MORAL EDUCATION FOR NURSING

EDUCATION \ k LFOR

NURSING

284 VOLUME xrx NO. 3 1980

by Thomas Johnston

URSING, the profession of dilemmas, is, by its very N nature, circumscribed by the demands of moral decision making. Indoctrination of students, and more recently, values clarification, have been tried; however, the destructive effects of indoctrination and the limitations of values clarification have led the profession to the need for a new approach to moral education.

Previous Approaches

Although nursing has traditionally been involved with moral reasoning, in the past nurse educators approached moral education with the idea that students should be “told” how to function morally. The method of teaching moral reasoning was simple but effective: “If you wish to get into and graduate from our nursing program you must act this way. While you are in the nursing program your feelings are less important than the obligations to physicians and patients” - an ideology that not only crippled students development of moral reasoning,but placed the emphasis on remaining at a conventional level of thought. The faculty’s message to students to follow orders, listen to the physician, and “good” nurses should act this way, came through despite the stated goals of becoming autonomous and “professional.”

The need to follow the wishes of others and to comply with formalized hospital standards for the standard’s sake was given priority over autonomous thinking. What often hap- pened was that nursing students played “the game” while in school and, upon being graduated, dispensed with that form of thought, or were so well indoctrinated they followed the

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teaching blindly. Unfortunately, neither option lent itself to a young graduate’s moral development.

Indoctrination, as a teaching method, is by no means unique to nursing. Both public school educators and the clergy employ avoidance and indoctrination in teaching moral reasoning: avoidance in the sense of denying one’s feelings in response to a dilemma, and indoctrination in the sense that “good citizens and Christians act this way if they want to be patriots and go to heaven.” Medicine’s influence on the early development of nursing programs is well known! “If medicine is doing it this way, it must be good.” “This is what we expect of you and what you will emulate. Whatever is going on inside you as a person is unaddressed as long as you adhere to our standards. ’ ’

A more recent means of addressing moral development has been through values clarification. Values clarification is the exploration of one’s values with the acknowledgement that everyone is entitled to his/her own values and each person’s value is just as important as another’s. Values clarification re- cognizes nurses as persons with inherent values; however, it does little to facilitate moral development. Yes, the nurse’s values are important in the classroom but in the clinical area how could they ever possibly be equal to a physician’s or a client’s? Such a realization in itself limits values clarification to a status of discussion.

A second point of concern is the notion that one person’s values are just as important as another person’s values. The connotation of this notion negates the concept of hierarchical levels of reasoning or functioning. Socrates’ autonomous level of reasoning is indeed different from the person preoccupied with award and punishment. In eiiher example, each person has his/her own value system. However, the moral reasoning of one is obviously at a higher level than the other. Values clarification has done little to raise one’s level of moral reasoning. The integration of the affective and cognitive domains

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with the moral domain should be the heart of a progressive nursing curriculum.

A New Approach to Moral Education

Nurse educators need a different approach to moral education, which may well be found in the writings of Lawrence Kohlber, who has done much to define the levels and stages within moral development. Looking at Kohlberg’s stages, one can see there are higher stages of “autonomy” and lower stages of “dependence and follow the rules.”

Incongruency in moral functioning is most vivid in nursing. The incongruency appears to create confusion and ambiva- lence in the student. An important consideration here is that what the student hears in lectures is often quite different from what role model is portrayed by practicing nurses and, very often, the faculty members themselves. Nurse educators would obviously hope to strive toward greater autonomy for themselves and their students. It is to the end of providing an education sensitive to, allowing for, and encouraging, progression in moral reasoning that I refer to the work of Kohl berg.

As one reviews Kohlberg’s moral stages the following char- acteristics should be kept in mind:

1. Stages are structured whole or organized systems of thought, which means individuals are consistent in levels of moral judgement.

2. Stages form an invariant sequence. Under all conditions, except extreme trauma, movement is always forward, never backward. Individuals never skip stages, movement is always to the next stage up.

3. Stages are hierarchical integrations. Thinking at a higher stage includes or comprehends within it lower stage thinking. There is a tendency to function at or prefer the highest stage available.

