Nursing's Ethics
of Caring: A Feminist Ethical Perspective from the Trenches
Pat Anderson
De Paul University
Spring 1995
Class: Women
Across Cultures
Working on:
Masters in Liberal Studies
Professor Aminah B. McCloud
September 4, 1995
Abstract
I examine
nursing's ethics of caring from the feminist perspective of a practicing
registered nurse. Academic research is combined with thirty years of nursing
experience: as a nurses aide, licensed practical nurse, and registered nurse.
Opinions of philosophers, educators, researchers in psychology, and nurses are
included. The view through my feminist and experiential lens, reveals an ethics
of care that acts as a link in a chain of internalized oppression that merely
enables nurses to survive in the patriarchal medical system. When the
psychology of the health care system is illuminated and finally blended with
the historical devaluation of women, it will become clear that the ethics of
care is a tool to perpetuate the oppression of a predominately female
profession. I go so far as to compare the psychology involved in the battered
woman syndrome to the role of a nurse. The practical effect that the ethics of
caring has on nursing, outside of "academic ivory towers," negates
its altruistic, humanitarian intention because nurses themselves are neither
cared for nor valued.
Table
of Contents
Abstract
Nursing's
Ethics of Caring: A Feminist Ethical Perspective From The Trenches
Ethics
and Emotionality
Differences:
Male\Doctor Versus Female\Nurse
Impossible
Expectations and No Decision-Making Power
In-Between
Status
Nowhere to Go to Deal With Ethical Issues
No
Care for the Care Givers
Nurse
Stress\Illness: Physical\Psychological
Health
Care's Hierarchal/Stratified "Family"
Psychology
of the System
Solutions
Empowerment
Ethics
Nursing
Consciousness Raising
Nursing
Ethics Committees
Revolution
Policy
Making
Conclusion
References
Nursing's Ethics of Caring: A
Feminist Ethical Perspective from the Trenches
Some authors claim the ethics of
caring stemmed from traditional male theories, while others assert that it came
about as a result of Gilligan's work in the early eighties illustrating women's
"different voice" in morality. Regardless of its origination, the
result has been that nursing's ethics of caring have not functioned to empower
nurses. Despite the fact that caring is indeed what most nurses feel and do,
caring is not appropriate as an ethical framework. The ethics of caring is
simply descriptive of what nurses do. My passionate belief in the basic tenets
of feminist ethics and my experiential knowledge, from nursing's trenches, are
what have fueled by arguments.
The main premise of feminist ethics
is that people's oppression must be included in the ethical discourse for it to
truly be ethical. By denying oppression, patriarchy rationalizes that there
isn't a moral imperative to include it in their discussions. Not only does the
health care system and traditional medical ethics not include nurses'
oppression in its discourse, it's hierarchal structures maintain the oppression
of nurses - thus treating nurses UNethically.
Medical ethics has the same
hierarchal structure as the rest of society (Sherwin, 1992). Ethicists concern
themselves with issues faced by doctors, because they're the ones in power.
Problems vital to nurses and other health care workers are not addressed,
suggesting whose work is valued and viewed as worth studying. Problems faced by
caregivers are treated as irrelevant, despite the fact that difficulties they
face might have a powerful effect on patient care (Sherwin, 1992).
Traditional theories stem from
abstract, universal rules where moral agents are not concrete individuals with
their own lives that encompass unique histories, emotions, and desires. To
traditional theorists, relationships, communities, and friendships do not affect
moral judgments. Sichel (1992) compares a traditional moral agent with a placemark, a variable in an algebraic formula, being no better or worse than anybody
else in that moral situation. Women's morality stems from relational, caring
perspectives in which each person and situation is considered in its uniqueness
within its historical and sociological context including emotions. Despite
caring's focus on attitudes, feelings, and emotions, reasoning and intelligence
also serve to enhance sentiment (Sichel, 1992).
Fry (1992) says the development of
nursing ethics stemmed from traditional male theories and principles, such as
autonomy, beneficence, theologically-based contract theory, theories of
justice, and secular-based theories of human rights. Biomedical theories are
not directly applicable to developing a theory of nursing ethics because they
don't fit the practical realities of a nurse's workplace; as a result, theories
tend to deplete a nurse's moral agency, rather than enhance it (Fry, 1989).
