h e i r own r i g h t s . E t h i c a l l y they were i n a quandry. The percept ion of bounded relevance presented a problem because the foundations of the system and bureaucrat ic s t ructure were not designed or were not perceived to be designed to promote nurs ing r i g h t s or nurs ing a c c o u n t a b i l i t y . Thus, t h i s bounded status compromised both nurs ing ac t ion and pa t i ent autonomy. This compromise i s expressed i n f i v e themes. They are (a) r e l a t i o n s h i p versus r o l e r e s p o n s i b i l i t y ; (b) nurs ing r i g h t s versus p h y s i c i a n r i g h t s ; (c) nurs ing r i g h t s versus i n s t i t u t i o n a l r i g h t s ; (d) nurs ing r e s p o n s i b i l i t y and the r i g h t of the pa t i ent to d ie wi th d i g n i t y ; and (e) i n d i v i d u a l r i g h t s versus s o c i e t a l r e s p o n s i b i l i t y . Given that the nurses at th i s l e v e l were capable of conventional and postconventional thought and that they resolved the c o n f l i c t by 172 applying a lower q u a l i t y of conventional reasoning, what v a r i a b l e s inf luenced the r e s o l u t i o n process? In answer, one facet of th i s problem seems indisputable—nurses d id have a reasonable grasp of the concepts, both e t h i c a l and l e g a l , that u n d e r l i e nurs ing p r a c t i c e . And a number of nurses showed evidence of having a s u b s t a n t i a l knowledge base i n t h e i r area. Wi th in the environmental context they were w e l l aware of what was expected of them by others . This p a r t i c u l a r awareness proved to be a potent force cont r ibu t ing to the way i n which they organized the parameters of the c o n f l i c t . For example, defense avoidance t r a i t s emerged and nurses used bu f fe r ing or r a t i o n a l i z a t i o n i n order to cope wi th the dilemma. In shor t , t h e i r cogni t ive and a f f e c t i v e funct ioning was inf luenced by the s t r u c t u r a l and s o c i a l underpinnings w i t h i n the environment. Yet t h i s cons t ra int d i d not provide s u f f i c i e n t grounds to negate adequate care but q u a l i t y of care d id su f fe r . However, a l l nurses hoped that s t ructures and s o c i a l r e l a t i o n s h i p s could change for the b e t t e r , r e s u l t i n g i n r e c i p r o c a l changes i n nurs ing p r a c t i c e . Completing the n a r r a t i v e , l e t us now discuss the process of c o n f l i c t r e s o l u t i o n from the perspect ive of those who functioned under percept ions of imposed re levance . While capable of Stage IV or V patterns of reasoning these nurses resolved c o n f l i c t s us ing Stage I or II reasoning. Centra l to th i s conception i s the percept ion of i n e q u a l i t y compounded wi th the f e e l i n g that nurses funct ion as the means to the ends of others . Pass ive behavior was common as was 173 acquiescence to the demands of others which led to behavior highly incongruent with the nurse's own standards. Cognitive dissonance, an attempt to normalize inconstancies, arose as did the desire to avoid unpleasant situations, elude punitive consequences and rationalize reasons for or against behavior. Feelings of inadequacy and anxiety led nurses to perform or ignore factors that would contribute to the wellbeing of the patient and to the enhancement of their professional practice. They were governed by what Pennock and Chapman (1972) term dispositional coercion. In these cases people are faced with negative sanctions i f they do not perform as expected: "Individuals are treated," state Pennock and Chapman, "as things governed by causes rather than a person guided by reason" (p. 146). And with numbing regularity nurses who were capable of choosing a more positive approach permitted instances of unethical and unsafe treatment for their patients. However, decisions to not act in these cases remain decisions. The knowledge that egocentric self preservative values overcame values promoting nursing obligations to the patient led to the emergence of themes of resentment, anger, and revenge. Hence, the essential flaw or key determinant underlying the regression in patterns of reasoning appears, at least partly, to be due to the environmental authority structure and i t s powerful effect on the nurses' perceptions. Principled Determinants for Action Cognitive and affective determinants contributing to perceptions of relevance affect how obligations to the patient, family, physician, 174 employing agency, professional standards and personal ethical beliefs are constructed when conflict occurs. Table 1 represents a conceptual breakdown of the inductively derived variables, expressed in terms of principle and rule, which typify the central focus associated with decision making in multiple loyalty conflict situations. The principles refer to those fundamental assumptions grounding the cognitive-affective interaction for each dimension of perceived relevance. The rules signify regulating c r i t e r i a which exercise control over behavior (see Table 1). It i s these principles and rules with their respective moral cognitions and affective interconnections that reflect perceptions gained from the past. They contribute to perceptions of the present and thereby offer an explanation for the way in which patient autonomy is upheld. What is more, i t is the perceptions of relevance that determine the manner in which the code of ethics and standards of care are interpreted in nursing practice. Summary It can be seen that cognitive patterns of reasoning on a moral level are related to perceptions of relevance and their subsequent affective repercussions. The perceptions themselves are associated with principled determinants and rules for action resulting in varying modes of conflict resolution. As well, each mode of conflict resolution reflects behavioral outcomes which maintain varying degrees of patient autonomy because on a normative basis each nurse understood Table 1 Principled Determinants for Action Imposed Relevance - Preconventional Level P r i n c i p l e : 1. Blind obedience to rule i s the relevant factor i n decision making. 2. Obligations have an order of p r i o r i t y : f i r s t , obedience to overt and covert rules within the milieu; second, to s e l f protection; and t h i r d , to patient autonomy. Contributing Rules: 1. Nurses who take a professional stance are not supported. 2. Nurses do not interfere with physicians. 3. Nurses do not inform patientB of their right to quality care i f quality i s not maintained. 4. Nurses w i l l compromise their e t h i c a l stand. 