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Am I My Students’ Nurse? · Health Ethics Podcast

0:08
Speaker 1: Welcome to Health Ethics, a series of conversations with leading
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Speaker 1: experts about ethical considerations associated with health and healthcare, both
0:17
Speaker 1: locally and globally. I am Brian Pilkington, Professor of Bioethics
0:21
Speaker 1: in the Department of Medical Sciences at the Hackensack Meridan
0:24
Speaker 1: School of Medicine. This series, like its predecessor, which focused
0:29
Speaker 1: on the COVID nineteen pandemic, relies on the idea that
0:32
Speaker 1: challenging ethical issues are best addressed by folks from diverse
0:36
Speaker 1: backgrounds practically reasoning together, and complements the Health Ethics Series
0:41
Speaker 1: with its panel of leading experts from medicine, nursing, politics, economics,
0:46
Speaker 1: philosophy and the law. Thank you and enjoy the episode.
0:59
Speaker 2: Welcome everyone to the Health Ethics Series podcast. I'm Brian
1:02
Speaker 2: Pilkington and it is my great pleasure to be speaking
1:04
Speaker 2: with Paul Snelling. Professor Snelling had a clinical career in
1:08
Speaker 2: intensive care in general nursing before becoming on a lecture
1:11
Speaker 2: in two thousand and one. Paul is currently Principal Lecturer
1:14
Speaker 2: and Adult Nursing at the University of Worcester, where he
1:16
Speaker 2: teaches mainly about research methods on the undergraduate Preregistration nursing program.
1:21
Speaker 2: He completed his PhD at the University of Manchester in
1:24
Speaker 2: twenty fourteen and was concerned in his work there with
1:26
Speaker 2: the nature and extent of personal responsibility for health. His
1:29
Speaker 2: research in the field of professional ethics, principally as the
1:32
Speaker 2: lead of the Philosophy and Ethics of Professional Practice research Group,
1:36
Speaker 2: has been excellent. He's published papers on public health ethics
1:39
Speaker 2: and the nature of professional regulation and codes of ethics
1:43
Speaker 2: and conduct. He also serves on the editorial board of
1:46
Speaker 2: Nursing Ethics, and on a personal note, I can say
1:49
Speaker 2: has given phenomenal comments to some work that I've done.
1:51
Speaker 2: So Paul, it is great to have you here. Thanks
1:54
Speaker 2: so much for joining me.
1:56
Speaker 3: Well thanks for asking me, Brian, that's quite a build up.
1:59
Speaker 4: You given me the so.
2:02
Speaker 2: And we'll jump rain in. So, I mean, your work
2:05
Speaker 2: is extensive, but what I'm really interested in is sort
2:07
Speaker 2: of considerations of teaching and of practice. And so you've
2:10
Speaker 2: written a really nice article sort of raising big questions
2:14
Speaker 2: about whether nursing professors. We can extrapolate this other health
2:17
Speaker 2: professions as we talked through, but whether you are your
2:21
Speaker 2: student's nurse. So before I ask, I mean I suspect
2:26
Speaker 2: a bunch of folks who are listening to this probably
2:28
Speaker 2: have read the paper. Others after we chat, will listen
2:31
Speaker 2: more so they can get sort of the minutia of
2:33
Speaker 2: the argument there. But before we run through the basic argument,
2:37
Speaker 2: what motivated you to think about this topic to write
2:40
Speaker 2: about it? Yeah, to write about whether you're your student's nurse.
2:43
Speaker 4: Ron.
2:44
Speaker 3: I'm knocking on a bit and coming to the end
2:47
Speaker 3: of my kind of full time academic career, and this
2:50
Speaker 3: has been something that I've been mulling over for a
2:53
Speaker 3: long time, and a couple of years ago Anne Gallagher,
2:57
Speaker 3: who's the editor of Nursing Ethics, was doing a simple
3:00
Speaker 3: useum at University of Exeter about cultivation of character. And
3:04
Speaker 3: this is where finally I kind of got the motivation
3:08
Speaker 3: to stop mulling it over and actually trying concrete put
3:11
Speaker 3: some concrete ideas down on paper. And it's really kind
3:15
Speaker 3: of about identity, because you know, if I was at
3:20
Speaker 3: a party and I said, what do you do?
3:21
Speaker 4: I mean? What am I? I mean?
3:23
Speaker 3: I'm a nurse. It's a statement of facts.
3:25
Speaker 4: So I'm a nurse.
3:26
Speaker 3: I'm a registered nurse who can look me up on
3:27
Speaker 3: the register. But my work has been in education for
3:33
Speaker 3: over twenty years, and students often say to me, you know,
3:37
Speaker 3: do you miss nursing? Are you still a nurse? And well,
3:41
Speaker 3: I am still a nurse and the NMC, my regulator,
3:43
Speaker 3: thinks that what I'm doing is nursing, So that kind
3:46
Speaker 3: of led me to this thing, Well, am.
3:47
Speaker 4: I a nurse? Am I teacher? You know what? Am I?
3:51
Speaker 3: And comparing different sorts of relationships within the kind of
3:56
Speaker 3: sphere that I've inhabit or the spheres that I inhabit
3:59
Speaker 3: has kind of led to this kind of expiration of
4:02
Speaker 3: that questions.
