This article focuses on “morality” as such, a concept well known in every country and certainly playing a leading role in many debates, even before matters of work and certainly in professional ethics. Every one of us knows the basic ways of behaving and of relationships between people.
Many of us have certainly learned many things—through school as well as through experience—about various ethical theories, principles, views, attitudes, and reflections. We can define morality, ethics, law, freedom, and many of us may think we know almost everything about ethics. It would be unnecessary now to philosophize or to use the scientific definitions of a great philosopher like Kant. I would rather like to direct your attention to the practical use of morality in interpersonal relationships.
A person accepts the moral framework of the society in which he or she lives, but also creates a personal framework and a personal system of values. A person is a rational being, but at the same time also a great tactician. If one theorizes about ethics, one may know almost everything almost 100%, yet a little real life is enough for this same being to forget all ethical theories and to forcefully defend his or her own rights and ego—and often without thinking about the moral foundations that are so well understood.
What is really hidden in us? Can we really apply ethical theories in practical life and follow them? Is our conduct truly permeated by morality?
Putting theory into practice is very difficult, because violating moral foundations in the subtlest shades is not punishable, and sometimes this even helps our growth or satisfaction. So let us ask a rhetorical question: how can we fix this, how can we improve ourselves, how can we transform the human soul so that it is truly human?!
If someone had a simple recipe, they would surely be awarded a Nobel Prize for it. For this reason, I believe it is necessary to talk about this issue and to think at least a little about ethics.
Let us therefore look at the meaning of interpersonal relations and professional ethics in our work. A home nursing care agency is an organization-run facility like any other. It may have one advantage: relatively few employees. So one could say fewer people, more emotional well-being. This is where good interpersonal relationships must be emphasized. Each employee needs to understand their place and position at work.
Whether in a leadership role or as a staff worker, every person must keep in mind in their subconscious that, as we live in a democratic society, each of us has the opportunity for growth. That means that today each of us can be both a student and a teacher at the same time, and therefore these key actors are depicted in a circle, in contrast to how we have been used to seeing things arranged. This is because it does not represent organizational structure, but human relationships. It shows that the manager is indeed at the top of the enterprise, but also a coordinator, and nurses sit with them in the circle, symbolizing equality—humanly speaking, they are not only subordinates, but full employees with their dignity and rights.
If we talk about morality, we need to start with morality in ourselves. Even in the workplace, it is necessary to educate by example, so that others can carry this “gift” further into clients’ homes, into the homes of those for whom we exist here.
Alignment between the personality of the healthcare professional and the rights and personality of the patient is very important, because the outcome should be not only a satisfied patient but also a balanced healthcare professional.
Our unspoken counterpart is, again, human rights—from basic human rights to those of patients in various categories: hospitalization, stomas, children, oncology, dying, and many others that we all understand well.
The phenomenon of optimality in practice cannot be fully achieved at 100%, but let us at least try to come closer to theoretical understanding.
Everyone knows that the patient has the right to dignified care. In addition to high professional competence, a nurse must carry within herself a sense of dignity so that she can fulfil the patient’s legitimate demands. Are we doing this? This applies to information about health services, health status, treatment procedures, risks, alternatives to treatment, and prognosis. Is this really done, and how does a person obtain it?
There is also the right to care and treatment that should be accessible, high-quality, and continuous. This means care and treatment should match current possibilities in medicine and nursing and the needs of a particular patient, and should include collaboration of all relevant providers in diagnosis, therapy, nursing, and prevention so that suffering is relieved, pain is soothed, and humane palliative care is ensured. Think back just to the last week in our work—can we say this is always done this way?
Important too is the right to express consent and refusal before any intervention or procedure, while the consequences of such refusal must be explained, whether it is an adult or a child’s representative. Here, I can say for myself: yes.
I would add that if we want to fulfil and enrich our work with “humanity” as well as high competence, we must continuously improve ourselves in doing good so that our actions remain, in most judgments, moral actions and moral behavior.
