Relationships Between Nurses and Physicians Matter
Physicians, nurses, and other clinicians readily acknowledge being troubled by The full impact of moral judgment on healthcare relationships, patient outcomes .. Stereotypical thinking, moral judgments, and coercive behavior increased in the microculture, sustained by the nurses' own matrix of personal relationships. Perhaps the best explanation may be that physicians and nurses are members of a Requiring physicians to uphold the highest standards of personal conduct no preexisting relationship and about whose personal characteristics they know. Jul 7, Doctors and nurses are often prime targets of promotions from of conduct for interactions with healthcare professionals in January Individual cases should be monitored and policies put in place to clarify expectations. 4.
VIP treatment for donors and other influential people. Individual cases should be monitored and policies put in place to clarify expectations. Managing pediatric and geriatric patients who may not have decision-making capacity. The patient also should be able to rationalize in selecting one choice over another.
And it bothers them that others go without care due to lack of funding. Examples like the Terry Schiavo case in Florida — in which the patient was kept alive and cared for in a vegetative state for 15 years, including a long, publicized legal battle involving family members with opposing points of view — showed how difficult these cases can be for everyone involved. Berlinger emphasized the importance of helping nurses and other staff members deal with these kinds of issues.
Institutional investment in advance care planning, which helps patients to identify and document their treatment preferences in ways that can guide care if they are unable to make decisions in the future, is one step institutions can take to prevent crises. This mechanism is generally an ethics committee.
Ethics committee members or consultants should be available around the clock to assist employees, patients and families, and can be called on to help resolve a perceived conflict between the parties.
Administrators and clinicians can also enhance ethical practices at their institutions through ongoing education and open discussion, said Joseph Carrese, M.
A vignette study using the IAT found that physicians had no explicit bias against black patients but did have implicit biases that predicted their decisions to use thrombolytic treatment in the scenario [ 70 ]. A study of actual cardiac patients found that surgical recommendations varied by race for Black men, but not Black women or Hispanics, and that the effects of race were mediated by physician perceptions of patients' education and activity levels [ 71 ]. The social and psychological dynamics producing racial disparities are as yet poorly understood [ 72 ].
Neuroscience studies have shown that automatic, unconscious attitudes are highly sensitive to new information and new contexts [ 73 ]. While the amygdala produces a rapid, stereotypical initial response to a stimulus, other brain regions including the prefrontal cortex can follow with iterative reprocessing at a rate of eight cycles per second, leading to more complex and nuanced responses [ 74 ].
People who are chronically committed to egalitarian goals can inhibit stereotype activation preconsciously, that is, without awareness or new effort [ 75 ]. Social and moral intuitions shaped by extensive experience and learning can operate without any conscious awareness [ 76 ].
Researchers no longer think of moral judgments as exclusively cognitive [ 77 ]. Even those who minimize the emotional component acknowledge that emotions play a powerful role in motivating relevant action [ 78 ].
Using functional MRI, we can now visualize the neural substantiation of moral emotions. Guilt and compassion activate different distributed brain networks than do disgust and indignation [ 79 ]. The simple stimuli and vignette studies that are stock-in-trade for social psychologists and neuroscientists are appropriate for research on first impressions in healthcare, where encounters with strangers increasingly characterize the patient experience [ 80 ].
But negative appraisals may develop dynamically over the course of an encounter and may arise, change, or disappear as encounters become relationships, much as Goffman described for the discovery and management of stigma [ 81 ].
Fortunately, social psychologists themselves recognize the need for more naturalistic research strategies [ 8283 ]. Subjects in an immersion virtual environment may respond as if the situation is real, as shown by a virtual replication of the Milgram obedience experiment [ 84 ]. Neuroscientists have begun to use videogames as stimuli for subjects in functional MRI scanners [ 85 ].
Within healthcare, Debra Roter and colleagues have called for more creative simulations to investigate emotion and non-verbal behavior, not only by using standardized patients but also by having patients or clinicians respond to vignettes and videotaped interactions [ 86 ]. Variation among clinicians Studies of clinician personalities, habits, and skills have offered only modest insights into variations in moral judgment.
One study of medical student Machiavellianism--itself predicted by male gender, authoritarianism, intolerance of ambiguity, and external locus of control--found that Machiavellian students had more negative attitudes toward geriatric and hypochondriac patients [ 87 ]. Benjamin Chapman and colleagues studied community primary care physicians in Rochester, Minnesota, using personality tests and audiotaped standardized patient visits, and found that personality characteristics shaped their interviews of depressed patients [ 88 ].
