Elizabeth Peter

Nursing ethics and conceptualizations of nursing: profession, practice and work

BACKGROUND Nursing has been understood as a calling, vocation, profession, and most recently, a practice. Each of these conceptualizations has associated with it an ethics that has emphasized particular aspects of nursing reflecting the social position of nursing in a given historical period. The ethics associated with current understandings of nursing as a profession and a practice are, we believe, no longer adequate to address the social realities and moral challenges of health care work. AIM The aim of this paper is to discuss the limitations of the ethics associated with profession and practice and to show why the concept of work can contribute to a nursing ethics. DISCUSSION The characteristics that have socially defined professionals, among them the possession of a unique body of knowledge, provision of an altruistic service to society, and autonomy in the sense of control over their work and work conditions, only partially reflect the realities of contemporary health care work. This is true even for physicians, an exemplar of a professional group. The ethics associated with the professions has tended to limit what counts as a moral concern and who is authorized to label them as such. More recently, the idea of a practice has been used to argue for an ethics in which professional activities of a certain kind and understood in a specific way are inherently moral. However, this approach is limited for similar reasons. Because morality cannot be separated from the social organization of health care, we argue that considering nursing primarily as work, in contrast to a profession or a practice, offers the possibility of an ethics that more completely reflects the complexity of contemporary health care. CONCLUSION Beyond the obvious conclusion that nursing is work, conceptualizing nursing as work points to changing social realities that are raising significant ethical issues. As a concept, work inherently conveys value, connects intellectual and manual labour, and recognizes social divisions of labour. At the moment an ethics of work is merely an idea, but we believe that such an ethics would lead nurses to ask different questions and propose different answers to the moral challenges of the present and near future.

An Institutional Ethnography of Nurses’ Stress:

There are three main conceptualizations of nurses’ stress: occupational stress, moral distress, and traumatization (compassion fatigue, secondary traumatic stress, vicarious trauma). Although we have learned a great deal from these fields, some of them lack important contextual aspects of nurses’ practice, such as the gendered nature of the workforce and the nature of the work, including bodily caring. The purpose of this study was to reformulate the nature of stress in nursing, with attention to important contextual aspects of nurses’ practice. Smith’s sociological frame of institutional ethnography was used to explicate the social organization of nurses’ stress. Data collection methods included in-depth interviews, participant observation, and focus groups with pediatric intensive care nurses. Data analysis focused on the social organization of nurses’ stress, including negotiating power-based hierarchies and articulating the patient to the system. The article concludes with recommendations for addressing nurses’ stress through a more critical and contextual analysis.

Moral Distress Reexamined: A Feminist Interpretation of Nurses’ Identities, Relationships, and Responsibilites

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life.

Media Portrayal of Nurses' Perspectives and Concerns in the SARS Crisis in Toronto

Purpose: To describe nursing work life issues as portrayed in the media during the SARS crisis in Toronto. Methods: Content analysis of local and national news media documents in Canada. Media articles were sorted and classified by topic, and themes were identified. Findings: Themes were: (a) changing schemas of nursing practice: the new normal; (b) barriers to relational nursing work; (c) work life concerns: retention and recruitment; (d) nursing virtue: nurses as heroes and professionals; (e) paradoxical responses to nurses from the community; and (f) leadership in nursing during the SARS crisis. Conclusions: This analysis enhanced understanding of how nurses are portrayed in the media, but it indicated the significance of quality of work life and issues about work‐home life. Some descriptions of the care and caring of nurses have made nursing seem like an important and influential profession to potential applicants who might previously have dismissed nursing as a career.

Respect in forensic psychiatric nurse-patient relationships: a practical compromise.

Abstract The context of forensic psychiatric nursing is distinct from other psychiatric settings as, it involves placement of patients in secure environments with restrictions determined by the courts. Previous literature has identified that nurses morally struggle with respecting patients who have committed heinous offences, which can lead to the patient being depersonalized and dehumanized. Although respect is fundamental to ethical nursing practice, it has not been adequately explored conceptually or empirically. As a result, little knowledge exists that identifies how nurses develop, maintain, and express respect for patients. The purpose of this study is to analyze the concept of respect systematically, from a forensic psychiatric nurses perspective using the qualitative methodology of focused ethnography. Forensic psychiatric nurses were recruited from two medium secure forensic rehabilitation units. In the first interview, 13 registered nurses (RNs) and two registered practical nurses (RPNs) participated, and although all informants were invited to the second interview, six RNs were lost to follow‐up. Despite this loss, saturation was achieved and the data were interpreted through a feminist philosophical lens. Respect was influenced by factors categorized into four themes: (1) emotive—cognitive reactions, (2) nonjudgmental approach, (3) social identity and power, and (4) context. The data from the themes indicate that forensic psychiatric nurses strike a practical compromise, in their understanding and enactment of respect in therapeutic relationships with forensic psychiatric patients.

The ethics of Canadian entry-to-practice pain competencies: How are we doing?

BACKGROUND Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards. OBJECTIVES To perform a systematic, comprehensive examination to determine the entry-to-practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature. METHODS Entry-to-practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine. RESULTS Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics. CONCLUSIONS The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry-to-practice pain competencies may ultimately have the greatest impact on education and practice.

