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CURRENT CONTROVERSIES IN CRITICAL CARE |
To industry employees faced with outsourcing and downsizing, as well as to young men and women embarking on their first professional commitment, nursing is beginning to look like a secure and worthwhile career. In this climate, many people who previously may not have considered the nursing profession are now finding it a way to connect with people in need and to improve life and health in a world in which caring practices have been devalued. People also choose nursing because they are interested in the secondary goods of the job: security, shift flexibility, a limited workday, and a relatively high salary. The current trends toward higher salaries, higher nurse-patient ratios, and streamlining the path to RN licensure to ease the nursing shortage are making the nursing profession more attractive. The influx of people with various reasons for entering the nursing profession creates a challenge for professional nurses in critical care as well as in other areas of healthcare. The work of imparting professional values and instilling integrity in students and new nurses, some of whom are primarily interested in a secure, well-paying job, falls heavily on nurse educators and preceptors in new graduate- training programs.
In an important book on professionalism and integrity titled Work and Integrity: The Crisis and Promise of Professionalism in America, Sullivan1 describes nursing as a profession of civic responsibility that is entrusted with the confidence of a community. Sullivan is trying to bring back to professional practice a discussion of and commitment to the values or goods that are internal to the practice.2 What are the values that form the ground on which critical care nursing practice stands? What values are we promoting in our nursing students and new graduates and how are we promoting these values? I think these are the basic questions for nurse educators in academic and clinical settings. Inspired by Sullivan, I want to begin a discussion of values and ethical comportment—the most important area of emphasis for nursing education—focusing on the training of new graduate nurses in critical care.
Overemphasis on Analytic, Procedural, and Technical Aspects
The critical care environment is thick with technology and complex pathophysiologic phenomena. A new graduate nurse who is beginning practice in critical care will be attentive to the tasks and procedures as is the nature of a beginner.3 As Benner3 has described, the beginner wants to know how the technology works, how to handle the equipment, and is intently focused on getting tasks done on time. Equally compelling to the beginner is the sight of pathophysiology unfolding in real life—that the patient’s condition matches the textbook descriptions. It is important that the preceptor understand and acknowledge the beginner’s skill level and support his or her need to master the technology and tasks. It is also important for the preceptor to bear in mind that focusing only on technology, technical skills, and the application of pathophysiologic theory is not enough to properly introduce the beginner to the practice and is not enough to sustain the professional practice of the next generation of nurses.
A primary and sometimes exclusive focus on the development of technical skills lends itself to a procedural approach to education. In choosing how to structure an introduction to professional nursing in a critical care unit, nurse educators often emphasize procedure; success is achieved when the student or orientee is able to choose the right set of steps, execute the steps in the correct order, and complete the hands-on skills involved in a timely fashion and without error. For example, a new nurse is said to be successful when he or she follows the proper steps to obtain a blood sample for arterial blood gas analysis, including filling out the paperwork and delivering the sample to the lab. Once the beginner demonstrates a mastery of technical skills and tasks, his or her initiation to the practice is thought to be complete.
Critical care nurses rely on a procedural approach when teaching beginners because it is difficult to articulate and convey the substantive values of the practice and even more difficult to evaluate ethical comportment in orientees. Even in bioethics, the trend is toward procedure rather than substance. If a new graduate orientation program contains content related to ethics, instruction often addresses quandaries or dilemmas and defines success as demonstration of the ability to apply a rational procedure to an ethical dilemma and arrive at a justifiable decision. The underlying concerns and values of ethical practice may not be part of the discussion except as abstractions of the procedural model. For example, autonomy, nonmaleficence, and beneficence might be included in the discussion as commonly understood theoretical constructs but not as clear and specific articulations of concerns. A procedural approach is useful and sometimes necessary when a person is faced with a quandary or dilemma. However, this approach is not as useful in the formation of the moral character of the professional, a necessary step for the theoretical constructs used in ethical decision-making procedures to have any meaning and for the technical skills to have any compelling purpose. Thus, the formation of moral character in nursing forms the foundation for practice.