The authors note that "patients who are belligerent, distressed, passively noncompliant, medically complex, or particularly knowledgeable, congenial, and appreciative" might thereby influence communication, but their study did not examine that influence. Emotional intelligence measures appear to be emerging from an infancy troubled by methodological concerns and popular hype [ 89 ], but their application in healthcare [ 90 - 92 ] has yet to focus on difficult patient relationships.
One pilot study of psychiatric patients and staff suggested that attachment theory may predict the success of therapeutic relationships: Medical students with secure attachment styles are more likely to seek relationship-focused primary care residencies [ 94 ].
Gender is often a factor in clinical relationships, as illustrated by Hall's reciprocal likability study cited above in which female physicians said they liked their patients more than male physicians did.
Patients agreed that female physicians liked them better and also said that they liked female physicians more than they liked male physicians [ 13 ]. We do not know, however, how gender may figure in clinicians' moral judgments of patients. Sonia Crandall found that female medical students had more favorable attitudes toward poor patients than male medical students [ 95 ], although later studies have not replicated this finding [ 4496 ].
Women, including female physicians, generally score higher than men in empathy, but we still lack evidence that such differences are of consequence in clinical interactions [ 97 ]. In a laboratory study using emotional videos as triggers, women had greater responses than men in empathy, monetary generosity, and oxytocin levels [ 98 ]. In addition to its roles in birth, lactation, and mother-infant bonding, oxytocin has complex effects upon the brain and social behavior in females and males [ 99 ], but its roles in moral emotions are far from clear .
A single intranasal dose of oxytocin in male students increased their trust and social risk-taking in interactive dyads [ ]. Carole Gilligan's hypothesis that women and men employ different modes of moral reasoning care versus justice has failed to garner strong support [ ]. Indeed, Kohlberg's theory of developmental moral stages, on which Gilligan's work depended, has itself been significantly modified [ ] or abandoned [ 77 ].
Nevertheless, studies continue to appear with evidence of gender differences in emotionally-charged moral appraisals [ ]. Using functional neuroimaging, Carla Harenski found that even when women and men make similar moral judgments, they may do so via different dynamics, activating different brain circuitry [ ].
Diverse studies cited here demonstrate the folly of expecting unifactorial attributes of either patient or clinician to dominate moral judgments. Once the clinician is engaged in dyad and context, a complex system is in play.
In the course of this review I asked colleagues how they managed their own moral judgments of patients. Two simple examples illustrate these dynamic, often conflicted appraisals. An experienced midwife working in public sector explained that she felt little moral judgment while caring for wayward pregnant women and girls.
But upon learning that a patient had a prison background, "I had to ask why. It was alright with me if he lied about it, but I had to ask. In response to continual invasive questioning, patients routinely withhold, distort, and otherwise injure the truth, either consciously or not, and yet within the clinical relationship and its contextual frame, such violations usually do not merit moral notice and do not trigger moral appraisals.
The power of setting and organizational factors Organizational factors may weigh more than individual skills and attitudes in the salience of moral judgments, as suggested in Bowers' study of facilities for criminal patients with personality disorders [ 20 ].
In the University of Colorado teaching program described above, frustration with the poor and behaviorally difficult patients occasionally escalated into hostility from students and teaching staff [ 42 ].
The researchers noted that such hostility was "almost always temporary," however. After all, a cooperative and appreciative patient with Nazi tattoos is still a cooperative, appreciative patient. For those in middle-class or well-to-do clinical settings, on the other hand, the issue of morally reprehensible patients rarely arises. I did not find evidence in the literature to support Jodi Halpern's assertion that, once physicians have invested in caring for patients, they then "invest a great deal in idealizing" them so as to avoid their own negative emotional reactions [ ].
Halpern may be right nevertheless. Clinicians with middle-class practices generally do not ponder what percentage of those men and women have molested children, whereas moral issues are quite salient where convicted criminals come labeled as such. Idealizing distorts clinicians' perceptions and thus limits biopsychosocial comprehension, but it may help motivate clinicians to provide good care. In some cases, it may also protect patients from clinicians who would be unprepared for their own reactions to a more complete picture.
