Applying learning theory to an ethical nursing dilemma

Teaching Theories and an Ethical Nursing Situation

The purpose of this paper is to apply a learning theory to an actual educational case study and scenario. The situation must be seen from the point-of-view of the nursing student scenario. The situation must be challenging to handle. This includes being able to identify events and critical indicators of the scenario that made the case challenging to the student. These indicators may include: a student's developmental state, education level, socioeconomic standing, cultural status or any personal, family factors that may influence the situation.

Literature suggests that these indicators apply in situations of an ethical nature and the challenge remains to make the right moral decision. Nurses are faced with moral and ethical issues every day especially when it comes to building a relationship of trust with the patient. Research also suggests that the indicators above influence one's ability to make the correct choices as different views on truth telling within the medical community exist. Still due to the prevalence of "lawsuit happy" society, slowly an ethical framework and protocol is being adopted world wide when it comes to ethical issues like truth telling. Ethics can be challenging for a nurse when faced with coworkers and other associates who may have a different set of values and the nerve to deviate from protocol and hospital policy. The issue meant to be explored from the student's point-of-view is the influence of family on patient care and the patient's right know their condition and course of treatment for that condition. The scenario will be described in greater detail in paragraphs below. This paper is also meant to explore the events and indictors that the student may be influenced by if such a scenario should present itself in their career. How will they react? Has their training given them the framework from which to treat the patient while dealing with a family's influence on treatment. This paper will also present a theory and model from which one can guide the process of intervention. Within in this theory, one can examine applicable issues involved with the scenario and offer the student feedback. For the purpose of teaching nursing skills, it is important to look at the framework in which the profession is built and look at evidence-based nursing as a framework. This will allow one to explore theories presented by Bigge and Shermis that behavior influences outcomes. This allows the paper to take the scenario one step further to describe how a more experienced nursing student would intervene in the scenario. This will require further analysis of existing theoretical tenets and the critical indicators that may affect this student's intervention plan.

Case Study: A Nurse's Dilemma, Challenging Scenario

From the case study proposed by Joan Callahan (1988), imagine now that you are a nurse on a medical/surgical floor in a large private hospital (p. 4). A woman is admitted on a Sunday for a series of medical tests you are assigned as her primary nurse. The testing begins on Monday and you are off for the next few days. You return to work the following Saturday and resume your duties as the woman's primary nurse. When you arrive on the floor, you go over her chart and find that the tests have revealed that she has chronic lymphocytic leukemia and is being transfused in an attempt to put the disease into remission. As you approach her that morning she greets you happily and asks you if you know when she will be able to return to work given her diagnosis you are a bit puzzled by her exuberance and you judiciously reply that you have not seen her physician since her return to work but that you will talk with the physician about her d/c from the hospital

On your way back to the nurses' station, one of the woman's two daughters approaches you and urges you to assure her mother that there is no reason for concern. Her daughter tells you her mother has just been through a painful divorce and that she and her sister had decided her mother should not be burdened wit the news that she has a terminal illness. You discuss the whole situation with your head nurse. She tells you to talk with the woman's physician who is also the new director of the hospital's medical service. You avoid going to the woman's room until the physician arrives on the floor. When she arrives you tell her about the woman's request for information regarding her discharge and about your conversation with the daughter. The physician informs you that the woman has been told simply that she has refractory anemia (which in fact is a result of leukemia) and has not been told the true nature of her illness in order to spare her unnecessary anxiety. You protest that the woman does not seem mentally unsound in any way and therefore she has a right to know about her diagnosis and prognosis. Still the doctor interrupts you and says that further disclosure on your part would have to be considered inconsistent with the best medical care of this woman. You are deeply troubled and return to your head nurse who is sympathetic but advises you to follow the physician's suggestions.

Teaching Theories and Nursing

It was Nightingale that recognized the potential of combining sound logical reflection and empirical research in the development of scientific knowledge that lead to evidence-based practices of today. She saw the need to only classify one's illness by the best possible available knowledge but to also collect patient information in the form of survey. Nightingale's work was also groundbreaking as it was the first to integrate such ideas into one method. She understood how factors such as housing and nutrition could have a direct influence on the patient's health and prognosis (McDonald, 2001, p. 68). Still many researchers to come would look at her work as primitive, inconclusive and one-sided. They would see how such details act as an extension of evidence and the attention paid to details as research of evidence (McDonald, 2001, p. 68). Many academics would argue that Nightingale served her purpose to offer a foundation for modern nursing but did not invent evidence-based nursing. Is it possible that such a foundation could grow into something broader to encompass modern research?

Many researchers argue the credit Florence Nightingale is given as the founder of modern nursing, evidence-based nursing and care. Many researchers argue that the framework in which evidence-based care is principled on did not exist prior to the 1960s and that the Nightingale method of questioning and survey also died with the matron. Simply, this is the basis of any academic dilemma, which side is right and which side is wrong? Literature suggests many points-of-view when it comes to evidence-based nursing and its evolution into a primary method of treatment in modern medicine. It is method not only used by nurses but also doctors and other medical professionals. Part of the issue and what raises evidence-based nursing and care as debated issue is the fact that it can be difficult to effectively label evidence. Depending on the professional consulted, each may have a different insight into what defines evidence and how it is collected. George Castledine believes evidence-based nursing did not start until the 1960s. Castledine (1997) writes, "research or evidence can be used in more than one way and the sue of research as a specific form of knowledge involved political, organizational, socioeconomic and attitudinal components" (p. 1).

