Tuesday 4 June 2013

Freeda Hayes...

I promised to reveal the outcome of the Freeda Hayes case.

You may remember that Freeda was a 48 year old woman who died in a hospice. The doctor and Freeda's brother and sister, who were with her at the time of her death, were charged with 'wilful murder'.  All three were acquitted. The book relating to the case by investigative writer - and ex-nurse - Robin Bowles, takes us carefully through the legal case and suggests the characters of the key players. It is helpsful to have the perspective of an author with inside knowledge of healthcare and who is also free to ask questions of those involved (See http://www.abc.net.au/pm/stories/s696378.htm). The most interesting aspect of the case described is not perhaps 'whodunnit' but rather insights shared regarding what motivates people to act or not to act in such circumstances...

Does this suggest a better model for applied ethics than our usual engagement with frustratingly short case summaries with little information regarding the perspectives of the key players?  If I recall correctly, Carol Gilligan describes a common response of female participants in response to ethical dilemma cases as "it depends".

More engagement, more listening, more inclusion of a range of diverse perspectives seems to be in keeping with 'slow ethics'...

So now back to catching up with neglected projects, students and manuscripts....

Saturday 1 June 2013

Heading north…
My sojourn to the south has been instructive, challenging and enjoyable
I have been fortunate to meet with, and learn from, colleagues in Australia and New Zealand (NZ).Megan-Jane Johnstone encouraged us to think more broadly about end of life ethicsand suggested that we abandon the concept of moral distress.  Martin Woods described the role and importance of cultural safety and detailed his research with NZ nurses on moral distress. Tula Brannelly urged a consideration of the relationship between personal and professional lives as we relate to marginalised groups.  Elizabeth Niven, author of a first book on nursing ethics in NZ, demonstrated the moral wisdom that comes from experience as we travelled around Auckland today. We discussed the role of bystander and our responsibility to act in different contexts.  Should you challenge a market stallholder who was making  unsupported research claims about a health product? She did. Should you ask for an extension seatbelt for a passenger on a flight who did not ask for one himself? You will recall that I did not.
I also met with David Seedhouse. I did the first dignity in care study with David in 1999. I learnt about his on-going work with the online Values Exchange. He talked enthusiastically about the engagement of children in the Exchange and the opportunity for cross-cultural and cross-generational dialogue about values. I also spent time with Jocelyn Peach, Director of Nursing and Midwifery and Jenny Parr, Associate Director of Nursing at Waitemata District Health Board and Stephen Neville at Massey University. I thank them for their hospitality and generosity.
I have been challenged by debates about responsibilities to indigenous peoples wronged in the past and been pushed to ponder my own ‘unearned privilege’. It is right to seek to understand the historical context for our present relationships, to consider the meaning of marginalisation and to strive for social justice. But it is not enough if we absent ourselves from whatever cultural context we find ourselves in. Colleagues here seem particularly sensitive to the evolution of their personhood and sense of family and place in relation to that of local populations.
I have enjoyed some of the cultural and natural highlights of both countries: savouring an occasional local wine;experiencing the ambience of the Opera House;observing a kangaroo family in the bush;witnessing the antics of dolphins in Sydney harbour; andseeing Auckland from Eden hill and learning about its volcanic and cultural past.
And now I am preparing to head back to theUK. There is a good deal of catching up to do with projects, students and journal work. Visiting new places broadens our view and enables us to better appreciate the inter-relationships between individuals and cultures. Perhaps the most important thing, however, is not the physical travelling from place to place but the travelling that takes place in our minds and hearts as we engage with different people in different conversations about the things that matter to us.
So I leave with some new perspectives and resolve to pursue new lines of enquiry in nursing ethics. We have a lot to do and it is reassuring to be reminded that we can learn from colleagues in other cultural contexts. I look forward to continuing to engage with the many committed people I have met here.

Thursday 30 May 2013

A long way from anywhere…. care, internet angst and unearned privilege



The weekend in Sydney provided some space and time to engage with culture and nature. The weekend newspapers reported the death of Hazel Hawke, a ‘first lady’ of Australia, with extracts from an interview with her grandson and friends. They described her many positive qualities, her experience of dementia and provided details of her final hours. Details, that few outside families, would generally come to know about.

 A concert at the Sydney Opera House reminded me that care and dignity are not just applicable to healthcare contexts. Band members and crew of an extraordinaryR & B performer demonstrated sublime sensitivityand care as they supported their lead singer who seemed physically frail who remained more than capable, however, of providing wonderful entertainment.

I arrived in New Zealand on Monday afternoon and have spent the last few days visiting the three Massey University nursing departments at Palmerston North, Wellington and Auckland and two hospitals. I met with staff and students and gave talks on the theme of ‘sustaining ethical practice in challenging times’.

