Responding to Ethical Complexity

Simplicity is a word not commonly used when describing nursing. The practice of nursing is entangled as nurses consider not only the patient's presenting needs, but also what should be a person-centered response to these needs. Nurses do this in context of the complexity of healthcare delivery, having to consider human and physical resources, economics, policies, and practices. Simplicity in nursing practice is not about ignoring or avoiding complexity. The simplicity referred to here is a felt experience that comes from embracing and navigating the complexities to arrive at a course of action that attempts to reconcile the various aims of the broader healthcare system with the patient's needs and desires. As a nurse educator, I distill a large volume of complex theory, content, and skills into a 2- or 3-hour class for students. This theoretical knowledge is foundational for safe, competent, and ethical care. This process has me thoughtful about the ideas of simplicity, complexity, salience, and guideposts. Finding our way through complexity requires the skill of distinguishing between the salient and the non-essential aspects of a situation. Benner et al. (2010) highlight this concept of salience, which they describe as “being able to recognize what is more or less important in a clinical situation” (p. 94). Developing the skill of salience begins in school as nursing students use theoretical knowledge in clinical situations, coming to understand the meaning of nursing practice. More important, students learn how to recognize the salient information of particular clinical situations. For example, in a quote from Benner et al. (2010), nurse educators explained, If we are asking [students] a question about heart failure we're not going to ask: “What's the difference between right-sided and left-sided heart failure physiologically?” We're going to ask a question about how a nurse would care for a patient with left-sided heart failure. (p. 94) Teaching for salience goes beyond specific educational strategies used in classroom and clinical practice such as case studies, care planning, and questioning. It encompasses the importance of the relational aspect of teaching and the need to use these strategies within the context of actually knowing the student. In the same way, nurses provide person-centered care by identifying salient information from their knowledge of the particular patient. Central to teaching for salience is embodiment. Because of the nature of developing clinical reasoning, knowledge comes alive in the context of figuring out what theoretical elements are most pertinent (salient) in a particular clinical situation (Benner et al., 2010). Just as nursing students use nursing instructors as guides in bridging knowledge to practice, nurse educators rely on their code of ethics to serve as an ever-present guidepost that points the way and sets the boundaries for addressing complexity. Nursing codes of ethics articulate the values of the nursing profession, laying out expectations for ethical behavior and obligations for individual nurses and the profession. Although codes of ethics may look different across countries, the values of competence, safety, respect, dignity, compassion, and equity remain constant. These values serve as guideposts as nurses find themselves in a progressively complex world and help nurses distinguish the most important salient details of a situation. Developing the skill of salience begins as nursing students and nurses gain further salience experience through an embodied engagement in clinical practice. We carry the skill of salience into all aspects of practice, including ethical aspects of everyday care as we integrate theoretical knowledge with our knowledge of the particular patient, making clinical decisions that are genuinely in the patient's best interest. Globally, nurses involved in updating codes of ethics have become more attentive to demonstrating how the values of the nursing profession can be lived out in practice to serve as a guidepost, and a boundary, in the provision of care: A guidepost because the values of the profession point the way through ethical complexity by reminding nurses of the priorities of practice; a boundary because the code of ethics helps nurses separate the important information from the unimportant. Few would dispute that there is increased complexity of ethical issues being faced by healthcare providers, including nurses. One of the barriers nurses can experience as they confront ethical issues is the noise that surrounds these issues. One example of noise that can interfere with determining salience in ethical situations can come from political sources. Globally, we have witnessed politicians co-opting healthcare issues for political gain, consequently adding noise to what are, in fact, ethical issues. Several examples of the politicization of health issues include euthanasia (in Canada, referred to as Medical Assistance in Dying [MAID]), gender and sexuality, decriminalization of drugs, a harm reduction approach, and attempts to address health inequities. Each of these issues is underpinned by deeply human experiences, such as vulnerability and suffering, worthy of thoughtful discussion. For example, MAID/euthanasia raises important questions for society to carefully consider and debate around the ideas of human dignity, disability, the meaning of being a burden, and worthiness. Instead, discussion around MAID/euthanasia has become polarized and divisive, interfering with nurses' ability to find salience and have a person-centered response based on knowing the particular patient. Nursing is an inherently political act as reflected in the history of nursing and in the values explicated in nursing codes of ethics. Advocacy and political activism in the nursing profession are directed toward improving the health outcomes of the individual patient, community, or society. Another source of noise is time. Critical thinking is hampered by time constraints imposed on decision making due to the nature of illness itself and an emphasis on efficiency in healthcare. Nurses often feel like they do not have time to delve into ethical complexity; instead, they desire (and need sometimes) a fast answer so as to respond effectively to the situation. In their haste, they may default to a superficial response to difficulties, risking a potentially ineffective, even harmful, outcome. In the face of deeply ethical issues, nurses may ask, “How do I find salience in this situation?” An effective response is one that reflects the heart of nursing practice, a simplicity that embraces complexity, draws on the skill of salience, and trusts the guideposts provided by the values of nursing articulated in the code of ethics. This approach requires that a nurse actively seek out an understanding of the contextual elements that contribute to complex health issues in order to determine the salient details of the problem that needs solving. A nurse can then apply that knowledge using a person-centered approach, attending to the relational aspects of care. Where an issue is politically polarized and polarizing, nurses tap into their communication skills to seek respectful and honest dialogue for a common understanding of the foundational values of nursing laid out in nursing codes of ethics. Further, though all nurses can use their code of ethics and the values of nursing as a guidepost, Christian nurses have a further guidepost for ethical nursing practice found in the New Testament from Jesus when he was tested by religious leaders of his day: “Teacher, which is the greatest commandment in the Law?” Jesus replied: “Love the LORD your God with all your heart and with all your soul and with all your mind. This is the first and greatest commandment. And the second is like it: Love your neighbor as yourself. All the Law and the Prophets hang on these two commandments.” (Matthew 22:36-40, NIV) The simplicity of this guidance as the route through complexity has to do with Jesus sidestepping the complexity of many rules and regulations to instead seek the face of God and God's reflection in the faces of those we encounter (Pope Francis, 2014). In this way, Jesus offers to all the fundamental criteria on which to base one's life: the law of love. This is a guidepost for everyday nursing practice. FOR REFLECTION: What do you think is your primary guidepost for your nursing practice? What noise do you experience as you try to determine the most salient features of an ethical situation (i.e., time constraints, policies, politics)?

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