4:03
Speaker 2: Yeah, I mean it's it's a really interesting one and
4:06
Speaker 2: sort of what role you occupy And when students ask
4:10
Speaker 2: are you are you a nurse? I mean in part
4:12
Speaker 2: because if we think, and this is my own biases,
4:14
Speaker 2: but sort of how I view professions. Part of what
4:17
Speaker 2: a profession is required to do is to disseminate certain
4:21
Speaker 2: kinds of information right and train up future professionals. So,
4:25
Speaker 2: given the demands of clinical nursing practice, if you don't
4:29
Speaker 2: have folks doing the teaching, if you don't have folks
4:31
Speaker 2: doing the research, the profession as a whole sort of
4:34
Speaker 2: loses something really important. So I see, I see the
4:37
Speaker 2: identity tension. I also and for folks who listen to
4:41
Speaker 2: the podcast will have heard some of these questions and
4:46
Speaker 2: concerns pop up. We had Bob Trugan Sam Dornberg on
4:50
Speaker 2: talking about sort of spheres of morality and role morality,
4:55
Speaker 2: and they were really interested in physicians who got pulled
4:57
Speaker 2: into different kinds of work and what the norms were.
5:00
Speaker 2: There might be a similar question later on. I want
5:02
Speaker 2: the sort of basic argument in the paper, just for
5:05
Speaker 2: folks who haven't read it, but sort of when the
5:07
Speaker 2: norms of teaching or not, when if the norms of
5:12
Speaker 2: teaching ever run a foul of the norms of clinical practice.
5:16
Speaker 2: So do you owe things?
5:18
Speaker 3: Yeah, that's the tension, the tension, Brian. And when just
5:21
Speaker 3: before I start, before the before students, you know, they'll
5:24
Speaker 3: say do you miss being a nursing? Are you still
5:26
Speaker 3: a nurse? Because they're not very impressed by my my
5:29
Speaker 3: or not always very oppressed by my response. You know,
5:32
Speaker 3: look me up on the register. I am still a
5:33
Speaker 3: nurse because I've not done clinical nursing. And many often
5:38
Speaker 3: students see a difference between clinical nursing and educational management.
5:43
Speaker 4: You know, they're nurses.
5:44
Speaker 3: They're out there in the wards and people's homes, caring
5:46
Speaker 3: for people. I'm in my office and in the classroom.
5:49
Speaker 3: They see it, they see a distinction. It's it's yeah,
5:53
Speaker 3: it's an interesting one. But the paper is an argument
5:55
Speaker 3: from analogy, and I think that's something that I've used before.
5:58
Speaker 3: And I think people drawn to this sort of argument
6:01
Speaker 3: from analogy because they're very They compare things a lot.
6:05
Speaker 3: Everyone compares things. You know, my students in the classroom,
6:08
Speaker 3: they compare what they do with what I do. I
6:11
Speaker 3: think arguments from analogy and I've used it before in
6:14
Speaker 3: other spheres. I think I find them attractive. I find
6:16
Speaker 3: that kind of inductive argument attracted, rather than that the
6:20
Speaker 3: kind of theory led stuff. I just I find it
6:23
Speaker 3: much more engaging. And I think others do as well,
6:26
Speaker 3: stories and cases.
6:27
Speaker 4: That kind of thing.
6:29
Speaker 3: So that the kind of points of comparison were two
6:32
Speaker 3: sets of relationships. One set of relationship is the relationship
6:36
Speaker 3: between a nurse and a patient, and that's a fascinating
6:39
Speaker 3: relationship anyway, But that's one side of the comparison, and
6:44
Speaker 3: the other side of the comparison is the relationship between
6:47
Speaker 3: a lecturer and a student. Now, my students are also nurses.
6:52
Speaker 4: But that they don't have to be.
6:54
Speaker 3: And of course a third relationship for comparison would be
6:58
Speaker 3: another lecture you for exams, Uncle Brian, you're a lecturer,
7:01
Speaker 3: but you're not a nurse. So so if you were
7:04
Speaker 3: to teach my students ethics rather than me teaching, well,
7:06
Speaker 3: I'm a nurse, I'm bound by these things. You're a philosopher,
7:09
Speaker 3: you're not bound by them.
7:10
Speaker 4: You might be.
7:11
Speaker 3: There might be a philosopher's code of conduct that I
7:13
Speaker 3: don't know about. So you've got these number of different relationships.
7:16
Speaker 3: That last one I think is really interesting and I
7:18
Speaker 3: have touched on it a bit, but I'm mainly interested
7:21
Speaker 3: in the in the first two arguments. So the first
7:25
Speaker 3: question is am I am I a nurse? Well, yes
7:29
Speaker 3: i am. I am on the register. And the code says,
7:31
Speaker 3: our code says completely unequivocally that these values are not negotiable.
7:39
Speaker 3: If you're working in education, if you work in practice,
7:41
Speaker 3: you are still a nurse. You are still bound by
7:44
Speaker 3: the code. And the codes are kind of always regarded
7:48
Speaker 3: as a kind of more of a legal thing than
7:51
Speaker 3: an ethical thing that might come up in conversation later on.
7:55
Speaker 3: But the NMC says to me, I can't put that
7:58
Speaker 3: away saying I'm not really a clinic a nurse, you
8:00
Speaker 3: are a nurse. And that seems to me to lead
8:03
Speaker 3: to some contradictions, which perhaps we can go through one.
8:07
Speaker 3: But I don't want to read the whole thing out.
8:08
Speaker 3: But but there are some there. I can give you
8:10
Speaker 3: some examples, if that's all right.
