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Giving Voice to Values: An undergraduate nursing curriculum project
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Giving Voice to Values: An undergraduate nursing curriculum project Sandra Lynch a, Bethne Hart b,∗, Catherine M. Costa b a
School of Philosophy and Theology, and Director of the Centre for Faith, Ethics and Society, University of Notre Dame Australia, Australia b School of Nursing, University of Notre Dame Australia, Australia Received 28 July 2013; accepted 17 September 2013
KEYWORDS Values; Nursing ethics; Values education; Values curriculum
Summary Among the competency standards stipulated by the Australian Nursing and Midwifery Council for graduating students are competencies in moral and ethical decision making and ethics education within professions such as nursing has traditionally focussed on these competencies, on raising ethical awareness and developing skills of analysis and reasoning. However, ethics education in tertiary settings places less emphasis on developing students’ capacities to act on their values. This paper explains and explores the adoption of Dr. Mary Gentile’s curriculum (the Giving Voice to Values curriculum) which specifically focuses on developing students’ capacities to act on their values. The curriculum (Gentile, 2010) assists students and professionals to explore, script and rehearse responses which build upon their capacity to respond in accordance with their own values in complex workplace settings in which they face conflicts of value and belief. The paper firstly examines the theoretical underpinnings of the Giving Voice to Values (GVV) curriculum. It then presents the integration and evaluation phase of a Project inspired by the GVV methodology, using a case study approach within two areas of an undergraduate nursing curriculum. As a pilot project, this initiative has provided signposts to further curriculum development and to research pathways within the UNDA School of Nursing, by highlighting students’ uncertainties regarding their own professional values, and their intense struggles to voice their values within health care contexts. © 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction Giving Voice to Values: an overview ∗
Corresponding author at: School of Nursing, University of Notre Dame Australia, 160 Oxford Street, Darlinghurst, NSW 2010, Australia. Tel.: +61 2 8204 4294; fax: +61 2 8204 4422. E-mail address: [email protected] (B. Hart).
The Giving Voice to Values curriculum designed by Gentile (2010) offers an innovative approach to the teaching of ethics in tertiary institutions. It takes as its premise the proposition that practitioners within professional fields are
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often able to recognize a conflict of values in the workplace, but are less able to articulate their own position and to decipher a course of action which enables them to act on their values in an effective way; that is, in a way which addresses and helps resolve the ethical conflict they have encountered and ensures that they avoid or minimize any systematic disadvantage which might accrue to them as a consequence of their decision to act. Gentile argues that both experience and research demonstrate that many professionals will encounter values conflicts in their professional practice, e.g. when what they wish to accomplish conflicts with the expectations of their clients, customers, patients, students, peers or bosses. The GVV curriculum is designed to help individuals learn to recognize, clarify, speak and act on their values when those conflicts arise. Thus the focus of this curriculum is on the way in which professionals raise an issue of concern in an effective manner; it addresses what professionals need to take into consideration, what they need to do and say in order to be heard when facing ethical conflicts in complex workplace contexts. The distinctive features of the GVV curriculum are that it focuses on positive examples of ways in which practitioners have been able to act on their values in the workplace; it emphasizes the importance for practitioners of finding alignment between an individual sense of purpose and the purpose of the organization in which they work via a process of self-assessment and reflection. The curriculum is also distinctive for the opportunity it provides to construct and practise responses to frequently heard reasons and rationalizations for not acting on one’s values; as well as for building commitment and enhancing effectiveness by repeated practice in delivering responses and providing peer feedback and coaching. The methodology acknowledges that there are different strategies that can be used to enable us to act on our values. They can involve looking for a ‘‘win/win’’ solution for those involved in conflict; alternatively, a practitioner might attempt to change a manager’s mind on an issue through persuasion and logic; approach a higher authority within the organization in an attempt to address an issue; or build coalitions of like-minded employees who might work together to address an issue of concern. These are not unlike the kinds of strategies suggested by other theorists. For example, Rigolosi (2005) approaches conflict resolution by identifying various potential strategies (including ‘‘win/win’’) and describing the process by which conflict can be managed. Rigolosi recognizes phases in conflict resolution from problem recognition, to routine attempts to resolve the problem (e.g. via confrontation, compromise or accommodation), to attempts to redefine the problem and finally to attempts to resolve the redefined problem. The role of assertive communication in resolving conflict is recognized, as is the fact that ‘‘[c]onstructive conflict resolution is characterized by solutions that respond to the needs of all participants in the conflict’’ (p. 212). But Rigolosi’s focus appears to be on comprehensively clarifying the concept of conflict resolution by describing what it is that causes conflict, listing problem-solving moves and then offering, in the form of a prescription, guidelines for the negotiation of conflict in particular situations (2005, p. 206—9). However, her approach does not adequately address the question of how one can
communicate assertively or how one might go about taking account of the needs of others within complex workplace contexts. By comparison, Gentile’s approach by-passes the kind of analysis Rigolosi undertakes to focus on personal and professional motivation to act, and on the development of practitioners’ skill, confidence and competence to act in accordance with their values. Gentile’s methodology facilitates a process of exploring and producing appropriate responses to practical scenarios which illustrate ethical conflict by pre-scripting, practicing, rehearsing and coaching with regard to those responses. In this sense it is Aristotelian in flavor since this process can be seen as analgous to the development of habits or dispositions to behave in particular ways. Aristotle took the habits we develop to be crucial, arguing that we become temperate and good-tempered or self-indulgent and irascible: by behaving in one way or the other in the appropriate circumstances. Thus, in one word, states of character arise out of like activities. This is why the activities we exhibit must be of a certain kind; it is because the states of character correspond to the differences between these. It makes no small difference, then, whether we form habits of one kind or of another from our very youth; it makes a very great difference, or rather all the difference. Aristotle (1984) The Nichomachean Ethics, Book II, 1, 103b25 Gentile also bypasses another feature of contemporary moral debate: debate about the genesis of moral values. Discussions of moral agency in the literature have long recognized the tension between social constructionist views of the moral voice and the fact that moral language is unique in its claims to certainty. For example, Tronto (1999) makes this point in discussing the work of Hekman and Susan (1995) and Bowden (1997). Gentile appears to deal with claims to certainty by asserting that, as members of civilised communities, we share a commitment to some central values, such as honesty, respect, responsibility, fairness and compassion. Martha Nussbaum makes a similar point about shared values, as do Grace and Cohen (2005), when she argues for three normative criteria (compassion, reciprocity and individuality) which ‘‘can be endorsed by a wide plurality of reasonable ethical conceptions’’ (2001, p. 48). In the context of a book on love, Nussbaum (1990) is arguing that emotions such as compassion are important in ethics since they make us alive to value and their assessment ‘‘is part and parcel of the overall assessment of a person’s value judgements and cognitive attitudes’’ (2001, p. 460, 478); although we must be wary of the vicissitudes of personal emotion and partiality, ‘‘compassion is the eye through which people see the good and ill of others’’ (2001, p. 392). For Gentile, this convergence on values such as compassion provides the basis for an ethics education that is focussed on action, rather than on raising awareness or developing skills of analysis, in relation to the ethical issues which nurses and other healthcare professionals face. There are a many useful texts available which deal well with these latter two aspects of ethics education in the context of healthcare; e.g. Campbell, Gillett, and Gareth (2005), Thompson, Melia, Boyd, and Horsburgh (2006), Kerridge, Lowe, and Stewart (2009) and Butts and Rich (2005). The
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An undergraduate nursing curriculum project GVV methodology is distinctive for its focus on the moment of deciding to speak and on finding a way to do so that is both most likely to be effective in the situation at hand; and is also one with which we are at ease, given our own personal style of communication and personality. Hence recognising and responding to: one’s personal attributes and style, as well of those of others involved in a situation of conflict; the connection between the private and public spheres of life; and the various factors which combine to create complex workplace contexts is seen as crucial to the development of confidence and competence to act on one’s values. Consistent with the GVV curriculum, the core premise of this project is that training in developing such confidence and the competence, in situations in which a conflict is clear, is likely to develop the ‘‘moral muscle’’ which enables individuals to respond with integrity to situations of ethical conflict. Further study is needed to test that the training provided by the GVV curriculum will help develop in practitioners and trainee practitioners the capacity to tackle ethical debate on especially complex issues.