New Zealand, a guidebook informs me, is known by “its people” as “Godzone” (God’s own country).  Later on the same page, we are informed, that the indigenous Maori people refer to New Zealand as Aotearoa – the land of the Long White Cloud.  We might ponder the point about ‘its people’ and ask if the author meant indigenous and/or non-indigenous inhabitants…

My host in North Palmerston said that one of the reasons he liked New Zealand is that ‘it is a long way from anywhere”.

Common to each encounter here has been an acute cultural sensitivity and an awareness of the importance of family and place. I learnt something of the history of New Zealand (for example, of the Treaty of Waitangi), of the relationship between the Maori  and non-indigenous people and of current norms and practices in universities and hospitals that support cultural safety.  I learnt also of Maori rituals that welcome new members to the hospital community. A senior nurse who had returned to NZ from the UK, told me of her Maori welcoming ceremony that included her partner and family.

The second year nurse student seminars I observed at Palmerston North reminded me that some ethical challenges in healthcare are universal.  They related to: truth-telling (should an elderly patient be told of a poor prognosis against family wishes?); responses to patients who lack capacity (how to manage a patient who wanders and disturbs other patients?); resource allocation (should a nurse intervene on behalf of a family when doctors decide that dialysis is not appropriate?); and nurse involvement when family members decide that an elderly woman should be moved to a nursing home against her wishes.

I was impressed by the sensitivity and creativity of the students as they considered a range of strategies to respond ethically and also by their ability to negotiate a wide range of personal, professional, Maori and legal values. 

I also had to negotiate my own ethical challenges outside the academy and hospital…

On the very tiny plane from Wellington to Palmerston North I sat opposite a very large passenger.  As one of the pilots walked down the aisle to check that we had fastened our seatbelts, my neighbour put his hand over the fastening and did not disclose that he needed an extension. I was reminded of those car safety adverts where, sans seatbelt, the passenger in the back seat becomes a lethal missile….So did I quietly suggest to my neighbour that he ask for an extension for his seatbelt?

I reasoned that his loss of dignity was likely to outweigh the low likelihood of harm resulting from a head on crash. It seemed much more likely  that we would plunge into the sea or that the tiny precarious craft would explode and we would be scattered over the very green land.

So did I do the right thing? What would you have done?

One of the most interesting aspects of Australia and New Zealand has been engagement in discussions about the negotiation of relationships with indigenous peoples. During a lively discussion in Australia, we were challenged to consider our ‘unearned’ privilege or advantage in terms of our colour, class, gender, language and history. The openness to dialogue regarding the responsibilities of individuals and communities has been impressive. There is an opportunity here for us to learn from Kiwi and Australian responses to past wrongs and from journeys towards social justice and non-discriminatory practice.

I have had to also learn this week that computer problems can result in a good deal of unnecessary angst. My lack of blogging has been due to the fact that I have had to prioritise other activities - such as submitting a research proposal by a deadline - and rely on the generosity and goodwill of my hosts here to access a reliable internet connection.

Just two more days in this part of the world…

Thursday 23 May 2013

Melbourne - après ICN congress...

Final day in Melbourne and I attended the open day hosted by the School of Nursing and Midwifery at Deakin University. The venue was the university's very plush premises in central Melbourne, shared with Deloitte.

We had presentations from researchers relating to, for example, the work of the strategic research Centre for Quality and Patient Safety Research (QPS) and research projects on diabetes, exercise in renal patents, emergency care and oncology.

These last few days I have been made aware of a wide range of views relating to appropriate engagement with the Aborigine people.   It is recognised that the Australian indigenous peoples were treated appallingly in the past and continue to experience discrimination and worse health outcomes than the majority population. It was suggested that welfare initiatives may be more harmful than helpful.

Deakin University staff talked of the nurse education programme they run specifically for Aborigine students. They said that it has taken a long time to develop trust with their communities but they can now celebrate some success as students graduate from the programme. The importance of working with community elders to support the programme and student professional development was also discussed. There has, it seems, to be some negotiation to reconcile cultural values and practices with those of the health professions.

My time in Melbourne has been very rewarding with two great conferences and many opportunities to talk and work with colleagues from other countries. It was also extremely interesting to learn something of the diverse culture of Australia and to experience the natural beauty of the region....not to mention the local wine and cuisine :-)

I am particularly grateful to Megan-Jane Johnstone and her colleagues at Deakin for hosting the very successful ICNE conference and the open day today. I look forward to future collaboration..

Tomorrow I am leaving for Sydney and then to New Zealand early next week. Another update then. And I also need to tell you the outcome of the Freeda Hayes case....

Have a great weekend.



Tuesday 21 May 2013

Day 7 -Melbourne - convicts, moral distress and challenging positions

The walk to the Melbourne Convention Centre for the ICN Congress brings me over the Yarra river via the Sandridge bridge (See http://en.wikipedia.org/wiki/Sandridge_Bridge). The bridge has transparent plates detailing the number of immigrants to the region from different countries and the background to their arrival. There are, for example, a large number of Irish people in Victoria and some arrived in the late 18th and early 19th century as convicts and labourers.

