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Jolanta Toliusiene and Eimantas Peicius

Key words: ethical problems; nursing education; nursing ethics The post-Soviet scene in Lithuania is one of rapid change in medical and nursing ethics. A short introduction to the current background sets the scene for a wider discussion of ethics in health care professionals education. Lithuania had to adapt rapidly from a politicized nursing and ethics curriculum to European regulations, and from a paternalistic style of care to one of engagement with choices and dilemmas. The relationships between professionals, and between professionals and patients, are affected by this in particular. This short article highlights these issues and how they impact on all involved.

Study of the humanities does not only educate people but also develops an appropriate debating culture closer to patients, especially in the health care professions.1 While improving the more specific teaching of ethics, bioethics and other related disciplines in Lithuania / as in other new EU member states / our experience was that ethical questions were still understood as moralizing and too sophisticated in our society.2 Despite the recognized feeling of a lack of moral competency in general, the public is quite skeptical and sometimes dismissive of ethical issues. However, the actual ethical problems do not disappear and new confusions come to the surface repeatedly, such as the crisis of health care resources, unofficial hidden euthanasia, or misuse of biotechnologies etc. Medical ethics in Lithuania is therefore becoming a new kind of lens for nursing professionals that opens to wider horizons of contemporary health care, thus contributing to significantly greater possibilities for a more profound analysis of health care problems, especially that of physician/patient relationships.35 Our aim is to analyze the development of nursing ethics in post-Soviet Lithuania, as well as consider the future prospects of potential interdisciplinary studies.

Nursing education in Lithuania: historical background

Nursing as a profession started in 1920 in Lithuania, when nursing staff were educated by qualified physicians. Until about 1941 a simplified nursing education curriculum
Address for correspondence: Jolanta Toliusiene, Siaures pr. 16/40, Kaunas 49155, Lithuania. Tel: ' 370 5 266 0456; Fax: ' 370 5 264 9119; E-mail:

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included some non-systematic approaches on how to cope with physiological and psychological problems in order to assist physicians in the process of caring and curing.6 While analyzing some educational documents, we discovered that some classic questions of medical ethics (mainly based on the Hippocratic Oath) had already been introduced during that time.7 Nevertheless, the basic function of nursing was reduced to contributing to physicians clinical encounters, not actually to participating in medical decision making. Between 1945 and 1990, nursing as a profession and the nursing education curriculum changed significantly. The demand for nursing services, as well as the lack of qualified medical professionals, raised the importance of nursing in Soviet society. The nursing education curriculum was strongly unified and centralized by the government institutions of the USSR; it was not supposed to be changed or even adjusted to any specifications. Nurse training evolved to the level of higher education and was taught in six medical schools around the country. This meant that the curriculum was extensively politicized: besides the medical subjects, study of the history of the Communist Party, military medicine, dialectic materialism and atheism was recognized as mandatory and displaced the important role of the training of nurses.8 Meanwhile, ethical aspects of nursing were mostly related to these subjects, especially atheistic ideology, and the role of the nursing profession was limited to technical and procedural duties in medicine.9 Undoubtedly, nursing studies have made enormous progress since 1990 in Lithuania and now the curriculum is very close to the recognized western European standards. Nevertheless, nursing practice is lagging behind; this is especially evident in the provinces. In many cases nurses can perform only some specific treatments under the supervision of physicians. Only two university hospitals and some large regional hospitals have adopted new nursing knowledge, such as nursing documentation and the use of the nursing process in clinical practice, and allowing nurses to work more independently. After Independence, a Law of Nursing Practice was issued by the Parliament of the Republic of Lithuania, which details the standards expected of registered nurses and the standards for ethics for nurses that came into force recently.10

Curriculum changes in nursing ethics education

The main period of development of medical ethics was characterized by the predominance of the paradigmatic model of biological sciences (the biomedical model), whereas later on there was a shift to the biopsychosocial model. Changes occurred in the levels emphasized in ethical analysis (from individuals to complex social structures) as well as in the methods applied. Studies of organizational and professional ethics began a movement of change from individual hospitals to social control and socialization of institutions, and the scope of studies of social roles broadened.11 A significant shift took place: from analysis of sociopsychological factors to an institutional level of analysis; from studies of microsocial relationships to the analysis of macrosocial systems; from clarification of individuals relationships and/or peculiarities of communication to analysis of power structures; from analysis of individual roles limited by concrete conditions of the environment to a complex organizational analysis; and from behavior analysis to a contextual analysis of policy