Shifting Emphasis to Ethical Comportment
Sullivan1 describes 3 areas of apprenticeship in learning professional practice: a thinking or cognitive apprenticeship, a hands-on skill-based apprenticeship, and an apprenticeship in ethical comportment. It is important that nurse educators, including preceptors in both academic and clinical settings, pay attention to all 3 of these areas of professional development. But, as Sullivan points out, "The overall context must be a formative one that can encourage students toward entering and understanding the meaning and purposes of the particular professional community."1 The meaning and purpose speak to what is at stake in the practice of nursing, to what is demanded of the practitioner, and to what values form the practice. In discussing nursing practice in particular, Sullivan emphasizes the importance of trust.
...the increasing importance of establishing trust between professional and patient shows that identification and formation of skillful ethical comportment must be the organizer of competence and inspiration of expert work.... Therefore, the goal of professional education cannot be analytic knowledge alone (or perhaps even predominantly). Neither can it be analytic knowledge plus skillful performance. Rather, the goal has to be holistic: to advance students toward genuine expertise as practitioners who can enact the profession’s highest level of skill in the service of its defining meanings.1(pp253,254)
To accomplish the formation of skillful ethical comportment, Sullivan describes a shift in the emphasis of professional nursing from technical knowledge and tasks to what is at stake. This shift exposes the values and concerns of nurses and gives the student or new graduate nurse a point of access to the practice of patient care that situates her or him in a trusting relationship with other individuals and with a community. From this situatedness arises a commitment to community service and professional ethical comportment or a way of being in relation to others that forms the background necessary for the development of all other professional skills beyond task mastery. Once the nurse’s ethical comportment is situated in a community of practititioners and in relation to advocating and caring for the patient’s best interests, the importance of such internal goods establishes the new nurses’ civic professionalism.3,4 This situatedness in a good practice community will give the new nurse ideas about what to pay attention to, what to be concerned about, and what skills and techniques to draw on, and will influence all aspects of his or her practice.3,4
Internal goods define a practice. These are the rewards that can be realized only by honest engagement in the work and are values that both constitute and are constituted by the practice. As such, they matter only if professionals—critical care nurses—engage in the practice as if they matter. It is important that new nurses be taught procedural steps, technical skills, and theoretical knowledge. But it is also important to actively teach new nurses what to care about regarding procedures, skills, and knowledge—the defining meanings of nursing practice. Teaching appropriate concerns can then transition to appropriate responses to what a patient needs. For example, what is at stake in the simple and routine procedure of drawing a blood sample for arterial blood gas analysis? Is this a joyful task that is likely to indicate the patient’s readiness to be successfully extubated so that he can finally talk to his family? Or is this a tense task that may confirm the need for intubation in a patient who is ambivalent about her wishes regarding treatment of her chronic lung disease? To feel the weight of these significant possibilities is to be engaged in caring practice and to begin to cultivate the comportment, clinical judgment, and responsiveness of a professional nurse that is necessary to avert clinical emergencies and ethical dilemmas.3
The transition from focusing on technical skills to responding to the patient’s needs recently was demonstrated for me by a beginning nursing student, Minnie Wood, who was in a clinical rotation associated with her advanced acute care class. She was responsible for the care of patients on a general surgical unit and tells the following story about placing a nasogastric (NG) tube.
I was assigned to Mrs R. She was diagnosed with a small bowel obstruction secondary to pancreatic cancer. During report they said that Mrs R had been overwhelmed by nausea throughout the previous night and that she needed to have an NG tube placed but that she was refusing it. My first thought was, "Thank God she’s refusing it," because I knew that it would be my responsibility to insert it.
Since I started nursing school, I’ve been completely terrified of NG tubes and the whole idea of inserting them. I remember looking through our nursing skills book my first quarter and thinking that having such a big tube put through your nose down to your stomach seemed like one of the most terrible things I could possibly imagine, never mind actually doing it to another human being.
I sat in report that morning hoping that I was off the hook because Mrs R didn’t want an NG tube anyway. As soon as report was over, I checked in with the staff nurse I was working with that day. I said, "So it sounds like Mrs R is pretty nauseous and miserable but she’s refusing the NG tube." "That’s right," my nurse said, "So you better get in there and convince her that she really needs it." I knew she was right, but I was completely dreading the whole experience.
