Symphonology in Nursing Care

Have you ever refused a distraught whānau or family member from entering the emergency resuscitation room because you think it is not a right thing to do?

In our daily nursing practice, we are confronted with varying human experiences that shaped our career. From asking our patients to tick their daily meal menu to administering medications, there is an ethical involvement. Complex as it may seem, ethical decision making on the part of the nurse is paramount in every aspect of nursing care. For an action to be deemed ethical, an underlying agreement should exist.1  For two people to beautifully dance a tango, an agreement keeps the synchrony, just as the agreement between the nurse and the patient, or the patient’s whānau when it is their call to decide.

As nurses, regardless of our ethnicities and geographical locations, we employ various models of nursing care. Most often, we perform our professional roles and responsibilities in a manner that suits our style. Our own techniques in delivering our nursing care make us unique as individuals. Knowing one’s style as a novice practitioner might be a challenge at the beginning, but as time passes by, we get to know our techniques of what we think is beneficial to us and to our patients. However, a question from hindsight needs a bit of a thought, “Do we do it right?”

In New Zealand, the Te Whare Tapa Whā and the Te Wheke Māori health models serve as guiding tools amongst health care workers in the delivery of care.10 These two models emphasise and recognise the importance of the roles of whānau members on patient recovery and general well-being. Although these health models are based on Māori culture, its applicability across different cultures is evident where the integral role of family on general health is crucial. These models have been adapted by hospital policy makers on the vision to provide a culturally safe health care. While some hospital departments foster a patient-centred care framework, some adapt a patient and whānau/family-centred care framework as an approach to quality health care among New Zealanders.3,4

Aim

This article explores the Bioethical Theory of Symphonology by James Husted and Gladys Husted, its applicability to our practice in New Zealand context and its interrelatedness to the health models familiar in New Zealand. Symphonology comes from the Greek word symphonia, which means agreement. This article will attempt to expound the Bioethical Theory of Symphonology using patient and whānau-based case studies approach.

Symphonology

The Bioethical Theory of Symphonology is a context-driven, ethical decision-making model that guides holistic interaction and explores the nature of agreements between patients and health care providers in diverse clinical settings. It is a bioethical theory developed by James Husted and Gladys Husted that centralizes on bioethics in patient care. It particularly presents the need to address individualistic approaches and to prevent the pitfalls of some bioethical principles. Symphonology emphasizes patient preferences, psychological and theological knowledge, and context of awareness and of the situation.1 Implicit in this theory is the preface that for participation to exist, agreement must exist between all rational beings.1

In the context of whānau-centred nursing care, the provision of care does not just focus on our patients but also the needs of the whānau in crisis, especially if the patient becomes incompetent to decide or there are no predetermined wishes of the patient to exclude whānau members in the plan of care. If our patients could not rationally act for themselves, we should remain to act as their rational advocates.

Bioethical Standards

Its goal is to ethically provide patient care using six bioethical standards. These standards are autonomy, freedom, objectivity, self-assertion, beneficence and fidelity. These bioethical standards serve as preconditions of each agreement. They reflect characteristics intrinsic to both health care staff and patient—to anyone who has the potential to make an agreement. For health care providers, these standards provide a means to learn more about the patient and identify aspects of care that need support.1

Autonomy

Autonomy is considered as the "umbrella of the agreement" – everything stems from one's core identity.1 The patient or the whānau use his/their individual rights and power to control and to fulfil their desires. It does not connote to the usual meaning of autonomy but to the uniqueness of a person as an individual. A whānau member may be very motivated to witness a cardiopulmonary resuscitation and to support the patient in this most critical situation. This may stimulate the patient's will to live or to provide comfort as the patient dies.5,6 The reason for his motivation to witness the resuscitation makes him a unique individual. The experience would help him confirm the reality of the patient's condition and may help him cope in the process.7

Freedom

The patient's whānau needs to have the ability and the freedom to act and to make decisions about his actions. Freedom must be a precondition to any agreement.1 A patient's wife utilizes her freedom by choosing to help the staff nurse performing a bed wash to her husband and by choosing to stay beside the patient during his futile times. The patient's whānau member chooses the actions that will help her cope in the process with what she thinks are convenient to her.

