Ethical interprofessional collaboration-in-practice.

Ethical interprofessional collaboration-in-practice. Ethical interprofessional collaboration-in-practice. I need help with a Health & Medical question. All explanations and answers will be used to help me learn. See Instructions in Unit 3 Discussion instructions interprofessional_collaboration_in_practice.pdf levels_of_intervention_.pdf the_abc_of_health_care_team_dynamics.docx unit_3_discussion_1_instructions.docx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Article Interprofessional collaboration-in-practice: The contested place of ethics Nursing Ethics 20(3) 325–335 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733012462048 nej.sagepub.com Carol Ewashen University of Calgary, Canada Gloria McInnis-Perry University of Prince Edward Island (PEI), Canada Norma Murphy Dalhousie University, Canada Abstract The main question examined is: How do nurses and other healthcare professionals ensure ethical interprofessional collaboration-in-practice as an everyday practice actuality? Ethical interprofessional collaboration becomes especially relevant and necessary when interprofessional practice decisions are contested. To illustrate, two healthcare scenarios are analyzed through three ethics lenses. Biomedical ethics, relational ethics, and virtue ethics provide different ways of knowing how to be ethical and to act ethically as healthcare professionals. Biomedical ethics focuses on situated, reflective, and nonabsolute principled justification, all things considered; relational ethics on intersubjective, professional, and institutional relations; and virtue ethics on prephilosophical tradition and what it means to be good and to be human embedded in social and political community. Analysis suggests that interprofessional collaboration-in-practice may be more rhetoric than actuality. Key challenges of interprofessional collaboration-in-practice and specific conditions perpetuating dissension and conflict are outlined with specific education and policy recommendations included. Keywords Biomedical ethics, ethics, interprofessional collaboration, interprofessional practice, relational ethics, virtue ethics Introduction Collaborative practice and nursing in Canada have a long and intertwined history. A key ethical responsibility of professional nurses is that ‘‘nurses collaborate with other healthcare providers and other interested parties to maximize health benefits to persons receiving care and those with healthcare needs, recognizing and respecting the knowledge, skills and perspectives of all’’ (p. 10).1 Nurses are positioned as moral agents who reflect on everyday practice and work with others ‘‘to create moral communities that enable the Corresponding author: Carol Ewashen, Faculty of Nursing, University of Calgary, 2500 University Dr. N.W., Calgary, AB T2N 1N4, Canada. Email: [email protected] 326 Nursing Ethics 20(3) provision of safe, compassionate, competent and ethical care’’ (p. 5).1 To qualify as professional, nurses are obligated to be collaborative, to know and to practice collaboration to maximize health benefits, and to create workplace environments that qualify as moral communities. The professional imperative to collaborative practice resonates with a national call for new models of healthcare delivery.2 One such model, collaborative patient-centered practice, is designed as integral to healthcare renewal, a way of healthcare professionals working together in practice and with patients, families, and communities actively involved.3 Collaborative practice is conceptualized as the continuous interaction of two or more professionals or disciplines, organized into a common effort to solve or explore common issues, with the best possible participation of the patient. (p. 28)4 Collaborative practice is envisioned as ‘‘an interprofessional process of communication and decisionmaking that enables the separate and shared knowledge and skills of healthcare providers to synergistically influence the client/patient care provided’’ (p. 4).5 Interprofessional collaboration-in-practice becomes a complex arena of different knowledges, practices, and value orientations, a place of differential relations of power6 and moral complexities.7 While designed to promote a synergistic working together whereby the knowledge and practice of each profession are respected and enabled, issues of turf protection and differences in value orientations surface yet often remain unexamined.8,9 Curran3 noted that ‘‘the professional system is based on separate silos of professional practice which acts as a barrier in different ways to collaborative practice’’ (p. 24). Ethical interprofessional collaboration-in-practice. A critical question arises: How do nurses and other healthcare professionals ensure ethical interprofessional collaboration-in-practice as an everyday practice actuality? We propose that understanding different ethical perspectives is critical to interprofessional collaboration-in-practice that ‘‘fosters respect for disciplinary contribution across all professions’’ (p. 28).4 Ethics lenses become especially relevant and necessary when practice decisions are contested. We propose that if professionals practice from an understanding of different ethics lenses, the probability of successful interprofessional collaboration-in-practice would increase. New knowledges are brought to examining the ‘‘self,’’ the ‘‘other,’’ and the ‘‘institution.’’ Reflexive contemplation of interactions with others and anticipation of the effects for health service delivery are consciously examined from the lens of ethical interprofessional collaboration-in-practice. To illustrate this, two healthcare scenarios are presented and analyzed using three different ethics lenses: biomedical, relational, and virtue ethics. Biomedical ethics,10–12 relational ethics,13–15 and virtue ethics16,17 provide different frameworks for knowing how to be ethical and to act ethically as healthcare professionals. These lenses, embedded with different emphases in current professional codes of ethics, provide direction for the examination of interprofessional practice.1,18,19 The analysis focuses on the how of practice. Specifically, how do professionals interact with each other, how is a shared common effort organized to solve or explore issues, and how does each contribute. Recommendations for healthcare policy and interprofessional education are included. We begin with a brief overview of each ethics perspective. Biomedical ethics: principlism In 1979, the first edition of what was to become an authoritative text on ethics, Principles of Biomedical Ethics, was published.20 With subsequent editions, a radical reconstruction occurred.21,22 The ‘‘old’’ deontological principles established historically as the canons of biomedical ethics were embedded in a common morality framework reconceptualized as a universally shared product of human experience and history with particular moralities as subsets.12 Significantly, previous accounts of the ethic of care were revised ‘‘as a form of virtue ethics’’ (p. vii). The task of the agent is to determine and justify, all things considered, actual obligations specific to the situation often in the face of competing values, principles, and norms. Four clusters of moral principles were defended and elaborated as general guidelines: 326 Ewashen et al. 327 (1) respect for autonomy (a norm of respecting and supporting autonomous decisions), (2) nonmaleficence (a norm of avoiding the causation of harm), (3) beneficence (a group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs), and (4) justice (a group of norms for fairly distributing benefits, risks, and costs). (p. 13) The proposed method, oriented to action, high moral conviction, and the lowest level of bias, was an integrated model of coherence or reflective equilibrium, a reflective testing and reconsidering of moral beliefs, principles, and theoretical postulates applicable to the case. In case analysis, principles become more specific to the case while case particulars are illuminated through the lens of moral principles, norms, and values. Analysis questions may include the following: Which moral principles are in question, by whom, and with what justification? Which rules and ideals come into play? Where are particular professional moralities and differences apparent and to what effects for ethical practice? The process of justification when united with common morality requires thoughtful considered judgments particular to moral life and to the case—individual, institutional, cultural, and situational. Ethical interprofessional collaboration-in-practice. Arrival at a final lasting coherence is assumed a utopian ideal, and thus, ethical judgments become never-ending searches for best justifications, all things considered. Relational ethics: ethic of care Bergum13 further developed Gadow’s23 work on relational narratives and the proposed relational ethic of care. Nursing practice narratives became a means for understanding care, moral choice, and ethical practice. Two key assumptions underpin relational ethics: (a) ‘‘The kind of knowledge needed for ethical care must be constructed in the relationship between the professionals and the patient, between the patients and their families, and even between theorists and practitioners’’ and (b) ‘‘truth is a matter of the context in which it is embedded’’ (p. 72). Three different forms of knowledge were proposed: descriptive, disengagement or abstraction, and inherent. Descriptive knowledge, subjective knowing, consists of the meanings of the lived experience. Disengagement or abstraction, objective knowing, is valued for its universality and generalizability most evident in theorizing, categorizing, and determining causality. Inherent knowledge, constructed knowing, emerges from the event of health and illness and involves social relations, intersubjective meanings, and the lived experience as a whole. The relational space, the location of enacting morality through practice-in-relation, holds all these forms of knowledge. Four dimensions of relational