8:11
Speaker 2: Please, yeah or yeah, pick your yeah, an example or
8:15
Speaker 2: two would be great.
8:15
Speaker 3: So I've got there's six examples in the paper. Maybe
8:19
Speaker 3: i'll I'll just I'll pick a couple of I mean,
8:22
Speaker 3: the first one is about confidentiality, and that's really about
8:25
Speaker 3: if a patient, if sorry, if a student tells me something.
8:27
Speaker 3: I'm bound by confidentiality because it's in the code. But
8:31
Speaker 3: but you, Brian, if if they told you the same thing,
8:35
Speaker 3: you're not bound by the same confidentiality. I don't if
8:38
Speaker 3: there may be a code of if it's common morality
8:41
Speaker 3: that would that would would would guide your actions if
8:45
Speaker 3: someone told you something. Well, I mean, I'm just pointing
8:48
Speaker 3: out at this point that these are these are different
8:50
Speaker 3: and they could lead to interesting cases.
8:52
Speaker 2: You're nodding, yeah, I agree, I agree, because and this
8:54
Speaker 2: is something that's come up in conversation sort of around
8:57
Speaker 2: the institution I work in is what are the and
8:59
Speaker 2: it's working amount of school mainly with positions, but you
9:02
Speaker 2: know last year I was sort of with nurses and
9:04
Speaker 2: physicians everybody else, and it's I mean, this is really interesting.
9:06
Speaker 2: And even when I talk to students, I say, look,
9:08
Speaker 2: I will never be both in terms of confidentiality, but
9:11
Speaker 2: in other kinds of situations. I'm never going to be
9:14
Speaker 2: in that care situation. And you, I mean, having practiced
9:17
Speaker 2: clinical nursing, I'm not aware of it. Maybe I'm just
9:19
Speaker 2: a bad philosopher, but I'm not aware of the philosopher's
9:22
Speaker 2: code of conduct. But yeah, I mean, so tensions that
9:27
Speaker 2: might arise in certain instances where you know you're required
9:30
Speaker 2: to keep confidentiality or you're living out the values of
9:33
Speaker 2: a nurse quad nurse not even though I need a
9:37
Speaker 2: better sort of but as you are educating the future
9:40
Speaker 2: generations of nurses, you may be obligated in certain kinds
9:45
Speaker 2: of ways, which I think I am not. So yeah,
9:47
Speaker 2: I mean that that resonates with me. Maybe we need
9:49
Speaker 2: one of your students, or we need a third interlock
9:52
Speaker 2: here to hear who's a nurse? Who sort of holds
9:54
Speaker 2: that tighter position. But yeah, yeah, this is I think
9:56
Speaker 2: that's right.
9:57
Speaker 3: But in I mean a part of the pipe is
10:01
Speaker 3: about comparisons, but it's also about whether or not the guidance.
10:04
Speaker 3: I mean, most nurses will follow guidance on this sort
10:06
Speaker 3: of thing, and the guidance in the UK, as I've
10:11
Speaker 3: discovered in the previous previous work, is really badly written
10:14
Speaker 3: and inconsistent on the point of whether or not you
10:17
Speaker 3: can breach confidence in the public interest. So I guess
10:20
Speaker 3: that was just a bit of a kind of dig
10:24
Speaker 3: at this idea of different you know, professional ethics and
10:27
Speaker 3: following codes are actually not really the same thing, although
10:30
Speaker 3: they overlap. I've got a slide, you know, with a
10:33
Speaker 3: Venn diagram when you teach the beginning nurses say, well,
10:37
Speaker 3: look this is ethics, this is regulation slash law. They
10:40
Speaker 3: don't always overlap, and it's just just that's just probably
10:43
Speaker 3: not such a good example the others. The others might
10:46
Speaker 3: be more interesting. So my next thing is is close
10:50
Speaker 3: relationships with patients. And again this is something that it's
10:55
Speaker 3: almost slightly lucky to talk about because they're obviously there
10:59
Speaker 3: are things in places they should be to prevent people
11:02
Speaker 3: from abusing the positions they have in terms of medical practice,
11:07
Speaker 3: nursing practice, and also in terms of nursing education. But
11:12
Speaker 3: again they are slightly different. There's a there's a kind
11:14
Speaker 3: of absolute prohibition on relationships with patients. Albeit I think
11:20
Speaker 3: the regulators' codes and guidance on that are fairly unsophisticated,
11:26
Speaker 3: and if you look to other jurisdictions medicine and other
11:29
Speaker 3: professional groups, they're much more nuanced and sensible. In the
11:33
Speaker 3: nursing code that they've kind of forbidden patients and previous patients,
11:38
Speaker 3: but in putting aside the kind of the potential for abuse,
11:44
Speaker 3: you know, you are going to meet people, maybe not
11:46
Speaker 3: when you're my age, but you are going to meet
11:48
Speaker 3: people of a similar age, not necessarily on your course,
11:51
Speaker 3: but in the university. And you met that relationship may
11:57
Speaker 3: progress after someone has left the university. So if you
12:00
Speaker 3: apply the nursing Code to the to that situation, then
12:03
Speaker 3: again there's a big difference there, And partly I think
12:07
Speaker 3: it's because of guidance. You know, you have, I think
12:11
Speaker 3: people can understand that you have to prevent you have
12:14
Speaker 3: to prevent abuse, but actually relationships can mature. Loving relationships
12:19
Speaker 3: can flourish in this in this environment, you want to
12:22
Speaker 3: stop one and allow the other. It's actually quite hard
12:24
Speaker 3: to write that in a document, and our regulator does
12:28
Speaker 3: it poorly. Other regulators in the UK do it better.
