Resultados de la metodología de compensación

Finally in this section, ethical dilemmas occurred in this study within the secondary care context. Melia (1987) notes that nurses, who view nursing as a craft, help others to do what they would normally do for themselves, striving to become competent skilled individuals. Nursing as a profession, built on nursing theory and

178 requiring both professional association and academic qualifications, results in an increase in the nurse’s power and allows autonomous practice (Melia, 1987). This can result in conflict and challenges to some of the historically accepted hierarchies occurring, due to the new nursing roles and the blurring of professional boundaries (Oberle and Hughes, 2001; Halcomb et al., 2004). The role of the nurse has changed substantially over the last 20 years; reasons for this include the increased technological advances in health care (Storch et al., 2004). This has occurred due to the limited availability of appropriately qualified staff to undertake all the technical work, in some cases previously undertaken by medical staff. Nurses have also strived to become appropriately qualified processionals, including specialist practitioners required to meet the needs of the service (DH, 2000; DH, 2006; Darzi, 2008). This has impacted on what organisations and individual patients expect from nurses. These changes have resulted in a need to renegotiate professional boundaries and, in some cases, this can be extremely challenging; nurses refer to this as ‘working in between’ and explain how they choose their battles (Varcae et al., 2004).

Melia (2004) identified, through sociological analysis, that in the intensive care unit (ICU) team members, regardless of scientific knowledge or position within the healthcare professional hierarchy, were able to contribute to the discussions during ethical decision-making, concluding that this contributed to the smooth running of the ICU and that the wider healthcare community could learn from this.

Within the context of secondary care the difference in the power attached to team members and the patient’s position is difficult to justify, as all are working for the best

179 interests of the patients (as well as other objectives) ( Sellman, 2011). The nurse is in the unique position of spending more time with patients than many of the other professionals, which may facilitate a greater understanding of the patient’s perspective (Storch et al., 2004). Nurse participants interviewed for this study demonstrated how, by developing and maintaining effective relationships with patients and other professionals, they were able to empower themselves to achieve this. They influenced others and decisions made about patient care through working collaboratively to respect the patient’s wishes and work in their best interests. Nurses, in some cases, needed the courage to challenge those in authority and this conflict became evident when the nurse involved felt strongly that the alternative suggested course of action was not in the best interest of the patient involved.

10.3 Moral reasoning

The initial critical discussion of moral reasoning presented in this thesis focussed on a premise that it is based on the values, beliefs and expectations of the nurse. Thematic analysis of the data collected in this study has further conceptualised the theoretical framework, as presented in Figure 2. This conceptualisation, based on the in-depth interpretative analysis presented particularly in Chapter 5, refers to the theme of ‘best for the patient’ and, within this, the further sub-themes of ‘advocacy’ and ‘standards of care’.

180 Using Kohnke’s (1982) definition of advocacy as an act of loving and caring, which is consistent with a nurse’s duty of care (NMC 2008), it is argued that maintaining the highest possible standards of care for patients is a part of the role of advocate.

This is supported within the results pertaining to the accounts provided by those in the managerial position of Charge Nurse. Both Sam and Brooke talked extensively about how they worked to ensure that the standards of care provided were the best possible; both recognised that supporting and motivating staff who, for whatever reason, might have been perceived as having provided substandard care, would benefit all patients as well as the staff themselves (see Chapter 5).

Nicky and Charlie, faced with limited resources, had to consider and maintain the standards of care received by individuals and groups. In doing this these nurses were demonstrating how they advocate for the community (Caulfield, 2005, NMC 2008), in this case, the community of patients needing care; for Brooke and Sam this was primarily about standards of care and caring for the patient community. It is also evident from their accounts (see Chapter 5) that they were also concerned for the staff and, as such, were advocating in some part for the community of nurses on the ward.

The nurse participants also believed nurses have a shared value base and are likely to make similar decisions in similar circumstances, which supports the guiding principles of nursing practice (NMC 2008); this is supported in the results of the research presented (see Chapter 6).

181 10.3a Collaboration and relationships.

Working effectively within a team to resolve ethical dilemmas and provide nursing intervention within an accepted framework of central practice policy supports the sub-theme identified as ‘moral action’. The nurse’s contribution to the resolution of ethical dilemmas in the context of secondary care is facilitated through the relationships they choose to build and maintain. These relationships are identified by Peter and Liaschenko (2013) as central to morally correct culture and context and embrace the core aspects of moral agency, identities, relationships and responsibilities. Participants’ accounts highlighted the importance of these relationships in achieving moral action, as discussed below.