The landscape between prison and polite suburbia, based on the literature reviewed above and confirmed by my own interviews, is one of great variation. I certainly heard people assert that moral appraisals were off-limits and best avoided. We know little about when such judgments occur, what impact they have, which corticolimbic "gears" get "switched," how, and why. Promising subjects, settings, and strategies Progress in understanding professional development and skills often emerges from close studies of experts [ ].
Recent empirical studies have focused on clinicians chosen for expertise in de-escalating aggressive psychiatric patients [ ], in role-modeling humanistic bedside behavior [ ], and in discussing advance directives [ ]. Expertise may be largely tacit [ ] and embodied in habits that operate automatically without conscious intention [ ]. Such expertise may be more or less reliable . William Branch and colleagues, noting that well-intentioned traditional ways of teaching respect to students generally fail, have begun gathering empirical data on expert approaches to modeling and teaching humanistic behavior [, ].
They have not, however, addressed issues of moral judgment, nor have they focused on challenging safety-net and other stigmatized settings. Even without knowing exactly what should happen, understanding what actually happens in such settings would be invaluable. Safety-net settings concentrate extreme outgroups, e. Who decides to work in such settings, who performs well there, and who survives over the long haul?
With experience and age, many people improve their emotional regulation and more skillfully defuse negative situations [ ]. Do clinicians demonstrate these improvements over the course of their careers? Most of us can point to role models who move with such capacious modesty, competence, and wisdom that patients and trainees respond with their better humanity. These role models seem to take in, contain, and transmute negativity and pain.
It would be helpful to know the resources they bring to bear and the strategies they use. Research on emotion regulation may help us understand how clinicians manage moral judgment.
We can regulate our emotions by focusing attention to task, as implied by the dirty work studies cited above, or by reappraising the situation. Cognitive reappraisal appears to have healthier personal and interpersonal consequences than emotion suppression strategies [ ].
A simple suggestion to control one's feelings can decrease disgust reactions to a stimulus. The same stimulus will increase autonomic stress markers when the instruction is to hide suppress one's feelings [ ]. Emotion regulation can also occur via more global strategies [ ].
Mindfulness training, which has well-established physiological and psychological benefits [ ], can lead to improvements in physicians' wellbeing and strengthening of their patient-centered attitudes [ ]. Evidence for the multilevel benefits of narrative expression, as described for Balint groups [ ] and narrative medicine [ ], is also beginning to emerge from controlled studies in patient populations. Creation of narratives facilitates integration of experience into cognitive frameworks, thereby down-regulating disturbing emotions.
Paramedics learn to cope with gore and danger using cognitive strategies and organizational and interpersonal support, but they report long-lingering distress from events that they could not "make sense of" and integrate into coherent stories [ ]. Is interest as an essential quality? One of the factors that may prevent clinicians from triggering moral appraisals is interest, often equated with curiosity.
Recall that a subject in the Fiske experiment could avoid lighting up her amygdala by focusing on whether the person in the photo liked a certain vegetable or by looking for a dot on his face [ 30 ]. Good teachers have stressed the value of curiosity for clinical care ; one of my teachers insisted that "every cirrhotic is different.
Several sociologists have long included interest, surprise, and boredom in their work on emotions [ ]. Social psychologist Paul Silvia has recently posited that interest depends upon a combination of the stimulus complexity and a person's appraisal of her ability to comprehend and cope with the stimulus [ ].
Once a stimulus--or perhaps patient, for our purposes--appears beyond one's comprehension and ability to manage, interest wanes.
Relationships Between Nurses and Physicians Matter
These appraisals mediate individual personality differences in curiosity and the experience of interest . Carol Sansone points out that we can use interest to self-regulate our motivation. When intrinsic motivation lags, we can activate strategies to engage our interest and thereby remain motivated for the task [ ]. When all else fails, we can try to take interest in our own boredom, a classic maneuver in reflective practice.
One of the respondents in my informal survey, a psychologist with a police background, described his strategy in leading therapy groups for sex offenders, some of whose victims he had met and interviewed: In the broader moral communities outside of healthcare, we make legitimate moral judgments of each other's behavior on a continuum from virtuous to contemptuous. Sustained community contributions garner our praise; child abuse, our censure. We also make distorted-mirror judgments that are demonstrably inaccurate and illegitimate because of stereotypes derived from a host of factors such as age, gender, ethnicity, wealth, and power.