I may be repeating myself, but I am convinced that good interpersonal relationships are the ideal foundation and reflection for a nurse’s work in the field—in the home, which is actually where we belong through this work.
If you allow me, for brevity, I will focus on at least two circles of ethical issues that are—please grant me this view—common in our home-based work. Let us consider a routine situation and a nurse’s daily work. The nurse goes to the patient’s home, into their home, into their privacy.
How should she behave, and what must she watch for? What problems may she encounter here? The nurse enters as a stranger into domestic territory, yet takes responsibility for what has been done or not done. We are in a home that is open to us with everything it involves, and we often even receive apartment keys. In many cases, intervention in the home environment is necessary. Frequently, adjustment is needed not only for the bed—its height or position in the room— but also adjustments such as removing rugs or changing shoes that hinder walking, and many other modifications, about which we must convince people. It is even harder because especially older people often refuse to change things. Even respecting the patient’s time and natural biorhythm is not as negligible a problem as we might think at first glance. We all know it well: everyone wants to be cared for first, and as soon as they call, and they want to choose when the nurse should come. What about them, about our often non-cooperative patients? But of course they also have their rights, their own activities, their own interests...
Let us now bring to mind daily reality, and that is physical nudity. In nursing care it is often necessary to expose the human body and uncover intimate areas many times, where we encounter embarrassment. Whether in front of us or in front of relatives and acquaintances. Our behavior must be highly professional and tactful, revealing no more and for no longer than is absolutely necessary. Ensuring privacy during care—whether or not anyone is watching or controlling that.
Psychological nudity is also unavoidable. We often see into deeper family relationships—“how healthy” they are—and this falls within our competencies. In addition to the actual care, we often have to process and sometimes respond to current problems or states of the specific person, who may also frequently have other problems, most often relational and financial ones, from which derive anxieties, fear, uncertainty, loneliness... and many others related to their needs and dependence on the help of others, which in no small measure affects treatment and the course of healing. A nurse’s emotional support can ease this greatly and sometimes transform it. Even so, it has still somehow not been included in the list of services ordered by health insurance; and yet we meet it every day and provide it.
Confidentiality relates to the right to protect personal and health data. In our work this mainly concerns data about health status and the sharing of related information with relatives, acquaintances, neighbors, friends, or other patients.
We can see that superexpertise alone would not suffice from a distance; what emerges as a priority is personality, moral conduct, and sometimes the nurse’s independent moral acts. After all, as we all know, if a nurse lacks even a fraction of dignified behavior, they will not reach the patient as a person and will be rejected—unlike in the hospital, where we are “at home” as healthcare workers.
Let us go further and consider our patient: what may trouble them? Another puzzle in our work is the situation where we must deal with the patient’s fear—their sense of threat and also refusal of care by a particular nurse. The reasons range from antipathy, through concerns about the nurse’s competence, to concerns about understanding of needs or humanity. The patient is afraid of incompetent and unethical intervention by a healthcare worker and does not know whether and how they can defend themselves; even when they cannot objectively assess the quality of a performed procedure in many cases, they evaluate it subjectively according to sympathy and general traits of the nurse: whether they are interested, whether they try to understand, whether they can arrange a remedy, whether they keep their word, etc.
We also encounter concern about the complexity of care provided by nurses. Until now, the patient was used only to the doctor’s competence, who arranged everything needed. Does the nurse also ensure that nothing “escapes us” and nothing necessary is forgotten? Can the patient rely on the nurse to forward the relevant information about a change in condition in time and correctly—for example, to a family doctor or another specialist—so that, for example, inadequate pain management could be made more effective?