12:32
Speaker 3: So so I think that's again an interesting one. Maybe
12:35
Speaker 3: the more interesting ones coming up now, which is a
12:38
Speaker 3: power dynamic the one that really kind of vexed me,
12:44
Speaker 3: because you know, the power dynamic between a healthcare professional
12:47
Speaker 3: and a patient is you know, there's there's bucket loads
12:51
Speaker 3: of stuff.
12:51
Speaker 4: On that and we're all aware of it.
12:53
Speaker 3: But the point is is that you see you see
12:55
Speaker 3: lots of different ways in which people are aware of
12:59
Speaker 3: it and they work to minimize it. And you see
13:02
Speaker 3: this in principles and you also see it empirically in
13:05
Speaker 3: this kind of notion which might come to later on
13:07
Speaker 3: patient centered care. You're kind of aware of it and
13:11
Speaker 3: actively minimize it. Now I'm not saying it happens all
13:14
Speaker 3: the time. I mean we've all got stories about how
13:17
Speaker 3: we've kind of let ourself be steamrolled and thought about
13:20
Speaker 3: it later on. But the kind of narrative is, look,
13:23
Speaker 3: this isn't a good thing. But in education course it's
13:27
Speaker 3: the other way around, you know, I'm allowed to and
13:30
Speaker 3: I don't, but I'm allowed. You know, I can disapprove
13:32
Speaker 3: of my students. I can tell them to come and
13:34
Speaker 3: see me. I can I can tell them what to do.
13:38
Speaker 3: I can wring them up, ask them where they were,
13:40
Speaker 3: you know this, this, and then strict terms in power.
13:44
Speaker 3: I'm the one that marks their essays. I decide whether
13:46
Speaker 3: they become a nurse or not. The institution has to
13:49
Speaker 3: sign them off as being good character, and if we
13:51
Speaker 3: don't do that, they can't register. So not only is
13:54
Speaker 3: this power relationship much more obvious, it's not challenged so
13:59
Speaker 3: much so when you say to colleagues, you know, yeah,
14:01
Speaker 3: I'm not sure you should be teaching students or treating
14:04
Speaker 3: students like that. You know, sometimes it doesn't occur to them,
14:07
Speaker 3: it seems okay to do that. And we're looking a
14:09
Speaker 3: minute about how that plays out in institutions as well
14:12
Speaker 3: as individuals.
14:14
Speaker 2: Yeah, no, I mean, I think that's an important point
14:16
Speaker 2: and connects up to conversations we've had for folks who
14:19
Speaker 2: listen to the show and previous iterations of the podcast
14:22
Speaker 2: around topics on hidden curriculum. Fred Hafferty was on sort
14:25
Speaker 2: of talking about some of these ideas ages ago, and
14:28
Speaker 2: I think that that that they're alive and naming them
14:30
Speaker 2: is actually important. You have a really nice line which
14:34
Speaker 2: I had marked when I when I read this, because I'm,
14:36
Speaker 2: you know, old enough, I still need paper copies of
14:40
Speaker 2: certain kinds of things. And so this is the line
14:43
Speaker 2: that in nursing education, difference is dispatched to a bygone age,
14:47
Speaker 2: replaced by informal, closed and first name terms. Yet power
14:51
Speaker 2: remains visible and some of the policies in practicate. Yeah. Yeah,
14:54
Speaker 2: so I mean even though and I remember when I
14:57
Speaker 2: taught a nursing I mean, everyone was wonderfully nice. But
15:00
Speaker 2: you know, if you're the outside in a way, you
15:02
Speaker 2: can you notice the paradynamic playing out with respect to
15:06
Speaker 2: that relationship, because at the end of the day, if
15:08
Speaker 2: you're the one grading the powers there and the kinds
15:11
Speaker 2: of things that you maybe shouldn't well, there's lots of
15:14
Speaker 2: things that nobody should do. But even the sort of
15:17
Speaker 2: there's a category of things between me, ah, you probably
15:19
Speaker 2: shouldn't do, But is it checked.
15:21
Speaker 4: I mean, you've reminded me.
15:23
Speaker 3: I mean, I've kind of a lot of my thinking
15:24
Speaker 3: is about the way I relate to someone who's sitting
15:27
Speaker 3: on the chair. Then we're having a tutorial because you
15:29
Speaker 3: can see them in institutional policies, and I've quoted some
15:32
Speaker 3: I found them on you know, by Google search. I'm
15:34
Speaker 3: not breaking any confidence if I find them anyone else.
15:37
Speaker 3: And they say things like this university, we require you
15:39
Speaker 3: to come to every class, we require you to engage
15:43
Speaker 3: with this sort of thing, and that you know you
15:45
Speaker 3: would never ever see that.
15:47
Speaker 4: In healthcare practice.
15:49
Speaker 3: I mean, you will come to obligations in a minute.
15:52
Speaker 4: You just wouldn't.
15:53
Speaker 3: It wouldn't enter your heads talking to a patient, I
15:56
Speaker 3: require you to come to my to my surgery, or
15:58
Speaker 3: come to my office at this You just would you
16:01
Speaker 3: wouldn't you would?