Giving Voice to Values: a nursing context The preparation of nursing students for ethical professional practice is a multidimensional challenge. The profession of nursing legislatively requires safe and proper practice, with continuing competencies in moral and ethical decision making, and significantly in patient advocacy, cross cultural competence, team work, collaborative care, social justice and critical thinking (ANMC, 2006). Historically and currently, the undergraduate units of study in the Bachelor of Nursing at the University of Notre Dame Australia (UNDA), Sydney, have dedicated areas of study to these competencies. There has always been the pedagogical imperative to make study meaningful and relevant for our undergraduate students, whose experiences in health care contexts are fragmented and whose life experiences are diverse. In late 2010, UNDA began to examine the teaching of ethics in its professional disciplines with the aim of supporting and improving its delivery. As part of this work, in 2012 Dr. Mary Gentile presented workshops across the University campuses, introducing the GVV framework in healthcare contexts. A core group of the academy established a GVV Project, incorporating a pilot study of the implementation of this framework into the undergraduate nursing curriculum.
The GVV nursing project The GVV framework for ethics education was undertaken within two Units of study within the Bachelor of Nursing Degree during the latter semester of 2012. The presentation of the GVV Framework involved introducing GVV as a pioneering action-oriented pedagogical approach to developing the skills, knowledge and commitment requisite to values-based practice and leadership within nursing. This introduction noted that the GVV curriculum does not focus on convincing students or practitioners to be ethical. Rather its aim is to empower those of us who in many cases do already act on our values, or want to act on our values, by supporting the development of moral competence. Consideration was given to using a moral competency inventory
3 prior to beginning this project, but research by Martin and Austin (2010) questioned the validity of this tool. Due to the limitations of time, no inventory was used. However, future research will identify and use a validated assessment tool. The introduction the students received summarized the methodology and explained the ‘‘Seven Pillars’’ of the GVV approach, describing those factors which provide the theoretical underpinnings of the approach. These pillars are values, choice, normalisation, purpose, self-knowledge and alignment, voice, and reasons and rationalisations. To briefly address each of these, the first of the pillars (values) encapsulates the assertion as explained above, that members of civilised societies share a set of central values, such as honesty, respect, responsibility, fairness and compassion and that this set of shared values provides the basis for ethically defensible action. The second pillar (choice) asserts that all human beings have a choice as to whether to act on their values and all can examine the factors which either enable or disable them from doing so. The third pillar (normalisation) encourages us to see ethical conflicts as normal and hence to approach them calmly and competently. The fourth pillar (purpose) enjoins us to have reflected on our personal and professional purposes before ethical conflicts arise. The fifth pillar (self-knowledge and alignment) encourages us to generate a ‘‘self-story’’ which is consistent with our self-image and which builds on our strengths and preferences to assist us in voicing our values. This pillar draws attention to self-awareness and to the relevance of emotions in interaction with reason and imagination in the process of developing ethical competence. Martha Nussbaum’s work in Love’s Knowledge and also in Upheavals of Thought, addressed above, provides a rationale for our recognition of the role of emotion in moral life. The sixth pillar (voice) emphasizes the importance of practice, of developing the skill and the habit of speaking up in a style with which we are comfortable and which is most appropriate to the situation. The final pillar (reasons and rationalisations) draws attention to the typical and predictable rationalisations that are offered for failing to act ethically and encourages us to identify counter-arguments. Within the introduction the seven GVV pillars were explained in the context of nursing ethics. Three pillars were given particular attention (choice, normalisation and selfknowledge and alignment) since these drew attention to areas of concern as regards ethical education in our opinion as educators. These pillars were discussed in the context of Carol Gilligan’s three stage process of developing an ‘‘ethics of care’’: caring for oneself, caring for others; and caring for oneself and others. In the context of the goal of voicing their values, students recognized that each stage involved a transitional period at which individuals were able to identify examples of a conflict or anxiety as regards choices to be made in managing and integrating different aspects of care. They were able to recognize the inevitability of such conflicts and then to consider and rehearse approaches which might resolve the problem. With regard to the consideration of self-knowledge and alignment, students identified the skills requisite to working through a problem: listening carefully, not interrupting, seeking clarification and respecting differences, particularly cultural differences; and being attentive to another’s body language or being able to
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succinctly explain a point of view while still being empathic toward the other’s perspective. This discussion led students to focus on the implementation of decisions to act ethically, rather than on conceptual analysis and decision-making. In addition to the seven foundational pillars of the GVV curriculum, a set of twelve assumptions underpin the curriculum. These assumptions acknowledge the desire of human beings to voice and act on their values and their recognition that they have done so in the past. The curriculum also assumes that we recognize that we could voice and act on our values more often or more effectively and that we find it easier to voice our values in some contexts by comparison with others. In addition, it acknowledges that individuals are more likely to voice and act on their values if they have practised potential responses to frequently encountered ethical conflicts; and that our example is powerful, since mastering and delivering responses to common rationalisations can empower others, although we cannot assume that we know who those others might be. The curriculum also include assumptions about self-knowledge and interpersonal interaction, suggesting that the better we know ourselves, the more able we are to play to our strengths and when necessary to protect ourselves from our weaknesses; that the more we believe that it is possible to voice and act on our values, the more likely it is that we will do so; that we are not alone in our desire to voice and act on our values; and finally, that while we may not always succeed in our endeavours to do so, voicing and acting on our values is worth doing since it positively influences our capacity to make better decisions and upholds our sense of integrity. With these assumptions and the theoretical underpinnings of the GVV curriculum made explicit, the project explored the way in which the GVV curriculum aligns with a model of ethical decision-making which has been commonly used within the nursing school and in ethics education generally. The Markkula Centre for Applied Ethics (http://www.scu.edu/ethics/practicing/decision/making. pdf) offers a model which is similar to a number of ethical decision-making models, a selection of which are outlined by Stephen Cohen in The Nature of Moral Reasoning (2004). The Markkula Centre model includes the following stages: identification of a problem; data or fact collection related to the problem; exploration of strategies which might resolve the problem; implementation of the strategy chosen as most likely to be effective; and finally evaluation of the impact of the strategy and the decision-making process. The GVV method can be mapped onto the Markkula Centre model, but in doing so the way in which the GVV method extends and develops traditional decision-making models becomes clear. For example, under the Markkula Centre model, identifying the problem may involve us in a description of a particular situation and of the risks it poses. But the GVV method encourages us to go beyond this to engage explicitly with our own attitudes and expectations so that in identifying the problem we also remind ourselves that we must expect problems to arise; we reflect on the particular values which are being challenged by this situation; and we recognize that we have a choice as to whether we act on this problem. With regard to the data collection stage of the Markkula Centre model, we go beyond the descriptive facts
Table 1
A Tale of Two Stories.