5. Nurses w i l l avoid issues i n order to keep emotionally stable. 6. Nurses fear repercussions. 7. Nurses w i l l cope with their cognitive—affective c o n f l i c t . 8. Nurses w i l l avoid punishment. 9. Treatment i s to be given i f a treatable cause exists. 10. Treatment i s necessary at a l l cost. Bounded Relevance - Conventional Level P r i n c i p l e : Stage III 1. The need for relationship and right action i s equatable with relationship maintenance. Stage IV 2. There i s an unresolvable disparity between what nurses believe to be right and what they know to be necessary. Contributing Rules: Stage 111 1. When a patient i s inadequately informed a nurse does not interfere, 2. A nurse i s not l e g a l l y responsible for a patient's lack of knowledge. 3. Obligations to patients are based on relationship-promoting components only. Stage IV 4. Dependent nursing functions take precedent over independent and interdependent functions. 5. The medical or administrative value system overrides the nursing value system. 6. Patient status i s defined by other professionals. 7. Disease states take precedence over individual uniqueness. V o l i t i o n a l Relevance - Postconventional Level P r i n c i p l e : 1. The competent and informed individual (or appointed surrogate of the incompetent) has the right to choose treatment measures congruent with his or her value system as long as others are not harmed and s o c i e t a l resources u t i l i z e d i n a f a i r and just manner. 2. The registered nurse has the right to f u l f i l l l e g al and e t h i c a l duties and obligations as they are outlined in the ICN Code and Standards of Care. 3. The registered nurse has the right to and i s responsible for upholding her own standards and p r i n c i p l e s for action. Contributing Rules: 1. Individuals w i l l be treated i n a just and f a i r manner. 2. Legal and ethical rights of the patient w i l l be upheld. 3. Legal and ethical rights of the nurse w i l l be upheld. 4. Professional pride i s of great value. 5. Accountable nursing action i s a necessity. 6. Interdisciplinary cooperation i s to be encouraged. 7. Standards of care within the i n s t i t u t i o n are to be maintained. 8. Rational and objective decision making processes can be i n s t i t u t e d . 9. Nurses are independent f i r s t , then interdependent. 10. Nurses do not have a dependent function. and v a l u e d t h e c o n c e p t o f p a t i e n t au tonomy . H e n c e , e a c h n u r s e had t h e p o t e n t i a l f o r r e s o l v i n g m u l t i p l e l o y a l t y c o n f l i c t s f r o m w i t h i n a f r a m e w o r k t h a t a c k n o w l e d g e s t h e v a l u e o f p a t i e n t autonomy and r e c o g n i z e s t h e g u i d e l i n e s f r o m t h e Code and S t a n d a r d s . 177 Chapter Six: Summary, Conclusions, Implications and Recommendations Summary The depth and breadth and d i v e r s i t y of o b l i g a t i o n faced by the registered nurse i n the c l i n i c a l s e t t i n g r e s u l t s i n multiple l o y a l t y c o n f l i c t and c a l l s f o r more than excellent c l i n i c a l s k i l l s , more than competence i n the area of interpersonal r e l a t i o n s h i p s and communication; i t c a l l s f o r c r i t i c a l thinking based on a l e v e l of personal and pr o f e s s i o n a l i n t e g r i t y that many nurses aspire to yet few c o n s i s t e n t l y a t t a i n . This i n t e g r i t y i s founded on p r i n c i p l e d thinking and i s backed by perceptions of equality within the i n t e r d i s c i p l i n a r y health care s e t t i n g . Such a focus tends to promote nursing's independent function by ensuring accou n t a b i l i t y while at the same time enhancing the interdependent r o l e by increasing i n t e r d i s c i p l i n a r y cooperation. When th i s occurs, patient autonomy i s responsibly upheld. The purpose of t h i s study was to explore how patient autonomy was upheld i n c o n f l i c t s i t u a t i o n s . S p e c i f i c a l l y , the study was designed to explore the patterns of reasoning which registered nurses use to resolve multiple l o y a l t y c o n f l i c t s i n v o l v i n g patient autonomy and to compare these with the patterns of reasoning that depict a preferred or normative outcome. Exploring how c o n f l i c t s are resolved plus the reasoning which supports the c o n f l i c t r e s o l u t i o n and comparing t h i s reasoning with 178 a more objectively considered normative viewpoint requires a qualitative research approach. Grounded theory with i t s emphasis on comparative analysis of concepts derived from empirically based data and i t s requirement that theory must be substantively based proved appropriate. A method of intraprofessional referral was ut i l i z e d for selection of eleven registered nurses. Each respondent read a letter of introduction and signed a consent form prior to being interviewed. Six nurses had two, one and one-half hour interviews and the remaining five had one, two-hour interview. Six nurses graduated from diploma schools of nursing, four had their baccalaureate in nursing and one a master's degree in nursing. Of the eight nurses who worked in hospitals, four were staff nurses, two assistant head nurses, one a head nurse, and one an assistant director of nursing. Of the three nurses who worked in the community one represented long term care and the other two the prevention program. The number of respondents and the manner of selection serves to limit the generalizability of the findings; nevertheless, since aspects of the findings do substantiate concerns voiced by Davis and Arsokar (1978), Crisham (1980) , Ketefian (1981a, 1981b), and many other authors mentioned here, they can provide useful input for those who are committed to supporting nurses in their quest for professional standing. Findings are substantively grounded in the core concept of perceived relevance. The three dimensions of this concept, imposed relevance, bounded relevance, and volitional relevance, describe an 179 i n t e r r e l a t i o n s h i p between the cogni t ive and a f f e c t i v e domain, This i n t e r a c t i o n i s viewed i n a d u a l i s t i c fashion as the patterns of reasoning i n the ac tua l c o n f l i c t r e s o l u t i o n are compared with more ob jec t ive normative reasoning. The r e s u l t of these r e l a t i o n s h i p s led to the d e r i v a t i o n of themes w i t h i n each dimension. I t was found that the greater the d i s p a r i t y between the normative reasoning and the reasoning that supported the ac tua l outcome, the greater the dissonance experienced