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Changes in nursing ethics education in Lithuania


in macrosocial contexts.4,11 This shift conditioned the introduction of a multitude of new branches of interdisciplinary subject areas such as nursing ethics, bioethics and professional ethics in the curriculum. In addition, new study topics came into force in the field of medical ethics. For instance, when analyzing issues of modern moral dilemmas (abortion, euthanasia, stem cell studies, etc.), nursing students are increasingly exposed to the socioethical content of new medical technologies and presented with various approaches to these phenomena. Thus, medical ethics in general is today tackling topics such as the social aspects of physical and mental diseases, physician/patient (and nurse/patient) relationships, the organization and structure of health care institutions, and the socioeconomic basis of the health care system, and is fully applicable and pragmatically justified in the context of nursing education.12 The so-called graded education system has been implemented at Kaunas University of Medicine during the last decade. This means that study for every medical specialization includes the basics of normative ethics as well as specific professional ethics in the later years of undergraduate and postgraduate study. For instance, the curriculum for undergraduate nursing studies integrates a course of ethics (34 academic hours) in the first semester and a more specialized course in bioethics in the sixth semester (20 academic hours). The ethics course consists of 50% lectures and 50% seminars. Every lecture is followed by the study of texts and interpretation, together with discussion and moral problem identification during the seminars.11,13 The bioethics course focuses on the more specific clinical dilemmas and is more applied to nursing professional practices. This kind of transformation in education led us to encourage students to reflect critically and sensitively on ethical issues as well as to improve their skills in making constructive as well as consensus-building decisions.12 For the last 10 years the ethics syllabus has been changed each academic year after feedback from students and the experience of international co-operation within the SOCRATES/ERASMUS, LEONARDO and other educational projects. For example, by using more comprehensive texts for students, the subject of moral philosophy in ethics (and original readings of Aristotle, Kant and Mill) was changed and extended to include moral values, principles and norms. This also encompasses the most important codes of ethics and international declarations. This was necessary to bring it in line with the syllabus in philosophy. Thus teachers are exposed to the crucial concepts of human dignity, autonomy, paternalism, informed consent etc. during lectures and discussion of medical cases and situations. Debates about the pros and cons of contemporary moral dilemmas that occur frequently in clinical care, such as those concerning informed consent from incompetent patients, the limits of autonomy in patients with Alzheimers disease, truth telling with cancer patients etc. are frequent topics at such seminars. By describing lived experiences and events rather than claiming any statistical validity, we have achieved a focus on real, substantial and relevant ethical questions to enhance student nurses interest and satisfaction with ethics education in general, motivating them to participate more in hypothetical decision-making exercises during seminars. In addition, teachers and researchers have also benefited from this method of teaching ethics.12,13 Despite these achievements, many problems of ethics education still remain in Lithuania. Should we engage student nurses in such personally or socially painful problems as priority setting when health care resources are scarce, or oncologists are

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involved in unofficial or hidden euthanasia? What about the risk of disappointment and frustration, or feeling morally distressed? The typical problem for ethicists in our country is how to balance pro-life and pro-choice viewpoints; that is, should we take a stand against abortion and respect human life, or should we encourage autonomous deliberation and promote individual choice? The question is not so much if we should, but how best to present the topics and encourage informed discussion.

The future of nursing ethics

The perspectives of health care ethics in Lithuania rest on three basic determinants: their association with scientific research; the specific politics and sociocultural environment of Lithuania; and reforms and innovations in the educational system. Following the achievements of western European scholars in nursing ethics, further development must encompass the heritage of cultural values as well as the integration of new disciplines, such as bioethics, social anthropology and psychology.13 Nursing ethics should be based on scientific research, contributing to the large pool of fast growing nursing research in health care, and therefore be adequately incorporated into all levels of the nursing education curriculum.14 The scientific contribution of nursing ethics implies a number of questions. How can nursing ethics as a subject be a tool for institutions and contribute to and enrich biomedical research, as well as public participation in health care decision making? Does nursing ethics play a part in the adoption of cultural, institutional and political changes in post-Communist countries like Lithuania? Should we teach and require explicit knowledge in nursing programs, or just assist and be in a mentoring role in the learning process? Such questions are important because nursing ethics is currently defined as a multiparadigmatic and pluralistic (not merely interdisciplinary) subject of an academic course.14 This allows researchers to formulate alternative theoretical approaches and strategies for empirical research that are oriented to wide interpretations of ethical principles, and especially concern EU rules.15

Any curriculum changes in nursing ethics are good if future professionals (physicians, nurses, managers): gain a sense of respect and compassion for living beings, especially human beings, whatever the circumstances; develop moral sensitivity in identifying the potential or actual ethical problems and the moral competence to choose the criteria, make decisions and act rationally and critically; and demonstrate a sense of responsibility to patients/clients, colleagues and society, and tolerance and true comprehension of their rights and duties. Hence, to balance the contradictions between clinical disciplines and the humanities, especially between nursing and ethics, we should employ a strategy of partnership. In order to have ethical (happy) professionals, we should train them by using respectful, good-natured and student-oriented lively communication based on dialogue. Although the development of nursing ethics as an independent branch of science in Lithuania was impeded during certain times, recent research demonstrates that modern research topics and techniques in this field have gained in esteem. Such tendencies indicate that the Lithuanian scientific

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community is accepting the ethical standards that predominate world-wide. Nursing ethics should be associated with the analysis of new challenges, for instance, to what extent modern biotechnologies should be applied, how to improve the situation of patients rights, and how to combine knowledge from social sciences and biomedicine in order to improve the quality of health care services and to ensure better functioning of the health care system in Lithuania as well as in the whole of eastern and central Europe. Jolanta Toliusiene, Vilnius University, Vilnius, Lithuania. Eimantas Peicius, Kaunas University of Medicine, Kaunas, Lithuania.

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