A Tale of Two Stories: exercise 1 Recall a time in your work experience when your values conflicted with what you were expected to do regarding a particular, non-trivial situation and you spoke up and acted to try to resolve the conflict in a way that was consistent with your values. What did you do and what was the impact? What motivated you to speak up and act? How satisfied are you? How would you like to have responded? (This question asks you to consider your ideal scenario, rather than to justify/criticise your past actions.) What would have made it easier for you to speak and act? (Consider both things within your control and things within the control of others.) A Tale of Two Stories: exercise 2 Recall a time in your work experience when your values conflicted with what you were expected to do regarding a particular, non-trivial situation and you did not speak up and act to try to resolve the conflict in a way that was consistent with your values What happened? Why did you not speak up and act? What would have motivated you to do so? How satisfied are you? How would you like to have responded? (Again, this question asks you to consider your ideal scenario, rather than to justify/criticise your past actions.) What would have made it easier for you to speak and act? (Consider both things within your control and things within the control of others.)
to include consideration of a variety of factors which may be personal (e.g. involving reflection on our motivations, fears or aspirations); organisational (e.g. related to institutional structures, limited resources or vested interests); or related to social-cultural or professional expectations. During the workshop which followed the students’ introduction to the GVV method, students participated in small group exercises which required them to identify two stories (Gentile’s ‘‘Tale of Two Stories’’, 2010, 52—3) as outlined in Table 1. The goal of these exercises was to encourage students to identify a list of factors which they considered to positively (enablers) and/or negatively (disablers) impact upon their ability and willingness to voice and act on their values. In small and then larger group discussions, facilitated by academic staff, students were encouraged to analyze their ‘‘tales’’ and then to consider how the enablers and disablers they identified resonated with the pillars and assumptions of the GVV curriculum; e.g. how their own and others’ motivations, values and communication styles affected their choices. Then they were asked to begin to develop, practice and accept coaching in possible responses they may have made in situations in which they did not voice their values but wish they had been able to do so.
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An undergraduate nursing curriculum project
Student evaluations Student evaluations were conducted one week following the presentation of the GVV workshop. These consisted of openended questions that asked for anonymous responses to the following: What were the benefits to you in learning the GVV framework? What were the weaknesses for you in the learning of the GVV framework? What does the GVV Framework add to traditional models of ethical decision making? What further comments would you like to give? The student evaluations were collated, and thematically analyzed (Minichiello, Sullivan, Greenwood, & Axford, 2004; Richards, 2005). Reports on these evaluations, often using the students’ own words, are presented with reference to the two curriculum contexts in which the GVV workshops were held. Three dominant themes emerged: knowledge of values, speaking on values and acting on values.
Case study one: the GVV framework in a legal and ethical issues unit of study The Unit Legal and Ethical Issues in Nursing is a second year Unit of study focussing on ethical and legal issues central to nursing theory and practice and on the responsibilities of the nurse in caring for patients within a variety of clinical settings. The students are encouraged to identify different situations in which a sense of moral obligation, moral anguish or conscientious doubt would be likely to arise in relation to ethical issues within nursing practice. The aim of this unit is to improve the ability of students to critically analyze and debate ethical and legal issues they may face in their nursing practice. The introduction to the GVV methodology occurred in weeks 6 and 7 of the unit in two lectures. This was followed by tutorial discussion and workshops in which students undertook the small group activity (‘‘A Tale of Two Stories’’) outlined above in relation to clinical scenarios that were generated by the unit of study co-ordinator. These scenarios were presented for shared discussion and reflection, to facilitate the students’ identification of their own ‘‘tales’’. Prior to and in preparation for the presentation of the GVV Workshop, this cohort of students were first encouraged to reflect on their own values, personal and professional goals, attitudes to conflict and risk-taking, communication styles and self-identification as regards their approach to ethical negotiation. The aim of this reflection was to sensitise students to particular aspects of the GVV framework (e.g. selfknowledge and alignment). The reflective exercises entailed students responding to questions about aspirations, attitudes to conflict and risk, communication and negotiation styles (see Appendix A); and students also completed the values rating and ranking sections of the John Hopkins School for Public Health Questionnaire for Values Clarification (Johns, 2002).
5 2nd year student evaluations Perceived benefits in learning the GVV framework. Evaluations indicated that students recognized that the GVV methodology gave them ‘‘ways of dealing with conflict’’, of ‘‘speaking [their] thoughts and values’’ and of having the ‘‘courage to speak’’; ‘‘it enables the nurse to act, showing . . . the enablers and disablers’’ and acts as ‘‘an accessory to decision making. . .. [indicating] how to act’’. Students’ comments also indicated that they found the framework provided ‘‘interesting new knowledge’’; that it ‘‘simplifies ethical decision making’’, ‘‘allows for personal circumstances’’ and ‘‘can be applied to oneself’’. Additionally students commented that the methodology provided ‘‘insight into critical thinking, and into ‘‘the value of . . . [the student’s] beliefs and instincts’’. Students also commented that the framework ‘‘is more relevant to nursing care, giving insight to critical thinking’’, and showing ‘‘the value of [the student’s] . . . beliefs and instincts’’. It can be presumed that the reference to the framework’s greater relevance implies a contrast between GVV and the more traditional decision-making models discussed in this unit. Perceived weaknesses in learning the GVV framework. Evaluations indicated that students wanted more opportunity to discuss the GVV framework and that they were uncertain about their understanding of the framework and its application. Some students indicated that they were unsure of ‘‘how to respond when value conflicts arise’’ and perceived ‘‘difficulty in applying [the GVV framework] in biased contexts (hospitals)’’. Students sought scenariobased practice with ‘‘relevance to nursing’’ and commented that the framework was ‘‘hard to get conceptually as theory’’. The GVV framework in relation to other traditional models. Evaluations indicated that the framework ‘‘reinforces our [student] values’’; ‘‘gives a reason to stand up for rights of patients and nurses’’; ‘‘gives confidence, certainty’’; that it ‘‘grounded actions’’; ‘‘helps [students]. . . to respond to values conflict’’ and to ‘‘act out/to speak [about] ethical decisions’’; that it ‘‘has a focus on actions’’ and ‘‘gives a strategic rationale, a broader scope for practice’’; that it ‘‘guides rational choices’’ and ‘‘encourages nurses to be proactive’’.