by the nurse . Themes of anger, resentment, and revenge based on perceptions of i n e q u a l i t y or imposed relevance depicted the greatest dissonance. Regression i n reasoning a b i l i t y and d e c i s i o n avoidance s t ra teg ie s occurred as nurses re treated us ing s e l f p ro tec t ive subordinate and passive behaviors . E t h i c a l and l e g a l standards of care were not maintained. As the d i s p a r i t y between preferred and ac tua l outcome lessened i n another set of c o n f l i c t s , nurses noted an awareness of l i m i t a t i o n s due to i m p l i c i t or e x p l i c i t ru le s and r e g u l a t i o n s . This dimension was termed bounded relevance because the i n s t i t u t i o n a l p o l i c i e s and procedures were perceived to not support pat ient autonomy and were geared to n u r s i n g ' s dependent r o l e . Themes d e p i c t i n g dilemma s i t u a t i o n s and much f r u s t r a t i o n arose i n f i v e areas. Dilemma r e s o l u t i o n often re su l ted i n a lowering of q u a l i t y care s ince nurses respected the system's per spec t ive . Nevertheless , bas ic minimal standards of care were maintained. On the other hand, when reasons supporting the preferred and performed ac t ion harmonized c o n s i s t e n t l y , 180 nurses perceived they had v o l i t i o n a l relevance of an equal r i g h t to p ro fe s s iona l p r a c t i c e . Funct ioning as equal members of the hea l th care team, t h i s group of nurses demanded high standards of care and used i n t e r n a l i z e d personal and pro fe s s iona l p r i n c i p l e s to guide t h e i r ac t ions . They experienced pr ide along with f ee l ings of r e s p o n s i b i l i t y and competence. Themes of i n t e r d i s c i p l i n a r y cooperation and pro fe s s iona l a c c o u n t a b i l i t y came f o r t h . Nevertheless , each group of nurses be l ieved i n pa t ient autonomy. Each nurse be l i eved that pat ients should, w i t h i n reason, c o n t r o l t h e i r own environment, s e lec t t h e i r own treatment from among s u i t a b l e options and c o n t r o l t h e i r own process of nontreatment. A l l nurses agreed that the pat ients have the r i g h t to be respected and to maintain t h e i r own i n d i v i d u a l i t y and i d e n t i t y as long as t h e i r choices are supported by f a i r and ju s t hea l th care p r a c t i c e s . Yet while a l l nurses shared t h i s view, when placed i n c o n f l i c t of l o y a l t y s i t u a t i o n s , only a few could p a r t i c i p a t e i n r e s o l v i n g the c o n f l i c t i n a manner that d id indeed uphold t h e i r view of pa t ient autonomy. Other nurses upheld pat ient autonomy to a degree that lowered the q u a l i t y of pat ient care whi le a few found that pa t ient autonomy was nonexis tent . Each group of nurses , fo l lowing a combination of cogn i t ive and a f f e c t i v e percept ions , functioned from w i t h i n a d i f f e r e n t framework of p r o p o s i t i o n s , p r i n c i p l e s , and r u l e s . C l e a r l y , only one set of nurses upheld d i r e c t i v e s from the ICN Code. These cons iderat ions led to the conclusions as l i s t e d . 181 Conclusions 1. In cases of m u l t i p l e l o y a l t y c o n f l i c t , i f a nurse i s capable of Stage IV or V reasoning and i f she perceives h e r s e l f to have imposed re levance , then the c o n f l i c t w i l l be resolved with Stage I or IT patterns of reasoning. Under these condi t ions the emerging themes of resentment, anger, and revenge grounded i n the a f f e c t i v e domain lead to symptoms of severe cogn i t ive dissonance and r e s u l t i n unsa t i s f ac tory pat ient care . At t h i s time two p r i n c i p l e s d i r e c t the nurse ' s a c t i o n : a. B l i n d obedience to r u l e i s the re levant fac tor i n d e c i s i o n making. b. Obl iga t ions have an order of p r i o r i t y ; f i r s t , obedience to overt and covert ru le s w i t h i n the m i l i e u ; second, to s e l f p r o t e c t i o n ; and t h i r d , to pa t ient autonomy. 2. In cases of m u l t i p l e l o y a l t y c o n f l i c t , i f a nurse i s capable of Stage TV, V, or VI reasoning and i f she perceives h e r s e l f to have bounded re levance , then the c o n f l i c t w i l l be resolved with Stage II I or TV patterns of reasoning. Under these condi t ions the emerging themes take on dilemmatic proport ions wi th losses noted i n the q u a l i t y of pat ient care . I f the nurse uses Stage I I I reasoning, a c t ion i s d i r e c t e d by a p r i n c i p l e s t a t ing that : a. The need for r e l a t i o n s h i p and r i g h t ac t ion i s equatable with r e l a t i o n s h i p maintenance. 182 I f Stage IV reasoning i s used, the fo l lowing p r i n c i p l e i s guiding a c t i o n : b . There i s an unresolvable d i s p a r i t y between what nurses be l i eve to be r i g h t and what they know to be necessary. 3. In cases of m u l t i p l e l o y a l t y c o n f l i c t , i f a nurse i s capable of Stage V or VI reasoning and i f she perceives h e r s e l f to have v o l i t i o n a l re levance , then the c o n f l i c t w i l l be resolved with Stage V or VI patterns of reasoning. Under these condi t ions the emerging themes of cooperation and a c c o u n t a b i l i t y show a balance of cogn i t ive and a f f e c t i v e c a p a b i l i t i e s such that nurs ing behavior leads to high q u a l i t y pat ient care . Three p r i n c i p l e s d i r e c t a c t i o n : a. The competent and informed i n d i v i d u a l (or appointed surrogate of the incompetent) has the r i g h t to choose treatment measures congruent with h i s or her value system as long as others are not harmed and s o c i e t a l resources u t i l i z e d i n a f a i r and jus t manner. b. The reg i s te red nurse has the r i g h t to f u l f i l l l e g a l and e t h i c a l dut ies and ob l i ga t ions as they are ou t l ined i n the ICN Code and Standards of Care. c. The reg i s te red nurse has the r i g h t to and i s respons ib le for upholding her own standards and p r i n c i p l e s for a c t i o n . Impl icat ions and Recommendations The f ind ings and conclusions have impl i ca t ions which r e s u l t i n recommendations for nurs ing educat ion, p r a c t i c e , admin i s t r a t ion , and research. 