Objectivity

One’s intellectual capacity is known as objectivity.1 The need to be aware of all pertinent information affects the bioethical decision-making process. Hence, the healthcare professional provides information about the patient that aids the patient's whānau member to develop an objective view of the situation, which is a major factor in executing end-of-life decisions when emergency interventions fail. The patient's whānau then, has information to make the decision about the medical treatment and subsequent ways to whether or not withdraw patient's life support, when it becomes their call to decide on a patient’s behalf.

Self-Assertion

Before entering into an agreement, the whānau members determine that they have freely chosen to get well and stay well. The patient's whānau has the power and right to control their own time and effort known as self-assertion. This implies a person's self-governance.1 In desiring to control their time at this stressful event, they optimize the brief time that they have to be comforted by their loved one. Nevertheless, when there is an unexpected death, there will be no time for those last intimate moments.8 The nurse, along with the other health care team members, can control time and effort and be able to optimize it by arranging appropriate time for families to visit, whānau conference or making the whānau room available for them. In a clinical setting where a nurse caters multiple patients, it is deemed unethical for a nurse to stay longer with Patient A who has the same acuity with Patient B, simply because the former is more talkative.  A nurse can control time and effort via fair prioritisation of needs, boundary setting and by always putting in mind other patients who are yet to be attended.

Beneficence

If the clients cannot act on their own behalf, it is the health care provider's role to do what is for the patient's or the whānau’s best interest in a benevolent manner. This is called beneficence. Whānau members will be assessed by a health care provider for appropriate levels of coping, age limit, the absence of combative behaviours, extreme emotional instability and behaviours of concerns during emergency situations. The whānau will be presented with the option to be present and members who prefer not to be present will be supported in their decision. The desire to avoid an ethical dilemma or compromise in safety from occurring is the presumed benefit.

Fidelity

Fidelity is also considered as a base structure of an agreement.1 No agreement is established if there is no intent to be faithful. The patient or the whānau member needs to be true to his uniqueness; to stay true to the decisions that have made him who he is. This is fidelity. For the health care providers, fidelity is commitment to the obligation of our corresponding professional roles.1 The whānau members who want to witness resuscitation are expected to resume to normal lifestyle and to cope well the grieving process if in case emergency interventions fail. The team provides a supportive role to the clients during bereavement as a way of being faithful to the role. However, if there is difficulty for patients or whānau members to resume to normal living like unexpressed grief, it is the responsibility of the health care team to devise approaches e.g. adequate referrals in order to address the problem and to avoid the consequences that could occur. By taking this into account, we are being faithful to our professional role.

Symphonology and Cultural Defiance

While cultural factors need to be considered in caring for a patient, there is still no justification for refusing patient’s personal wishes considered defiant to her culture in order to serve as the standard of culturally congruent care.9 If the competent patient defies her culture and prefers for her needs to be addressed differently, her autonomy and her individual wishes have to be regarded. It is the nurse’s ethical responsibility to serve as her advocate for her wishes, unless when the patient is deemed incompetent to decide and there were no prior known wishes that it’s time for the next of kin to make a call. This is due to the fact that cultural differences can also occur between different persons of the same culture.9 For example, if whānau members coordinated with the staff about doing a prayer vigil at the sedated and intubated patient’s bedside and the patient had specifically expressed prior wishes to the nurse requesting not to have this done on her, it is the nurse’s responsibility to advocate for her and explain to the whānau about her wishes in a manner that this does not disintegrate the patient from her whānau onwards.9 The bioethical standards of autonomy, freedom, objectivity, self-assertion, beneficence and fidelity should be put into consideration to address her individuality, rather than addressing the culture through the patient.9

Pitfalls of Utilitarianism and Deontology

This theory is designed to avoid the pitfalls of utilitarianism and deontology.1 The central concepts in utilitarianism focus on good versus evil. With this principle, ethical decisions are guided towards achieving what is good for a greater number of people, regardless of what is good for the individual.1 If a showering a patient in the morning yields a presumed benefit to the majority and a nurse sticks to this principle, she will do this to all her patients; however, this does not benefit few patients who only shower every other day. If a nurse provides complex details about a new condition to an anxious patient who fears to hear anything about her diagnosis on the premise that this would benefit her, it breaches the ethical standards despite the fact that a greater number of people want to know everything possible.

