Patricia Benner, R N. Ph.D., FAAN
copyright July 2021, EducatingNurses.com
“I’m guessing that many of you teach ethics and it’s either your least favorite or most favorite course…I’m here to talk with you about how to make it your most favorite course.” Sarah Shannon
We are featuring video selections on EducatingNurses.com by leaders who are noted nurse educators that are drawn from their presentations on the three professional apprenticeships:
1) The Cognitive Apprenticeship: focuses on the knowledge of science, technology, and theory necessary for the practice discipline;
2) The Practice Apprenticeship: is related to skilled know-how in the practice and situated use of knowledge in particular clinical situations;
3) The Ethical Comportment and Formation Apprenticeship: focuses on learning how to enact the ethical notions of good embodied and internal to the practice itself, and professional standards in the Profession’s Code of Ethics (ANA 2015).
The term, “apprenticeship” is used metaphorically, to represent the direct educational guidance in learning how to engage in a practice, rather than “on-the-job training.” Situated, skillful know-how is required in all practices, and requires situated coaching by coaches who deeply understand the notions of good and ends of the practice. It also requires skilled knowledge and situated clinical judgment about how to understand and respond in particular clinical situations. The term, “apprenticeship” is used metaphorically, to represent the direct educational guidance in learning how to engage in a practice rather than “on-the-job training.” Students must be guided by faculty who have the perceptual acuity to recognize clinically urgent, or salient situations, what is an ethical concern, how to skillfully ethically comport oneself with patients/families and professional colleagues and co-workers in actual clinical practice. In Educating Nurses: A Call for Radical Transformation (Benner, et al., 2010), we found that senior nursing students identified, through their experience-based narratives, the following notions of good as being the most essential to good nursing practice:
1. Meeting the patient as a person, is exemplified by getting to know the patient as a person rather than treating them only as a “patient” with a disease or injury. Hospitals, skilled nursing facilities, clinics, and other health care delivery systems can be large and depersonalizing at times when people need to be met, known, and reassured by being recognized as a person by health care providers.
2. Preserving the dignity and personhood of the patient: There are many assaults on one’s dignity due to illness, pain, suffering, and impersonal treatment by health care workers. Health care workers can focus only on the injury or disease objectifying the patient, as they attend to “objective” signs and symptoms, perform needed tasks and interventions along with the impact of treatment interventions. In addition, pain and suffering often infringe on the person’s sense of self and identity. Having caregivers recognize, acknowledge, and affirm the personhood of the patient is central to the person’s coping with illness, recovery, and healing.
3. How to respond to substandard practice: Nursing students gave many examples of encountering substandard practice, and were concerned with how they could and should respond with their limited power and status as student nurses. This ethical concern is central to a developing sense of professional ethics, which Dr. Sarah Shannon points out in her presentation how to teach for strengthening the student’s competency and skilled know-how in responding and correcting substandard practice.
4. Patient advocacy: Students gave many examples of patient advocacy and they struggled to correct any problematic combination of treatments or medication, as they sought to get the appropriate responses from the health care team in the patient’s best interest. Patient advocacy including giving the intimidated or silent patient a voice; educating the patient about their rights as a patient; troubleshooting difficult or conflicting diagnostic or treatment plans, and many more concrete examples of “running defense” for the patient in complex environments of health care.
5. Students and faculty seriously engaged in learning to do good practice: At the end of a clinical practicum, students were often questioned by faculty about how they could improve their practice if they had a chance to care for the same patient again. This is at the center of ethics in any practice, that it be a self-improving practice (MacIntyre, 2016). A practice cannot be like a museum, full of artifacts of the past, nor engaged in a “traditionalism” that continues past practices, but fails to improve or update practice. A self-improving practice requires the commitment of all practitioners, and this was evident in the emphasis on improving daily practice in the debriefing sessions observed and written about by students as they gave narrative examples of trying to improve their practice.
Dr. Sarah Shannon uses the metaphor of “helping students find their keels” — that part of the boat that keeps it from tipping over or veering off course — or as Dr. Shannon, points outs, being blown by any wind, shifting their course with no sense of being guided by ethical principles and notions of good practice. Dr. Shannon points out key distinctions between professional ethics and bioethics. Bioethics or biomedical ethics is a rights-based ethic, that focuses on ethical dilemmas, practice breakdowns, and conflicts about what is the best ethical course in a particular clinical situation. She uses the Jonson, Siegler, and Winslade Clinical Ethics book (2015) for addressing and solving biomedical dilemmas and ethical conflicts in practice. Professional ethics involves confronting substandard practice, relational ethics, both with patients/families and co-workers, and barriers to living up to the ethical standards of the nursing profession.
Dr. Shannon, who was selected in EducatingNurses.com as a paradigm of excellent teaching in the ethical professional apprenticeship, emphasizes in her ethics course, the goal of teaching the students to identify and articulate ethical issues encountered in practice. She stresses in her teaching and learning — how the student will actually respond in a particular situation, for example in a professional ethics issue. How would the student respond to a colleague in a situation of ethical conflict? How would the student address the professional ethical conflict related to confidentiality, privacy, fidelity, broken trust in patient relationships, racial or gender ethics? She has students avoid idealizing or “pontificating” about what they would do in a situation of a professional ethical breach, instead, Dr. Shannon asks them to role play and enact how they would respond to the professional ethical conflict. She wants them to develop the words they would use before actually being in the clinical situation.
It is useful to begin with the ethical comportment and formation apprenticeship in this series on the Three Professional Apprenticeships drawn from HealthImpact.org, California because it is the most integrative apprenticeship. For example, there is no good clinical reasoning without a notion of what good or end outcome one is trying to achieve through one’s situated clinical reasoning. In the next installment, we continue with the Ethical Comportment and Formation Apprenticeship with Dr. Marsha Fowler, a key leader in the A.N.A. Code of Ethics and Interpretative Statements. Dr. Fowler will challenge readers to distinguish biomedical ethics from nursing ethics.
Watch Dr. Shannon:
American Nurses Association Code of Ethics for Nurses with Interpretive Statements. (2015) American Nurses’ Association.
Benner, P., Sutphen, M., Leonard, V., Day, L., Educating Nurses: A Call for Radical Transformation. Stanford, CA: Jossey-Bass, 2010
Jonson, A.R., Siegler, M., Winslade, W.J., Clinical Ethics, A Practical Approach to Ethical Decisions in Clinical Medicine. 8th Ed. (2015) McGraw.
MacIntyre, After Virtue. A Study in Moral Theory. 3rd Ed. (2016). University of Notre Dame Press.