183 Nursing Education Given that not only nurse leaders but also the society in general i s demanding more accountable action from a l l health care professionals, i t is time nurses considered, both in the work place and in schools of nursing, the need for principled reasoning prior to action. This form of reasoning can occur within a framework of volitional relevance or one of bounded relevance when institutional philosophies, policies and procedures are designed to provide high quality professional contributions from a l l members of the health care team. Education in the Work Place Implications. Staff nurses, team leaders, head nurses, in fact, a l l levels of nursing administration have at one time experienced a multiple loyalty conflict situation and more than likely found themselves in a position somewhat similar to that of one of the three groups of nurses described in the study. With the legal community in the United States directing a sharper focus on institutional l i a b i l i t y (President's Commission for the Study of Ethical Problems in Medicine, 1983) and Fiesta (1983) suggesting that nurses are facing l i t i g a t i o n in increasing numbers, i t follows that nurses must learn how to contend with the problematic loyalty of conflict area. At the least, the nursing profession must take steps to ensure that decisions are not made based on perceptions of imposed relevance backed by anxiety and the need for self protection. Each time this occurs the nursing profession becomes more vulnerable. The potential threat of legal 184 s u i t e x i s t s . The dependent, submissive r o l e of the nurse i s r e i n f o r i n the m i l i e u . The philosophy and p o l i c i e s of the i n s t i t u t i o n may be ignored and as w e l l , i t i s pos s ib le that the admini s t ra t ive team up to and i n c l u d i n g the Board of D i r e c t o r or Board of Trustees are placed i n a p o s i t i o n of compromise. Since an informed i n d i v i d u a l i s more capable of consc ious ly seeking o b j e c t i v e s , s e l e c t i n g the most appropriate outcome and planning a method for a t t a i n i n g i t , i t fol lows that educative steps must be taken to correct the worse scenar ios . In a d d i t i o n , steps to provide s u i t a b l e in format ion , to support nurses who require encouragement and to acknowledge those who prove to be the strongest r o l e models are necessary. Recommendations. I t i s recommended that : 1. The nurs ing department promote l e g a l l y and e t h i c a l l y sound nurs ing p r a c t i c e by : a. i n c l u d i n g re levant m a t e r i a l i n the o r i e n t a t i o n program; b . u t i l i z i n g b i o e t h i c i s t s or nurse e t h i c i s t s to help design i n s e r v i c e programs and e th ic s committees; c. informing the h o s p i t a l adminis trator and Board of D i rec tor s or Trustees of the need for nurses to funct ion from w i t h i n a cooperat ive and accountable framework i f economically e f f i c i e n t , e f f e c t i v e and e t h i c a l l y v i a b l e pa t ient care i s to be achieved. 2. Plans to encourage an informed, ac t ive and respons ib le pa t i ent p a r t i c i p a t i o n be devised with input from each of the hea l th care profes s ions . 185 3. The professional association act as a resource centre providing continuous updating on how nurses can maintain professional ethical standards by having a liaison member within each health care institution or agency. Education in Schools of Nursing Implications. Nurses in c l i n i c a l practice are concerned with the manner in which they are resolving multiple loyalty conflicts. In fact several nurses remarked on how they wished they had been prepared to deal with these issues for only over time, coping by t r i a l and error, had some of them developed the a b i l i t y to take principled stands. It follows that schools of nursing have responsibilities in this area. Ethical content designed to develop cognitive and affective awareness of basic values is necessary. Such content can be designed so that i t encourages c r i t i c a l thinking s k i l l s and i n s t i l l s a more indepth internalization of the values held by the nursing profession. Recommendations: It is recommended that: 1. Nursing curriculums be analyzed and the quantity and quality of ethical content be identified and supplemented as necessary. 2. Student nurses be encouraged to be c r i t i c a l thinkers who have s k i l l s in assertiveness yet value accountable collaboration and cooperation. 186 Nursing P r a c t i c e The nursing act, standards of care and e t h i c a l codes focus on and attempt to provide guidance for nursing p r a c t i c e . Nursing actions, i f p r o f e s s i o n a l p r a c t i c e i s valued, should be congruent with the d i r e c t i v e s set f o r t h i n these three documents. In p a r t i c u l a r , the propositions, p r i n c i p l e s and rules derived from the theory of perceived relevance imply that i n t e l l g e n t . r e f l e c t i o n i n the decision making process in v o l v i n g patient autonomy when obligations are deemed i n c o n f l i c t i s inconsistent. Yet, as the respondents claimed, the c o n f l i c t s remain so obvious and so pervasive. This implies that there i s a need to have the issue addressed and strategies for r e s o l u t i o n developed. Implications and recommendations w i l l be viewed with respect to the ICN Code and the Standards of Care Document. ICN Code for Nurses Implications. Nurses are asked to respect l i f e , d i g n i t y , and the r i g h t s of the i n d i v i d u a l — a l l i n d i v i d u a l s . Because, as the dimension of v o l i t i o n a l relevance and postconventional reasoning implies, only when nurses respect themselves, have pride i n t h e i r accomplishments and function within a framework of personal and p r o f e s s i o n a l i n t e g r i t y can they t r u l y respect the r i g h t s and d i g n i t y of others. The following statements from the Code c l a r i f y t h i s : "the nurse when acting i n a p r o f e s s i o n a l capacity should at a l l times maintain standards of personal conduct which r e f l e c t c r e d i t 187 upon the profession"; plus, "the nurse sustains a cooperative relationship with co-workers in nursing and other fields"; and, "the nurse plays a major role in determining and implementing desirable standards of nursing practice and nursing education" (ICN, 1973). The findings of this study point to one way of achieving such goals. That i s , nurses who consistently maintained high personal and professional standards chose principles of justice and fairness to guide their conduct. This focus enabled them to u t i l i z e propositions, principles, and rules which brought a dual focus to multiple loyalty conflicts. Firs t , they took a professional dispositional stand and, secondly, they gathered the appropriate data, sought additional information, then formulated a solution for nursing in a manner that promoted patient autonomy. Legal sanctions and societal expectations were upheld. As a corollary, nurses who perceived they had either bounded relevance or imposed relevance were unable to successfully meet these standards. Resolution of various dilemmas resulted in a lowering of the quality of patient care and frustrations for the nurses. Retreats to self protective behavior by nurses resulted in failures to uphold either the code or standards of care creating severe cognitive dissonant repercussions for the nurses. It becomes logical then to recommend a re-endorsement of the statements in nursing's Code of Ethics. 