Case study two: the GVV framework within a rural and remote area nursing unit of study The GVV framework was introduced to a small group of third year nursing students who had selected an elective area of study: rural and remote area nursing. This Unit of study was organized as an interactive seminar series, with focus topics for each week, extending over eight weeks. The students also worked collaboratively with the unit co-coordinator to present and publish a seminar paper examining a contemporary issue within this domain of nursing practice. The GVV workshop was scheduled in the sixth week of the series, anticipating that the enduring ethical issues that characterize rural remote health and health care would have emerged powerfully by this stage (Nelson, Pomerantz, Howard, & Bushy, 2007). A clinical scenario (generated by the unit of study co-ordinator) was presented for shared discussion and
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reflection, to facilitate the students’ identification of their ‘‘tales’’. 3rd year student evaluations Perceived benefits in learning the GVV framework. Evaluations identified the GVV Framework as a valuable methodology to allow ‘‘input [of] our own values and to assist students to ‘‘speak up without fear, humiliation or shyness’’. It was also seen as a reflective process that drew attention to ‘‘enablers’’ as well as ‘‘disablers, which are ‘‘our barriers to speaking up’’. Perceived weaknesses in learning the GVV framework. Evaluative comments identified needs ‘‘for more time for understanding and application of the GVV framework’’ and for specific ‘‘relevance to Rural Remote Nursing and Aboriginal and Torres Strait Islander Health’’. An insightful contribution recommended that the GVV framework ‘‘should be inter-professional learning (to work through power imbalances and differences in practice amongst medical and nursing staff’’). The GVV framework in relation to other traditional models. Evaluations indicated students’ thoughts that ‘‘traditional models are often impractical and rarely used in the real world’’, that the GVV framework ‘‘allows theory to be put into practice’’; that it ‘‘shows us the enablers and disablers’’ and ‘‘involves our own experiences, beliefs and values’’; and that it ‘‘gives pathways for speaking up’’. One comment indicated that students ‘‘often can not remember traditional models’’.
Reflections from the educators This pilot project evaluated the integration of the GVV framework within the Bachelor of Nursing Program. It involved two cohorts of students at different phases of their degree program. We acknowledge that there are differences between and within these two cohorts, but maintain that the student evaluations and our teaching experiences do provide the basis for important reflections on this curriculum initiative. The second year students exhibited uncertainty about identifying and articulating their own values, and for some there was uncertainty even about the nature of values per se. This suggests a need in the curriculum for an increased focus on values clarification within pedagogy, but that focus must recognize the connection between values and dispositions to act: what ethicists might refer to as virtues and to which Kirschenbaum (1992) alludes in his discussion of values clarification. This can be effectively aligned with an exploration of the values of the nursing profession, within historical and sociological analyses. It is also clear that these students sought further opportunities to rehearse voicing of their values within a learning context that gave space for the acquisition of communication skills, self-confidence, and interpersonal awareness. The GVV framework was recognized at this introductory level as being a valuable framework that supported considered action, decision making and developing the capacity to ‘speak up’. The process of identifying enablers and barriers to action appeared to support both awareness and reflection.
The third year students exhibited uncertainty in their capacity and ability to ‘speak up’. This cohort was completing their undergraduate studies, with several clinical practicum experiences behind them, and an anticipation of their imminent transition to graduate nursing practice and status. They readily identified values conflicts that they had witnessed and experienced during their learning within health care contexts. They were aware of power inequalities and inter-professional dynamics that influence decision making and action. Their role as patient advocates, and their developing professionalism intersected with the very real limits that they perceived as shaping their nursing practice. In this regard, they appeared certain of their values, but were uncertain about acting on these values within the contexts of health care. They readily identified barriers to giving voice to their values, yet struggled to strongly identify enablers. Confidence and courage were resources that they sought to strengthen. However, the GVV framework did support both their analysis of values conflicts and their motivation to give voice to a reasoned value position. Overall, the GVV framework gave students a structured exploratory space in which to speak out. During the GVV workshops there was an evident interaction between affective process, and cognitive development. Some students experienced mixed emotions and distress in referring to the clinical scenarios in which they had experienced values conflicts. Their sense of disempowerment was notable, although their exploration of thoughts and actions within the GVV framework did appear to assist them in their difficult struggles to find ways of dealing with their uncertainty and hesitation. As educators, we have concluded that the GVV curriculum would be more effective if we had presented it in a more structured format and made it more relevant to the students’ clinical experiences and areas of study. We also recognize the benefits of trans-disciplinary teaching in which a fertile exchange of ideas creates a gestalt of knowledge that also serves as a collaborative template for students to observe and learn within.
Conclusion This pilot project has been completed as the UNDA School of Nursing also enters a stage of curriculum review. The results of this initiative suggest that the educational power of simulation, experiential or scenario-based learning that is central to the GVV methodology is clearly a valuable pedagogical initiative, one which ought to take a more prominent place in our educational endeavours. Our recommendation will be that the School of Nursing should facilitate the systematic integration of the GVV framework throughout the school’s revised curriculum. This pilot Project will also inform the development of research that aims to rigorously identify the outcomes of the introduction of the GVV curriculum within the school’s existing units of study. Our vision is to establish the Bachelor of Nursing Program as a valuesbased curriculum, from which graduates emerge ready for practice within a profession dedicated to values-based competency. However, readiness to practice must be taken to include possessing the confidence, competence and courage
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An undergraduate nursing curriculum project to give voice to one’s values when faced with a conflict; and to collaboratively and effectively function in delivering healthcare with integrity and in an ethically defensible way.
Appendix A. Reflective exercise (2nd years) • Questions of purpose: What are your personal and professional goals? How do you define your impact? What do you hope to accomplish? • Questions of risk: What is your risk profile? Are you a risk-taker? Or are you risk-averse? What are the greatest risks you face in your line of work? Are they personal, professional or societal? • Questions of personal communication/style preference: How do you deal with conflict? Are you nonconfrontational? Do you prefer communicating in person or in writing? Do you think best from the gut and in-themoment, or do you prefer to take time out to reflect and craft on your communications? • Questions of loyalty: Where would you say your greatest loyalty lies: to your family, your work colleagues, your employer or to other stakeholders? • Questions of self-image: do you identify as shrewd or naive in regard to negotiation? As idealistic, pragmatic or perhaps as opportunistic?
References Aristotle. (1984). Nichomachean ethics. In B. Jonathan (Ed.), The complete works of Aristotle. Princeton, NJ: Princeton University Press. Book II, 1 Australian Nursing and Midwifery Council. (2006). Registered nurse competency standards. www.nmb.nsw.gov.au/ Competency-Standards/default.aspx Bowden, P. (1997). Caring: Gender-sensitive ethics. London: Routledge. Butts, J., & Rich, K. (2005). Nursing ethics. London: Jones & Bartlett Publishers. Campbell, A., Gillett, G., & Gareth, J. (2005). Medical ethics. South Melbourne, VIC: Oxford University Press.