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Kohlberg has identified six stages of moral development, categorizing them under three levels: preconventional, conventional, and postconventional. The first two stages are at the preconventional level. The nurse who acts just to avoid punishment is functioning at stage one. The nurse functioning at this moral stage does not respect the authority of physicians for the moral principle from which their reasoning may eman- ate, but from the basic need to avoid being chastised. The nurse who functions at the stage two level of reasoning is less egocentric than the nurse functioning at the stage one level in terms of looking out for him/herself. The level of hislher moral reasoning is reflected in the quid pro quo philosophy, “you scratch my back and I ’ l l scratch yours.” This nurse would have a regard for reciprocity in that s / h e would pro- duce for the instructor or supervisor to get personal satisfac- tion, but would not necessarily be working in the clinical setting to help patients.

The conventional level of reasoning encompasses both stage three and stage four. Nurses functioning in stage three toil endlessly for the needs of others, but disregard their own needs. The “nice little nurse” who is helpful to the physician to gain approval is functioning at this level. The intention of the act becomes important here. Nurses who function at stage four are directly tied to authority, rules, and obligations. They feel obligated to carry out the rules of the authority figures without regard for personal moral principles. They follow the law for the law’s sake. At stage five, one sees autonomous or postconventional moral reasoning. The nurse functioning at this stage is well aware of the obligations involved, but is also aware that laws can be changed and need not be followed blindly. Stage five takes into consideration individual rights: the right of a nurse to disagree with a rule, personal opinion, or value. The sixth and last stage, which builds upon the other five, is the stage in which the nurse has identified a set of personal, moral principles. However, these principles are not


written in stone like the Ten Commandments, but are principles of justice, of right or wrong for the individual. The nurse in this stage would disobey the rules decreed by an authority figure if s / h e felt strongly enough.

The Use of Moral Dilemmas to Encourage Moral Development

Where does the nurse’s obligation to authority and client separate from her/ his obligation to self? This overriding question pervades the nurse-client-physician relationship and poses a classic dilemma in moral reflection. As one of my students asked, “Why can’t nurses have feelings? Nurses have feelings that must be realized.”

With the concept of moral reasoning so intertwined in nursing, and the observed need to formally address the issue of moral education within the nursing schools themselves, I chose to use moral dilemmas as an approach to encourage progression of moral reasoning. 1 selected two student groups to serve as prototypes of the more common forms of responses to the dilemma experiences. The following responses may be interpreted as being reflective of the other student groups with whom I have worked during the past few years.

In developing situations relevant to nurses, I used some of James Mackey’s examples of dilemmas as stepping stones. Two dilemmas, which typify the format and objectives, are presented here. The first dilemma was created for three purposes:

1. To introduce and expose students to moral reasoning. 2. To allow students to feel comfortable in an atmosphere

where they can express their thoughts and feelings freely. 3. To serve as a tool to assess the stages of moral reasoning

employed by the students.

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Barry’s Dilemma In early April, 1977, the Wisconsin Supreme Court ruled that

state laws prohibiting Electro Convulsive Treatment (ECT) were unconstitutional. The greatest opposition to this ruling came from the Patient’s Rights Organization (PRO).

member of the PRO, was very troubled by this decision. The memories of his roommate’s deterioration following ECT were vivid. Although his roommate’s experience occurred several years ago, Barry’s memory of his deterioration persists.

Barry remains active in the PRO. Most members of the PRO believe that although ECT is legal, it does irreversible damage to patients, and that there is more effective treatment available. Barry shares this conviction.

One of Barry’s patients, a mother of three, is moderately de- pressed. The patient has been convinced that the only thing that will help her is ECT. Her doctor has scheduled her for ECT the morning of April IS. Barry is the only R.N. working that day. It is hospital policy, an R.N. must assist the doctor during ECT. When Barry expresses his concern, the doctor points out that his nurse’s oath requires him to serve the needs of his patients i f these are not unreasonable or illegal.

Barry Olson, R.N., a previous psychiatric patient and

What should Barry do?

Our sample consisted of fourteen, second semester, junior nursing students, divided into two equal groups of seven members. Discussions on Barry’s Dilemma took place the first week in a private room during an allotted half-hour postcon- ference time. Subsequent dilemmas were discussed in the latter weeks.