188 Recommendations. It is recommended that: 1. Professional associations and nursing educators develop strategies to inform nurses about the role of the code of ethics by: a. Interpreting the meaning of the statements so that nurses can identify multiple loyalty conflict situations and can discern how congruent their actions are with values promulgated by the Code; b. Increasing the nurses' awareness of the types of cognitive and affective dissonance they may experience i f they f a i l to uphold the code of ethics; c. Assisting nurses to analyze the propositions, principles and rules associated with each dimension of perceived relevance so that they can evaluate their own nursing behaviors. Standards of Nursing Practice Implications. The CNA Standards for Nursing Practice (1980) states that "nurses value a ho l i s t i c view of [the individual] and regard [the individual] as a biopsychosocial being who has the capacity to set goals and make decisions and who has the right and responsibility to make informed choices congruent with [individual], beliefs, and values" (p. v). It also says that "nurses are committed to the development and implementation of standards for their own profession" (p. v). Findings in this study imply that nurses who 189 maintain t h i s commitment function with v o l i t i o n a l relevance and postconventional reasoning, that nurses who use conventional thought and perceive they have bounded relevance i n t h e i r p r a c t i c e are aware of t h i s philosophy yet are unable to f u l f i l l i t s demands, and that nurses, who view c o n f l i c t from a preconventional l e v e l and who contend they are unequal members of the health care team require considerable a d d i t i o n a l assistance i f they are to gain such commitment. Nevertheless, the majority of nurses were s i m i l a r i n one r e s p e c t — t h e y desired more support for nurses from within the nursing profession. They ask for standards of care that e f f e c t change i n the world of c l i n i c a l p r a c t i c e . This implies that the four standards of care are not functioning adequately as guides to nursing p r a c t i c e . Problems e x i s t i n implementation. Standard I states: Standard I Nursing p r a c t i c e requires that a conceptual model for nursing be the basis for the independent part of that p r a c t i c e . This standard combined with Standard II which sta t e s : Standard II Nursing p r a c t i c e requires the e f f e c t i v e use of the nursing process as the method for carrying out the independent, interdependent and dependent functions of nursing. lead to e f f e c t i v e nursing p r a c t i c e . Thus, the nursing process u t i l i z e d with a nursing model constitutes a w e l l organized and s c i e n t i f i c a l l y sound approach to nursing care. 190 Nursing interventions are directed to meeting the needs of the patient by using problem solving techniques combined with nursing knowledge and. s k i l l . Assessment and problem identification—as directed by the model—can be thoroughly documented thereby providing a rationale for the planning and implementation phase of the process. Accuracy and thoroughness in documentation provides the nurse with both legal and ethical c r i t e r i a with which to support nursing actions. Without this framework for practice, nursing documentation may contain meaningless description and destroy nursing credibility (Philpott, 1985, p. i i i ) . Indeed, as this study shows, nurses were unsure of how to u t i l i z e documentation effectively; perhaps, this is because they require a framework or model to direct nursing practice. As well, study findings had implications for Standard III which states: Standard III Nursing practice requires that the helping relationship be the nature of the client-nurse interaction. In particular, nurses functioning from the stance of imposed relevance were unable to provide congruent and consistent messages to the patients. The same nurses were unable to follow through with nursing support once patient participation had been el i c i t e d , plus, nurses, at times, found i t impossible to share nursing input with patients or to teach the patient how to set r e a l i s t i c goals and accept responsibility for his or her own wellness. Standard IV is also relevant: Standard IV Nursing practice requires nurses to f u l f i l l professional responsibilities in their independent, interdependent and dependent functions. 191 Professional responsibilities were consistently sustained by nurses assuming volitional relevance. They were upheld to a moderate degree when pressures within the milieu permitted by nurses who perceived they had bounded relevance and rarely upheld by nurses who functioned under the assumption of imposed relevance. Pressures within the milieu were perceived to be too threatening. Recommendations. It is recommended that: 1. The CNA in conjunction with the provincial registered nursing associations develop strategies for ensuring that standards of care are upheld in nursing practice. 2. Nursing administrators and hospital administrators work in cooperation to develop policies and procedures that support professional practice and thereby protect both the hospital and the nurses from threat of l i t i g a t i o n . 3. Nurses in c l i n i c a l practice become more aware of their legal and ethical responsibility to implement standards of care. 4. Nursing administrators reassess the need to promote nursing practice based on the nursing process directed by a nursing model. 5. Staff nurses and nursing administrators develop plans for selecting and implementing a nursing model. 6. Hospital administrators, physicians and nurses look at the economic and humane repercussions that follow when patients are treated as passive recipients of varying degrees of highly technical, extremely expensive, painful and invasive therapies that the patient either hasn't consented to or has requested to have discontinued. 