Stumbling onto Nursing Ethics:A Road Less Traveled

From Nursing Ethics; 1880s to the Present (p. 359-365)
Used by permission 2024 © Marsha Fowler
Chapter 11 Notes

A nurse and midwife in England, my mother loved her job but came by it the hard way. Her protective working-class parents thought that a nurse’s work was too arduous and steered her toward secretarial work in a mill in Manchester. She hated it and, after a few years, rebelled and signed up for nurse training at Hope Hospital in Salford, before telling them what she had done. It was the beginning of World War II. The hours were long as she told it: 72 hours per week with a half day off, lectures after night shift, and many seriously wounded among the patients to care for. As luck would have it, she ended up on a ward that cared for prisoners of war and had many a tale to tell of good and bad behavior. An SS officer who bullied his subordinates, and a kind young Italian soldier who, unasked, helped the other patients and cried at night for his family. Her hospital was bombed during the Blitz of Manchester in 1941; the nurses’ home suffered a direct hit, and 14 nurses were killed. According to family lore, some vulnerable patients were evacuated to Wales, and she was sent with them, so missed the hospital bombing. But in an era before easy access to phones, her family did not know this and thought her among the dead until she returned three days later.

I enjoyed the tales she told, and as teenagers my sisters and I were co-opted to help at various events on the geriatric floor where she was the senior sister (nurse manager). We got to see discipline, kindness, and compassion in action. However, I was not sure I wanted to be a nurse. For a brief period, I thought I would be a medical doctor, but a profound lack of studiousness, a distaste for the classroom, and a disinclination to do homework led to the headmistress of my academic high school ‘suggesting’ my parents remove me from school. This was not uncommon in the UK at that time. Only the most studious finished the last two years and went on to university; the remainder were steered towards practical occupations.

This was the beginning of my stumble into opportunities that directed my career. Luckily, I could sign up for pre-nursing work as a cadet nurse. Which meant I worked two to three days per week in my local hospital and attended classes in the technical college the other days. I loved it! I had hated my very academic and rather dryly taught classes in high school and being confined to a classroom all day long. Cadet nurses in the UK during that era rotated through all of the hospital departments to see how they worked. We assisted physical therapists, X‑ray technicians, autoclaved instruments for theater, made up the unguents in pharmacy, and so on. On the wards we fed patients, helped them walk, changed flower water, and buttered bread for afternoon tea. All things that might seem mundane, but offered opportunities for countless interactions with patients, and a sense that one was needed. After two years, I was accepted into a nurses’ training school in a large hospital in Liverpool, and the real work began. This education, which resembled that of the US diploma schools, was in many ways a trial by fire. We staffed the wards and were often expected to know what we had not yet been exposed to, a problem that puzzled me. Also, there was an accepted bullying of younger students by older students, staff nurses, and sisters. Not everyone engaged in this behavior and there were wonderful role models. But it did not make sense to me, and I could see how such attitudes interfered with good patient care. I vowed that as I moved up the hierarchy, I would not be one of those who bullied. It just did not make sense to me to expect people to know something that they had not been exposed to. For example, in the first few months, I was sent to get a sphygmomanometer and I had no idea what that was but was afraid to ask. Luckily, my second place to look was the general supply closet where the shelves were labeled.

All of this is to say that the environments in which nurses worked could be troubling, and avenues to express concerns did not exist. Not all of the wards were difficult places to work, however. I was also privileged to work in some areas where there was a sense of camaraderie that put patients at ease (wards in the UK at that time were the long open Nightingale type)—thus I knew things could be different.

A few years post-registration, I applied for an assignment in the US, not meaning to stay, yet here I am. The US has been good to me in terms of educational opportunities that I might not have been afforded in the UK, given my earlier rather sketchy educational history. However, I continue to have concerns about the US health-care (non-)system, in which my students now work. It leaves a lot to be desired in terms of justice, access, and equity.

Florida was the site of my first nursing position in the US. I found the work environment radically different from what I had experienced in the UK. For example, there was a lot more documentation as well as more restrictions on what nurses could do independently. I came to understand this was in part a response to legal pressures and worries about lawsuits that were rising during this time, but also had to do with the way health care is financed in the US. Nevertheless, the cumbersome paperwork and need to get “orders” for even the most mundane things such as evaluating when a post-op patient could be safely allowed out of bed, or when stitches could be removed, I felt hampered care. Also, I still encountered difficult situations where I saw that patients were not receiving the care they needed or had delayed care so long that they were in dire straits. Additionally, support for nurses was, for the most part, lacking. To be fair, I was recruited in an era of a severe nursing shortage and often found myself responsible for more patients than I could possibly handle well. There seemed to be an acceptance of this as status quo. But it was exhausting, frustrating, and I often felt inadequate to the task. Surely, if this was expected, it must be possible. Thus, there was something wrong with me. I should be able to work faster and more efficiently. But how does one keep track of 50 patients with only two licensed practical nurses and two aides for assistance? Granted, in the 1970s, there was not so much technology as currently. However, patients were still very sick and deserving of attention. Logically, prevention of potential crises is almost always better than trying to manage them at their peak.