The dilemmas are introduced to students as examples of plausible moral circumstances they may encounter in practice. To allay any qualms about participating, the students are told there are no absolute “right or wrong” standpoints and their discussion would in no way affect their grades. (The realization that there are standpoints that are “more” right than

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others becomes obvious to students as their discussion pro- gresses.

The initial responses by students to Barry’s Dilemma is a questioning as to “how could this happen” and “does this really happen.” After students are assured this type of situation may indeed occur they begin to deal with Barry’s situation in earnest. Most students say they would have gone through with the procedure. The primary reasons given for this decision are:

U “ I f the patient is convinced and wants it bad enough, I may go ahead and do it.”

U “Barry has a legal obligation and must follow through with it .”

U “He is obligated to help, if he is opposed, he should work through the PRO rather than fight the doctor.” 0 “His feelings are interfering with his functioning-

he should do it .” 0 “Once you step on the clinical floor your obligation to

authority, the doctor, and the patient, are most important,” and finally, 0 “He did take the oath and he shouldn’t shirk his respon-

sibility.”

These responses demonstrate a strong tendency toward stage three and four functioning. The majority of students are quite concerned with helping others and gaining approval through absolute adherence to authority. Their allegiance to the physician is based on authority rather than on the physician’s reasoning for the procedure.

Several students invariably state they would have refused to comply with the physician’s orders as evidenced by such comments as: 0 “He shouldn’t do it because it is his strong belief.”

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O“lf I feel real strongly, I wouldn’t do it because I feel

0 “ I would go against it, but in another issue I may go along

0 “ H e shouldn’t do it because he has a strong convic-

These students seem aware of their obligations yet are also cognizant of Barry’s right to refuse to comply to the order. By their responses, they indicate they are functioning at a higher, more postconventional autonomous stage.

Generally, two or three students are quite indecisive as to what Barry should do. In time, they change their position from advocating compliance to advocating refusal. Their reasoning appears to include elements of levels three, four, and five. It is encouraging to see the influence students have upon each other. One may infer that the indecisive students may indeed be progressing toward a higher, postconventional level of reasoning. However, one may also infer that presented with Barry’s Dilemma in a clinical setting, they may, in their ambi- valence, comply with the physician and patient.

The Graduate Nurse Dilemma typifies the second type of dilemma presented to the students. Although similar to the purposes of Barry’s Dilemma, this dilemma has additional purposes:

1. To expose students to autonomous thinking, a stage five

2. To summarize students’ feelings in regard to the dilemma

myself that it would be wrong.”

with it.” and,

tion against it.”

form of moral reasoning.

experience.

The Graduate Nurse

Gerry Blake felt great. When she had graduated from her nursing program there was real concern that she might not find employment in her small hometown. But the hospital decided to hire her because the Director of Nursing knew Gerry’s


parents quite well. Gerry, as one of the few R.N.s with a B.S. degree, had a lot of responsibility. However, she was getting in- valuable support from the other personnel who worked with her, many of whom were old friends.

On April 29, eight months after Gerry had been hired, she was working on the weekend as nurse in charge. What had started as a routine day suddenly turned into an unforgettable experience. That day, Gerry saw staff members she had known for a long time go apparently berserk. Gerry came unexpectedly onto the small psychiatric care section and witnessed the staff members physically beating a patient in their attempt to restrain him and continued to d o so even after he was restrained.

Later that afternoon, the Director of Nursing came to Gerry’s office to inquire about the morning’s incident, something the Director had never done before. Although she never came right out and said it, the Director was clearly sug- gesting that Gerry might be better off if she did not report the incident.

What should Gerry do?

This dilemma generally elicits two markedly different responses from students. One student group responds to the dilemma in a “transitional” fashion. Initially, the students want to file an incident report, then change their minds about halfway through the discussion. By the end of the discussion, the student group returns to a unanimous view that the incident report should indeed be filed. What is most important here is the students’ reasoning for their judgments as to what Gerry should do.