7. Nursing administrators and nurses in practice seek ways to encourage patients and families to participate in patient care so that the h o l i s t i c view of an active and responsible individual i s maintained. Nursing Administration Multiple loyalty conflicts invariably reflect back to the Director of Nursing because conflicts i n obligation, over time, affect the environment of any institution or agency. And this environment can function as a support and encourage employees as a detrimental force and discourage them. At present, according to Dr. Helen Glass, the current controversies in health care (many of these in the realm of ethics) w i l l require the nurse administrator's role to become even more significant (CNA, 1983). In fact, Dr. Glass contends that nursing administrators w i l l be required to play a " v i t a l " role as they contribute to the direction of health care in the future. A position paper presenting standards and c r i t e r i a for nurse administrators was developed by the CNA in 1983. Each standard reflects back to the need for nurse administrators to be innovative leaders using advanced managerial s k i l l s . In particular, findings in this study imply that c r i t e r i a under Standards I to V and VIII be considered further. 193 Standards for Nurse Administrators  Implications: Standard I Nursing administration requires registered nurses with the education and experience to assume professional and corporate responsibilities within the organization. Criteria The nurse administrator, 3. possesses progressive nursing management experience; 4. understands the Acts and Regulations which affect nursing and health care; 6. strengthens professional self development through continuing education. Standard II Nursing administration represents the department of nursing i n , and for, the organization and contributes to the administration of the entire organization. Criteria The senior nurse administrator, 3. i s administratively responsible for a l l nursing personnel in the organization including other nurse administrators; Standard III Nursing administration provides a structure for the delivery of nursing care. Criteria The nurse administrator, 1. promotes the periodic review of the philosophy and objectives of the nursing department and standards of nursing care; 2. promotes the periodic review of policies and procedures to f a c i l i t a t e nursing care; 6. provides a committee structure which allows nursing staff to participate i n decision-making. 194 Standard IV Nursing administration provides for the selection and evaluation of human resources for the nursing department. Criteria The nurse administrator, 2. provides for an orientation program based on the assessed needs of the employee; 3. provides a staff development program; 4. provides an employee performance appraisal program. Standard V Nursing administration f a c i l i t a t e s the u t i l i z a t i o n of the nursing process in the delivery of nursing care. Criteria The nurse administrator, 1. implements a system for the delivery of nursing care to meet the individual needs of clients in the context of their families; 2. provides the necessary qualified nursing staff; 3. ensures that work is assigned on the basis of client needs, and s k i l l s of nursing personnel; 4. provides for the documentation of nursing care; 5. implements a quality assurance program. Standard VIII Nursing administration establishes an open communication network throughout the department of nursing. Criteria The nurse administrator, 1. defines and maintains clear lines of communication for the department of nursing; 2. disseminates appropriate information to nursing personnel; 4. provides opportunities for nursing staff to discuss professional concerns. Nursing administrators have a crucial role. For example, when Standard I, Criteria 3, 4, and 6 are addressed, fewer nurses feel obliged to perceive they must function from within a framework of imposed relevance. Substandard patient care w i l l not occur. When Standard II, Criteria 3, and Standard III, Criteria 1, 2, and 6 are followed, nurses should be able to function professionally at the level of bounded relevance because the Director of Nursing w i l l have provided for congruency between philosophy, objectives, and policy. Nursing input w i l l be required and guidelines from nursing codes and standards w i l l be explicitly evident. Inevitably, the principles and rules depicted in this study would change as professional responsibilities are set within a f a i r and just structure. Hence, policies derived to resolve conflicts would then meet the standards of each health care discipline and require patient participation. Findings also relate to certain c r i t e r i a under Standards IV, V, and VIII. Standard IV, Criteria 2, 3, and 4 ensures that nurses know what performance is expected and that they are given support and the necessary knowledge base. Standard V, i f demonstrated through the use of a nursing model, guarantees that nurses have a conceptual framework for practice. This promotes s k i l l in thorough documentation and brings in an increasing awareness of factors relevant to quality assurance. These two standards can be f u l f i l l e d i f Standard VIII, Criteria 1, 2, and 4 are maintained. Development of a thoroughly professional nursing department depends on the concerted efforts made to meet these standards. 196 When procedures to meet these c r i t e r i a were not developed, nurses in the study claim "there is no structured position for nurses" and "I don't believe anyone is representing the grass roots nurse anywhere." Subsequently, i t becomes much harder for nurses to perceive volitional relevance and, consequently, easier to use defense avoidance strategies and faulty decision making techniques. Thus, perceptions of imposed and bounded relevance lead to frustration and anger which is compounded by the recognition of poorer quality patient care. Recommendations. It is recommended that: 1. Nursing administrators as individuals and in groups examine the Position Paper on the Role of the Nurse Administrator in detail. 2. Standards and c r i t e r i a listed here combined with other standards deemed advisable be studied with the intent to provide ongoing education courses and workshops for nurse administrators. 3. Nurse administrators network more closely with each other and their staff nurses in order to identify and find ways of resolving conflict of loyalty problems in a manner that supports professionalism in nursing. 