I was already pretty familiar with Mrs R’s history and condition because I did lots of research the night before. When I walked in the room, Mrs R could barely open her eyes. She was completely overcome with nausea and was hesitant to even move. Her abdomen was really distended. Suddenly, here was this woman that I was taking care of who really needed some relief from this tremendous discomfort. I sat down and talked to Mrs R about the NG tube and why she didn’t want it. She was scared, of course, and wondered if it was necessary. I explained how the procedure would work, that I would do it myself with the supervision of the staff nurse and that once we began to suction out all the fluid that was building up in her stomach that she would start to feel some relief from the nausea. She agreed to go ahead with the procedure. Putting the NG tube in wasn’t even that remarkable. It happened just like in the nursing skills books. We connected the NG tube to suction and in the first hour drained 700 mL from Mrs R’s stomach. About 1450 mL total after 8 hours.
That whole day was a real turning point for me. Before that, I was completely focused on myself—my own fears, anxieties, incompetence, and disgust. But when I met Mrs R and really understood her suffering, the NG tube was transformed from this thing I was terrified of to this thing that could alleviate Mrs R’s misery. A couple of hours later, after a lot of suction, Mrs R wasn’t feeling nauseous anymore. When I went into her room to check on her she said, "Thank you so much for convincing me to get this tube put in. I feel so much better."
This student’s story illustrates the transition from a focus on technical skills—what Minnie Wood describes as focusing on herself—to responding to what the patient needs. By using this example, I do not mean to suggest that mastery of technical skill is not important, only that it is not sufficient. The reason completing the procedure itself was not remarkable to Minnie Wood was because she had practiced and achieved facility with the technical skills involved in placing NG tubes. The story points to the power of knowing and taking seriously what is at stake in any patient care situation. Had the student taken the opportunity to place the NG tube as simply a chance to practice and perfect her own skills, given her aversion to the idea of placing the tube, she might have continued to avoid the procedure by deferring to a thin notion of patient autonomy. Instead, the student’s confrontation with the patient’s suffering and realization of the patient’s need for the tube went beyond her technical knowledge of the tube’s purpose, beyond her technical knowledge of the procedure, and beyond familiarity with the patient’s condition gained from the medical record. The student’s response to what she experienced firsthand and correctly perceived as the patient’s need helped to avert the clinical emergency of a perforated bowel or trauma associated with vomiting. Minnie Wood’s response also averted the ethical dilemma that arises when a patient refuses a simple, ultimately comforting, and potentially life-prolonging intervention.
Crisis for Civic Professionalism
In recent years, the healthcare professions, like all professions, have tended to emphasize the importance of specialized technical knowledge and skill mastery while downplaying the professional’s fiduciary relationship to his or her community. Sullivan1 attributes this partly to the rise of "market fundamentalism," an atmosphere in which external reward is the primary driving force that motivates professional practice. When this is the case, professional integrity and attention to internal goods fall away in the pursuit of material gain, and expertise becomes a narrow application of hegemony sometimes at odds with community and patients’ needs and understandings. Ultimately, this causes a failure of responsibility and of public trust in professional decency.
Several healthcare-related professions, including the hospital, pharmaceutical, and insurance industries have yielded to market fundamentalism and abused their privileged positions of trust in the community. In response, nurses have been instrumental in developing rules to try to disimpede the conscientious discharge of nursing function: overtime rules and patient-nurse ratio laws, for example. These actions, while providing relief to some of the most pressing crises in patient care, do not address adequately the underlying crisis of professional integrity in healthcare. Without a discussion of the values these rules and laws represent and engagement with these values in practice, especially in the education and training of new nurses, we risk seeing a permanent shift toward procedure and technique and further loss of substance in the practice of the next generation of nurses.
ACKNOWLEDGEMENTS
Thank you to Patricia Benner, RN, PhD, for help with the content of this article, and to Minnie Wood, RN, for her clinical narrative.
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