To fit the context of nursing
practice, which includes the context of the nurse-patient relationship, a moral
point of view of persons, rather than a theory of moral action or a moral
justification system is needed (Fry, 1989).
Nursing is ninety-eight percent women
and is culturally viewed as feminine (Miller, 1991). Eighty-three percent of
physicians are male (Rounds, 1993). Boyer and Nelson (1990) have noted that
nursing ethics takes little note that the profession is almost all women,
despite this, the theories postulated came from male theories like contract
theory, consequentialism, and other perspectives that don't fit women's life
experience. If scholars could leave out gender, it illustrates how successful
the obscuring forces are (Boyer & Nelson, 1990). (Theorists not only left
out gender, they left out anyone who is not a white-heterosexual-male.)
The ethics of care gained popularity
around the same time as Gilligan's (1982) famous work, In A Different Voice.
Gilligan's work illustrated that women make moral decisions differently than
men, due to their very different life experiences. Sherwin (1992) summarized Gilligan's empirical study that identified a gender difference in women's moral
thinking. Women seek creative solutions that consider all parties involved and
look for solutions that avoid harm to anyone (Sherwin, 1992). Men try to find
the right rules for a situation, and select an action that goes with the rule, even
if someone's interests must be sacrificed to justice (Sherwin, 1992). Women
frequently feel a responsibility not to sacrifice anyone, which explains why
women frequently see situations in a more complicated manner than men. To men, the right rule or theory is the "bottom line".
Gilligan (1982) illustrated that
women look to the contextual details of relationships to solve moral dilemmas
and judge themselves on their ability to care and actually define themselves
within relationships. Male theories of psychological development have devalued
women's caring (Gilligan, 1982). Gilligan (1992) suggests both care and justice
perspectives be included in moral discourse.
What Gilligan learned about women
certainly fits nursing. Nurses roles demand they please everyone. The nurse's
interests are sacrificed within male justice models. Parker sees Gilligan's
framework as a challenge to nursing to go beyond the idea of care, to reach for
a level that would include the need to care for oneself that is as vital as the
directive to provide care (Parker, 1990).
Noddings (1989) relational ethics
stems from an ethics of care perspective, that differs dramatically from
traditional individual ethics that judges acts by their conformity to rules or
theories. Relational ethics not only considers physicality but includes the
feelings and reactions of others within situations (Noddings, 1989).
Relational ethics comes out of and
depends on natural caring which mothering exemplifies, the caring one responds
to the needs of the one requiring care. This mode of response is characterized
by: engrossment (nonselective attention or total presence to the other during
the caring interval), displacement of motivation (her motive energy flows
toward the other's needs), and responsibility and response (Noddings,
1989).
Noddings (1989) claims in traditional
ethics the ethical point of view is viewed as higher than natural caring.
Within the relational perspective caring stems from our experience of caring,
being cared for, and from a commitment to respond with care to others.
Relational ethics validates its actions on the response of a genuine other,
rather than through a principle or theory, and does not require all humankind
to act in the same manner, in a similar situation. Ethical thinking
strengthens and is informed within relationships (Noddings, 1989).
Relational ethics may have been
historically overlooked and even despised because of connections to the
subordinate feminine - compelled to retain caring relations as a survival
tactic (Noddings, 1989). Traditional ethics ignores questions of importance to
women, and doesn't address feelings that predispose people to break the rules
(Noddings, 1989).
Engrossment is impossible in nursing
because you have too many patients to care for. While engrossed with one
patient you're tortured, knowing if you take time with one, you are
jeopardizing another's care. Nurses face this ethical dilemma every day. It's a
common expectation for nurses to displace their own needs to everyone in the
health care system. Relating ethics to mothering describes a "martyr
mother syndrome" that nursing certainly does exemplify.
While on the phone asking questions
about a position advertised in a nursing publication, I became aware that being
a nurse was not a requirement. I asked why they were looking to have a nurse
fill the job. The answer I received was quite telling, We're looking for
someone with a nurse's work ethic. Someone who is very caring, perfectionistic,
and willing work very hard, long hours, for very little money.