4. In conjunction with hospital administrators, the nurse administrators examine the interrelationship among economic reality, patient responsibility, and the health care professional's role. 5. Nursing administrators seek ways to promote interdisciplinary cooperation as policies which encourage informed, active and responsible patient input are devised. 197 Nursing Research Increasing attention has been given recently to nursing research aimed at improving nursing p r a c t i c e and resolving nursing p r a c t i c e problems within the c l i n i c a l s e t t i n g . I n s t i t u t i o n a l philosophies and goals, nursing knowledge, and the type of administrative support a l l r e f l e c t back on the q u a l i t y of patient care and the degree of pr o f e s s i o n a l behavior. Findings from t h i s study suggest that foundations for c o n f l i c t r e s o l u t i o n and l o y a l t y p r i o r i t i e s focused on the nurses' perceptions of relevance. Implications. Findings imply that when nurses are caught with c o n f l i c t i n g o bligations t h e i r l e v e l of cognitive a b i l i t y and a f f e c t i v e perception greatly influences how they contribute to the problem r e s o l u t i o n . Each dimension of perceived relevance led to c e r t a i n p r i n c i p l e s and rules for action which affected the ethics of the re s o l u t i o n . These rules and p r i n c i p l e s were at l e a s t p a r t l y formulated i n response to pressures i n the m i l i e u s i t u a t i o n . Supporting patient autonomy became a nursing p r a c t i c e problem: (a) some nurses suffered high l e v e l s of cognitive dissonance when t h e i r patient's autonomy was not upheld; (b) other nurses upheld t h e i r patient's autonomy as long as the i m p l i c i t and e x p l i c i t rules within the agency provided for i t ; and (c) a c e r t a i n percentage of nurses functioned autonomously supporting patient autonomy even when faced with negative forces within the m i l i e u . Consequently, these findings imply that the ICN Code i s only t r u l y upheld i n the nursing p r a c t i c e of t h i s l a t t e r group of nurses. 198 Recommendations. It is recommended that: 1. Further studies be conducted with a larger sample of registered nurses to determine the accuracy of the results presented here. 2. Studies be developed to point out more specific factors within the milieu situation that detract from nursing's support of patient autonomy. 3. Research on consumer perspectives of nurses would help nurses determine how to promote patient autonomy more effectively. 4. Studies in social economics be conducted to see i f health care costs are reduced when informed patients make their own decisions regarding foregoing l i f e sustaining treatment or highly invasive therapies. 199 References Arsokar, M. (1982, April). Are nurses' mind sets compatible with ethical practices. Topics in Cli n i c a l Nursing, k_ (1), 24-28, 30. Arsokar, M., & Davis, A. (1978). Ethical dilemmas and nursing practice (pp. 4, 35-37). New York: Appleton-Century-Crofts. Aune, B. (1979). Kant's theory of morals (p. 83). New Jersey: Princeton University Press. Beauchamp, T., & Childress, J. (1979). Principles in biomedical ethics (pp. 9-10). Oxford: Oxford University Press. Canadian Nurses Association. (1980, June). A definition of nursing practice: Standards for nursing practice. Ottawa: Author. Canadian Nurses Association. (1983, February). Position paper on the role of the nurse administrator and standards for nursing administration. Ottawa: Author. Cassel, E. (1983). What is the function of medicine. In Z. Gorovitz, R. Macklin, A. Jameton, & J. O'Connor (Eds.), Moral problems in medicine (p. 75). Englewood C l i f f s , NJ: Prentice Hall. Chaska, N. (1983). The nursing profession: A time to speak (p. 482). New York: McGraw H i l l . Chinn, P., & Jacobs, M. (1983). Theory and nursing (pp. 2-4, 20). Toronto: Mosby. Crisham, P. (1980, April). Measuring moral judgment in nursing dilemmas. Nursing Research, 108-110. Curtin, L. (1978). A proposed model for c r i t i c a l ethical analysis. Nursing Forum, 17 (1), 15. Davis, A. (1980). Ethical decision-making: Consideration for future ac t i v i t i e s . In Ethics in nursing practice and education (pp. 23-24). MS: American Nurses Association. Davis, A. (1982, February). Helping your staff address ethical dilemmas. Journal of Nursing Administration, 11 (12), 10. Davis, A. (1983). Ethics and nursing administration. In N. Chaska, The nursing profession: A time to speak (p. 652). New York: McGraw H i l l . Diers, D. (1979). Research in nursing practice (pp. 86-87, 100-110). New York: Lippincott. Duska, R., & Whelan, M. (1975). Moral development: A guide to Piaget and Kohlberg (pp. 43, 50). New York: Paulist Press. Dworkin, R. (1978). Taking rights seriously (p. 279). Cambridge, MA: Harvard University Press. Feffer, M. (1959). The cognitive implications of role taking behavior. Journal of Personality, 27, 152-168. Feffer, M. (1970). Developmental analysis of interpersonal behavior. Psychological Review, 77 (3), 205-214. Fenner, K. (1980). Ethics in law and nursing (p. 24). New York: Van Nostrand Reinhold. Festinger, L. (1962). A theory of cognitive dissonance (pp. 2, 3-10, 13, 16, 87, 183). California: Stanford University Press. 201 Fiesta, J. (1983). The law and l i a b i l i t y (pp. 13-14, 113). New York: John Wiley & Sons. Flaherty, J. (1981). Accountability i n the nursing profession. In M. Staum & D. Carsen (Eds.), Doctors, patients and society (p. 167). Waterloo: Wilfred Laurier University Press. Freedman, B. (1981). A prolegomenon to the allocation of responsibility. In M. Staum & D. Carsen (Eds.), Doctors, patients and society (p. 77). Waterloo: Wilfred Laurier University Press. Gilligan, C. (1982, April). New maps of development: New visions of maturity. American Journal of Orthopsychiatry, 52 (2), 207, 211. Gilligan, C. (1983). In a different voice (pp. 71, 167). Cambridge, MA: Harvard University Press. Glaser, B. (1978). Theoretical sensitivity (pp. 1-11, 38, 53, 55). M i l l Valley, CA: Sociology Press. Glaser, B., & Strauss, A. (1967). The discovery of grounded theory (pp. 24, 45, 50). New York: Aldine. Glass, H. (1983, February). Position paper on the role of the nurse administrator and standards for nursing administration. Ottawa: Canadian Nurses Association. Gortner, S. (1974, December). Scientific accountability i n nursing. Nursing Outlook, 22 (12), 767. Hersch, R. , Miller, J., & Fielding, G. (1980). Models of moral education (p. 119). New York: Longman. Hersch, R. , Paolitto, D., & Reimer, J. (1979). Promoting moral growth (pp. 