Becoming critical professional beings: the ethics and politics

of student engagement

Julie Wintrup and Kelly Wakefield4th July 2013

University of Brighton

‘Can any of us be fully confident that we would never neglect a patient, bully a colleague or collude with an unethical organisational culture?’ asks Ann Gallagher, Reader in nursing ethics, Surrey, in the Nursing Times…

http://www.nursingtimes.net/ann-gallagher-we-must-understand-fallibility-and-develop-moral-resilience/5055277.article

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‘..nurses who have unmet needs are more likely to collude with uncaring practices; and a lack of ethics education, leadership and role modeling contributes to moral erosion in practice…’

Ann Gallagher

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What do we mean by ‘ethics education’? • Pragmatic (typified by ethical codes), embedded

and theoretical (Illingworth, 2004)

• Theoretical / moral theories approach and its relationship to practical / applied ethics, critiqued by Lawlor, 2006

• Virtue ethics (in nurse education - critiqued by Holland, 2010, also by Bolsin et al, 2004)

• Values based approaches (shared=invisible, not shared=visible - Fulford, VBM)

• Moral development (Kohlberg, Rest, Lind, subsequently Gilligan et al and early care ethics) including empathy

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What do we know about ‘ethics education’ in

health professions?

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Research: headlines • Much research

exists based on Kohlberg’s developmental stages..

• ..in general supporting ‘education’ as a source of moral development

• …but the research is not without its problems / critics

• ..and little persuasive evidence exists that dedicated ‘ethics education’ plays a role

• …while some evidence contradicts stage theory, suggesting ‘regression’ occurs after exposure to practice

• Satterwhite et al, 2000

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Research: the impact of practice• Some students feel

less able to make clear decisions when exposed to the complexities of practice (Nolan & Markert, 2002)

• Some struggle with feelings of loyalty to friends, colleagues (Haas et al, 1988)

• Or deny the concept of ethics, resorting to what is legal, or individual / personal choice, or a religious requirement / practice (summed up by ‘it’s personal choice’)

• Leget, 2004 7

A response to Gallagher…

‘…two things jump out here around 'ethics educations': one is a lack of education in that all 'study time' goes into mandatory training which is bilge no matter how hard the trainers try to make it meaningful, they are limited by CNST* and sends out the message 'don't think, be corporate, obey' and the apparent lack of ethics within the ethos of Trusts to support anyone with an ethical notion in their head…’

NT comments. Anon.

*Clinical Negligence Scheme for Trusts

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Research: practice or classroom?

Practice

• The need to belong, in order to be able to learn

• Levitt Jones, Lathlean, 2007 ++

• Aveyard et al, 2005

• Others – Kerry-Lee Krause 2006

Classroom

• To reflect, discuss in safety, compare notes, draw abstracts from concrete, generalise

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Micro ethics…

Can we infer that the aim of ‘ethics education’ is to affect the individual in their relationships with others - whether through inculcation of theories, personal moral development or professionalisation / socialisation processes?

If so how does it prepare us for what Francis (and so many others) have found?

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Research: the powerful urge to conform• From Milgram

to Derren Brown..

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Bolsin et al, 2004 assert:

‘…whistleblowing should be considered central to any medical ethics emphasising professional virtues and conscience’

They consider the ‘paucity of professional or academic interest in this area and examine the counterinfluence of a continuing historical tradition of guild mentality professionalism that routinely places relationships with colleagues ahead of patient safety’

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Courageous role models?

Margaret Haywood Toni Hoffman

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She said she had tried to raise standards and prepared a report but the information had been 'hushed up', forcing her to go to the BBC.  

'I understood that I was breaching patient confidentiality but I thought my actions were justified,' she added.  

'I only wanted to help people. I am a very caring and compassionate person.'

http://www.whale.to/a/whistleblower_nurse.html

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• http://www.youtube.com/watch?v=xwQk_wO2how

• .21 – 1.30 mins

How does ‘ethics education’ prepare us for what Francis (and so

many others) have found?