Institutions profit from nurses
accepting exploitative expectations. The more patients each nurse cares for the
less money the institution has to expend on salaries. No one cares what caring
imposes upon nurses. The nurse is expected to care about the patient, care
about following doctor's orders without question, care about the institution
saving costs, follow institutional policies to the letter, and not complain
about low financial compensation.
Indeed our responsibility is to
respond to patients, but we are asked to respond selflessly, in lieu of
ourselves, making the ethics of care unethical.
Although Nodding's relational ethics
attempts to be contextual and avoids traditional male abstract rules, it still
does not include a nurse's realistic contexts. The nursing profession certainly
does exemplify mothering in its caring, however, it's problematic to expect a
female profession to adopt an ethics that will serve to perpetuate its
oppression. Mothering has been historically devalued by men and was partially
defined by men to fit their purposes. Mothering is not an ethical model that
will empower or help nurses find solutions to their problems. The same
"blame the victim" mentality that blames mothers for multiple
societal problems, is used to blame nurses when unrealistic expectations aren't
met. Our professional ethics must come from our own "knowing" gained
through experience, not from male theories. The only escape from internalized
oppression lies within and among ourselves. We must demand an ethics that
empowers.
Noddings relational ethics seems to
fit what is practiced by a hospice team. The dying person's whole family is
included in the team's care plans in order to keep the family functioning under
the challenging situation. The internalized oppression is so powerful that
despite the fact that hospice team members tell family caregivers to care for
themselves, the lack of care toward the nurse caregivers is not acknowledged.
No matter how much I can theoretically see that Nodding's relational ethic is
altruistic and stems from a nurturing intent toward patients, I cannot separate
my experiential knowledge that informs me on a daily basis that I don't have
the power or ability to fulfill the caring responsibilities expected of me
without sacrificing myself (due to the tremendous workload).
In reference to traditional
philosophy, Hoagland (1991) asserts that principles don't inform us when to
apply them and end up, in the long run, only working when they aren't really
needed. Hoagland (1991) does not suggest that we throw out rules altogether,
but suggest they be used as guides rather than arbiters of actions.
In criticizing Noddings analysis of
caring that uses mothering as a model, Hoagland (1991) objects to its
unidirectional descriptions of caring found in displacement and engrossment.
The unidirectional nature of one-caring reinforces oppressive institutions.
Noddings focuses on an unequal mother\child relationship where the child's
dependency elicits a maternal response - a mother's natural caring is turned
into a moral caring (Hoagland, 1991).
Hoagland (1991) questions an ethics
of caring whose model stems from a relationship in which one party is
dependent; it justifies the inequality of the relationship and lacks an
expectation of reciprocity from the cared-for.
Hoagland (1991) suggests we ask what
values are promoted by using an unequal relationship as an ideal, instead of
something to be overcome or worked on. In our society, an ethics that addresses
how we meet each other morally must induce change and challenge
oppression. Motivational displacement
and engrossment involve acting on behalf of another, suggesting the
appropriateness of taking control over another's situation and making it all
right, thus actually undermining the moral ability of both parties. (Hoagland,
1991). Adults don't require parenting when they're ill, so the mother-model
truly does not fit.
I have seen nurses act like
judgmental, controlling mothers in trying to enforce and implement doctor's
orders. They're justification being - they must see to it that doctor's orders
are carried out. Internalized oppression mandates that nurses carry out
doctor's orders even when the nurse thinks the orders are not right. She was
told not to question the male dominated medical model, sadly she frequently
doesn't.
Hoagland (1991) says we need
something far more radical than an ethical appeal to the feminine because
femininity itself has been defined by men. If ethics of caring was to be
morally successful in replacing a male morality of rules and duties, it must
consider an analysis of oppression, function under oppression, acknowledge a
self that is separate and related to others, and provide a vision for change
that challenges the values of the fathers (Hoagland, 1991).
Ethics
and Emotionality
In patriarchal societies, female
values are not only secondary, they're viewed as defective; the argument being
that they're based on emotion rather than logic and incapable of shaping
ethical decisions (Toufexis, 1993). The ethics of caring demands an emotional
involvement and an expectation to practice in a selfless manner that would not
be expected of a male-dominated profession. It's unethical to expect
emotionality and self-sacrificing behaviors from a profession.