This only opens the issue to more analysis as one contemplates the factors that make up evidence-based nursing. Is it fair for evidence to be based on guesswork? He also cites, "the problem with evidence-based approach is that it may become obsessed with the academic basis of nursing and fail to acknowledge the art of the subject" (p. 1). This creates the concept that nurses need to not only implement a fact-finding approach not just based on medical knowledge but also on humanity. Castledine (1997) believes, in order for such a method to work there must be a healthy balance (p. 1). Still this argument is just one point-of-view and does not create a framework or description of modern nursing. It, however, is advise to the nursing student in how to formulate their own approach. David Sackett, et al. (1996) understand the historical basis of such a method but are concerned with the power it presents to nurses. There is the concern that the practice while innovative may be out dated and only used to cut administrative costs to the health care system. Sackett, et al. (1996) write:

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systemic research. (p. 71)

While clear and distinct, this definition seems conservative in nature and devoid of creative, critical thinking. There is also the concern in modern medicine that when faced with a scenario of treating a patient, two outcomes will result. One, nurses will rely too heavily on their gut instinct and passion for care or two, nurses will look to clinical explanations and medical knowledge more than actual symptoms and listening to the patient's needs. This leads to problems regarding quality of care, customer service and administrative cost benefits. In this day and age of managed health care, evidence may not play a greater role; the reality of treatment efficiently becomes the main issue for hospitals. This can lead to mistakes, lack of compassion and possibly liability. With this in mind not only is it important for nurses to use all skills available it is also important to examine the impact that evidence-based medicine has on nursing practices and the welfare of the profession.

Possible Interventions

Once the nursing student has observed the situation and gathered evidence to support his or her continuing treatment, it is important that they must follow hospital policy of a patient's bill of rights. Dr. Drane (2002) writes, "the loss of reputation for honesty in medical practice means the end of medicine as a profession" (p. 1). Clearly there is great concern for current behaviors to deviate from ethical codes of conduct and how such behaviors are influenced by outside agents. As a part of invention, one must also take into account how a person's behavior predicts future behavior. As voiced earlier, this may stem from a cultural background where it is seen that not telling the truth is acceptable behavior. Leaving a situation without taking action or voicing any information can have the same impact and cause harm but may still be seen as acceptable by that person (Drane, 2002, p. 2). As a nurse, it is part of the job responsibilities to convey the correct information to the patient about their diagnosis and treatment. This continues to challenge the nursing student and educators as they search for new ways to intervene.

Possible ways to assist the student experiencing this situation is to provide the correct advise using evidence-based nursing as a tool for analysis but also referring back to the hospital's code of ethics. With regard to truth telling, clinical judgement is always required because in some cases the patient refuses to hear the truth or only wants to hear some truths. If the patient makes such a request, this too can cause harm but at this time the family does not have a say. The nurse has three options in this scenario: (1) go along with the doctor's plan of withholding information, (2) tell the patient the truth and (3) be assigned to another case. Assigning the nurse away from the situation may solve the problem for the short-term as then their individual background cannot influence the scenario but it is a situation ever nurse will be faced with. As part of the intervention, a teacher or more experienced nurse can share with the student stories of their own experiences dealing with ethics, truth telling and over protective families. This gives the student nurse a foundation from which to formulate their own way of expressing the information, it also gives them a feeling of not being alone in difficult situations. Thew best case solution would be to allow the student to tell the truth to the patient, this will make the next experience easier having learned from the first one.

Conclusion

The purpose of this paper was to apply a learning theory to an actual educational case study and scenario. The situation was to be seen from the point-of-view of the nursing student scenario. The situation was presented as challenge in need of careful consideration. This included being able to identify events and critical indicators of the scenario that made the case challenging to the student. These indicators included: a student's developmental state, education level, socioeconomic standing, cultural status or any personal, family factors that influenced the situation.

Literature suggested that these indicators apply in situations of an ethical nature and the challenge remains to make the right moral decision. Nurses are faced with moral and ethical issues every day especially when it comes to building a relationship of trust with the patient. Research also suggested that the indicators above influence one's ability to make the correct choices as different views on truth telling within the medical community exist. The issue was meant to be explored from the student point-of-view is the influence of family on patient care and the patient's right know their condition and course of treatment for that condition. The scenario was described in greater detail in paragraphs above. This paper was also meant to explore the events and indictors that the student may be influenced by if such a scenario should present itself in their career. This paper presented a theory and model from which one could guide the process of intervention. Within in this theory, one could examine applicable issues involved with the scenario and offer the student feedback. This allowed the paper to take the scenario one step further to describe how a more experienced nursing student would intervene in the scenario. This required further analysis of existing theoretical tenets and the critical indicators that affected this student's intervention plan.