Why do students initially shift from filing the incident report to deciding to “discuss” it with the people involved? The answer may be that during the early part of the discussion students do not consider thoroughly the consequences of filing the incident report. In other words, they have not analyzed the conditions of the dilemma. The major determinant in deciding not to file the report is the effect it may have upon Gerry’s

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friends. One may therefore infer that the initial response to file the report is not based on stage five reasoning but rather on a superficial analysis of data and a quick response to that data. Once presented with the obligation to friends, the students respond more on stage three or stage four than stage five in their reasoning.

During the discussion, my main function is to question or comment from either my role of Gerry’s friend or the Director of Nursing. Several pointed questions will stimulate further in- depth consideration of the circumstances involved with Gerry’s Dilemma:

1. “Well, what are Gerry’s obligations to her friends?

2. “What about the hospital if you file it?” 3. “What will happen to the other people who work there

and weren’t involved in the incident?” 4. “What would happen if Gerry had a friend who filed an

incident report previously and was fired?” The students respond to these questions with comments such as :

These are the people that hired her.

0 “ I think she should find out the circumstances, talk first.” 1 guess when I first read this I didn’t think there was

much of a problem, I’d just file it, now I don’t know.” 0 “Something should be done, but when it comes down to

doing it. . .” 0 “Give them one more chance, then if they goof up, then

file it.”

Toward the end of the discussion different areas are con-

I . “Are things done in the hospital which if done outside

2. “What if a person was attacked and knifed in the street,

sidered, and the following questions are posed:

the hospital would be considered a crime?”


it was the first time the antagonist had stabbed any - one, should he be given another chance?”

3. “Where does the obligation to oneself break from the obligations t o one’s friends?”

4. “Would Gerry be able to live with herself if she didn’t file the report?”

With these questions as a basis for discussion, the students examine their reasoning in greater depth. They begin to consider their obligation to the patient, friends, Director of Nurs- ing and, most important Gerry’s obligation to herself. The consideration of obligations and doing one’s duty connotes a stage four rationale; however, the comments made on consid- ering one’s responsibility to self raises the discussion to stage five reasoning. The general tendency is upward, away from a stage three rationale to stages four and five. The basis for this upward movement is the students’ exposure to higher levels of moral reasoning-an atmosphere conducive to uninhibited rapport with other group members, and an individualized attempt to consider the consequences and conditions of either filing the incident report or witholding it.

Unlike the first group of students, the second group does not go through a “transition.” It comes out strongly for filing the critical incident report and holds to that conviction. All members of the second group share this conviction, but generally a few students are so strongly in favor of filing the report they hold the group consensus intact. Throughout the discussion, only a few students waiver in their decision.

Because of the firm position of the second group of students, I handle the context of their discussion differently from the discussion of the first group. In the earlier discussions I play various roles, presenting considerations or comments which may have emanated from the characters in the dilemma. In this discussion, I become involved not as the instructor but in the role of the Director of Nursing and the students in the

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discussion are considered one individual, Gerry. Each student “wears Gerry’s shoes.” Comments or questions brought up by students are phrased as remarks of Gerry’s.

The effects of this format are observable both in the verbal and nonverbal communication. Members of the group tap on the table, fidget in their chairs, and laugh to release tension. Other observations are that students increase the volume of their responses, their voices crack, and their words are mis- pronounced more frequently. The following excerpt will make the context and feeling level of the discussion more apparent. It demonstrates the intensity and heat with which the dilemma is discussed. The students are placed “in the dilemma” and do not speak hypothetically.

This excerpt is concerned with the three staff members who beat the patient, but did not perceive anything wrong with their actions, and disagreed with Gerry’s perceptions.

Student #]-There is no way you can strike a person (voice shaky), They should be released from their jobs.

Director of Nursing-You’re basing that on two or three minutes of observation.

Student #I-No, I’m basing it on what I saw! Director of Nursing-You came in on it at the tail end, he

(the patient) is a known alcoholic and an assaultive person. My staff members have the right to defend themselves.

Student #1 -You’re not defending yourself, you’re not defending yourself!

Student #2-You’re not defending yourself when you strike at another person!

Student #1-You’re not defending yourself, not in a hospital!

Student #3-Everyone has an opinion, three wrongs (three staff members) don’t make a right, they are wrong.

2% VOLUME XIX NO. 3 1980

Director of Nursing-In this case, the voice of three people are stronger than one, they have far more experience than you, and have had no previous problems in their records.