16:04
Speaker 2: And yeah, well no, no, I mean that's a nice one,
16:06
Speaker 2: and even sort of I think that it goes even further.
16:09
Speaker 2: I mean, at least in a lot of the conversations
16:10
Speaker 2: I've had right as the patient, because I'm not a clinician.
16:13
Speaker 2: If I walk in and you throw your old clinician
16:15
Speaker 2: hat on, So, Brian, you really got to stop eating
16:17
Speaker 2: at all that pizza or fish and chips or whatever
16:20
Speaker 2: it is, right, Actually, what did I like the fries
16:23
Speaker 2: with the cheese on the chips and cheese.
16:24
Speaker 4: Or that was Yeah.
16:28
Speaker 2: But if it's a hey, you really don't need and
16:30
Speaker 2: and I talk about my values and my goals right
16:32
Speaker 2: for your health, you really need to do the following things,
16:34
Speaker 2: that's a different kind of conversation. Even though there's a
16:37
Speaker 2: huge power to power differential there, it's a different kinds
16:40
Speaker 2: of conversation in that I'm offering my values and goals
16:44
Speaker 2: and all of that. And it's in light of that
16:46
Speaker 2: as opposed to, you know, it's a certain kind of
16:48
Speaker 2: imperative as opposed to you know, it's no, no, if
16:51
Speaker 2: you want to be a member of our profession, you
16:54
Speaker 2: do the following things and you do the following exam. Otherwise, Yeah,
16:57
Speaker 2: you've pointed, you've illustrated this tension well, and I think
17:00
Speaker 2: the example is powerful.
17:02
Speaker 3: I come to some practical implications. But just on this
17:06
Speaker 3: point that there's there's a couple of other examples. One
17:08
Speaker 3: is that this narrative in patient centered care and student
17:13
Speaker 3: centered learning. And again this is just an observation. People
17:15
Speaker 3: might might want to object to this with probably with
17:19
Speaker 3: reason and with evidence, but the narrative of patient centered
17:22
Speaker 3: care is quite strong. That the narrative of students centered
17:25
Speaker 3: learning isn't quite so strong. You know, we talk about it,
17:28
Speaker 3: but actually you've still got to come to my lecture.
17:31
Speaker 3: You've still got to do the essay that I set.
17:33
Speaker 3: It's still marked in a way I do it. I
17:35
Speaker 3: still disapprove of you if you don't engage in class.
17:38
Speaker 3: It's student centered learning is rhetoric to a much higher
17:43
Speaker 3: degree and not reality than patient centered care, which you know,
17:47
Speaker 3: I think is really much more a legitimate thing that
17:52
Speaker 3: that's my I hope it's a legitimate thing.
17:54
Speaker 4: But but I'm.
17:55
Speaker 3: Just talking about the literature. Really you do see patient
17:58
Speaker 3: centered learning.
18:00
Speaker 2: You may have just made yourself the hero of all
18:03
Speaker 2: of my students who don't like attendance policies. And that's yeah.
18:10
Speaker 4: We'll come to those.
18:11
Speaker 3: But but the other one where it's similar as this
18:14
Speaker 3: idea of patient autonomy and student learner autonomy, because you know,
18:18
Speaker 3: part of the idea of patient centered care is that
18:20
Speaker 3: this is is an autonomous person. And of course we
18:24
Speaker 3: say to people. I say to my learners, you know,
18:26
Speaker 3: I'm not your boss, I'm not your dad. You know
18:28
Speaker 3: I'm telling you what to do. You know, I'm this
18:31
Speaker 3: is my advice. I hope, I hope you can consider
18:34
Speaker 3: it and then make your own decision. But again that's
18:37
Speaker 3: not always done. It's you know, this is where you
18:40
Speaker 3: have to turn up. We say that they're autonomous. They
18:43
Speaker 3: are AUTONAMU their adult learners in the sense that they're
18:45
Speaker 3: learners and their adults. But this idea of of making
18:50
Speaker 3: choice about how they learn and what they learn is
18:54
Speaker 3: it's largely absent. I don't think it's the same the
18:57
Speaker 3: same thing at all.
18:58
Speaker 2: Yeah, you know, I mean there's this all resonates with me.
19:01
Speaker 2: I need to become a better critic because it just
19:03
Speaker 2: I mean that just seems exactly right. There's this tension
19:06
Speaker 2: between you know, because if were I training students up
19:09
Speaker 2: in philosophy, I mean, there are certain kinds of things
19:11
Speaker 2: that I think they ought to do, and there are
19:13
Speaker 2: certain kinds of approaches that they ought to consider in
19:16
Speaker 2: order to properly have, you know, engage philosophical pursuits. And
19:22
Speaker 2: I think nursing may even be more rigorous in that
19:25
Speaker 2: way or potentially given sort of a whole other but
19:27
Speaker 2: evidence based practice. I mean, you know, there's certain ways
19:30
Speaker 2: in which I see the norms that are necessary for
19:33
Speaker 2: good health care, maybe bleeding into or seeping into other
19:37
Speaker 2: kinds of practices which get us into some bad hidden
19:39
Speaker 2: curriculum spaces.
19:40
Speaker 3: But anyway, continue I think the hidden criculums is a
19:43
Speaker 3: really interesting and the last one a couple more examples.