7 Cohen, S. (2004). The nature of moral reasoning: The framework and activities of ethical deliberation, argument and decisionmaking. South Melbourne, VIC: Oxford University Press. Gentile, M. (2010). Giving voice to values: How to speak your mind when you know what’s right. New Haven and London: Yale University Press. Curriculum site:. www. GivingVoiceToValues.org Grace, D., & Cohen, S. (2005). Business ethics (3rd ed.). South Melbourne, VIC, NY: Oxford University Press. Hekman, & Susan, J. (1995). Moral voices, moral selves: Carol Gilligan and feminist moral theory. University Park: Pennsylvania State University Press. Johns Hopkins Bloomberg School of Public Health Center for Communication Programs. (2002). Questionnaire for Values Clarification. Maryland: USA (p. 2—4). accessed at http://www.jhuccp. org/research/download/Valuesinstrument.pdf Kerridge, I., Lowe, M., & Stewart, C. (2009). Ethics and law for the health professions (3rd ed.). Annandale: NSW: The Federation Press. Kirschenbaum, H. (1992). A comprehensive model for values education. The Phi Delta Kappan, 73(June (10)), 771—776, p1-p5 accessed at http://www. hi-ho. ne. jp/taku77/refer/ kirsch.htm Markkula Centre for Applied Ethics. Santa Clara University; accessed at: http://www.scu.edu/ethics/practicing/ decision/making.pdf Martin, D. E., & Austin, B. (2010). Validation of the moral competency inventory measurement instrument: Content, construct, convergent and discriminant approaches. Management Research Review, 33(5), 437—451. Minichiello, V., Sullivan, G., Greenwood, K., & Axford, R. (Eds.). (2004). Handbook of research methods for nursing and health science. Frenchs Forest, NSW: Prentice Hall Health. Nelson, W., Pomerantz, A., Howard, K., & Bushy, A. (2007). A proposed rural ethics agenda. Journal of Medical Ethics, 33, 136—139. Nussbaum, M. C. (1990). Love’s knowledge: Essays on philosophy and literature. Oxford: Oxford University Press. Nussbaum, M. C. (2001). Upheavals of thought: The intelligence of emotions. Cambridge: Cambridge University Press. Richards, L. (2005). Handling qualitative data: A practical guide. London: Sage Publications. Rigolosi, E. La. M. (2005). Management and leadership in nursing and healthcare: An experential approach (3rd ed.). New York: Springer Publishing Company. Thompson, I. E., Melia, K., Boyd, K., & Horsburgh, D. (2006). Nursing ethics (5th ed.). Edinburgh: Churchill Livingstone. Tronto, & Joan, C. (1999). Care ethics: Moving forward. Hypatia, 14(Winter (1)), 112—119.
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Giving Voice to Values: An undergraduate nursing curriculum project Sandra Lynch a, Bethne Hart b,∗, Catherine M. Costa b a
School of Philosophy and Theology, and Director of the Centre for Faith, Ethics and Society, University of Notre Dame Australia, Australia b School of Nursing, University of Notre Dame Australia, Australia Received 28 July 2013; accepted 17 September 2013
KEYWORDS Values; Nursing ethics; Values education; Values curriculum
Summary Among the competency standards stipulated by the Australian Nursing and Midwifery Council for graduating students are competencies in moral and ethical decision making and ethics education within professions such as nursing has traditionally focussed on these competencies, on raising ethical awareness and developing skills of analysis and reasoning. However, ethics education in tertiary settings places less emphasis on developing students’ capacities to act on their values. This paper explains and explores the adoption of Dr. Mary Gentile’s curriculum (the Giving Voice to Values curriculum) which specifically focuses on developing students’ capacities to act on their values. The curriculum (Gentile, 2010) assists students and professionals to explore, script and rehearse responses which build upon their capacity to respond in accordance with their own values in complex workplace settings in which they face conflicts of value and belief. The paper firstly examines the theoretical underpinnings of the Giving Voice to Values (GVV) curriculum. It then presents the integration and evaluation phase of a Project inspired by the GVV methodology, using a case study approach within two areas of an undergraduate nursing curriculum. As a pilot project, this initiative has provided signposts to further curriculum development and to research pathways within the UNDA School of Nursing, by highlighting students’ uncertainties regarding their own professional values, and their intense struggles to voice their values within health care contexts. © 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction Giving Voice to Values: an overview ∗
Corresponding author at: School of Nursing, University of Notre Dame Australia, 160 Oxford Street, Darlinghurst, NSW 2010, Australia. Tel.: +61 2 8204 4294; fax: +61 2 8204 4422. E-mail address: [email protected] (B. Hart).
The Giving Voice to Values curriculum designed by Gentile (2010) offers an innovative approach to the teaching of ethics in tertiary institutions. It takes as its premise the proposition that practitioners within professional fields are
1322-7696/$ — see front matter © 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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often able to recognize a conflict of values in the workplace, but are less able to articulate their own position and to decipher a course of action which enables them to act on their values in an effective way; that is, in a way which addresses and helps resolve the ethical conflict they have encountered and ensures that they avoid or minimize any systematic disadvantage which might accrue to them as a consequence of their decision to act. Gentile argues that both experience and research demonstrate that many professionals will encounter values conflicts in their professional practice, e.g. when what they wish to accomplish conflicts with the expectations of their clients, customers, patients, students, peers or bosses. The GVV curriculum is designed to help individuals learn to recognize, clarify, speak and act on their values when those conflicts arise. Thus the focus of this curriculum is on the way in which professionals raise an issue of concern in an effective manner; it addresses what professionals need to take into consideration, what they need to do and say in order to be heard when facing ethical conflicts in complex workplace contexts. The distinctive features of the GVV curriculum are that it focuses on positive examples of ways in which practitioners have been able to act on their values in the workplace; it emphasizes the importance for practitioners of finding alignment between an individual sense of purpose and the purpose of the organization in which they work via a process of self-assessment and reflection. The curriculum is also distinctive for the opportunity it provides to construct and practise responses to frequently heard reasons and rationalizations for not acting on one’s values; as well as for building commitment and enhancing effectiveness by repeated practice in delivering responses and providing peer feedback and coaching. The methodology acknowledges that there are different strategies that can be used to enable us to act on our values. They can involve looking for a ‘‘win/win’’ solution for those involved in conflict; alternatively, a practitioner might attempt to change a manager’s mind on an issue through persuasion and logic; approach a higher authority within the organization in an attempt to address an issue; or build coalitions of like-minded employees who might work together to address an issue of concern. These are not unlike the kinds of strategies suggested by other theorists. For example, Rigolosi (2005) approaches conflict resolution by identifying various potential strategies (including ‘‘win/win’’) and describing the process by which conflict can be managed. Rigolosi recognizes phases in conflict resolution from problem recognition, to routine attempts to resolve the problem (e.g. via confrontation, compromise or accommodation), to attempts to redefine the problem and finally to attempts to resolve the redefined problem. The role of assertive communication in resolving conflict is recognized, as is the fact that ‘‘[c]onstructive conflict resolution is characterized by solutions that respond to the needs of all participants in the conflict’’ (p. 212). But Rigolosi’s focus appears to be on comprehensively clarifying the concept of conflict resolution by describing what it is that causes conflict, listing problem-solving moves and then offering, in the form of a prescription, guidelines for the negotiation of conflict in particular situations (2005, p. 206—9). However, her approach does not adequately address the question of how one can
communicate assertively or how one might go about taking account of the needs of others within complex workplace contexts. By comparison, Gentile’s approach by-passes the kind of analysis Rigolosi undertakes to focus on personal and professional motivation to act, and on the development of practitioners’ skill, confidence and competence to act in accordance with their values. Gentile’s methodology facilitates a process of exploring and producing appropriate responses to practical scenarios which illustrate ethical conflict by pre-scripting, practicing, rehearsing and coaching with regard to those responses. In this sense it is Aristotelian in flavor since this process can be seen as analgous to the development of habits or dispositions to behave in particular ways. Aristotle took the habits we develop to be crucial, arguing that we become temperate and good-tempered or self-indulgent and irascible: by behaving in one way or the other in the appropriate circumstances. Thus, in one word, states of character arise out of like activities. This is why the activities we exhibit must be of a certain kind; it is because the states of character correspond to the differences between these. It makes no small difference, then, whether we form habits of one kind or of another from our very youth; it makes a very great difference, or rather all the difference. Aristotle (1984) The Nichomachean Ethics, Book II, 1, 103b25 Gentile also bypasses another feature of contemporary moral debate: debate about the genesis of moral values. Discussions of moral agency in the literature have long recognized the tension between social constructionist views of the moral voice and the fact that moral language is unique in its claims to certainty. For example, Tronto (1999) makes this point in discussing the work of Hekman and Susan (1995) and Bowden (1997). Gentile appears to deal with claims to certainty by asserting that, as members of civilised communities, we share a commitment to some central values, such as honesty, respect, responsibility, fairness and compassion. Martha Nussbaum makes a similar point about shared values, as do Grace and Cohen (2005), when she argues for three normative criteria (compassion, reciprocity and individuality) which ‘‘can be endorsed by a wide plurality of reasonable ethical conceptions’’ (2001, p. 48). In the context of a book on love, Nussbaum (1990) is arguing that emotions such as compassion are important in ethics since they make us alive to value and their assessment ‘‘is part and parcel of the overall assessment of a person’s value judgements and cognitive attitudes’’ (2001, p. 460, 478); although we must be wary of the vicissitudes of personal emotion and partiality, ‘‘compassion is the eye through which people see the good and ill of others’’ (2001, p. 392). For Gentile, this convergence on values such as compassion provides the basis for an ethics education that is focussed on action, rather than on raising awareness or developing skills of analysis, in relation to the ethical issues which nurses and other healthcare professionals face. There are a many useful texts available which deal well with these latter two aspects of ethics education in the context of healthcare; e.g. Campbell, Gillett, and Gareth (2005), Thompson, Melia, Boyd, and Horsburgh (2006), Kerridge, Lowe, and Stewart (2009) and Butts and Rich (2005). The