The issue of safety in home nursing care is also crucial. There is concern about safety, whether professional during procedures or human safety. Again, trust in the nurse comes first: trust in her responsibility, character, and respect for assigned competencies. The issue of changing the caring nurse is also frequently discussed. Here resistance can reach refusal because established contacts are broken, which is usually a typical problem especially with isolated people—an already formed bond has broken and changes, especially for older people, are harder to accept and are in essence undesirable, because the client does not wish another new person to enter the home and does not want another person to know about the patient’s illness, and so on. Once again, a suitable approach, personality, and professional competence of the nurse are important.
To be comprehensive, however, let us briefly look at what may trouble the other side—the nurse. One important aspect of home care is responsibility, flexibility, and independence of both the nurse manager and other employed nurses. This autonomy brings not only benefits but above all significant responsibility: for treatment, for the work performed, for oneself and one’s conduct, for the employer as such, and for employed nurses as such. The nurse takes over part of the responsibility that was previously covered by the physician, enters into fairly complicated and multifaceted legal relationships, and the role of the independent nurse in nursing practice takes on new and broader dimensions: economic, legal, moral, and more. The nurse creates and presents not only an image of herself or the agency in which she works, but in the end represents the nursing profession.
Work in the field is not always easy for the nurse, despite professional competence and experience. Patients can be difficult, but so can relatives. The care itself is greatly hindered in aggressive, psychiatrically decompensated, or demented patients. Reaching consensus is problematic even among people with reduced socio-economic status, and problems often involve relatives due to non-compliance with the treatment regime, refusal of instructions, or methods of care, among others.
A nurse can also feel threatened, and it happens that she refuses to visit a household. This group of ethical issues concerns a nurse entering various social environments where the nurse may be potentially endangered. This type of population has been expanding recently and is a major reason for frequent demotivation of nurses and refusal to work in the field—in such an unattractive, risky environment. Does a nurse have the right to refuse to care for such a patient? In view of our profession, we cannot be too selective, and especially not in an acute condition. After all, everyone has a right to healthcare. We can see that fears are mutual. Our position as healthcare professionals suggests we should have the advantage because, in addition to high expertise, we should be able to understand many things through knowledge of psychology and ethics—and presumably we do.
Conclusion
If I spoke about professional ethics at the start, I would like to say at the end that the moral behavior of healthcare professionals, and especially ADOS nurses, is at least as important as their professional erudition, as we had the opportunity to see and hear. I must say that our nurses are competent in this area too and can hold their own against nurses in other countries. There remains, however, one residue—perhaps from the past—that we must remove: we need to teach nurses to use all the theoretical knowledge and practical skills they certainly have in order to shape the image of a morally mature and discerning personality. The path is difficult, because ethics is not like mathematics; a defined formula is not enough. Here we all have to be teachers to one another. Let us therefore work on ourselves so that, at the end of our effort, the nurse’s hands are open with heart rather than by routine.
Author: PhDr. Daniela Hlavačková, MPH
ADOS Partizánske s.r.o., R. Jašíka 156/4, Partizánske
List of bibliographic references
[1] GLASA, J. – ŠOLTES, L a kol. 1998. Ošetrovateľská etika1. Martin : Osveta, 1998. 211 s. ISBN 80-217-0594-9. [2] KOPECKÁ,K., - KORCOVÁ, M. 2008. Zdravotnícka etika. Martin : Osveta, 2008. 119 s. ISBN 978-80-8063-276-2. [3] SCHWEITZER, A. 1993. Náuka úcty k životu. Praha : DharmaGaia, 1993. 40 s. ISBN 80-901225-7-4. [4] VAJDA, J. 1993. Etika. Nitra : Enigma, 1993. 177 s. ISBN 80-85471-13-2.
The presentation was delivered at the international scientific conference Applied Ethics in Social Work and Other Helping Professions, held on 20.–21. October 2010 in Piešťany, and was published in the proceedings of this conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Aplikovaná etika v sociálne práci a ďalších pomáhajúcich profesiách. Zborník z medzinárodnej vedeckej konferencie. Bratislava : VŠZaSP sv. Alžbety. 413 s. ISBN 978-80-89271-89-4.