19:48
Speaker 3: One is the notion of obligation, so that there is
19:51
Speaker 3: a I mean, this is returning to my PhD is
19:54
Speaker 3: about what's your obligation for health? I developed a certain
19:57
Speaker 3: account of what people's obligation was, but it regarded health
20:01
Speaker 3: in a certain way that is odds with much of
20:04
Speaker 3: health promotion literature. But we say to students about obligations,
20:08
Speaker 3: what are their obligations for their learning? And you know,
20:11
Speaker 3: where do they come from and what exactly are they?
20:13
Speaker 3: And and of course when you're when you're facilitated, for example,
20:15
Speaker 3: dissertation or something, you know, I say to students what
20:18
Speaker 3: sort of mark are you looking for here? And often
20:22
Speaker 3: as far as their concern as well, I just I
20:24
Speaker 3: want to pass. So what is their obligation as a
20:28
Speaker 3: nurse and a learner to be the best that they
20:30
Speaker 3: can be within the resource envelope that they're willing and
20:34
Speaker 3: able to commit to it? Or is their obligation to
20:37
Speaker 3: themselves just say well, I've got enough I'll do enough,
20:40
Speaker 3: are do enough to pass? So in professional discourse there's
20:44
Speaker 3: this kind of notion when I want to do my best.
20:46
Speaker 3: I want to do my best for my patients. But
20:48
Speaker 3: does that extend to me saying, well, look I want
20:51
Speaker 3: to I don't want to get a D. I want
20:52
Speaker 3: to get an A. You know, And should I, as
20:54
Speaker 3: a as a teacher, disapprove of someone saying to me, look,
20:58
Speaker 3: I'm really busy, I'm short money, I've got people together.
21:01
Speaker 3: I'm going to do as minimum I can to get
21:04
Speaker 3: above the line.
21:05
Speaker 4: And that's a.
21:06
Speaker 3: Really interesting thing. What are the obligations of learners to
21:10
Speaker 3: that extent? Now, when you when you transfer that to
21:12
Speaker 3: the other way about obligations for patients for their health.
21:16
Speaker 3: You know, we've there's loads of stuff about this. You know,
21:19
Speaker 3: smoking is wrong, it's a it's it's a kind of
21:22
Speaker 3: categorical wrong rather than the hypothetical wrong. You see all
21:25
Speaker 3: of this stuff that just isn't quite the same. And
21:28
Speaker 3: I think the obligations of learners is a really interesting
21:31
Speaker 3: there's a whole paper in that What are their obligations
21:34
Speaker 3: and why? Who to whom do they owe an obligation?
21:37
Speaker 2: Well, yes, we might have to read this. That's a
21:39
Speaker 2: I mean, this is terrifically interesting because the I mean,
21:42
Speaker 2: they both make sense to me. It makes sense if
21:44
Speaker 2: someone says, look, I've got a super busy lef. I
21:46
Speaker 2: got three kids at home, I'm juggling whatever in the
21:49
Speaker 2: following things. What I want to do is I'd like
21:51
Speaker 2: to be a good nurse. But you know, in other spaces,
21:54
Speaker 2: I've had conversations sins like, well, this is bee work, yeah,
21:58
Speaker 2: and I'm good with the bee Yeah. Tough, but you know,
22:01
Speaker 2: it is there. I'm curious if one maybe translates more
22:05
Speaker 2: into the other. So we want excellent patient care. Maybe
22:08
Speaker 2: we're okay with good student work, but I mean, are there.
22:13
Speaker 2: I'm curious about it. In what areas we're okay with
22:16
Speaker 2: good student work and where we draw the line because
22:20
Speaker 2: we're I mean, you're training students to be nurses, right,
22:25
Speaker 2: You're training that. So if they are not as if
22:28
Speaker 2: they are barely proficient or whatever the cutoff is, if
22:31
Speaker 2: they've met the cutoff for certain kinds of practical nursing skills,
22:35
Speaker 2: does that mean I'm getting jabbed six or seven times
22:39
Speaker 2: in the needle when I could have been jabbed once?
22:41
Speaker 2: I mean, not a great exam. But there's yeah, I mean,
22:45
Speaker 2: this is really really interesting stuff and sort of the
22:47
Speaker 2: empirical work behind that translation. I don't know the litterure
22:51
Speaker 2: on this. I don't know if people have done it.
22:53
Speaker 3: But it's well, there is some interesting stuff on this
22:57
Speaker 3: because and what its is practice at the threshold and
23:02
Speaker 3: codes of conduct. Our code is a legal code, different
23:05
Speaker 3: sorts of code, but the code separates poor or not
23:08
Speaker 3: poor unacceptable practice from practice that I've always called just
23:12
Speaker 3: good enough. It's just good enough practice. The code is there.
23:16
Speaker 3: The code is not an aspirational practice.
23:18
Speaker 4: You know.
23:18
Speaker 3: It says, well, if you're below you, you're you know,
23:23
Speaker 3: will take action against you potentially, and if you're just
23:25
Speaker 3: above it, that means you're just good enough. And the
23:28
Speaker 3: similar thing is that the threshold and when you're studying
23:31
Speaker 3: for an essay, are you doing an SA if you're
23:33
Speaker 3: meeting the learning outcomes, if you're just good enough, you
23:36
Speaker 3: get your d it's not good work. So this is
23:40
Speaker 3: this idea of what's what's good practice and what's just
23:43
Speaker 3: good enough practice. It's a very difficult problem. And when
23:47
Speaker 3: when when there are you know the main reason why
23:51
Speaker 3: people in my view who are capable of getting higher
23:56
Speaker 3: grades who get lower growths. The one reason is that
23:59
Speaker 3: they have given it enough time. So should I be
24:02
Speaker 3: disapproving of them? Should I be wagging my finger at
24:04
Speaker 3: them or requiring them.
