Demonstrating respect is the hallmark of excellence in caring for critically ill patients and their families. Understanding the meaning of respect and the strategies that foster it are foundational for nurses as interdisciplinary healthcare professionals. Basically, respect is the act of esteeming another. Demonstrated by word and deed, it is fostered by attending to the whole person by involving the patient and family in decision making, providing family-centered care, bearing witness, and adopting a broader perspective marked by cultural humility. By creating processes that ensure everyone's views are heard, healthcare professionals as well as patients and their families are supported. One key process, known as the “Council Process,” shifts dialogue from telling to discovering, from judging to inquiring; it neutralizes conjecture, fosters the acceptance of moral conflict, and protects the integrity of healthcare professionals and their organizations. Acknowledging respect as a foundational ethical principle is the first step toward relationally rich healthcare environments for patients, families, and professionals.

Demonstrating respect is the hallmark of excellence in critical care practice. 1 Our relationships with critically ill patients and their families demand conscious attention to how our actions, decisions, and words uphold the essence of what it means to respect another. These relationships carry ethical responsibilities as nurses and interdisciplinary healthcare professionals. Rooted in internal beliefs about the value of another human being as one who shares a common human destiny, respect is expressed in how we care for our patients and their families. As professionals, understanding of the meaning of respect and the strategies that foster it are foundational to upholding our ethical obligations.

There are many definitions for respect . Basically, it is the act of esteeming another, an act that demands we ourselves have a sense of authenticity, integrity, and self-knowledge. It demands that we honor the wholeness, the essence, and the uniqueness of the other. When we give individuals respect, they experience a sense of worthiness, of being seen and heard. We demonstrate respect by our words, deeds, and behaviors when we honor another's choices, preferences, and boundaries for privacy.

The ethical principle of respect for persons is fundamental to creating an ethically grounded relationship. Respect for persons incorporates notions of self-respect and integrity, autonomy or self-determination, privacy, veracity (truthfulness), and fidelity (keeping promises). 2 Understanding the robust concepts of respect and respectfulness at the center of many ethical traditions can help us expand our notions of what is required of us in everyday interactions. So too can codes of ethics for nursing and medicine, which endorse respect as foundational to understanding our professional roles, relationships, and responsibilities. 3,4 Upholding the principle of respect means that we extend it to our patients and their families, our professional colleagues, and ourselves as well. Critical care nurses have identified respect as a key component of communication, collaboration, and in valuing the contributions of nurses. 5

Respecting individuals because they are human beings is different from respecting them for what they know, for their position or title, or for what they do. At times, our notions of respect can become confused or diluted. Respect is not about liking someone, condoning the decisions or behaviors of others, or avoiding conflict. When patients make decisions that we do not endorse, for example, we show respect by accepting their informed choices rather than engaging in behaviors aimed at convincing them of our way of thinking. Clarity about the boundaries of advocacy, persuasion, manipulation, and coercion is essential to respectful professional relationships. 2,6

Notions of respect based on a sense of “political correctness” are also insufficient. Saying the right words without sincerity, masking our biases by exerting our power to achieve the outcome we desire, behaving in ways that are contrary to our words, or abandoning patients physically, emotionally, or spiritually undermines our personal integrity and the integrity of relationships with others. Each of these examples involves subtle or overt disrespect that may be experienced as a form of interpersonal, emotional, or spiritual violence.

Likewise, when patients or families are aggressive or threatening in their interactions with us or when honest, authentic engagement is absent, respect is undermined. Critical care nurses report the highest incidence of verbal and physical abuse, sexual harassment, and discrimination in the workplace among patients and their families. 5 Less severe forms of disrespect arise when patients or their families do not fulfill their responsibilities to participate in treatment decision making or refuse to learn treatments that are necessary for discharge. The norms of respect are reciprocal: they are required in all interactions between patients, families, and healthcare professionals, among members of the interdisciplinary team, and within institutions. When respect is violated, clear norms of behavior, consistent responses, and organizational mechanisms for addressing the behaviors, such as zero-tolerance policies, are essential for upholding a respectful work environment and clinical care. 5 Documents that communicate patient rights and responsibilities in the healthcare relationship begin to create norms of shared responsibility and accountability. 7

Every member of the healthcare organization—and the organization itself—is responsible for creating an environment of respect. This accountability is for ensuring that there is coherence and integrity at every level of the organization. Although it is impossible to guarantee outcomes, we must act with integrity in every encounter and communicate our commitment to creating and honoring norms of respect within the organizations where we practice, norms that affect patients and their families, and reach within and across the professions, the institution, and the community.