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An undergraduate nursing curriculum project GVV methodology is distinctive for its focus on the moment of deciding to speak and on finding a way to do so that is both most likely to be effective in the situation at hand; and is also one with which we are at ease, given our own personal style of communication and personality. Hence recognising and responding to: one’s personal attributes and style, as well of those of others involved in a situation of conflict; the connection between the private and public spheres of life; and the various factors which combine to create complex workplace contexts is seen as crucial to the development of confidence and competence to act on one’s values. Consistent with the GVV curriculum, the core premise of this project is that training in developing such confidence and the competence, in situations in which a conflict is clear, is likely to develop the ‘‘moral muscle’’ which enables individuals to respond with integrity to situations of ethical conflict. Further study is needed to test that the training provided by the GVV curriculum will help develop in practitioners and trainee practitioners the capacity to tackle ethical debate on especially complex issues.
Giving Voice to Values: a nursing context The preparation of nursing students for ethical professional practice is a multidimensional challenge. The profession of nursing legislatively requires safe and proper practice, with continuing competencies in moral and ethical decision making, and significantly in patient advocacy, cross cultural competence, team work, collaborative care, social justice and critical thinking (ANMC, 2006). Historically and currently, the undergraduate units of study in the Bachelor of Nursing at the University of Notre Dame Australia (UNDA), Sydney, have dedicated areas of study to these competencies. There has always been the pedagogical imperative to make study meaningful and relevant for our undergraduate students, whose experiences in health care contexts are fragmented and whose life experiences are diverse. In late 2010, UNDA began to examine the teaching of ethics in its professional disciplines with the aim of supporting and improving its delivery. As part of this work, in 2012 Dr. Mary Gentile presented workshops across the University campuses, introducing the GVV framework in healthcare contexts. A core group of the academy established a GVV Project, incorporating a pilot study of the implementation of this framework into the undergraduate nursing curriculum.
The GVV nursing project The GVV framework for ethics education was undertaken within two Units of study within the Bachelor of Nursing Degree during the latter semester of 2012. The presentation of the GVV Framework involved introducing GVV as a pioneering action-oriented pedagogical approach to developing the skills, knowledge and commitment requisite to values-based practice and leadership within nursing. This introduction noted that the GVV curriculum does not focus on convincing students or practitioners to be ethical. Rather its aim is to empower those of us who in many cases do already act on our values, or want to act on our values, by supporting the development of moral competence. Consideration was given to using a moral competency inventory
3 prior to beginning this project, but research by Martin and Austin (2010) questioned the validity of this tool. Due to the limitations of time, no inventory was used. However, future research will identify and use a validated assessment tool. The introduction the students received summarized the methodology and explained the ‘‘Seven Pillars’’ of the GVV approach, describing those factors which provide the theoretical underpinnings of the approach. These pillars are values, choice, normalisation, purpose, self-knowledge and alignment, voice, and reasons and rationalisations. To briefly address each of these, the first of the pillars (values) encapsulates the assertion as explained above, that members of civilised societies share a set of central values, such as honesty, respect, responsibility, fairness and compassion and that this set of shared values provides the basis for ethically defensible action. The second pillar (choice) asserts that all human beings have a choice as to whether to act on their values and all can examine the factors which either enable or disable them from doing so. The third pillar (normalisation) encourages us to see ethical conflicts as normal and hence to approach them calmly and competently. The fourth pillar (purpose) enjoins us to have reflected on our personal and professional purposes before ethical conflicts arise. The fifth pillar (self-knowledge and alignment) encourages us to generate a ‘‘self-story’’ which is consistent with our self-image and which builds on our strengths and preferences to assist us in voicing our values. This pillar draws attention to self-awareness and to the relevance of emotions in interaction with reason and imagination in the process of developing ethical competence. Martha Nussbaum’s work in Love’s Knowledge and also in Upheavals of Thought, addressed above, provides a rationale for our recognition of the role of emotion in moral life. The sixth pillar (voice) emphasizes the importance of practice, of developing the skill and the habit of speaking up in a style with which we are comfortable and which is most appropriate to the situation. The final pillar (reasons and rationalisations) draws attention to the typical and predictable rationalisations that are offered for failing to act ethically and encourages us to identify counter-arguments. Within the introduction the seven GVV pillars were explained in the context of nursing ethics. Three pillars were given particular attention (choice, normalisation and selfknowledge and alignment) since these drew attention to areas of concern as regards ethical education in our opinion as educators. These pillars were discussed in the context of Carol Gilligan’s three stage process of developing an ‘‘ethics of care’’: caring for oneself, caring for others; and caring for oneself and others. In the context of the goal of voicing their values, students recognized that each stage involved a transitional period at which individuals were able to identify examples of a conflict or anxiety as regards choices to be made in managing and integrating different aspects of care. They were able to recognize the inevitability of such conflicts and then to consider and rehearse approaches which might resolve the problem. With regard to the consideration of self-knowledge and alignment, students identified the skills requisite to working through a problem: listening carefully, not interrupting, seeking clarification and respecting differences, particularly cultural differences; and being attentive to another’s body language or being able to
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succinctly explain a point of view while still being empathic toward the other’s perspective. This discussion led students to focus on the implementation of decisions to act ethically, rather than on conceptual analysis and decision-making. In addition to the seven foundational pillars of the GVV curriculum, a set of twelve assumptions underpin the curriculum. These assumptions acknowledge the desire of human beings to voice and act on their values and their recognition that they have done so in the past. The curriculum also assumes that we recognize that we could voice and act on our values more often or more effectively and that we find it easier to voice our values in some contexts by comparison with others. In addition, it acknowledges that individuals are more likely to voice and act on their values if they have practised potential responses to frequently encountered ethical conflicts; and that our example is powerful, since mastering and delivering responses to common rationalisations can empower others, although we cannot assume that we know who those others might be. The curriculum also include assumptions about self-knowledge and interpersonal interaction, suggesting that the better we know ourselves, the more able we are to play to our strengths and when necessary to protect ourselves from our weaknesses; that the more we believe that it is possible to voice and act on our values, the more likely it is that we will do so; that we are not alone in our desire to voice and act on our values; and finally, that while we may not always succeed in our endeavours to do so, voicing and acting on our values is worth doing since it positively influences our capacity to make better decisions and upholds our sense of integrity. With these assumptions and the theoretical underpinnings of the GVV curriculum made explicit, the project explored the way in which the GVV curriculum aligns with a model of ethical decision-making which has been commonly used within the nursing school and in ethics education generally. The Markkula Centre for Applied Ethics (http://www.scu.edu/ethics/practicing/decision/making. pdf) offers a model which is similar to a number of ethical decision-making models, a selection of which are outlined by Stephen Cohen in The Nature of Moral Reasoning (2004). The Markkula Centre model includes the following stages: identification of a problem; data or fact collection related to the problem; exploration of strategies which might resolve the problem; implementation of the strategy chosen as most likely to be effective; and finally evaluation of the impact of the strategy and the decision-making process. The GVV method can be mapped onto the Markkula Centre model, but in doing so the way in which the GVV method extends and develops traditional decision-making models becomes clear. For example, under the Markkula Centre model, identifying the problem may involve us in a description of a particular situation and of the risks it poses. But the GVV method encourages us to go beyond this to engage explicitly with our own attitudes and expectations so that in identifying the problem we also remind ourselves that we must expect problems to arise; we reflect on the particular values which are being challenged by this situation; and we recognize that we have a choice as to whether we act on this problem. With regard to the data collection stage of the Markkula Centre model, we go beyond the descriptive facts
Table 1
A Tale of Two Stories.
