Volume 3, Issue 11 - January 2001

Ethical Awareness for Community Care Nurses

"Do you mean to tell me that nurses who work in the community have ethical issues in their practice?" asked my surprised nursing colleague.

This colleague had had many years of clinical experience in an intensive care setting and could not imagine what ethical issues nurses working in the community could possibly face. Several community-based nurses have also told me that they have not had an ethical issue in their many years of practice (MacPhail, 1996). These nurses' words have become a kind of touchstone for my thinking about the idea of ethical awareness or sensitivity.

These conversations with nursing colleagues signal the need to actively cultivate reflection on and awareness of the ethical issues in the community, in both health care education and practice. The delivery of health care is moving into the community at a rapid pace. Ethical issues, I believe, present differently in the community than they do in institutional care, requiring us to raise awareness around these particular issues. How will we become sensitive to ethical conflicts if we continue to discuss ethics in nursing using clinical examples from an acute care model?

What is Ethical Awareness?

Ethical awareness or moral sensitivity in practice is the ability to recognize an ethical tension, understand the patient's situation as being vulnerable and appreciate the ethical implications of the outcomes of decisions made on behalf of the individual (Lützén, 1993, cited in Lützén, Johansson, & Nordström, 2000). My colleagues mentioned above seem not to be recognizing ethical issues or conflicts inherent in all nursing practice (Levine, 1977).

Raising our ethical awareness does not occur in a vacuum-it occurs through sharing our experiences from practice. It requires both reflection and dialogue. Hearing another practitioner's view of a situation and what the other sees as the ethical issues can be both instructive and enlightening. Many issues may be tangled into one single story about ethical conflict, so it is often advantageous to have more than one person's help to untangle them.

All of the community nurses that I interviewed for my research indicated that they had experienced ethical issues in their practice (MacPhail, 1996). Yet in hearing some of the stories of their conflicts, it was not immediately clear what the ethical issues were. Some of their stories were about issues such as:

• How do you support a mother that you suspect of being drug dependent and who would like to breast feed her infant, which might be the best way to foster a positive mother-infant relationship, but which may not healthy for the infant?

• How do you support client autonomy when you are being refused entry into a home by the elderly client who is acutely ill?

• How do you respond when your client asks you to adopt her unborn infant and you are unable to become pregnant with your own child?

• How do you continue to care for a patient in an unsafe environment when you are concerned about your own safety?

The issues were there for these ethically sensitive nurses.

Ethical issues that arise in community practice may be similar to those in other settings. However, they are made more complex because of the influence of the setting (isolation from nursing colleagues, role ambiguity, the shift in control, family dynamics, and the increased need to collaborate). Even something as simple as access to patients in the community cannot be assumed in the same way it can be in acute care.

In hospital it's understood that the patient is there for treatment (consent to treatment is, for the majority of patients, implied by the patient being there). In acute care, control over where, when, and how care takes place is assumed by the nurse and other health care providers. In community care, the health care provider may have to win the client's trust just to gain entry to the home, and then remains a "guest" in the home. If the client is "difficult", the nurse may have to tread very carefully in order to maintain access.

This example of differing access has implications for issues of consent. As Stulginski (1993, p.405) points out about the community: "The nurse may be the deliverer of care, but the setting is borrowed and every interaction is negotiated with respect to this." The community nursing literature is replete with articles about "gaining and maintaining access"; however, rarely is the ethical dimension of "gaining access to clients" talked about. What I am suggesting is that consent to enter a patient's home and consent to treat the patient may not be the same thing. And this is just one example of the differing kind of issue that nurses in the community face.

Open and Frequent Discussion

After all is said and done what am I advocating? I am advocating that in order for us to be ethically reflective in community practice, we need open and frequent discussion of the ethical dimension of our practice. Regular opportunities to discuss ethical issues in practice would raise ethical awareness as well as provide an opportunity to discuss solutions. They may also serve to potentially prevent some ethical issues from arising.

The majority of the nurses I interviewed spoke of the lack of an organized forum for discussion of the ethical issues in their practice (MacPhail, 1996). This suggests an obvious need for a space where issues that nurses have deemed to be ethical can be validated and recognized as such. It is important that we continue to read in the area of ethics, although it is my experience that discussing stories about ethical issues in practice can yield the most dramatic insights.