Curzer (1993) claims that the sort of
care described by Noddings involves an emotional attachment, a sort of
friendship with a patient which can cause serious problems in nursing's
context. The emotionality proposed by Noddings is a vice, not a virtue because
it can lead health professionals toward favoritism, injustice, inefficiency,
lack of objectivity, and burn-out (Curzer, 1993).
Fry (1989) wants to use the concept
of care, to forge a special unique spot for nursing ethics separate from
medical ethics, thus committing nurses to have a higher priority of duty to
care for patients than other people have to care for others (Curzer, 1993).
This commitment also leads to the implausible view that nurses have more of a
duty to care for patients than doctors do (Curzer, 1993). The slogan,
"Doctors cure and nurses care" relates to this implausible view
(Curzer, 1993, p. 179).
Feminists reject the idea of a moral
theory being totally separate from sentiment (Sherwin, 1992). I once served as
a nurse on a hospital ethics committee. While discussing whether or not a woman
should be taken off a respirator, I said that I couldn't even fully think about
the situation without seeing the patient and getting a "feel" for her
and her family. The director of nursing, the only other woman involved in the
discussion, said that we should not bring emotions into the decision-making, we
were supposed to use rationality. I knew she was speaking from a traditional
perspective. She detached herself from her past bedside experience so she could
maintain her status with "the boys". Having just recently completed
extensive research in feminist ethics, I could not and no longer felt obligated
to ignore my emotional perspective - I had learned to value it.
This incident also serves as an
example of how nurses in management use their internalized oppression to
sanction nurses who do speak up and question the status quo from a woman's
perspective. Instead of empowering their staff, managers maintain subservience
to patriarchy.
Feminist ethics recognizes women's
different moral views, including the ethics of care, and seeks to include caring
in our ethical discourse (Sherwin, 1992). Sherwin (1992) warns that we
demonstrate caution in using our caring philosophies because the very nurturing
and caring we're so good at were developed as coping mechanisms for women to
live next to oppressors. A possible danger lies in caring, women concentrate
their energy on others - even to the point of providing protection to the
oppressors (Sherwin, 1992). Feminist ethicists ask when is caring okay, and
when is it best withheld (Sherwin, 1992). A tough question.
We expect doctors and nurses
to use their scientific knowledge. Society does not expect doctors to become
involved emotionally, doctors are trained not to get emotionally
involved with patients. The ethics of caring includes the expectation of
emotional involvement on nurses that it does not expect of doctors. If nurses
behave without emotional involvement, they are criticized for being cold.
Imagine an ethics of caring as an expectation of an accountant, an attorney, or
other traditionally male profession. The added expectation of emotionality
certainly explains why nurses have high burn-out rates. The added emotional
investment drains psychological and physical energy faster.
Differences:
Male\Doctor Versus Female\Nurse
Life-enhancing tasks that women have
been responsible for (child care, nursing the sick) are the virtues we've
learned to admire in ourselves as women and affect our views of morality.
Physicians, because they don't participate in direct caring for patients, lack
equal opportunity with nurses to develop the attitudes of caring that hands-on
work engenders (Noddings, 1989). Women have centuries of experience with the
helpless and needy which stimulates and predisposes them to caring (Noddings,
1989).
Noddings (1989) cites an example of a
former minister who became an orderly in a nursing home, as evidence that the
tasks involved in nursing trigger caring responses. His theoretical education
had taught him caring, but the hands-on activity taught him something different
(Noddings, 1989). The hands-on experience prompted him to become involved in
patient's rights - the hands-on taught him that patients don't have any
(Noddings, 1989).
The training nurses receive may
affect their attitude and ways of being on the job (Noddings, 1989). A nurses
proximity to sufferers prevents her from being distracted by technology and
predisposes her to be an advocate of healing, which presents a daily dilemma
when doctors hold the power (Noddings, 1989).
While caring for a physician, dying
from cancer, I asked him how he felt about the care he was receiving from his
doctors. He said his doctors, (also his friends), peaked their heads in the
room (many did not even step inside the room), asked a few questions, and were
gone in seconds. Nurses don't have this option (Noddings, 1989).
This physician's experience as a
patient taught him that the doctors left the caring to nurses because they
could not deal with the emotionality of his situation.
