Confronted with patients whose situations conflict with their own core beliefs, nurses may experience moral distress, which may limit optimal patient care and contribute to job dissatisfaction (Rushton, 2016). Helping students identify and work through moral distress is a key way for nurse educators to promote the first two provisions in the Code of Ethics for Nurses: nurses must respect and care for all patients (American Nurses Association, 2015).
An example of a nursing topic that stirs strong emotions is the counseling and nursing care of women who request an abortion. Learning compassion and advocacy for these patients helps students develop their own capacity for resilience in the presence of moral complexity and dissonance (Rushton, 2016).
NEED FOR SPECIALIZED NURSING SKILLS
One Hundred Professors of Obstetrics and Gynecology (2013) recommended that, in order to keep abortion safe and available and foster broader, more educated support, medical schools have a responsibility to teach all students how to provide abortions. The American College of Obstetrics and Gynecology Committee on Health Care for Underserved Women (2014) recognized abortion care as a core skill that improves access and safety and recommended nearly universal abortion education to health care providers. However, access has been limited by a lack of skilled nurses.
Care for women requesting an abortion is similar to other operative procedures, but with deeply sensitive psychological implications. The nursing skill sets from labor and delivery and/or surgery are helpful but not sufficient (Simmonds & Likis, 2011). Patients need compassionate and knowledgeable nursing care all along the continuum: positive pregnancy test, options counseling, pre-op teaching, procedural and post-op care, contraception teaching, and follow-up.
Few guidelines exist for the nursing care for unintended pregnancy. Simmonds and Likis (2011) listed nurse responsibilities as assessment, options counseling, referral and care coordination, and follow-up. Three essential skills for nurses are nonjudgmental care, confidentiality, and recognition of the special needs of vulnerable populations: adolescents, the chronically and/or mentally ill, violence survivors, and immigrants (Simmonds & Likis, 2011). Hewitt and Cappiello (2015) suggested 27 essential nursing education competencies for unplanned pregnancy and prevention care, including the affective domain of unbiased, nonjudgmental care; self-insight regarding personal beliefs; and applying ethical principles (see http://nursingstudentsforsexualandreproductivehealth.org for additional resources).
ABORTION CARE IN NURSING CURRICULA
In many health care education programs, the topic of abortion is overlooked or optional (McLemore, Levi, & James, 2015). Nursing programs are more likely to prioritize prenatal care over other reproductive topics due to lack of relevant clinical sites, qualified faculty, material, time, and/or fear of religious objections (Hewitt & Cappiello, 2015).
The teaching of abortion could logically find a home in the family planning topics of a course about women's health, public health, health policy, or Quality and Safety Education in Nursing patient-centered care (Hewitt & Cappielo, 2015). Comprehensive instruction and quality teaching materials about abortion procedures, options counseling, psychological and ethical issues, legal issues, code of conduct standards, complications, and emergency contraception should be a standard part of nursing education (Hewitt & Cappiello, 2015; Levi, Simmonds, & Taylor, 2009; Simmonds & Likis, 2011).
RESPONDING TO STUDENT OBJECTIONS
Students are products of their environments. Societal lack of comprehensive understanding of the reproductive system creates "cultural unease among health care professionals" (Levi et al., 2009, p. 305). From the few studies on attitudes, nurses worldwide seem to lag behind other professionals in their conditional support for abortion care, often influenced by religious beliefs (Lipp, 2008).
In our undergraduate maternity nursing course, I was experiencing tension in the classroom during my lecture on abortion. There would usually be a handful that challenged me in class, walked out, or objected in writing. Certain evangelical Christians regard Timothy's call to "reprove, rebuke and exhort" (2 Timothy 4:2) as a religious duty to protest that which conflicts with their faith.
Noting that having a safe venue to voice feelings might deescalate the tension, I looked for a device that would allow students privacy and time to clarify and articulate their values, ahead of the class. An ideal device would allow some conservative students to safely drop their resistance in the classroom and actually hear and process the issues. I thought it equally important for pro-choice students to hear and acknowledge the concerns of students with religious objections.
One Solution: A Preclass Survey Tool
To address the tension and students' objections and give students a voice and agency in their own education, I now send a survey to students one week before the class. The survey is online, optional, and anonymous. Five open-ended questions allow students to address their questions and concerns:
1. What do you want to learn about contraception and abortion?
2. How do you feel about contraception?
3. How do you feel about abortion?
4. Do you have any concerns about caring for women asking for contraception or abortion?
5. Any other comments?
The Class Lecture
At the start of the class, I share how survey responses have dictated the design of the lecture and summarize the comments, without quoting verbatim (due to confidentiality). Typically, about half the class responds to the survey, some with long and thoughtful comments and personal experiences. The vast majority of students express their sincere desire to understand contraception and abortion so they can provide excellent and factual patient education, regardless of their personal feelings.
For some, this is a watershed moment when they realize that they will be called on to provide nursing care to people with whom they may fundamentally disagree. Some students experience for the first time an understanding that there may be times when abortion may be the best, or least bad, decision. A few have expressed discomfort with confronting the complexities of the abortion issue, as it may call into question other aspects of their faith. Although the majority express support for safe and legal abortions, attitudes become more negative with increasing gestational age, previous abortions, or unprotected intercourse.
This conditional judgment about abortion is consistent with research about nurse attitudes in general (Lipp, 2008). About 5 percent of the survey respondents express negative or absolute disapproval of abortion, with some saying they will never provide care, education, or referral. A few have commented that they wish it weren't even taught. Frequently, students share with me later that their feelings have evolved, and now they feel they can accept the patient's choice.
DISCUSSION
The survey provides a framework for the class that has greatly improved uptake of the material and fostered respectful, professional dialogue in and out of class. Some pro-choice students are surprised to learn about strong opposition to abortion, and those opposed to abortion are sometimes surprised to hear the abortion stories shared anonymously by their classmates. Students continue to examine their previous assumptions and mature as professionals, and their tone is thoughtful and collegial. Knowing their voices are heard allows the students to relax and process the material.
Arriving at the highest level of Gilligan's Moral Development (Juujarvi, Pesso, & Myyry, 2011) allows the nurse dual acceptance of self and others and places the primacy of the patient's need above the conscientious objection of the staff member (Nieminen, Lappalainen, Ristimaki, Myllykangas, & Mustonen, 2015). This allows the nurse to be more in harmony with the patient and avoid "leaking" microjudgments.
This review of literature confirms that research in the area of nurse attitudes about reproductive concerns remains sparse. Much needed research on attitudes, including longitudinal change across nursing careers and the influences of interprofessional education, would greatly enrich the ability to provide meaningful nursing education.
SUMMARY
Allowing students the opportunity to work through strong feelings gives them practice in developing beyond the novice stage. Whether or not students plan to provide abortion care, having exposure to abortion care curricula in nursing school creates an educated attitude as professionals and citizens. Learning to provide compassionate nursing care when confronted with moral complexity improves health care of the public.
REFERENCES