We demonstrate respect when we attend to the whole person, from his or her physical health to emotional, psychosocial, spiritual, and culturally bound needs. In addition, to ensure authentic engagement with patients to help them understand their illness, we give them appropriate choices while seeking to fully appreciate what matters to them and what would improve the quality of their lives.

Ideally, decisions for critically ill and dying patients are based on mutually determined goals of care and incorporate assessments of burdens and benefits, scientific evidence, and patient and family preferences. 8 Involving patients fully in decisions about their care is a way of demonstrating respect. We should routinely assess patients' capacity for decision making and ask about their preferences for treatment, even while on mechanical ventilation. 9 When patients are no longer capable, prior conversations and advance directives can facilitate decision making for the family. 10 Yet some patients may not know or have discussed their preferences with their family or caregivers. Even if they have, advance directives alone cannot eliminate the burdens of decision making at the end of life. 11 Conditions of uncertainty and ambiguity may create an environment where communication is ineffective, leading to conflict.

Communication, a key element in decision making, is particularly difficult in the critical care environment. The concerns of families of critically ill patients about the adequacy, reliability, and timeliness of communication 12,13 are well documented. So too are deficiencies in communication about the end of life 12,14,15 —a time when dissatisfaction with care focuses on communication and decision making. 13 Such dissatisfaction arises from incomplete and/or inconsistent information and lack of respect and compassion toward the patient and family, or from cultural incompetency. 14,16

Decision making in critical care presents considerable challenges to our understandings of respect. In a traditional hierarchical model, knowledge and power imbalances may skew decision-making authority. Even if we support the concept of shared decision making, an ideal for respectful care, our behaviors may convey contrary messages. As professionals, a robust model of informed consent requires that we go beyond disclosure of options and information and making recommendations for treatment. It demands that we accept the informed choices that patients or surrogates make, including the choice not to accept our professional recommendations.

Under conditions of uncertainty, neutrality must guide our interactions. Although we offer guidance and recommendations, we must be prepared to accept and honor choices different from our own. Neutrality—not being attached to a particular outcome, but being committed to a process of understanding and meaning—allows us to create an environment where authentic respect can arise. Related to this, we must be honest in disclosing options in order to avoid creating illusions of choice when there is none. When we offer treatments—particularly at the end of life—that cannot change the outcome, we must disclose that they may prolong an unacceptable quality of life or prolong dying. In such cases, for example, the choice is not about whether the patient will die but how he or she will live until death. Openness and truthful candor are essential for fostering honesty and trustworthiness when engaging in dialogue about these issues with patients and families.

Patient needs and preferences central to their care must be understood within the context of the relationships that are important to their lives. Thus, caring for the patient inherently includes caring for the family. Critically ill patients often lack decision-making capacity, and their families become intimately involved in and responsible for decisions. 17 Family-centered critical care is based on the values, goals, and needs of the patient and family, 18,19 including their understanding of the illness, prognosis, and treatment options and their expectations and preferences for treatment and decision making. 20 A family-centered approach is essential to understand patient interests within the context of their families and the relationships that are central to their lives. This is particularly true when caring for critically ill infants, children, and adolescents who generally rely on their families to speak on their behalf. 21,22

Processes should be in place to support routine questioning of patients and their families about what information is important to them, how they prefer to receive information and with whom, and who will speak for them when they are unable to speak for themselves. Dialogue and assessment of outcomes need to be ongoing, because preferences are dynamic and context-dependent. Methods for enhancing communication about these issues are discussed elsewhere. 15

Family-centered care also involves clarifying how to resolve conflicts between patient and family preferences. As discussed above, decisions made by patients with decisional capacity should be followed. When patients lose their decision-making capacity, the designated surrogate or healthcare proxy is authorized to speak on their behalf. 2,6

These situations can create ambiguity and uncertainty about how to respect the patient's expressed preferences. Advance directives offer some guidance but must be interpreted within the clinical situation. This leaves open the possibility that family members and healthcare professionals may disagree about how to apply the patient's preferences. A process that cultivates mutual understanding, explores any conflicts of interest, and focuses on what the patient would have wanted can help alleviate such conflicts. Proactive ethics consultation can be advantageous particularly when there is disagreement among family members or there are vast differences in interpretation of preferences by healthcare professionals.