Impossible
Expectations and No Decision-Making Power
The decisions that need to be made in
health care are not only scientific in nature (Sherwin, 1992). A physician's
scientific knowledge qualifies him to share this information with people trying
to make health-related decisions, but does not qualify him to make their
decisions (Sherwin, 1992). The training that physicians receive is technical,
not ethical, and yet society has afforded doctors ethical authority (Warren,
1992). Nurses are not to make decisions, they are to follow doctor's orders and
nurture (Warren, 1992). A nurse’s intimate contact with patients sensitizes her
to their needs holistically, this combined with her scientific knowledge,
actually makes her more qualified to facilitate patient decision-making.
In 1981, The National Commission on
Nursing reported that major issues in nursing involved nurse-physician,
nurse-administration relationships and the lack of organizational structures to
allow nurses to impact decision making related to nursing care (Aroskar, 1985).
Conflict between men and women, such as power and authority are also at stake
in the nurse-physician relationship (Aroskar, 1985).
One healthcare model that Aroskar
(1985) discusses relates an image of a hospital as a doctor's workshop with
other health professionals accountable for following his orders. This view has been
reinforced historically using the family concept to paint the institutional
framework. Nurses serve as the hospital mothers, meeting everyone's needs
(Aroskar, 1985). Nurses are expected to take full responsibility when doctors
are absent and relinquish all authority when doctors return. Nurses must also
support the institution, especially its male members (Aroskar, 1985).
Nursing school teaches that it is the
nurses' responsibility to refuse to follow doctor's orders when they know they
are incorrect. However, nurses risk severe sanctions when they do question a
doctor's order, no matter how wrong the order is. This duality places her in a
no-win, powerless, and unethical situation.
This paternalistic view with
physicians as primary decision maker perpetuates the nurse-physician game. The
nurse has to appear passive when making suggestions, so it appears that the
idea actually came from the doctor. This relationship is unethical because it
denies that nurses and physicians together are valuable to a patient's care;
neither should use the other as a means to an end decided by the other
(Aroskar, 1985).
In-Between
Status
Bishop and Scudder (1991) describe
nursing's status in health care as in-between physicians, patients, and agency
bureaucrats. Nurses are expected to actually bring together medical
contributions, regulative controls and permissions, and the desires of their
patients to create a system to provide daily care (Bishop & Scudder,
1991).
Making moral decisions in health care
requires considering what is medically correct, what the institution will
allow, and what the patient desires (Bishop & Scudder, 1991). A nurse's
in-between position and close proximity to patients places her in the unique
position of being able to bring these perspectives together in an advocate role
(Bishop & Scudder, 1991). Nurses certainly do function in this in-between
status, which is an impossible burden on nurses. Without any legitimate
authority to act on what truly is her unique informed perspective, the
nurse is trapped in a difficult and powerless position.
Thompson (1985) discusses three mindsets about health care that may prohibit or limit the ethical practice of
nursing. One is that health care revolves around medical cases, the major goal
is to cure disease. Here the nurse may see herself as accountable to the
doctor, his values dominate and her job is to follow his orders (Thompson,
1985).
The second is that health care a
commodity to be sold, making nurses accountable to the employer. Concern for
individual patients may have a low priority on the hierarchy of the
institution's values (Thompson, 1985).
The third centers on the patient’s
right to relief from pain and comfort, making the nurse's obligation to the
patient, thus demanding that nurses and institutions run by patient needs
(Thompson, 1985). If nurses view their role as subordinate to patients and
physicians they might find it difficult to implement autonomy, promote health
in an illness-dominated system or practice in an ethical manner (Thompson,
1985). I can see all three of these mind-sets functioning at the same time.
Nowhere to Go to Deal With Ethical
Issues
The typical nurse does not have
access to a forum to discuss or spend time reflecting on ethical issues (Fry,
1992). Paying nurses to discuss ethical issues does not fit into a cost-effectiveness analysis of nursing productivity. A nurse's ethical reflection
has not been deemed to have monetary or moral value.
I spoke to a nursing instructor at a
Chicago University and asked her what ethical problems she faced teaching
nursing. She said as a feminist, the most problematic issue is knowing how much
to encourage and empower students to speak up. She wants to be sure to limit it
at the point where they would loose their jobs. I know this to be true. I
worked as an intensive care nurse through agencies and was on many occasions
banned from a hospital because I had the nerve to speak up about unsafe
practices.