Student #4-1t sounds to me that you have made some real honest efforts to get control of the situation and ahhh I just feel that my critical incident report will help you to work with your staff and to carry on with your actions and it will show the community (pause) perhaps my work will show the community, the, the hospital administrator that there is a definite need for you and your staff to work together in this hospital for the sincere care of your patients. I resign.

Obviously, the instructor must have adequate time to allow students to come down from such an experience. Being there with the students, allowing them to ventilate and resolve their feelings, is important.

Although this group is almost unanimous on filing the critical incident report, its rationale or level of moral reasoning varies. Generally, two students are consistent in their convic- tions that a wrong or crime has been committed. They feel it is Gerry’s obligation to herself that should make her file the report. They acknowledge that “professional” nurses are obligated to report such incidents, but their focus is more on the individual’s rights. These students seem to be closer to stage five moral reasoning. However, the majority of students in this discussion base their rationale for filing the report on the nurse’s obligation: “It is Gerry’s duty to file the report.” These students are also able to disregard the pressures of friends and authority, which gives some evidence of autonomous thought; however, the context is different in that they are still doing what they think a “good” professional nurse should do. Gerry’s obligation to file the report is based on “good behavior” and professional duty. From such rationale

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one may draw the inference that the latter students are functioning in a stage three or four in moral reasoning. But trying to make an assumption as to the specific stage would be time consuming as the students demonstrate moral reasoning not just at one stage, but at various stages. I would conclude that these students are changing and progressing in their levels of functioning, that they do not appear to be static.

Student Response to the Experience

How do students respond to this experience? Do they feel it is worthwhile? Do they gain anything? The answers to these questions were alluded to by verbal communication during and after the dilemma discussion. However, to provide more validity, the primary source for the answers was obtained through written responses in which students identified their likes, dislikes, questions, and comments concerning the use of dilemmas as a teaching method.

The students’ comments fell into several categories. The most common remark was their response to being exposed to the “real world” situations inherent in their profession. A typical remark was, “all I keep hearing is that when we graduate reality shock will really hit us hard, these dilemmas offer us an opportunity to face reality.” Another common remark centered on the students’ opportunity to look at their own personal values or feelings. One student wrote: “If nothing else, some deep feelings are certainly brought out and I guess now is a better time to be faced with it than never, thanks.”

But not all the comments were positive. One student wrote, “ I disliked some of the comments brought out by the other students and instructor, however, this added to the realism of the situation,” and another wrote, “The dilemmas were very good, although I thought it was really hard to decide what course to take. You can’t really put yourself in that situation.” In analyzing these two statements the second is of greater con-


cern. It would lead me to believe that maybe I had failed to reach this student. However, since the dilemmas are geared toward putting the student into “that position” and since the rest of the students seemed able to empathize effectively, I evoke the old adage, that “you can’t please all of the people all of the time.” A suggestion to other instructors with such dilemmas would be to note a similar comment in the future and, if frequent enough, spend additional time analyzing your approach to the dilemma discussions.

Conclusion

Curriculums that are not only sensitive to moral reasoning but integrate moral education in its philosophy as well as practice are essential to any real actualization. Obviously, development in moral reasoning cannot be achieved in a few dilemma discussions. This type of process takes time and mandates the integration of moral education throughout the nursing program and the creation of other modes to approach it. Efforts to integrate the affective, cognitive, and moral domains are necessary for the progressive development of nursing.

References

Dupont, H . , Consultant, Psychology and Education, Decatur, Georgia, paper presented in his class.

Duska, R . and M. Whelan, Moral Development: A Guide to Piaget and Kohlberg, New York: Paulist Press, 1975.

Kohlberg, Lawrence, “Moral Education for a Society in Moral Tran- sition,” Educational Leadership, Oct. 1975, pp. 46-54.

Mackey, J . , “Discussing Moral Dilemmas in the Classroom,” English Journal

McCallun, E. and E. McCray, Designing and Using Questionnaires, Learning Concept, Austin, Texas, 1975.

Sprinthall, N, “Education and Personal Development,” pre- sentation at The Affective Education Symposium, University of Wisconsin-Eau Claire, Dec. 2, 1977.

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MORAL EDUCATION FOR NURSING