Deontology, on the other hand is a moral principle that determines what is right from wrong based on the adherence to the rule. When making decisions, the individual performs his role, and his role is to do what is right. Not doing one's role is wrong.1 Chinn and Kramer (2004), as cited by Cutilli (2009) stressed that what is right may not be good; it may not lead to achieving a favourable outcome.10 A nurse who employs a deontological approach on her practice does her duty regardless of the consequence of her action. If the hospital policy is not to allow whānau to be present during cardiopulmonary resuscitation in the emergency department and the health care provider sticks to the rule because he thinks that it is his duty to abide to the unit policy, it is considered ethical under the deontological principle, but this may not lead to a good outcome for the whānau member who prefer to be present, which may lead to heightened anxiety and unexpressed grief. While health care providers worry of negative psychological aftermaths on witnessed resuscitation, evidences on studies show that there is no or lesser negative psychological impact on relatives who witnessed than those who did not.11,12 Unexpressed grief leads to unresolved grief and is a known contributing factor to high cases of mental health issues.

As we further encounter bioethical issues in our practice, it is very important for us as health care providers to unlock the barriers that hamper a coordinated delivery of care. Agreement is the basis for a coordinated partnership, which enhances a smooth delivery of care in the process. By applying this bioethical theory in practice settings, we can bridge ethical gaps. As Cutilli (2009) implied, it is not a complicated job for the health care team to do especially for nurses, since most nurses are doing this already without the realisation of it. A nurse gains a feeling of efficacy for oneself by being a "consistent ethical agent" for the patient and their families.10 This is achieved by having awareness of the terms of the agreement and of the importance of the contexts within the agreement.1

Summary

Caring is the core embedded in our nursing profession. For an effective and efficient delivery of care, both patient and staff must be on the same light. It is by virtue of agreement that care becomes congruent to the individual needs of our patients and it is by then that care becomes ethical.

The writer currently works as a staff nurse in the Department of Critical Care Medicine at Auckland City Hospital in Auckland, New Zealand. 

This is the original  article of the same sort published in Kai Tiaki Nursing Journal, New Zealand, August 2015.. 

References

1. Husted, J. H., Husted, G.L. (2008) Ethical Decision Making in Nursing and Health Care: The Symphonological Approach (4th ed.). New York : Springer Publishing Company.

2. Ministry of Health. (2015) Maori Health Models. http://www.health.govt.nz/our-work/populations/maori-health/maori-health-models. Retrieved 07/04/2015.

3. Bay of Plenty District Health Board (BOPDHB). (2012) Excellence through Patient And Family-Centred Care. http://www.bopdhb.govt.nz/media/35057/1.1%20Literature%20Review.pdf.  Retrieved 07/04/2015.

4. Taranaki District Health Board (TDHB). (2014) Patient and Family/Whanau-Centred Care Framework. http://www.tdhb.org.nz/misc/documents/2014-Patient-Family-Whanau-Centred-Care.pdf.  Retrieved 07/04/2015.

5. Simpson, S. M. (2001) Near-death experience: a concept analysis as applied to nursing. Journal of Advanced Nursing; 36(4), pp520-526.

6. Laskowski-Jones, L. (2007) Should families be present during resuscitation? Nursing; 37(5), pp44-47.

7. Duran, C. R., Oman, K.S., Abel, J. J., Koziel V. M.., Szymanski, D. (2007) Attitudes toward and beliefs about family presence: a survey of healthcare providers, patients' families and patients. American Journal of Critical Care; 16(3), pp270-279.

8. Philips, B. R. (2002) Modern Medicine Network: Letters from the Heart. http://www.modernmedicine.com/modern-medicine/content/letters-heart?page=full. Retrieved 07/04/2015.

9. Zoucha, R., Husted, G. (2000) The ethical dimensions of delivering culturally congruent nursing and health care. Issues in Mental Health Nursing; 21(3), pp325-340.

10. Cutilli, C. (2009) Ethical considerations in patient and family education: using the symphonological approach. Orthopedic Nursing; 28(4), 187-191.

11. Robinson, S.M., Mackenzie-Ross, S., Hewson, G., Egleston, C., Prevost, A. (1998) Psychological effect of witnessed resuscitation on bereaved relatives. Lancet; 352(9128), pp614-617.

12. Jabre, P., Belpomme, V., Azoulay, E., Jacob, L., Bertrand, L., Lapostolle, F., ... Adnet, F. (2013) Family presence during cardiopulmonary resuscitation. The New England Journal of Medicine; 368(11), pp1008-1018.