The legitimate and illegitimate appraisals often reflect and interact, begetting uncertainty. Within the healthcare setting, barring incapacity, patients remain moral agents and retain accountability, so their behavior in this setting is also subject to legitimate moral judgments. Patients' violent or racist behavior within healthcare facilities, for instance, arouses clinicians' legitimate disapproval and triggers sanction.
The illegitimate, distorted-mirror judgments specific to healthcare include noncompliance with unrealistic or inappropriate instructions.
Clinicians frustrated by such non-compliance may label patients "bad. The good news for patients who may appear morally dubious is that clinicians who feel effective are often happy to overlook transgressions irrelevant to the healthcare task. Within the bounded and ritualized healthcare setting, these "outside" judgments may be inactivated or immaterial, especially if the patient presents with a readily remediable problem, e. In spite of clinicians' egalitarian beliefs and professionalism, however, it is unrealistic to expect that all their moral and social appraisals of patients as human beings will be immaterial.
As noted by Glaser and Strauss, favored patients are more likely to get "more than routine care" and less-favored patients, "less than routine care" [ 9 ].
Joan Cassell, who in the introduction described ICU nurses making judgments of patients, observed that the surgeons and intensivists attempted to be unaware of patients' stories and to reduce their work to technical, biomedical tasks [ 3 ]. Isabel Menzies Lyth described similar strategies among nurses [ 60 ].
Why have we neglected research on moral judgment? While speculative, explanations of the research neglect of moral judgment in healthcare could facilitate understanding and progress in this domain. Researchers may have assumed that bioethicists own the topic or that it requires literacy in moral philosophy.
The isolation of the medical and nursing literatures from mainstream sociology and psychology may play a role. It is also true that researchers and clinicians who concentrate on criminals or other deviant populations in jeopardy of moral judgment are themselves in jeopardy of what Goffman called "courtesy stigma" [ 81 ].
Thus legitimate concern about risk to reputation might dissuade some from exploring this terrain. Finally, given that healthcare leaders colluded in America's long history of dividing patients into deserving and undeserving groups, most modern educators and professionals have emphasized a nonjudgmental egalitarianism in which clinicians' moral appraisals are taboo.
Taboo or not, they are pervasive, and patients know this.
Five Ethical Challenges in Healthcare
Hall's likability study demonstrates that patients are exquisitely sensitive even to unspoken and perhaps unconscious appraisals. Egalitarian professionalism puts a brave face over a complex reality. Nursing in particular is beset by a caring ideology that discourages frank examination of what nurses actually feel and do [ ]. The issue of poverty illustrates the legitimate versus illegitimate looking-glass complexity of moral judgment. As noted in the review cited above, we have remarkably limited data on clinician attitudes to poor people [ 43 ].
Even in the data we have, there is a gap with regard to moral judgment. In their review, Wear and Kuczewski note that a majority of Americans give more credence to individual, blameworthy causes of poverty than to social or structural causes; they also note that such individualistic attributions are more common among right-wing or conservative Americans. The thrust of their article is toward overcoming stereotypical, illegitimate biases against the poor, but they never acknowledge the possibility that some people's behaviors may indeed be responsible for their poverty.
Researchers in the s University of Colorado study discussed earlier described how faculty and students were frustrated by the individual behavior patterns of some poor individuals and families. Such assessments and frustrations seem to have dropped off the healthcare research agenda. The only article I could find from the past two decades directly addressing physician explanations of poverty was from Belgium [ 40 ]. The physicians serving a high-poverty area there showed commendable empathy, understanding, and concern for their patients, and they cited sociopolitical explanations of the poverty.
They cited psychological and individual explanations as well, however, most commonly patients' lack of ambition and motivation to improve their situation but also addiction, laziness, and lack of skills or intellectual capacity. There is reason to be cautious in this looking-glass space, subject as it is to subtle and not-so-subtle distortions.
Many poor people, while themselves suffering from inaccurate, cruel, and damaging stereotypes, attribute the poverty of other poor people to individual behavioral causes [ ]. More seriously, theories of the culture of poverty and the underclass, originally advanced by liberal sociologists, were used by journalists and politicians to blame and demonize the poor [ ].
A final reason for caution and discernment is the overlap of morality and convention. In naturalistic settings, unlike the laboratory, the line between moral and non-moral violations of expectations and trust is often not sharp. Philosopher Margaret Urban Walker reminds us that our everyday lives are littered with small, ordinary violations to which we take offense, some of which are moral, others more conventional [ ].