ethics24 were proposed: engagement as a relational process of emotional and meaningful connectedness; mutual respect as a means to new understandings and as essential for coexistence between people who are different but of equal worth and dignity; embodiment as lived reality of the body, the lived reality of who we are, and a recognition of the lived body as object; and environment as being the natural lifeworld, the critical elements or characteristics of each lived (healthcare) situation. Nurses’ being-for-theother becomes a site of ethical sensibility, of emergent nursing knowledge assumed as prereflective, preontological, and residing on a moral foundation through which nursing practice wisdom and sensitivity are fundamentally related to ethics.15 In nursing practice, being-for-the-other involves openness to the vulnerability of the other, ‘‘the awakening of consciousness of another’s suffering’’ (p. 230). Furthermore, in healthcare situations, engaging in the lived life while engaging in the lived body is the embodiment of care. The four interrelated relational themes assist us in understanding ourselves as we engage with others. A practitioner asks, ‘‘How should I act?’’ and ‘‘What is the right thing to do both for oneself and for others?’’ (p. 485).23 All relationships are assumed as moral, and quality relationships are viewed as mutually respectful reciprocal processes of reflective dialogue oriented to achieving shared goals, a process of intersubjectivity essential to ethical relations. What is ethically relevant is considered in the context of a trusting and often complex environment where a clear understanding of the other’s circumstances is paramount. 327 328 Nursing Ethics 20(3) Virtue ethics MacIntyre16 in After Virtue offered what was to become a provocative work reexamining modern-day morality. He proposed that instrumental rationality dominates the modern ethos with actions primarily informed by reasoned beliefs, none of which may be right. This modern-day reliance on instrumental reason obscures the significance of values and means to ends, privileging facts and outcomes over motives and character. Ethical interprofessional collaboration-in-practice. He offers an alternative that relies on the ‘‘tradition of virtue’’ whereby ‘‘embodying the precepts of the natural law, would direct us towards the achievement of our common goods and educate us to become citizens who find their own good in and through the common good’’ (p. xi).17 A virtue ethos is conceptualized as a social and political practice, a narrative of human life, and a moral tradition. The notion of practice figures large for MacIntyre.16 Practice becomes the means to virtue and virtue the means to the internal good of practice. Through an iterative cycle of pursuing the internal good of practice (‘‘goods of excellence’’), practitioners both emulate and cultivate virtue. Practitioners only exercise sound practical reasoning through orienting to the ‘‘pursuit of goods of excellence inherent to social practices’’ (p. 12).25 This Aristotelian notion of practice rationality assumes that (a) to be human is to act rationally in society with others, (b) to act justly is to orient to the good, (c) reason and action are partially constitutive, and (d) the greatest good is the good life. Practical reasoning offers healthcare professionals a more complex discernment distinguished from traditional objective and instrumental reasoning in orienting practitioners to good and just action, the internal good of healthcare practice, the specifics of the healthcare setting, and virtuous character. Practical reasoning requires practitioners to be aware and sensitive to deeply held morals, values, and beliefs of self and others. Engagement in practical reasoning is agent centered and action centered requiring practice judgment or practice wisdom that is situated in place and tradition; in relation to self, other, and society; and in the particulars of each situation. The practitioner considers not only ‘‘what should and must I do?’’ but also ‘‘what kind of person am I and should I be’’ in relation to others and in relation to the good of practice.26 Virtue ethics is both an ethic of aspiration and an ethic of obligation, a way of being, and a means to the good of practice. Interprofessional collaboration-in-practice: scenario 1 The interprofessional team has an established tradition whereby the Psychiatric Mental Health Nurse (PMHN) is responsible for initially interviewing the client, completing a thorough nursing assessment, and determining the problems and needs of the client. The information is then presented at a team meeting, and a team approach to treatment is determined. Two new physicians recently joined the team. In this scenario, the PMHN is prepared to present the nursing assessment and analysis to the team. When the nurse attempts to do so, the physicians indicate indirectly that they do not require the information. The nurse states that ‘‘it was obvious that they were not interested in the information collected by the nurses as the physicians did not refer to the assessment or nursing notes.’’ This was further interpreted as nurses not being capable of completing accurate assessments and providing useful information, nor competent enough to assist in client diagnosis and treatment. The nurse felt insignificant, and the team approach became fragmented. In addition, the physicians would not attend team meetings on a regular basis, stressing how busy their schedules were. When one of the nurses approached one of the physicians to outline the nurses’ concerns, the physician reacted with surprise and then reassured the nurse that the team approach was important and necessary. In the short term, team attendance at meetings improved with the intent to review and discuss difficult ‘‘cases’’; however, this never materialized in practice. Ethical interprofessional collaboration-in-practice. Scenario 1 analysis: the lens of biomedical ethics Using the reflective equilibrium approach, it is important to consider the particular individuals; institutional, cultural, and situational conditions; and relevant moral principles. In this scenario, established team 328 Ewashen et al. 329 tradition is interrupted by the arrival of two new team members and by those new members changing an established team pattern of interaction and decision making. The new members do not follow the team approach tradition of sharing information. The new members’ actions are interpreted as disinterest in the information offered by other professionals. Consequently, the PMHN feels insignificant, the nurses are positioned as incapable, and interprofessional practice becomes fragmented. Two general principles come into play: (a) respect for, enactment of, and negotiation of professional autonomy and (b) the dual obligation of beneficence. Compromised professional autonomy emerges as a critical source of tension for the nurses and for interprofessional collaboration as a whole. For the nurses and implicitly for the collective, professional autonomy was diminished, perhaps even discounted and delegitimized. Where previously the nurses felt respected and contributed significantly to client care deliberations, current contributions by nurses were now interpreted as less valued. According to Beauchamp and Childress,12 two conditions are considered essential for autonomy—independence (self-rule) and agency (capacity to act). In interprofessional practice, autonomous independence and agency are subject to professional, legal, institutional, and ethical constraints. However, at minimum, professionals are asked to understand each other’s perspectives, responsibilities, and competencies. In interprofessional practice, professional autonomy becomes a negotiated principle whereby the views and rights of the other are to be respected as long ‘‘as thoughts and actions do not seriously harm other persons’’ (p. 64).10 A lack of respect for professional autonomy in this scenario has deleterious effects for particular professionals as well as for interprofessional collaboration. Interprofessional collaboration also implicates a dual obligation of beneficence, an obligation to act for the benefit of the recipients of care (the patient) and an obligation to act for the benefit of others. The question of paternalism is raised in that autonomous choice is limited through some form of interference, either overt or covert. Words may not coincide with actions and/or remarks may be interpreted as condescending or devaluing, and institutional procedures and policies may not adequately support interprofessional collaboration in decision making. An interprofessional tradition of shared decision making becomes undermined. Obligations of specific beneficence rest on team negotiation of professional roles, commitments, and attendant responsibilities with consideration for institutional policies and procedures as well as disciplinary codes of conduct and standards of practice. Scenario 1 analysis: the lens of relational ethics In this scenario, from the perspective of subjective knowledge, the PMHN felt devalued, patronized, and thwarted in attempts to engage in meaningful dialogue. The subjective meaning that emerged was that nurses were incapable of providing information worthy of the physicians’ consideration. From an objective knowledge perspective, the arrival of two new physicians resulted in a significant change to the team structure and team dynamics. The PMHN–physician relation became conflicted, and the nurse experienced profound tension that the physician ignored. Meaningful interprofessional relations, nurtured through mutual respect and dialogue, were missing, and thus, the coconstruction of inherent knowledge perpetuated professional relations of perceived injustice and paternalism. The nurse perceived that her knowledge and expertise were not valued. The psychiatrist appeared uncommitted and team collaboration deteriorated. Disengagement was perpetuated. Embodiment for the nurse resulted in moral distress, disempowerment, and anger. 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