24:06
Speaker 4: To do more more time? Should you know?
24:08
Speaker 3: It's it's a very difficult It's a difficult. It's one
24:11
Speaker 3: of those examples where you know, on the face of it,
24:14
Speaker 3: it seems a bit trivial, but you just have to
24:17
Speaker 3: scratch a tiny little bit of the surface of and
24:19
Speaker 3: it's fascinating underneath. The other cause, really big one is care.
24:27
Speaker 3: And this is where you and I have had many
24:28
Speaker 3: conversations in the past, Brian, because there is there is
24:32
Speaker 3: this notion of care and compassion that you see in noticing,
24:35
Speaker 3: and increasingly you see it in other professions. You didn't
24:38
Speaker 3: used to see it so much in medical codes, but
24:42
Speaker 3: you're you're beginning to see it now. You actually you
24:45
Speaker 3: saw it more in American codes than the UK codes,
24:48
Speaker 3: but but you are seeing that now. And of course,
24:52
Speaker 3: the the idea is is that there's it's a relationship
24:55
Speaker 3: based on on care.
24:57
Speaker 4: So so should I care? How? What? What? What does
25:00
Speaker 4: it mean to have.
25:00
Speaker 3: A caring relationship with your student? And it just there
25:04
Speaker 3: is there is an element of this. There is a literature,
25:07
Speaker 3: a small literature on what it is to be a
25:09
Speaker 3: caring teacher. There's not much in the nursing literature, and
25:14
Speaker 3: as I kind of engage with it, I didn't. I
25:16
Speaker 3: didn't really follow it, to be honest, because they talked
25:20
Speaker 3: often about reciprocity, and reciprocity is not something that I
25:24
Speaker 3: kind of think is really there in the either sets
25:28
Speaker 3: of those relationships between a nurse and a patient and
25:32
Speaker 3: a teacher and a student. Not to say that that
25:35
Speaker 3: that your care is met with utter indifference. Come in
25:38
Speaker 3: the other way. But it's not reciprocal, it's asymmetrical. But
25:42
Speaker 3: you do again, you do. You do get conversations with people.
25:46
Speaker 3: I've just been at the board, you know, and where
25:49
Speaker 3: we talk about students, and I found myself doing it
25:52
Speaker 3: as well, having advising people not to do it. I
25:55
Speaker 3: do do it sometimes And well, hang on a minute,
25:57
Speaker 3: you know she's signed this form, and did she really
25:59
Speaker 3: know that? You find yourself advocating for students because because
26:03
Speaker 3: there is an engagement I can't quite put my finger
26:05
Speaker 3: on it's I think I might argue against myself somewhere
26:09
Speaker 3: in there.
26:10
Speaker 4: To be honest, Brian, A.
26:11
Speaker 2: Lots of folks listening to the podcast a bunch are
26:14
Speaker 2: the medical students that I work with in student toler
26:16
Speaker 2: and I think sort of even just the sort of
26:19
Speaker 2: philosophically rooted thought process of going through these kinds of
26:24
Speaker 2: ideas is helpful, and occasionally, you know, there's a tension
26:26
Speaker 2: that we resolve it.
26:27
Speaker 3: I think it's it's you know, a lot of what
26:30
Speaker 3: we talk about, isn't it is in ethics is obligations
26:32
Speaker 3: and trying to find out exactly where they are and
26:37
Speaker 3: what they are and where they where they live, and
26:40
Speaker 3: how you arrive at them is part of what we do.
26:42
Speaker 3: But but I do think I mean this, this paper
26:45
Speaker 3: was started off by a symposium about character cultivation, and
26:49
Speaker 3: there's a lot of virtue and agent centered ethics.
26:51
Speaker 4: In our professions.
26:53
Speaker 3: And one of the one of the things that I
26:55
Speaker 3: can't again I struggle with this is this notion of
26:57
Speaker 3: that sort of ethics as a normative, as as kind
27:01
Speaker 3: of generating obligations. Because the reason why I do kind
27:05
Speaker 3: of advocate and maybe go a bit more than utter
27:08
Speaker 3: indifference is because of who we are, rather than than
27:12
Speaker 3: than trying to find our obligations in documents or moral theories.
27:16
Speaker 4: I've kind of.
27:17
Speaker 3: Moved towards the virtues, I think quite fully there.
27:21
Speaker 2: Yeah, but I'm moving that way. This is this is
27:24
Speaker 2: where I'm going to cut the podcast. This is the upshot, Right,
27:26
Speaker 2: you've now come over to the it's virtues. It's not
27:28
Speaker 2: rules none and this is music to my ears, but
27:31
Speaker 2: it's a good yeah. And so for folks listening, I'm
27:34
Speaker 2: speaking with Paul Snelling and we're talking through sort of
27:36
Speaker 2: considerations around nursing and whether nursing educators, broadly construed, might
27:44
Speaker 2: be their students nurses. Paul, I see on the clock,
27:48
Speaker 2: I'm roaming up against time, and I don't want to
27:50
Speaker 2: take too much more of your valuable time. So what
27:53
Speaker 2: give me sort of two things to close us out with?
