Nursing Ethics

I am excited to be back in classes for the Spring semester, and inspired by my reading last night which matches closely with my understanding of Buddhism.  Three paragraphs discussed the "three basic ethical principles of nursing": Respect for a persons right to self-determination, beneficence, and justice. 

Self Determination: Treat patients as autonomous individuals capable of making their own decisions.  My fiancee recently described working with a parent who was trying to get their child to stop playing with water.  I was impressed with her ability to hold the parent's point of view as well as the child's in the interaction that followed.  My reaction to hearing the situation was "I would have been like, 'it is okay if they play with water, we can clean it up later."  However, such a response would have undermined the parent's authority and potentially confused the child if there is an expectation around such play that will be enforced when the child is not in that setting.  Likewise, patients have different frames of reference from my own and it is not only counterproductive to impose my beliefs on them but also disruptive to their health and overall well being.  Buddhism takes the long-view.  The Buddha was enlightened some 2500 years ago and set out to "save all beings," however he did not exhaust himself trying to force people to accept one "way" of doing things.  In one story he sits in silence as a learned man sits and questions him, finally leaving convinced that the Buddha is a sham and has nothing to offer.  When asked why he was silent by his disciples the Buddha replied that the man didn't really want to hear he just wanted to argue.  It was not appropriate to teach what would not be heard.

Beneficence: Work for the benefit of the patient.  This includes the axiom "first, do no harm" common among doctors, and includes a wider sphere of active participation in ensuring the patient's well-being.  I can see how the art of nursing becomes important as potential conflicts exist between my personal and cultural norms and standards and the patient's right to self determination.  I am beginning to see my role as educator and advocate as potentially more fluid and dynamic than I thought.  Perhaps each patient brings a new frame of reference and boundaries within which my work to benefit a patient is somewhat constrained.  I say "somewhat" because I think it is also my role to explore these boundaries with patients and push to expand them where appropriate.

Justice: Treat all patients equally and fairly.  I referred to this in an earlier entry in which I saw the orange jumpsuit of prison patients as a kind of meditation bell.  A reminder to slow down and give the best care possible regardless of cultural learning that disregards prison populations, lower social classes, and minorities in general.  A number of readings in my program have also highlighted the role of nurses not only in their care settings but also in their communities.  This is a very Buddhist teaching.  If a problem exists in a community or nation that manifests as a recurring problem in a healthcare setting it is the nurses role to address the larger issue and not just treat the manifestation in the healthcare setting.  Cardiovascular disease among African-Americans, the obesity epidemic, low levels of health education... These are areas that can be addressed both in the microsystem of bedside or outpatient care as well as through advocacy, research, democracy, community involvement, mentoring, etc.

I am looking forward with beginners eyes and eagerness to develop my professional practice.  When I started this program I was excited by the calls from my teachers to view our profession as fluid and full of continuous learning.  I don't think that I will ever be "done" as a nurse.  That is one of the most exciting things about this profession.

Two Hands

I recently read about a very powerful practice in David Richo's The Five Things We Cannot Change.  It has been helpful for me in both my study of the duality inherent in Buddhism and in living my own life more mindfully.  This practice as described empowers me to takes seeming opposites and holds them both equally.  He uses the example of fear.

Fear can easily lead to a reactionary response, a conditioned response to avoid fear, anxiety, danger.  If I am afraid of what others may think I may act to control the situation by reacting and doing something to please others.  If I am mindful and use this practice I may act in a manner that recognizes this fear, and also honors my own needs and commitments.

I can hold my fear in one hand and my commitment to no longer act in a fear-based way in the other.  Somehow that combination seems more doable than no fear at all.

He continues:

A useful spiritual practice in any predicament is to hold both hands out, cupped, palms upward, and imagine them holding just such opposites.  We feel the light and equal weight of both, since our hands are empty.  We then say, for example, "I can serenely hold both my need for relationship and my not having one right now."

...

I have found that sometimes when I implement this practice I may act in the same manner as if I reacted, however when I mindfully act in this way I find that I am not tied to an outcome, but rather engaged in a process.  I am sure of my motives and I am not ashamed of my actions.

I honor myself by being true to myself and my own unique experience of the world.

David Richo emphasizes holding the current situation in one hand and the "power to work with it" in the other.  By doing both of these things we are able to honor our experience, but not be trapped in it.  It is a practice that acknowleges difficulties and also builds competene and self-esteem by working with difficulties as opposed to against them or in a way that avoids discomfort in our experience.  The later being impossible (see First Noble Truth).

Since this is a blog about Buddhism I will add that the seemingly opposite truth that my self, my being, my experience, etc. are also illusion.  I can hold these two truths serenely and with love in my heart.

Buddhism also teaches about dependent arising, impermanence and no-self.  In reflecting on this exercise I realize that it has been the recognition that two people having different experiences and truths can be equally "right."  The teachings of Buddhism seem to be pointing out that one person holding two "opposing" thoughts is similar to two people having unique experiences.  Both can be equally true.

The Buddha on Self-Care

If one going down into a river,
swollen and swiftly flowing,
is carried away by the current -
how can one help others across?
- The Buddha in Sutta Nipāta 2.321

When I saw this I had to share.  I have been trying to find the words to express the importance of nurses providing themselves with adequate self-care.  It has been pointed out by professors that this is something that nurses often struggle with, that nurses often have codependent tendencies, and that a lack of self-care leads to burnout and job dissatisfaction.

In my own life I have noticed in the last two years how taking care of my own needs leads to a more fulfilling life in which I am more available to help others.  I also find that I am less tied to specific outcomes and less stressed in general when I act because I want to and not because I think that a specific action will lead to a desirable outcome.

Although I have for years thought that acting (reacting) in this way was compassionate or altruistic the truth as I see it now is that I was reacting selfishly to save myself from suffering.  Many of my reactions were attempts to control the outcome of a situation.

It is my goal to act mindfully and accept that sometimes I can mindfully put my own needs ahead of those of another and trust that they will do the same.  This is empowering to both of us in ways that I did not experience as a youth.  I can see how I will both mindfully act to recognize a desire to control a situation and act out of compassion for myself.

The outcome of reaction and mindful action may look the same on paper (I may take the same action), however, when I have acted mindfully I have not regretted an action, and in some cases I have empowered others in ways reacting does not.

I am vowing to myself to act mindfully as a form of self-care
I am vowing to continue my exploration and implementation of self-care measures in my life.