The challenge continues to be how to foster such discussion in a climate of critical health care provider shortage. How can regular discussions about ethics occur in this current atmosphere of scarcity? Where is the room/time for raising ethical awareness when there is not enough staff to do the physical work? When does reflection on our practice take place? What would it look like to consciously work at raising our ethical awareness?

The answers to these questions are as varied as the regions of the province. For some the answer might be to dedicate time in regularly held staff meetings for discussion of the ethical issues of the moment. For others it might be that inservice time should be dedicated to ethics. Some nurses might choose to form an independent ethics interest group with discussions regularly facilitated by an ethics expert. Case conferences or nursing ethics rounds might specifically target difficult cases. Providing practitioners with the opportunity to talk with ethicists during rounds or case conferences has also been found to increase sensitivity to ethical issues (Lo & Schroeder, 1981).

Some strategies aimed at raising awareness might occur in collaboration with nurses' employing institutions and involve regularly scheduled meeting times so as not to add to the nurses' already full schedule. Others might be pursued by individual nurses coming together during non-work time for a common professional interest. No matter the context, Davis (1988) recommends that all strategies be grounded in clinical practice and hold one thing in common. That is, that there be a safe and supportive forum to share their experiences with other nurses.

Concluding Thoughts

Nurses have ethical issues in their practice every day by virtue of the fact that they work with people (Levine, 1977). Rodney (1988) and others remind us that not to be aware of or not to address the ethical issues that nurses face in practice leads to burnout and nurses leaving the profession. In this climate of critical nursing shortage, can we afford not to make the time to discuss our ethical issues from practice?

References:

Davis, A. (1988). Ethical dilemmas in nursing: A survey. The Canadian Nurse, 84(9), 56, 58.

Levine, M. (1977). Nursing ethics and the ethical nurse. American Journal of Nursing, 77(5), 845-849.

Lo, B. & Schroeder, S. (1981). Frequency of ethical dilemmas in medical inpatient service. Archives of Internal Medicine, 141, 1062-1064.

Lützén, K., Johansson, A., & Nordström, G. (2000). Moral sensitivity: Some differences between nurses and physicians. Nursing Ethics,7(6), 520- 530.

MacPhail, S. (1996). Ethical issues in community nursing. Unpublished master's thesis, University of Alberta, Edmonton.

Rodney, P. (1988). Moral distress in critical care nursing. Canadian Critical Care Nursing Journal, 5(2), 9-11.

Stulginski, M. M. (1993). Nurses' home health experience Part I: The practice setting. Nursing & Health Care, 14(8), 402-407.

Announcements

• PHEN is looking for a volunteer to moderate the Network's email listserv. The primary function of this role will be to facilitate discussion between members on the listserv by contributing regular postings to the mailing list, and possibly suggesting questions and comment for discussion. If you are interested in taling this on, please e-mail Colette Mooney at info@phen.ab.ca.

• Members of the Network should have received a membership renewal form for continuing their formal participation with PHEN. In order to avoid any lapse in your subscription to In Touch and to ensure you continue to receive the many benefits of being a PHEN member, please renew your membership at your earliest convenience! For more information, please call PHEN's Northern Alberta office.

• The Tenth Annual Ethics Conference sponsored by the College of Physicians and Surgeons of British Columbia and the British Columbia Medical Association will be held from March 29-31 at the Radisson President Hotel and Suites, Richmond, BC. The conference is entitled Ethics 2001: Challenges of the New Century. For further information please call Mary Lou Harrigan (604) 266-3572 or check out the conference website at www.cpsbc.bc.ca.

• The planning for PHEN's annual conference and general meeting is well underway. This year, the conference will be held in Red Deer on May 25, 2001. The title for the conference is Seeking Equity in a World of Difference. Stay tuned for more information!

Bioethics Week Activities

The PHEN staff is pleased to report that there is much excitement brewing around the province about the upcoming inaugural Bioethics Week. We would like to encourage all those who have planned programs for the week to register the details of these activities with the Network. The details of your activity will then be posted on the Network's website and will be circulated in any press releases PHEN distributes in your area. Help us help you advertise your event!

For those individuals interested in finding out what's going on in the province around Bioethics week, please check out www.phen.ab.ca.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.