Bearing witness is foundational to notions of respect. Naef 23 has posited that bearing witness is a moral stance for engaging in the nurse-person relationship. It is a human way of relating that is inextricably linked to the quality of presence one extends to another. It involves respecting the truth of the person, suspending our own judgment about it, and remaining true to and respectful of what the other has experienced. As a particular form of caring,

bearing witness is being with and relating to others that is based on the values and beliefs that give rise to a commitment to attend to, honour, and stay with persons' truths perspectives, priorities, hopes and dreams; that is, their lived experience. 23 ^(p149)

In critical care we are invited to see firsthand the sufferings of our patients and families and to witness their process of responding and adapting to illness, healing, recovery, or death. As nurses, our moral agency can be described as becoming conscious of the suffering of another 24 and the corollary responsibility to witness it, regardless of whether we can do anything to relieve or diminish it. Engaging in respectful attunement to the needs and preferences of the patient or family, avoiding harm by remaining present throughout their journey (regardless of the outcome), and compassionately responding to our own human limitations are foundational for optimal care. 25

Bearing witness is particularly difficult during times of profound suffering, intense emotional and spiritual crisis, or moral distress. 25 During these circumstances we may be overwhelmed by the intensity of the situation or by our own pain and human vulnerabilities. It is during these times that nurses and other members of the healthcare team have an opportunity to choose to stay present and bear witness to the situation or to turn away and disengage with the truth of the situation. In turning away, for whatever reason, we may end up abandoning the patients or families we serve, inadvertently disrespecting their truth, or causing ourselves moral distress and anguish about our unfulfilled moral commitments. 26 As a result, we must cultivate a respectful and compassionate response to our own experience by understanding our own limitations and those of the systems where we serve. 25

Respect for persons incorporates respect for the particular values, beliefs, and practices of the person we are interacting with. Often these beliefs, values, and practices reflect racial, cultural, religious, socioeconomic, gender, or other perspectives. To be authentically respectful, we must develop new and enhanced skills to honor diversity. Doing this means going beyond being “sensitive” to the diversity of others to adopting a stance of nonjudgment, engagement, and humility. Tervalon and Murray-Garcia 27 identify a concept they call “cultural humility,” which involves adopting a broad definition of culture and creating a web of meaning in which we each live. Cultural humility, as they explain it, requires the ability to critique our own culture and a motivation to understand the culture of the “other.” Such a commitment to understanding differences and similarities neutralizes power and authority imbalances. It allows us to ask “What can this patient and family teach me?” instead of “What can I tell them or how can I get them to agree to what I want to have happen?” This concept of cultural humility is a cornerstone for care, particularly palliative care. 28

A true commitment to respect demands that we broaden our frame of reference—in essence, to see what we do not see. As McKee 29 puts it, “We cannot see the facts that are relevant to another's frame until we first shift our way of looking…. Framing our practice worlds as we do, we find the facts consistent with our frames and inhabit the worlds they specify, no longer seeing the alternative worlds that might be outside the margins of what we have come to know.” In short, we suffer from “frame-induced blindness.” To overcome this blindness, we need a kind of “double vision” that allows us to respond to the particular (ie, the person, situation, illness, or pain) and at the same time see the deeper story and its meaning.

To realize this “double vision,” we must create processes that ensure everyone's point of view is heard and considered. Such processes bring to light the assumptions we are making about patients or families and the assumptions families are making about us. We may assume that a family member's irregular visiting pattern is a sign of disinterest, for example, when it may reflect a transportation problem or fear about their loved one's condition. Similarly, patients or families may assume we are not interested in them unless we invite them to share their perspectives with us.