I decided a change to working in an intensive care environment was in order. These specialty areas were becoming more prevalent and seemed better staffed. Also, I wanted to improve my skills and be able to better handle emergencies. As I moved around the US, taking different assignments in critical care environments, I thought that my discomfort with complex, sometimes conflictual patient care problems would lessen. Instead, I found so many more problems where my voice on behalf of a patient was not heard or patients and their families would be pressed to agree to interventions that it seemed to me were not in their interests. However, in the 1970s and 1980s, ethics resources were scarce; there was a general sense that patients should go along with recommendations, and nurses should know their place in the hierarchy and accede (this was not true of all the settings in which I worked). This was medical paternalism in action, although not exactly the legal concept of parens patriae, from which contemporary ethical ideas of paternalism are derived. Parens patriae is the doctrine that holds there is a responsibility of governments to protect the most vulnerable in society. The medical paternalism that I encountered was the predominant idea that a treating physician knows better than the patient what clinical interventions and/or courses of treatment are appropriate for that patient and pertained even when the patient obviously had decision-making capacity as we define it now. Medical paternalism tends not to take into account the patient’s context, desires, and preferences. At the risk of over-generalizing, medi- cal paternalism as practiced in earlier decades focused more on the possibility of physical cure, or improvements in vital signs rather than patient wishes and preferences. I saw a few nurses who would speak up to articulate patient wishes and these were my role models. Many, although by no means all, of these nurses had furthered their education. They had baccalaureate or master’s degrees and were confident about the boundaries of their knowledge.

Thus, I determined to pursue a Baccalaureate of Science in Nursing (BSN). Unfortunately, I was not initially accorded any course credit towards a BSN, so I limped along a bit at a time. I took content challenge exams, studied to exempt myself from some liberal arts courses via the College Level Exam Program (CLEP), and so on until I eventually graduated. These studies broadened my understanding of the world, enhanced my critical thinking abilities and my appreciation that the characteristics of individuals are significantly influenced by their background, and subsequent experiences. Their stories matter for the courses of action (or inaction) they take. Nurses can often provide a map, resources, and aids in their quest for better health or relief from suffering, but we have to know something about their goals or life trajectory. Navigating the increasing complexity and tangles of con- temporary health‑care environments can be difficult even for experts. We also have to tap into the resources of others. To effectively do this, we have to know how to cogently articulate the problem in order to propose solutions that will be heeded by the medical team, or at least tried.

In many ways, then, my baccalaureate studies introduced me to sociopolitical complexity. I determined that a graduate degree in nursing would provide further sophisticated thinking skills and it did. I became an Adult Nurse Practitioner (APN) in primary care. However, I discovered more problems in these settings, especially in rural West Virginia and Tennessee where I practiced. The lack of good primary care often led to more severe disease and impairment than needed to have occurred. One elective course taken during my master’s degree program provided an “aha!” moment. This was a bioethics course. I have described the profound effect the class had on me elsewhere and attributed the insights gained to philosopher Dr. Mark Wicclair, professor for this course. The beginning analytic and philosophical tools I gained led to me pursuing a PhD in philosophy with a concentration in medical ethics at the University of Tennessee, Knoxville. At the time (early 1990s), this program was remarkable for having both a full philosophy curriculum and a health‑care ethics practica. A significant proportion of graduates of this program went on to have careers as ethics educators and clinical ethicists under the guid- ance of Dr. Glenn Graber, director of the applied ethics portion of the curriculum. Two of my philosophy student peers (most of whom were half my age) remark- ably became nurses after completing a PhD in philosophy—the value of practical experiences was not lost upon them.

So this rather extensive background provides context for my interest in viewing nursing ethics as its own entity. I thought I would find the answers to my questions about how to address the issues most often faced by nurses during my PhD studies. However, what I found was that the focus in the ethics part of the course work was on difficult bioethical‑type conflicts, the sort that require a team approach to resolve. The questions I raised did not seem to be considered as important; as one faculty told me, “Those issues are just not as juicy.” Yet from my perspective, many of the issues that rose to the level of bioethical crises could have been avoided with better and earlier communication and the input of nurses, patients, and families. When I brought these insights to the fore, I was told to remove my nurse’s hat and put on a philosopher’s hat. Of course, I could not do that for the obvious reason that it was my nursing experiences that led me to study the role of philosophy in addressing nursing practice problems.