Another dilemma for her is teaching
students that their role is one of collegiality with physicians, knowing the realities of physicians'
condescending attitudes towards nurses.
Eleven years ago when I took ethics
in nursing school it was awarded two credit hours compared to eight or ten
credit hours awarded to other nursing classes. This weight disparity
illustrates the value placed on ethics by the university. I asked the Chicago
University nursing instructor how ethics was taught in the nursing program she
teaches in. She said they included ethics in all the classes, but they don't
have a specific class in nursing ethics. I find it very problematic for a
nurse's education not to address ethics specifically when she will face ethical
dilemmas every day in her work. This is a poor start for a profession so
entrenched in science, technology, and humanity. Right from the start she is
told that what she thinks morally is not valued.
I think ethics should be studied on
its own and incorporated into classes. Nurses also desperately need to
have their consciousness raised by teaching them about feminist ethics and
women's morality. Ethical discourse should also be made available to practical
nurses and nurses aids. Ethical issues should be for everyone to discuss and be
informed about.
The day that I spoke to the Chicago
University nursing instructor, her students were lobbying in Springfield to
attain independent functioning in Illinois for nurse practitioners. Nurse
practitioners are allowed to practice independently in many states. Can
you imagine a male dominated profession being told they could not practice what
they spent years studying? Our caring is educated and experienced. We study
health scientifically and should have the power to act on our caring and
scientific knowledge independently.
I interviewed a woman in
administration at a prominent ethics establishment, who told me that nurses
were not allowed to ask for an ethics consultation, only doctors and families
could do so. I asked what nurses were to do when they perceived an ethical dilemma.
She said their nurse ethicist would tell them to encourage the family to ask
for a consult.
Expectations of selfless caring
remain the rule, despite the fact that nurses voices and concerns were banned
from being heard directly. "Shut up and care" is the message I hear.
By following what we are told to do ethically we are participants in
maintaining our own ethical oppression - just what patriarchy wants.
No
Care for the Care Givers
If caring were valued in society and
in health care, adopting an ethics of caring would not only be ideal, it would
be smart. Caring is not valued, so the ethics of caring function to perpetuate
caregiver abuse within health care institutions. The recipients of this
ethics of caring are patients, health care institutions, physicians, and
society, but not the nurses aides, practical nurses, registered nurses,
and least of all minority caregivers.
Boyer and Nelson (1990) suggest that
the nurse's need to care for herself be explored, along with the propensity of
the care morality to reinforce women's oppression. The reality of the
exploitation of nurses begs feminists to take it into consideration to ensure
that patriarchy's deeply entrenched patterns are challenged (Boyer &
Nelson, 1990).
Hine (1989) discusses mixed messages
nurses get from society, they are frequently described as being special, but
are also taken for granted. Society has an ingrained tendency to devalue
women's work and nursing is the most female of all professions. Unless a person
is devastated by disease and needs a nurse, her value is not appreciated and
once she is no longer needed she is quickly forgotten (Hine, 1989). Whether
working in intensive care or in hospice, I always felt that no matter how much
I did or how much I cared, it just wasn't enough or was perceived as, just my
job. Beyond the call of duty is expected.
A philosophy of practice itself
obligates practitioners to seek reform and the expansion of its authority
whenever patient care requires it (Benner, 1991). Benner (1991) fears that the
philosophy of care is being used to maintain status inequity and subservience
but fears that if we were to abandon our caring in lieu of freedom for
ourselves it might require the loss of our voice in nursing to heal and provide
comfort.
I wish to add an obligation to
ourselves. When through consciousness-raising we become aware of how we are
being objectified and set up as the system's trapped middle person, we have an
obligation to do what we can to facilitate our own authority and to demand
ownership of how we use our professional knowledge. As we begin to see that we
are acting in ways that maintain our own patriarchal oppression we must make
attempts to achieve autonomy. What good is it to attain knowledge that can only
be used with someone else's permission or order? Nurses are not truly free to
heal now. How healing can you be while being exploited? Nurses are like
battered women trying to help their children heal from abuse while still being
beaten themselves.