As professionals, we must understand our professional values and how they are expressed so we can ensure our behavior is consistent with our organization's norms and with our professional code of ethics. In cases that challenge respectful relationships, our first step is to assess and draw upon the internal resources we bring to patient care situations, examining both our vulnerabilities and our coping mechanisms, including our personal use of self-care practices and support systems. Our next step is to identify what additional resources we need to enable us to provide care in difficult cases. Support systems can play a key role in helping us develop self-awareness and the skills that will better equip us to manage and prevent situations that give rise to disrespectful relationships. So too, it helps cultivate compassion toward ourselves and establish ways to acknowledge our own suffering in response to that of our patients and families. 30

Norms and strategies can help create a climate of respect. 5 As healthcare professionals, we can adopt strategies that create connections and allow us to foster our relationships with our colleagues and with the patients and families we care for. Each strategy is an expression of respect; all contribute to an environment in which connection can thrive.

One key strategy is to create respectful dialogue by shifting from telling to discovering, from judging to inquiring, and from blaming to uncovering. To do this, we can use a “Council Process” to help us speak truthfully and constructively; listen with openness, intention, and concentration without judgment or prejudice; and bear witness to the truth of the other. 25,31 Council process is a bridge to greater mutual understanding and right action. Contrary to the usual fast-paced, often abrupt culture of critical care, council process is a method for creating a respectful environment for communication and understanding by engaging in dialogue, respectful silence, and inquiry. Effective council process demands that all participants cultivate an internal quality of spaciousness and a sense of interiority, transparency, stillness, and openness. 31 Council is an experience of trust in the wisdom of the group and trust that each person can be in his or her own truth in any moment. Being in council is like going on a journey where the destination is unknown; the process reveals what is needed at each juncture and the outcome becomes known by remaining in the process to its conclusion. Key elements of the council process are given in Table 1 . 25,31

Professionalism demands that we demonstrate respect for human dignity and diversity through the roles we play, the relationships we form, and the knowledge and skills we acquire. It is not enough to work alongside with other healthcare professionals to achieve our individual goals in an interdisciplinary setting. We need to integrate our expertise with theirs and play complementary roles in pursuit of a common goal—in short, to work together in an interdisciplinary manner.

This kind of collaboration is marked by acts of integrity and trust and by shared ethical values. Based on the willingness to participate and the promotion of common interests, mechanisms such as the council process foster open communication and listening to seek understanding. By neutralizing conjecture and negativity, the council process coupled with skills to address conflict 33 enables us to make peace with conflict rather than struggle to extinguish it. When we accept moral conflict as part of the human experience, we free ourselves to use conflict as an opportunity for reflection, personal and professional growth, moral progress, and social change. Flowing from a council process, decision making involves explaining the reasons for decisions, making the process more transparent, and helping everyone affected by a decision determine whether he or she can act with integrity.

We must also protect our individual integrity and the integrity of the organizations we serve. We both support and are supported by an organizational ethics framework that provides for analysis of initiatives, policies, and decisions. Within the organization, a systematic and proactive ethics framework reinforces core values, offers a yardstick for the process of ethical analysis, and provides for periodic reassessment, recommitment, or revision on both individual and organizational levels.

As professionals, we are responsible and accountable for upholding the ethical framework that includes respect as a foundational value. Zero-tolerance policies that are consistently upheld can begin to create an environment of respect. 26 We need to identify any disrespect and loss of integrity through a range of strategies, by listening to what is said and what is not, taking anecdotes seriously, translating stories into data, monitoring behavior and practice, and documenting the care we give. Using a root-cause-analysis format, we can explore system issues that contribute to breaches of ethical conduct or routinely create moral distress. 26

Mutual participation is key to the preservation of integrity for everyone involved, and respectful communication allows for the resolution of conflicts when they arise. When we show respect for patients and families, we build the foundation for shared decision making that makes it possible to arrive at shared meaning and satisfaction with the process, regardless of the outcome.

Respect is foundational to all critical care relationships. Every encounter with patients, families, and our colleagues is an opportunity to demonstrate respectful engagement, communication, decision making, and understanding. In our relationally depleted healthcare environments, we must strive to create a workplace that creates authentic and respectful norms among patients, families, and healthcare professionals. 34 Honoring this foundational ethical principle is a first step in transforming our healthcare environments into sanctuaries of healing and excellence.

The author expresses deep gratitude to Roshi Joan Halifax, Dr Barbara Dossey, and the facilitation team of the Being With Dying: Compassionate End of Life Care professional training program for exposing her to the wisdom of the council process, bearing witness, and taking compassionate and respectful care of all persons. For details, visit www.upaya.org .

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Keywords: communication; critical care; ethics; respect

Original article at http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=714669