23, 45-51, 58-64, 93-94). New York: Longman. International Council of Nurses. (1973). International Council of Nurses Code for Nurses [Adopted by the ICN Council of National Representatives, Mexico City in May 1973]. Janis, I. (1982). Counselling on personal decisions: Theory and research on short-term helping relationships (pp. 5, 51). New Haven: Yale University Press. Janis, I., & Mann, L. (1977). Decision making: A psychological analysis of conflict choice and commitment (p. 207). New York: Free Press. Kaplan, J. (1974). In search of policies for care of the aged. In L. Tancredi (Ed.), Ethics in health care (p. 300). Washington, DC: National Academy of Science. Ketefian, S. (1981a, March/April). C r i t i c a l thinking and educational preparation and development of moral judgment. Nursing Research, 30 (2), 102-103. Ketefian, S. (1981b, May/June). Moral reasoning and moral behavior. Nursing Research, 30 (3), 175. Kohlberg, L. (1981) . The meaning and measurement of moral development (pp. 1-7, 35-52). MA: Clark University Press. Langham, P. (1977). Open forum on teaching ethics. Nursing Forum, 16 (3)(4), 221-227. M i l l , J. (1977) . Utilitarianism, on liberty and considerations on representative government (pp. 7-16). London: J. M. Dent & Sons. (Original work published 1910) 203 Murchison, I., Nichols, S., & Hanson, R. (1978). Legal accountability in the nursing process (p. 148). St. Louis: Mosby. Nurses (Registered) Act. (1979). Victoria, BC: Queen's Printers. O'Rourke, K. (1983, March). Moral development considerations in nursing curricula. Journal of Nursing Education, 22 (3), 112. Paton, H. (1964). Groundwork of the metaphysics of morals (trans. Immanuel Kant) (p. 36). 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The Philosophical Review, XCII (4), 543-571. Storch, J. (1982). Patients' rights: Ethical and legal issues in health care. Toronto: McGraw-Hill-Ryerson. Sullivan, E. (1977). Kohlberg's structuralism: A c r i t i c a l appraisal (p. 18). Ontario Institute for Studies in Education. Taussig, M. (1980). Reification and the consciousness of the patient. Social Science in Medicine, 14B, 9. Veatch, R. (1976). Death, dying and the biological revolution (pp. 204, 248). New Haven: Yale University Press. Wojak, J. (1978). Muted consent (pp. 1, 113). Indiana: Purdue University. Zimilies, H. (1981). Cognitive-affective interaction. In E. Shapiro & E. Weber (Eds.), Cognitive and affective growth (p. 47). Hillsdale, NJ: Lawrence Erlbaum. 205 Appendix A Canadian Nurses A s s o c i a t i o n Standards for Nursing P r a c t i c e 206 Standards for Nursing P r a c t i c e These four standards are nece s s a r i ly interdependent and i n t e r r e l a t e d . Standard I Nursing p r a c t i c e requires that a conceptual model for nurs ing be the basis for the independent part of that p r a c t i c e . Standard II Nursing p r a c t i c e requires the e f f e c t i v e use of the nurs ing process as the method for car ry ing out the independent, interdependent and dependent functions of n u r s i n g . Standard I I I Nursing p r a c t i c e requires that the he lp ing r e l a t i o n s h i p be the nature of the c l i e n t - n u r s e i n t e r a c t i o n . Standard IV Nursing p r a c t i c e requires nurses to f u l f i l l p ro fe s s iona l r e s p o n s i b i l i t i e s i n t h e i r independent, interdependent and dependent funct ions . 207 Appendix B International Council of Nurses Code for Nurses 208 In te rna t iona l Counci l of Nurses Code for Nurses E t h i c a l Concepts Appl ied to Nursing 1973 The fundamental r e s p o n s i b i l i t y of the nurse i s f o u r f o l d : to promote h e a l t h , to prevent i l l n e s s , to res tore hea l th and to a l l e v i a t e s u f f e r i n g . The need for nurs ing i s u n i v e r s a l . Inherent i n nurs ing i s respect for l i f e , d i g n i t y and r i g h t s of man. I t i s u n r e s t r i c t e d by considerat ions of n a t i o n a l i t y , r ace , creed, co lour , age, sex, p o l i t i c s or s o c i a l s ta tus . Nurses render hea l th serv ices to the i n d i v i d u a l , the family and the community and coordinate t h e i r serv ices with those of r e l a ted groups. Nurses and People The nurse ' s primary r e s p o n s i b i l i t y i s to those people who require nurs ing care . The nurse , i n prov id ing care , promotes an environment i n which the va lues , customs and s p i r i t u a l b e l i e f s of the i n d i v i d u a l are respected. The nurse holds i n confidence personal information and uses judgement i n sharing t h i s in format ion . Nurses and P r a c t i c e The nurse c a r r i e s personal r e s p o n s i b i l i t y for nurs ing p rac t i ce and for maintaining competence by cont inua l l e a r n i n g . The nurse maintains the highest standards of nurs ing care poss ib le w i t h i n the r e a l i t y of a s p e c i f i c s i t u a t i o n . The nurse uses judgement i n r e l a t i o n to i n d i v i d u a l competence when accepting and de legat ing r e s p o n s i b i l i t i e s . The nurse when ac t ing i n a p ro fe s s iona l capaci ty should at a l l times mainta in standards of personal conduct which r e f l e c t c r e d i t upon the pro fe s s ion . Nurses and Society The nurse shares with other c i t i z e n s the r e s p o n s i b i l i t y for i n i t i a t i n g and supporting ac t ion to meet the hea l th and s o c i a l needs of the p u b l i c . 209 Nurses and Co-Workers The nurses sustains a cooperative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard the individual when his care i s endangered by a co-worker or any other person. Nurses and the Profession The nurse plays the major role in determining and implementing desirable standards of nursing practice and nursing education. The nurse is active in developing a core of professional knowledge. The nurse, acting through the professional organization, participates in establishing and maintaining equitable social and economic working conditions in nursing. Adopted by the ICN Council of National Representatives, Mexico City in May 1973. Reprinted with the permission of the International Council of Nurses. Appendix C Letter of Introduction Appendix D Consent Form 213 Consent Form I have read the l e t t e r of i n t r o d u c t i o n concerning th i s study and understand i t s contents . I may refuse to answer any question I am asked or may withdraw from the study at any time. I consent to p a r t i c i p a t e and w i l l r e t a i n a copy of th i s consent form. Date: Signature of Respondent: Signature of Researcher: 

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