A Tale of Two Stories: exercise 1 Recall a time in your work experience when your values conflicted with what you were expected to do regarding a particular, non-trivial situation and you spoke up and acted to try to resolve the conflict in a way that was consistent with your values. What did you do and what was the impact? What motivated you to speak up and act? How satisfied are you? How would you like to have responded? (This question asks you to consider your ideal scenario, rather than to justify/criticise your past actions.) What would have made it easier for you to speak and act? (Consider both things within your control and things within the control of others.) A Tale of Two Stories: exercise 2 Recall a time in your work experience when your values conflicted with what you were expected to do regarding a particular, non-trivial situation and you did not speak up and act to try to resolve the conflict in a way that was consistent with your values What happened? Why did you not speak up and act? What would have motivated you to do so? How satisfied are you? How would you like to have responded? (Again, this question asks you to consider your ideal scenario, rather than to justify/criticise your past actions.) What would have made it easier for you to speak and act? (Consider both things within your control and things within the control of others.)
to include consideration of a variety of factors which may be personal (e.g. involving reflection on our motivations, fears or aspirations); organisational (e.g. related to institutional structures, limited resources or vested interests); or related to social-cultural or professional expectations. During the workshop which followed the students’ introduction to the GVV method, students participated in small group exercises which required them to identify two stories (Gentile’s ‘‘Tale of Two Stories’’, 2010, 52—3) as outlined in Table 1. The goal of these exercises was to encourage students to identify a list of factors which they considered to positively (enablers) and/or negatively (disablers) impact upon their ability and willingness to voice and act on their values. In small and then larger group discussions, facilitated by academic staff, students were encouraged to analyze their ‘‘tales’’ and then to consider how the enablers and disablers they identified resonated with the pillars and assumptions of the GVV curriculum; e.g. how their own and others’ motivations, values and communication styles affected their choices. Then they were asked to begin to develop, practice and accept coaching in possible responses they may have made in situations in which they did not voice their values but wish they had been able to do so.
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Student evaluations Student evaluations were conducted one week following the presentation of the GVV workshop. These consisted of openended questions that asked for anonymous responses to the following: What were the benefits to you in learning the GVV framework? What were the weaknesses for you in the learning of the GVV framework? What does the GVV Framework add to traditional models of ethical decision making? What further comments would you like to give? The student evaluations were collated, and thematically analyzed (Minichiello, Sullivan, Greenwood, & Axford, 2004; Richards, 2005). Reports on these evaluations, often using the students’ own words, are presented with reference to the two curriculum contexts in which the GVV workshops were held. Three dominant themes emerged: knowledge of values, speaking on values and acting on values.
Case study one: the GVV framework in a legal and ethical issues unit of study The Unit Legal and Ethical Issues in Nursing is a second year Unit of study focussing on ethical and legal issues central to nursing theory and practice and on the responsibilities of the nurse in caring for patients within a variety of clinical settings. The students are encouraged to identify different situations in which a sense of moral obligation, moral anguish or conscientious doubt would be likely to arise in relation to ethical issues within nursing practice. The aim of this unit is to improve the ability of students to critically analyze and debate ethical and legal issues they may face in their nursing practice. The introduction to the GVV methodology occurred in weeks 6 and 7 of the unit in two lectures. This was followed by tutorial discussion and workshops in which students undertook the small group activity (‘‘A Tale of Two Stories’’) outlined above in relation to clinical scenarios that were generated by the unit of study co-ordinator. These scenarios were presented for shared discussion and reflection, to facilitate the students’ identification of their own ‘‘tales’’. Prior to and in preparation for the presentation of the GVV Workshop, this cohort of students were first encouraged to reflect on their own values, personal and professional goals, attitudes to conflict and risk-taking, communication styles and self-identification as regards their approach to ethical negotiation. The aim of this reflection was to sensitise students to particular aspects of the GVV framework (e.g. selfknowledge and alignment). The reflective exercises entailed students responding to questions about aspirations, attitudes to conflict and risk, communication and negotiation styles (see Appendix A); and students also completed the values rating and ranking sections of the John Hopkins School for Public Health Questionnaire for Values Clarification (Johns, 2002).
5 2nd year student evaluations Perceived benefits in learning the GVV framework. Evaluations indicated that students recognized that the GVV methodology gave them ‘‘ways of dealing with conflict’’, of ‘‘speaking [their] thoughts and values’’ and of having the ‘‘courage to speak’’; ‘‘it enables the nurse to act, showing . . . the enablers and disablers’’ and acts as ‘‘an accessory to decision making. . .. [indicating] how to act’’. Students’ comments also indicated that they found the framework provided ‘‘interesting new knowledge’’; that it ‘‘simplifies ethical decision making’’, ‘‘allows for personal circumstances’’ and ‘‘can be applied to oneself’’. Additionally students commented that the methodology provided ‘‘insight into critical thinking, and into ‘‘the value of . . . [the student’s] beliefs and instincts’’. Students also commented that the framework ‘‘is more relevant to nursing care, giving insight to critical thinking’’, and showing ‘‘the value of [the student’s] . . . beliefs and instincts’’. It can be presumed that the reference to the framework’s greater relevance implies a contrast between GVV and the more traditional decision-making models discussed in this unit. Perceived weaknesses in learning the GVV framework. Evaluations indicated that students wanted more opportunity to discuss the GVV framework and that they were uncertain about their understanding of the framework and its application. Some students indicated that they were unsure of ‘‘how to respond when value conflicts arise’’ and perceived ‘‘difficulty in applying [the GVV framework] in biased contexts (hospitals)’’. Students sought scenariobased practice with ‘‘relevance to nursing’’ and commented that the framework was ‘‘hard to get conceptually as theory’’. The GVV framework in relation to other traditional models. Evaluations indicated that the framework ‘‘reinforces our [student] values’’; ‘‘gives a reason to stand up for rights of patients and nurses’’; ‘‘gives confidence, certainty’’; that it ‘‘grounded actions’’; ‘‘helps [students]. . . to respond to values conflict’’ and to ‘‘act out/to speak [about] ethical decisions’’; that it ‘‘has a focus on actions’’ and ‘‘gives a strategic rationale, a broader scope for practice’’; that it ‘‘guides rational choices’’ and ‘‘encourages nurses to be proactive’’.