27:56
Speaker 2: One at the end of the day, do you think
27:59
Speaker 2: you're your student's nurse? And then sort of for folks
28:01
Speaker 2: who found this really interesting, tell us what's next for you?
28:05
Speaker 2: Future directions, research, other things you've been thinking about. So
28:09
Speaker 2: are you your student's nurse? Solve the challenge for us?
28:13
Speaker 3: Well, I'm not going to answer that with a yes
28:14
Speaker 3: or no. I mean a matter as a matter of fact,
28:17
Speaker 3: as a matter of fact, I am.
28:19
Speaker 4: And I finished the.
28:21
Speaker 3: Paper with a with a with a call to my
28:24
Speaker 3: colleagues say, look, go back to your professional ethic, look
28:27
Speaker 3: at look at what you're doing as a teacher. Go
28:29
Speaker 3: back to your professional ethic and challenge policies. I just
28:34
Speaker 3: explain about attendance policies because because it's it's and the
28:38
Speaker 3: big data surveillance that the universities do, that's not so
28:43
Speaker 3: much about individuals. It's about institutions doing it. And if
28:48
Speaker 3: you're saying that, Okay, I'm making people come to class,
28:52
Speaker 3: I'm disapproving if they don't, or I'm seeing I'm watching
28:55
Speaker 3: them as they go in the library and all this
28:56
Speaker 3: kind of stuff, and then there's then something follows, even
28:59
Speaker 3: if it's just a nudge or something. Then the question
29:04
Speaker 3: is in whose benefit is that for? If it's for
29:08
Speaker 3: the student's benefit, it seems to me to be out
29:11
Speaker 3: and out paternalistic, and paternalism is largely frowned upon in
29:16
Speaker 3: healthcare practice. If you're saying it's not in the student's interests,
29:20
Speaker 3: it's in the university's interest, then it's authoritarian. And it
29:24
Speaker 3: seems to me that, however, you try and explain that
29:26
Speaker 3: sort of coercion and intrusion. You're up against either one
29:31
Speaker 3: or both of those things, which in another place i e.
29:34
Speaker 4: Healthcare practice is virtually forbidden.
29:37
Speaker 3: And that I think is in a kernel that's the problem,
29:40
Speaker 3: and people weren't really engaged with it. So what I'm
29:43
Speaker 3: saying is that, yes, go back to your professional ethics.
29:46
Speaker 4: Go back to your professional ethics.
29:48
Speaker 3: Be guided by your professional ethics and your personal interactions
29:51
Speaker 3: with students, but also consider how you are implementing these
29:54
Speaker 3: institutional policies which are not consistent with what I understand
29:59
Speaker 3: healthcare to.
30:00
Speaker 4: So yeah, I.
30:02
Speaker 3: Think as far as the future future goes Brian, I've
30:05
Speaker 3: I've I haven't got a i haven't got a list
30:08
Speaker 3: of things I'm going to do. But I'm I'm really
30:12
Speaker 3: really interested in this notion of of relationships, especially as
30:18
Speaker 3: as as as you know this, this notion of relationship ethics.
30:23
Speaker 3: And I think that rather than being a kind of
30:26
Speaker 3: normative thing this is what you've got to do, or
30:28
Speaker 3: this is what you're not allowed to do, it's really
30:30
Speaker 3: I'm picking what meanings of these things. I've got about
30:34
Speaker 3: half a dozen half written papers in my drawer which
30:36
Speaker 3: I shall be returning to when I've given work, but
30:39
Speaker 3: it's it's fairly.
30:42
Speaker 2: Eclectic, you know, this is this is good. I mean,
30:45
Speaker 2: the the open ended possibilities are excellent and I appreciate
30:48
Speaker 2: the answer as much as it is. And I think
30:50
Speaker 2: the students er here and folks listening the podcast will
30:53
Speaker 2: resonate with this, and for those who are putting sort
30:57
Speaker 2: of this conversation in conversation itself with the previous one
31:01
Speaker 2: mentioned with dorn Berg and Truge, I think will be
31:03
Speaker 2: especially interesting. And that you're on the virtue side. I mean,
31:06
Speaker 2: this is this is a big win that made my day.
31:08
Speaker 4: So this is.
31:10
Speaker 3: I'm not they, I'm not they Yet there was someone
31:12
Speaker 3: when I was looking at this saying that we're all
31:14
Speaker 3: we're all pragmatic pluralists. And I think that's the interesting
31:18
Speaker 3: thing for theories, none of them really account for the
31:21
Speaker 3: totality of the moral experience. But I'm I'm kind of
31:24
Speaker 3: leaning that way. I've got some old friends who will
31:26
Speaker 3: be delighted to hear me say that I can tell
31:28
Speaker 3: you this.
31:29
Speaker 2: Is it's good. Paul, thank you so much of the time.
31:32
Speaker 2: I really appreciate it as always, really enjoyed our conversation
31:35
Speaker 2: and uh yeah, more soon, Thanks Brian. This podcast series
31:40
Speaker 2: is a production of the Health Ethics Lab, and I
31:42
Speaker 2: am grateful to colleagues in the Department of Medical Sciences,
31:45
Speaker 2: the IHS Library, and the Hackensack I'm ready in the
31:47
Speaker 2: School of Medicine for making this collaboration possible. To learn
31:51
Speaker 2: more about our work or to engage with the series content,
31:54
Speaker 2: reach out to me Brian Pilkington at Brian dot Pilkington
31:58
Speaker 2: at hm h in dot org.