Displacement and tuberculosis: recognition in nursing care

Through a qualitative of study of public health nurses and their clients in Toronto, Canada, displacement is described as a central feature in illness and care. Specifically, how client experiences are anchored in circumstances of international migration and contagiousness is described, along with how nurses take up understandings of displacement as part of their daily work through diminishing the social displacement of immigration, connecting here and there, and minimizing the displacement of contagiousness. The research illustrates how responding to the implacing and displacing elements of the illness experience and broader lifecourse can be an important part of professional practice. Moreover it highlights how place sensitive geographical inquiry is insightful with respect to understanding the interplay between illness, wellbeing, and health care work.

Narratives of aggressive care: Knowledge, time, and responsibility

Background: While witnessing and providing aggressive care have been identified as predominant sources of moral distress, little is known about what nurses “know” to be the “right thing to do” in these situations. Research objectives: The purpose of this study was to explore what nurses’ moral knowledge is in situations of perceived overly aggressive medical care. Research design: A critical narrative approach was used. Participants: A total of 15 graduate nursing students from various practice areas participated. Findings: Four narrative types were identified, including “Wait and see: medical uncertainty,” “Deflected responsibilities to respond to dying, death, or futility,” “Divergent understandings, responsibilities, and temporalities,” and “Privileged medical understandings and responsibilities.” Discussion: The knowledge of differentially situated persons is acknowledged in dissimilar ways, the time required to determine that enough has been done is perceived differently, and how moral responsibilities are understood also varies. Conclusions: A better understanding of how social roles influence how time, knowledge, and responsibility are related to the provision of aggressive care is needed.

Advancing the Concept of Moral Distress

Moral distress, as both a concept and a phenomenon, has been described and examined widely in nursing for almost 30 years, with many calling for greater conceptual clarity (McCarthy and Deady 2008; Pauly, Varcoe and Storch 2012). I have found the subject of moral distress to be the source of endless debate, particularly surrounding experiences that can be rightly labeled as such. In fact, as Joan Liaschenko and I (Peter and Liaschenko 2013) were writing our paper for this symposium, the debate also continued between us, perhaps as a result of the variability in definitions that exist or perhaps just a result of our own confusion. These conversations brought us no closer to the “truth” of moral distress, but they did lead us to the working title of our manuscript, “Waiting for Godot.” For those less familiar with Samuel Beckett’s play, “Waiting for Godot” portrays two characters, Vladimir and Estragon, who wait in vain throughout the entire play for a man named Godot to arrive. As they wait, the two pass the time by talking and debating ideas (Beckett 1982). While the title of our manuscript changed, thematic elements of the play continued to resonate with us. Like Estragon, Joan and I did not wait for a “truth” to emerge and decided to develop a conceptualization of moral distress that was workable and meaningful for us and hopefully for others as well. Other authors in this symposium have taken a similar approach by further developing and applying the concept of moral distress in their own work. While most of the authors address moral distress in nursing, this is not to suggest that professionals outside of nursing do not also experience it. Nursing, however, has developed a significant body of scholarship about moral distress that has the potential to offer insights to other practitioners and disciplines. The lead paper in this symposium is written by Andrew Jameton (2013), who has been credited with introducing the concept of moral distress to nursing ethics. It is an honor to have his reflections on the concept’s early development, along with an extension of the concept to current major environmental issues related to health care overconsumption in the United States and other high-income countries. Jameton begins with a retrospective of bioethics and nursing ethics beginning in the 1970s, a time when philosophers explored the usage of ethical theories primarily to examine the ethical dilemmas that physicians faced. However, nursing students, like feminists, or perhaps as feminists, were concerned not so much with dilemmas but with institutional concerns such as power, inequality, and voice. Consequently, Jameton found that the concept of moral distress, i.e., “a challenge that arises when one has an ethical or moral judgment about care that differs from that of others in charge” (2013, ¶7 under “Moral Distress in Bioethics”), was more suitable than Bioethical Inquiry (2013) 10:293–295 DOI 10.1007/s11673-013-9471-6

¿Es ética la sumisión de las enfermeras? Una reflexión acerca de la anorexia de poder

Resumen Durante los ultimos 20 anos, muchos autores han escrito acerca de la falta de poder, real o percibida, de las enfermeras. Este articulo, se plantea rebatir la idea de esa incapacidad o falta de poder. Por el contrario, se afirma que las enfermeras pueden, y de hecho hacen uso de ese poder en su quehacer cotidiano. Se destaca que sus acciones, o la falta de ellas, tienen consecuencias, no solo para ellas mismas, sino tambien para las personas que cuidan. Se explica por que la reflexion acerca de como las enfermeras utilizan su poder, y su aparente falta de apetito de poder, es decir, la anorexia de poder, es fundamental para tener una vision global de las implicaciones eticas de las practicas de enfermeria. Este argumento se desarrolla a traves de una revision de la bibliografia y de los codigos de deontologia de Canada y Brasil. Autores que utilizan perspectivas criticas, como teorias postestructuralista y etica feminista, proporcionan la base al analisis presentado.