Further, and during this time, I was fortunate to teach in the College of Nursing (CON) at the University of Tennessee, Knoxville (UTK) and continued to work part time both as a nurse practitioner in UTK‑CON’s Veterinary Occupational Health Service and as a staff nurse in the coronary care unit (CCU) of a local hospital. This combination strengthened my emerging belief that nurses are not always well served by the bioethics community. This is because the problems we face are only rarely dilemmatic or complexly conflictual in nature. Problems in nursing contexts are, for the most part, encountered on a more frequent basis and include such things as being unable to access resources needed for optimal patient care, encountering family members who pressure the patient to choose certain interventions they do not want, or inadequate staffing that has put us in crisis mode. By crisis mode, I mean we do not have time to provide for patient comfort needs but must focus on handling the most critical or life-threatening events. Additionally, we were con- fronted with the fact that the life stories of many patients revealed a prior lack of access to care or to needed assistance and inadequate home support.

All of these circumstances contributed to my realizing that nurses have professional responsibilities to provide the care that the profession ostensibly exists to provide, and that we need to view our responsibilities as not just concerned with immediate patient care, but also how patients got to this stage of their ill health. In my case, this presented as caring for patients with cardiovascular problems, some leading to amputation, and learning how many had not had good primary care management or preventive care because of lack of access. This struck me as a grave injustice. It led me to explore the idea that professional advocacy cannot just be about speaking up in the moment but must also be concerned with root causes of poor health. As Fowler argues, this has historically been one of nursing’s concerns and we need to keep this as a focus for the discipline. Otherwise, we are neither serving individuals nor society well.

I had been interested for some time in the issue of advocacy and how nurses were urged to be advocates for their patients. Yet it was not clear what this meant or how far nurses should risk themselves to “advocate” for those in their care. The importance of exploring this concept, how it had come to be adopted as a nursing tenet—as amorphous as the term is—eventually led to my dissertation, which con- stituted a philosophical analysis of advocacy and its meaning for health-care prac- tice generally and nursing practice specifically. To be clear, this was not a concept analysis in the nursing sense. At the time, I was not even aware of concept analyses as used in nursing. It was an in-depth look at the legal, popular, and health-care literature to parse elements of the idea of advocacy. It resulted in an understanding of the risks to nurses and patients of relying solely on one of the various existing definitions as found in the literature.

Ultimately, what resulted was a caution about using the term advocacy to exhort nurses to act when the definitions, scope, and limits were not clearly articulated and risks to the nurse accounted for. Advocacy, from this exhaustive review, is best understood as professional responsibilities to act to provide the human “good” promised by a given health-care profession, via their disciplinary understandings and implicit or explicit codes of ethics. When we can act to get an individual what they need in the moment but intractable barriers exist, then we have to work with others to overcome them, and this may require addressing problematic policies and even negative sociopolitical circumstances. Thus, advocacy viewed as professional responsibilities to meet nursing goals is a broader concept than is often understood and is derived from the field of inquiry that is nursing ethics. Protecting, promoting, and restoring health and relieving suffering are the historically derived goals of nurs- ing internationally. When there are obstacles to our work, then we have concomitant responsibilities to individuals and society to strive to overcome these. Nurses and the profession more generally exist to meet an unmet social need. If we can no longer do this, then we have obligations to be transparent about what is and what is not possible and why. A tenet of moral philosophy is that we cannot hold someone ethically accountable if they have no action choices—it is a logical impossibility. The ethical objectives of nursing practice are essentially professional advocacy. It is acting to overcome barriers to the provision of the good promised at the individual, unit, policy, or societal level depending on the root cause or causes of the barrier.

I recognize controversy remains about what constitutes a profession and why the idea of profession is important. However, I have argued elsewhere that, for lack of a better term, identifying a group of persons who provide a critical human service, have specialized education, skills, and some level of autonomy over practice as a profession permits society to hold them accountable for delivering their services.

In turn, this leads to consolidation of the idea that nursing ethics is its own field of inquiry about the who, what, and why of nursing. In concert with prior scholars, we can understand nursing ethics as being “inquiry into the boundaries of prac- tice, the appropriate knowledge base for that practice and apt characteristics of members.”^9,10,11,12 As noted elsewhere and articulated slightly differently, nursing ethics is “the study of what constitutes good nursing practice, what obstacles to good nursing practice exist, and what the responsibilities of nurses are related to their professional conduct.”¹³ Nursing ethics necessarily intersects with the ethics of other health‑care professions which, similarly, is the field of inquiry about the roles and responsibilities of that group, their clinicians as well as the education necessary to develop ethical practitioners who can fulfill the goals of the profession. I do not see bioethics as a professional ethics per se, although health-care professionals necessarily have an interest in bioethical problems and their resolu- tion. Bioethics is the field of inquiry about the impact of bioethical technologies on human beings.

In conclusion, I feel fortunate that my life meanderings led to gaining the tools to explore the origins and locus of problems that I and other nurses face in practice. The tools of philosophy have helped me be clearer about what nursing ethics is and how to continue to develop nurses who can practice ethically in spite of obstacles, understand when remedies are beyond their singular abilities to address, and know how to access resources and/or collaborate with others as these are needed.