There is a little irony in the fact that at least some of those Irish travellers here to attend the ICN Congress are now engaging in debate regarding ethics.

The discussion in the parallel sessions explored varieties of ethics support for practitioners and differences and similarities in values' frameworks. The final main plenary of the day focused on ethics in end of life care with presentations from Australia (Megan Jane Johnstone on moral distress), Iran (Ahmed Nejetian on Islamic approaches to death)  and New Zealand (Elizabeth Niven on codes and dilemmas in dementia care).  Megan argued that we should abandon the concept of moral distress. Ahmed enabled us to better appreciate the Islamic approach to death drawing on his professional and personal experience. Elizabeth talked us through practice dilemmas regarding dementia care, for example a person who now requests meat after being a lifelong vegetarian, drawing on values from professional codes and traditional values. I invited Megan to submit her paper to Nursing Ethics as there is scope for much more critical debate regarding moral distress.

As those of you who have attended conferences know, much of the really interesting discussion takes place outside the formal sessions. I had dinner with colleagues from Italy, Ireland, Brazil, New Zealand and the UK. In addition to a good deal of debate about the conference sessions we also discussed the role of ICN and the withdrawal of the RCN from this. There was a consensus that this stance is not in the best interests of UK nurses.....a challenging position that seems difficult to defend.

Given the gains that come with membership of an international professional organisation, can UK nurses really mind that less than £2 of their annual fee to the RCN goes to ICN?

Today I am off to survey the great ocean road. More later.




Monday 20 May 2013


Day 6 - Melbourne - call to action and the aims of applied ethics

I recall someone saying that the definition of a lecture is when the notes of the lecturer are transferred to the notepad of the listener without entering the minds of either....

This morning's ICN plenary lecture by Lesley Mancuso - 'Holding up More than Half the Sky' - was a long way from this definition. Her delivery was compelling in both style and content and she referred to no notes. Her focus was women's health and the importance of nurses' roles.

We were immediately drawn in by the statement 'one woman dies every 2 minutes due to pregnancy related illness'. We were inspired by a citation from Gandhi presented at the beginning and end of the talk:  'be the change you want to see in the world'. We were called to action by encouragement to 'raise up women around the world', to innovate and to stand up for oneself as a nurse which includes negotiating 'your value'. The audience was clearly appreciative of her message and absorbed by her passion and ability to speak to nurses in practice. She engaged as much with hearts as minds.

However good the presentations have been in  the equity/ethics/human rights strand of the conference, they seem unlikely to rouse participants to action. Those I attended today are likely to raise ethical awareness of the ethics and experiences of patients and nurses in relation to issues such as end stage kidney disease, palliative sedation and nurses involvement in end of life decision-making.

We (Cristina Paganini and I) presented on the latter topic drawing on findings from a four country study (Brazil, Germany, UK and Ireland). We could not claim that we delivered a call to action as did Professor Mancuso, however, it was gratifying to have colleagues from different countries say that our findings resonated with their experience. In our session, there was also a good example of an innovation in multi-professional ethics education from the University of Texas. They have developed 'An interactive adventure in ethics for the health professions' .

Should we though be content with more modest aims in applied ethics?  To raise awareness of the ethical dimensions of practice? To enable colleagues to interrogate and articulate ethical concepts and arguments? To help them understand the impact of individual, organisational and political factors on ethical and unethical practice? To analyse the ethical aspects of research data?  and to learn from each other regarding innovations in ethics education?

Should we  indeed aim to do more? To inspire colleagues to act ethically? To be good people who consistently do the right thing? In personal and professional life?.... Is this possible? or Desirable?

I would welcome your thoughts so please do respond...





 

Sunday 19 May 2013

Day 5 - Melbourne - Politics, compassion and empirical ethics...

The keynote address this morning was by Michel Kazatchkine, United Nations Special Envoy for HIV/AIDS in Eastern Europe and Central Asia. The conference theme was the focus of his talk: Equity and Access to Healthcare.   He stated that 'equity' is 'an ethical principle consonant with and closely related to human rights principles'.

Mr Kazatchkine pointed out that 30 years after the discovery of the HIV virus, there is reason to celebrate in that there is a decrease in mortality and more people are now 'living with HIV' rather than dying with it. He argued that increasing inequity was the 'greatest killer'  and that despite great advances globally, the responses have been slower in developing countries.

Political activism and global political commitment were two important factors in bringing about change in relation to infectious diseases. He praised nurses for their positive contribution to health and cited Martha Nussbaum 'we must rely on compassionate individuals to keep political insights alive.'

The equity/ethics/human rights strand of the programme is of particular interest and I met several past and present Nursing Ethics editorial board members there. All of the presentations I attended today focused on empirical ethics projects. I wonder if we are doing enough to consider the challenge of relating philosophical scholarship with empirical findings in relation to nursing ethics topics, for example relating to dignity in care. This is an area I suggest we need to continue to engage with.....