Noddings (1989) discusses Gladys, a
black nurse and midwife who worked long hours, and was involved in many volunteer
activities, while raising a large family, as portraying the essence of the
ethic of care. Her life is a testimony of goodness far beyond the call of duty
(Noddings, 1989). This example illustrates the unreasonable expectations nurses
try to meet. Superwoman, the ideal image of a perfect female under patriarchy:
passive, selfless, perfectionistic, a martyr doing it all for everyone and
well.
Nurse
Stress\Illness: Physical\Psychological
Medical ethics has not addressed the
stresses that health care workers face on their jobs, despite higher than usual
rates of alcohol and drug abuse, and high divorce and suicide rates among
health professionals. In addition to the personal being political, the personal
is professional. What may be seen as personal problems can certainly have a
major affect on what occurs on the job. Because of this, stresses faced by
nurses should be addressed by medical ethics, but they are not (Warren, 1992).
Nurses must not wait for traditional ethics to address their problems. We must demand
that our issues be addressed. Those in positions of power will never offer to
do so.
Pulitzer (1993), in her article,
"Short Staffed and Working Scared-Can Nurses Just Say `No'?", shares
results from The National Nurse Survey that documents for the first time some
of what nurses face as a result of inadequate staffing. The survey illustrated
that the increased workloads damaged patient care, and led to decreased job
satisfaction, increased stress, and life-threatening health problems among
nurses. Nurses report much higher rates of stress and stress-related diseases:
high blood pressure, heart disease, ulcers, colitis, and depression. Nurses
cannot refuse an assignment no matter how unsafe or unethical the nurse thinks
it is (Pulitzer, 1993). Thus the nurse has no power to facilitate her caring.
If a nurse cannot refuse an unsafe assignment, she is a puppet whose caring is
actually a weapon used against her.
The following accusatory words and/or
phrases are used by hospital and nursing management to label nurses who speak
up about unsafe assignments: abandonment, unprofessional, incompetent,
unorganized, insubordinate, and not functioning within the scope of nursing; in
addition, hospitals may request that the state board examine her license
(Pulitzer, 1993). Accusing a nurse of abandoning her patients is as bad as
accusing a mother of abandoning her child. Hearing the above words repeatedly,
nurses take these criticisms to heart and blame themselves for speaking up
about safety, ethics, and unreasonable expectations?
Health Care's Hierarchal/Stratified
"Family"
Glenn (1994) illustrates the family
symbolism in the gender constructions in health care. The physician plays the
authoritarian father. The nurses play the mother who is subject to the ultimate
authority of the physician. Patients are dependent children with practical
nurses and nurses aids playing the part of servants (Glenn, 1994).
The family metaphor also has racial
implications (Glenn, 1994). Since historically most doctors were white males,
it only makes sense in this hierarchal ideology that the mothers, or the
registered nurses, had to be white. Eighty seven percent of nurses in 1980 were
white, despite their being only seventy seven percent of the population (Glenn,
1994). This dysfunctional family setup functions to maintain doctors power
over patients, nurses, women and minorities.
Psychology
of the System
Summers (1993) refers to healthcare
institutions as dysfunctional families; according to family systems theory, if
one person is sick, the whole family is sick. Each family member plays a part
in enabling other members (Summers, 1993). The following letter was written by
a nurse to a hospital's administration:
In the past, nurses have always said
"Okay." But soon we're going to have to stand up and say "No, we
need care too!" It's an insidious problem, something we all bought into,
though sometimes I wonder if we nurses aren't seen as women who have taken it
because "they care," and so will continue to take it. ... how can we care for patients
authentically when we are so desperately in need of care ourselves? (Summers,
1993, p. 87).
A dysfunctional system is a closed
system whose members feel powerless, develop survival patterns and function
using learned coping behavior (Summers, 1993). Summers (1993) lists the rules
that keep a dysfunctional system or family going, taken from Subby's book, Codependency,
an Emerging Issue: don't talk, don't feel, don't rock the boat, be strong,
be good, be right, and be perfect. When the expectations of a nurse include
these rules, it's likely there's a dysfunctional system at work (Summers, 1993).
I have sensed these rules on every job.