Case study two: the GVV framework within a rural and remote area nursing unit of study The GVV framework was introduced to a small group of third year nursing students who had selected an elective area of study: rural and remote area nursing. This Unit of study was organized as an interactive seminar series, with focus topics for each week, extending over eight weeks. The students also worked collaboratively with the unit co-coordinator to present and publish a seminar paper examining a contemporary issue within this domain of nursing practice. The GVV workshop was scheduled in the sixth week of the series, anticipating that the enduring ethical issues that characterize rural remote health and health care would have emerged powerfully by this stage (Nelson, Pomerantz, Howard, & Bushy, 2007). A clinical scenario (generated by the unit of study co-ordinator) was presented for shared discussion and
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reflection, to facilitate the students’ identification of their ‘‘tales’’. 3rd year student evaluations Perceived benefits in learning the GVV framework. Evaluations identified the GVV Framework as a valuable methodology to allow ‘‘input [of] our own values and to assist students to ‘‘speak up without fear, humiliation or shyness’’. It was also seen as a reflective process that drew attention to ‘‘enablers’’ as well as ‘‘disablers, which are ‘‘our barriers to speaking up’’. Perceived weaknesses in learning the GVV framework. Evaluative comments identified needs ‘‘for more time for understanding and application of the GVV framework’’ and for specific ‘‘relevance to Rural Remote Nursing and Aboriginal and Torres Strait Islander Health’’. An insightful contribution recommended that the GVV framework ‘‘should be inter-professional learning (to work through power imbalances and differences in practice amongst medical and nursing staff’’). The GVV framework in relation to other traditional models. Evaluations indicated students’ thoughts that ‘‘traditional models are often impractical and rarely used in the real world’’, that the GVV framework ‘‘allows theory to be put into practice’’; that it ‘‘shows us the enablers and disablers’’ and ‘‘involves our own experiences, beliefs and values’’; and that it ‘‘gives pathways for speaking up’’. One comment indicated that students ‘‘often can not remember traditional models’’.
Reflections from the educators This pilot project evaluated the integration of the GVV framework within the Bachelor of Nursing Program. It involved two cohorts of students at different phases of their degree program. We acknowledge that there are differences between and within these two cohorts, but maintain that the student evaluations and our teaching experiences do provide the basis for important reflections on this curriculum initiative. The second year students exhibited uncertainty about identifying and articulating their own values, and for some there was uncertainty even about the nature of values per se. This suggests a need in the curriculum for an increased focus on values clarification within pedagogy, but that focus must recognize the connection between values and dispositions to act: what ethicists might refer to as virtues and to which Kirschenbaum (1992) alludes in his discussion of values clarification. This can be effectively aligned with an exploration of the values of the nursing profession, within historical and sociological analyses. It is also clear that these students sought further opportunities to rehearse voicing of their values within a learning context that gave space for the acquisition of communication skills, self-confidence, and interpersonal awareness. The GVV framework was recognized at this introductory level as being a valuable framework that supported considered action, decision making and developing the capacity to ‘speak up’. The process of identifying enablers and barriers to action appeared to support both awareness and reflection.
The third year students exhibited uncertainty in their capacity and ability to ‘speak up’. This cohort was completing their undergraduate studies, with several clinical practicum experiences behind them, and an anticipation of their imminent transition to graduate nursing practice and status. They readily identified values conflicts that they had witnessed and experienced during their learning within health care contexts. They were aware of power inequalities and inter-professional dynamics that influence decision making and action. Their role as patient advocates, and their developing professionalism intersected with the very real limits that they perceived as shaping their nursing practice. In this regard, they appeared certain of their values, but were uncertain about acting on these values within the contexts of health care. They readily identified barriers to giving voice to their values, yet struggled to strongly identify enablers. Confidence and courage were resources that they sought to strengthen. However, the GVV framework did support both their analysis of values conflicts and their motivation to give voice to a reasoned value position. Overall, the GVV framework gave students a structured exploratory space in which to speak out. During the GVV workshops there was an evident interaction between affective process, and cognitive development. Some students experienced mixed emotions and distress in referring to the clinical scenarios in which they had experienced values conflicts. Their sense of disempowerment was notable, although their exploration of thoughts and actions within the GVV framework did appear to assist them in their difficult struggles to find ways of dealing with their uncertainty and hesitation. As educators, we have concluded that the GVV curriculum would be more effective if we had presented it in a more structured format and made it more relevant to the students’ clinical experiences and areas of study. We also recognize the benefits of trans-disciplinary teaching in which a fertile exchange of ideas creates a gestalt of knowledge that also serves as a collaborative template for students to observe and learn within.
Conclusion This pilot project has been completed as the UNDA School of Nursing also enters a stage of curriculum review. The results of this initiative suggest that the educational power of simulation, experiential or scenario-based learning that is central to the GVV methodology is clearly a valuable pedagogical initiative, one which ought to take a more prominent place in our educational endeavours. Our recommendation will be that the School of Nursing should facilitate the systematic integration of the GVV framework throughout the school’s revised curriculum. This pilot Project will also inform the development of research that aims to rigorously identify the outcomes of the introduction of the GVV curriculum within the school’s existing units of study. Our vision is to establish the Bachelor of Nursing Program as a valuesbased curriculum, from which graduates emerge ready for practice within a profession dedicated to values-based competency. However, readiness to practice must be taken to include possessing the confidence, competence and courage
Please cite this article in press as: Lynch, S., et al. Giving Voice to Values: An undergraduate nursing curriculum project. Collegian (2013), http://dx.doi.org/10.1016/j.colegn.2013.09.004
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An undergraduate nursing curriculum project to give voice to one’s values when faced with a conflict; and to collaboratively and effectively function in delivering healthcare with integrity and in an ethically defensible way.
Appendix A. Reflective exercise (2nd years) • Questions of purpose: What are your personal and professional goals? How do you define your impact? What do you hope to accomplish? • Questions of risk: What is your risk profile? Are you a risk-taker? Or are you risk-averse? What are the greatest risks you face in your line of work? Are they personal, professional or societal? • Questions of personal communication/style preference: How do you deal with conflict? Are you nonconfrontational? Do you prefer communicating in person or in writing? Do you think best from the gut and in-themoment, or do you prefer to take time out to reflect and craft on your communications? • Questions of loyalty: Where would you say your greatest loyalty lies: to your family, your work colleagues, your employer or to other stakeholders? • Questions of self-image: do you identify as shrewd or naive in regard to negotiation? As idealistic, pragmatic or perhaps as opportunistic?
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Please cite this article in press as: Lynch, S., et al. Giving Voice to Values: An undergraduate nursing curriculum project. Collegian (2013), http://dx.doi.org/10.1016/j.colegn.2013.09.004