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Francis, 2013:

“It was not the single rogue professional who

delivered poor care in Stafford, or a single manager who ignored patient safety, who caused the extensive failure that has been identified. There

was a combination of factors, of deficiencies throughout the complexity that is the NHS, which

produced the vacuum in which the running of the trust was allowed to deteriorate”

•…how does ethics education help us with macro ethics*?

•* ‘Entire social systems of morality’ Martin Barkin, Aditi Gowri, Joseph Furtenbacher

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Francis, 2010, 1st Mid Staffs report

‘Therefore, the true picture is not one of weak leadership being provided by a particular consultant, but of a system that

may well have ground down a conscientious practitioner into a seriously pressurised man and

of a management failure to ensure proper support for clinical staff to enable good leadership’

Francis 1st report

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Forces acting against a personal ethic:• The ‘hidden curriculum’,

cultures of compliance or blame, poor management

• The urge to conform, the need to belong, loyalty, ‘guild’ mentality

• Stress, moral distress and burn out, feelings of helplessness / powerlessness (Blake & Guare, 1997); ‘Not my problem’ (van der Arend et al, 1999).

• Job insecurity, fear of victimisation, loss of trust

• Francis: ‘system’, the ‘combination of factors’, deficiencies, complexities, ‘vacuum’, management failures

• Kennedy: ‘club culture’ among medics, power / abuse of, rigid hierarchies, poor / absent communication

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What alternatives are there to such a conception of ethics

education?

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• Understand the problem differently

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Bernstein: radical dependency‘..radical dependency is .. how I connect, get responded to, get recognised, fail to get recognised..by others.

Others can humiliate, harm, devalue, degrade…and I think that’s where human life is lived, in those relationships of intersubjectivity..’

http://www.youtube.com/watch?v=q_z2RWhgOBY

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• Understand the problem differently

• Connect the micro to the macro, the local to the national / international, the specific to the trend

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• Locating the specific within the bigger picture - not taking for granted everyone watches news, reads, follows twitter!

• Continuing to connect staff shortages / closures etc with treatment effects / mortality (eg Griffiths et al)

• Engaging with others / other disciplines (eg Bertolt Meyer) to broaden view

• Examining relationships between industry and healthcare / public and private / funding streams (eg Goldacre)

• ‘my story - politics as many stories’

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• Understand the problem differently

• Connect the micro to the macro, the local to the national / international, the specific to the trend

• Seeing a move from critical thinker to critical being as the only option

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Barnett, 1997

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“Critical persons are more than just critical thinkers. They are able critically to engage with the world and with themselves as well as with knowledge”

Critical being requires knowledge (critical reason), the self (critical reflection) and the world (critical action)

Barnett, 1997

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• Understand the problem differently

• Connect the micro to the macro, the local to the national / international, the specific to the trend

• Seeing a move from critical thinker to critical being as the only option

• Actively support critical being in ourselves and our students, as educators and practitioners - measure / assess awareness, action and proactivity in practice

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• Developing ethical awareness, sensitivity – improving our ‘antennae’ (Fenwick)

• Understanding how what gets measured drives behaviour – develop portfolio evidence / CPD evidence based on assessment of culture, norms, problems…

• ..and actions – what I did / who I spoke to / how I followed up / what happened next – discuss openly, professionally

• Use ideas – eg Bolsin’s self reporting of adverse incidents (Geelong Hospital and PDA), Carel’s philosophy toolkit, Zimbardo’s protective factors..

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• Understand the problem differently

• Connect the micro to the macro, the local to the national / international, the specific to the trend

• Seeing a move from critical thinker to critical being as the only option

• Actively support critical being in ourselves and our students, as educators and practitioners - measure / assess awareness, action and proactivity in practice

• Develop collective and communal responses – which involve and share responsibility with (all) educators 30

• Create safe places, times for students / learners to discuss their experiences, check out worries,

concerns, develop their antennae..

• …and follow up with regular discussion with educators who share responsibility with them for assessing, responding, acting

• Support (appraise etc) each other as educators in

developing our antennae..

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Thank you

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