Conflicts of Care

Helen Kohlen, Dr. phil., ist Juniorprofessorin für Care Policy und Gemeindenahe Pflege an der Hochschule Vallendar.

Contents

Acknowledgement

Introduction

State of the Art, Theoretical Framework and Methodological Considerations

1 State of the Art in Social Science Research

2 Theoretical Framework and Research Design

3 Method and Sources of Information
Germany and the United States: Literature Review, Interviews and Pre-Study
Field Research in Germany: Participant Observation and Interviews
Data Collection and Interpretation: Qualitative Content Analysis

Historical Analysis
Bioethics and Hospital Ethics Committees

1 US-American Bioethics and the Move into the Practical Arena
"Bioethics is not just Bioethics": Its Make and (Un)Concerns
The Move of Bioethics into the Practical Arena: "Strangers at the Bedside"

2 Traces and Beginnings of Consultation by Committees
Traces of Institutionalized Consultation Committees
From Professional Ethical Standards to Governmental Intervention

3 The Development of Contemporary Hospital Ethics Committees
The Story of Karen Quinlan
Multidisciplinary Advisory Committees as Physicians' Prognosis Committees
Types of Hospital Ethics Committees: From Ad hoc Committee to Optimum Care Committee at Boston Massachusetts General Hospital
The President's Commission and ist Support of Hospital Ethics Committees
From the "Baby Does' Cases" to Infant Bioethical Review Committees
Statutory Authority for Hospital Ethics Committees, Bureaucratization and Evaluation
The Talk and its Performance in Hospital Ethics Committees
The German Development: A Re-Make of the US-American Model

4 Summary

Relational Analysis
Care and Hospital Ethics Committees

1 The Care Ethics Debate and Nursing since 1980
Caring as a Women orientated Ethics and a Feminine Model
Caring as a Foundational Concept for a Theory of Nursing Ethics
Care Ethics from a Nursing Perspective in Germany

2 Feminist and Nursing Studies in Care Ethics since 1990
Caring as a Social Practice from a Political Science Perspective
Nursing Practices of Care: Competence and Clinical Realizations
Moral Understandings and Responsibilities

3 Concerns of Care, Conflicts and Nurses' Participation in Hospital Ethics Committees Concerns of Care in Hospital
Nursing Practice Nurses' Role and Participation in Hospital Ethics Committees

4 Summary

Practical Arena Analysis
Practices in Hospital Ethics Committees in Germany

1 Introduction of the Field Research
Method
The Case Stories

2 Analysis of the Field Data
Education and Policy Making: Training, Management and Regulations
Case Discussions and Nursing Issues: The Definition of an Ethical Problem and the Marginalization of Care
Case Discussions and Medical Issues: Age, Isolation and Caring Responsibilities
Evolving Issues of Concern: Exclusions and Questions of End-of-Life Care

3 Summary

Résumé

List of Abbreviations

References

3 Concerns of Care, Conflicts and Nurses' Participation in Hospital Ethics Committees

The complexity of the health care system makes it difficult to locate the problems and concerns experienced by nurses. One way of sorting it out is as suggested above, to divide the places of action and decision-making into three levels. Described by an inside-out perspective there can be understood: First, the individual level; second, the institutional level, and third, the societal-political level. While conscientious objection is the resource to take a stand on the individual level, raising one's voice in public debates and going on strike marks taking a stand on the societal-political level. Besides joining the works council, participation in Hospital Ethics Committees offers a way to take a stand on the institutional level. One would expect that taking a stand on caring concerns and conflicts falls into the realm of nurses since they represent the biggest group to be involved in care practices. But, as this chapter will focus on: Empirical studies will reveal different findings.

Concerns of Care in Hospital Nursing Practice

Concerns of care in nursing practice are not uniquely a North American or German phenomena. Nurses in countries with distinctly different health care systems like England and Scotland, report similar shortcomings in their work environments and the quality of hospital care. A study in 2001 of more than 43,000 nurses practicing in more than 700 hospitals in five countries indicates that fundamental problems in the design of work are widespread in hospitals in Europe and North America (Aiken, Clarke, Sloane et al. 2001). Several studies have shown: while discontent among hospital nurses is high, a vast majority believes that the competence of and relation between nurses and physicians is satisfactory.

In North America and Germany, nurses reported spending time performing functions that did not call upon their professional training (delivering and retrieving food trays or transporting patients), while care practices requiring their skills and expertise (oral hygiene, skin care) were left undone (Aiken, Clarke, Sloane et al. 2001). Nevertheless, the problems of hospital nursing do not represent the entire profession. Tasks and settings vary widely.

Everyday Nursing Concerns and Invisibilities

The dominant concerns found in stories and narratives of everyday nursing practice are the ones of caring, responsiveness to the other, and responsibility (Benner, Tanner, Chesla 1996). Since responsiveness and responsibility can be described as elements of a caring practice (see Tronto in Relational Analysis, chapter two), it is the caring practice itself to be the issue of concern. What else has been found about nursing conflicts and concerns?

When the nurse scientist, and director of the Kennedy Institute Carol Taylor (1997) interviewed nurses to get to know their ethical concerns, she had to realize that most of the nurses felt hard-pressed to describe the nature of these everyday nursing concerns that had ethical significance. She states "[...] while some everyday nursing concerns are unique to nursing, most derive from tensions that involve the interdisciplinary team and raise broader issues about the human well-being that are best addressed by the institution or health care system at large" (1997: 69). In order to reveal their concerns, she then analyzed her collected case studies that lead nurses to request ethical consultation. She identified that nurses mostly struggle for (1) the respect for human dignity, (2) a commitment to holistic care, (3) a commitment to individualized care which is responsive to unique needs of the patient, and (4) the responsibility for a continuity of care and the scope of authority, and (5) identifying the limits of care-giving (Taylor 1997: 69-82). Taylor discusses that none of the concerns are unique to nursing although they may be experienced with greater immediacy and urg