Summers (1993) describes how Schaef's
and others' work have described an addictive system. In this type of system, nurses impose unrealistic demands on themselves, expect that they should know
all the answers and never make mistakes. Despite being at 110% efficiency,
nurses are told to sign out early, reduce staff, and not work overtime - and
they go along. Nurses feel powerless over doctors' decisions, an example being
full code status on an aging patient who is begging the nurse to let them die.
It's hard to be around patients like this and not able to act on their wishes.
The nurse's feelings of rage and injustice may be pushed down, knowing that her
feelings don't matter in the system (Summers, 1993).
Nurses have to shut off their
feelings of fear, anxiety, and anger, as they would be a liability in a system that
doesn't provide an environment to express or experience them. Without
acceptance of their feelings, they refuse to experience what they see and know,
denying their own reality (Summers, 1993).
Noddings (1989) claims that one who
moves a pain-raked body feels sympathetic pain and develops psychic pain within
themselves. I wonder what influence this has on nurses not speaking up for
themselves more politically. Does their intimate knowledge of such profound
human suffering lead them to see their own pain as minuscule when viewed in the
holistic scheme of life? Does sensing another's pain so exquisitely inhibit
self-advocating behaviors? And if this is even possibly the case, then nurses
should be provided with avenues to deal with their psychic pain. It's unethical
for the health care system to place nurses in positions that affect them so
deeply on an emotional level without attempting to empower them in their work
and provide them with support.
Summers (1993) draws from Schaef's book The
Addictive Organization claims that demanding managers keep staff
afraid and out of touch with themselves and too busy to challenge the system.
Members of the system blame members at other levels for problems, keeping
parties in conflict with one another, thus preventing the system from being
challenged (Summers, 1993). Overwhelming, impossible work loads prevent people
from having the time or psychological energy to advocate for themselves.
Summers (1993) discussed Woititz's
book The Self Sabotage Syndrome in which Woititz says that guilt works
as a motivator for nurses. Self-sacrificing "angels of mercy" don't
see "no" as an acceptable way to deal with limitations (Summers,
1993, p. 89).
Instead of rewarding positive
behaviors, nursing evaluations frequently focus on the negative. Institutional
peers reviews use external referencing to compare nurses, making one person
better than another. The shaming messages hit home with similar messages heard
as children - we're not good enough (Summers, 1993). This constantly reinforced
devaluing prevents nurses from self-advocating.
Klebanoff (1991) says that nurses
face a serious occupational hazard - codependency\internalized oppression.
Klebanoff (1991) defines codependency as a set of survival skills adapted to
live with internalized oppression in patriarchy. It's a defense against
patriarchy that's also used by patriarchy to label and define its handmaidens
and "victims" (Klebanoff, 1991, p. 152). As a label and method of
social control, codependency serves as today's witchcraft. From a feminist
perspective, sexism and codependency exist as one (Klebanoff, 1991).
The idea of codependency stemmed from
family systems therapies used to treat addiction. The codependent, no addicted
partner exhibited the same behaviors even after the addicted partner was
treated (Klebanoff, 1991).
Having internalized patriarchy's
dominant value of inferiority, nurses act in a ways that supports this value;
they are "trained" to sacrifice themselves (Klebanoff, 1991, p. 157).
I view the internalization and training that nurses and women have received as
brainwashing. The only solution is de-programming by way of feminist
consciousness-raising, without which true empowerment will not be
obtainable.
The psychology involved in battered women's syndrome is the same psychology that disempowers nursing. What
keeps the ideology of the battering situation going is that both sides of the
situation believe that things should be as they are.
Typical questions nurses and battered
women ask themselves are similar and illustrate the self-blaming process. A
battered woman might ask herself: Maybe I did undercook the chicken? Maybe I
should have had dinner ready ten minutes earlier? Maybe I shouldn't have bought
myself a new jacket? Maybe I should do what he says? After all, he knows more
than I do.
Similarly nurses ask themselves:
Maybe I am incompetent and unorganized? Maybe I should be able to take care of
two, fresh, unstable, open heart patients at the same time? Maybe it is
unprofessional to discuss salary with a peer? Maybe I am abandoning patients if
I refuse to accept a patient load that I think is unsafe? My nurse manager
knows more than I do?
These questions paint a picture that
illustrates the internalization of the abuser's accusations, whether a lover or
a healthcare institution. Nurses are asking themselves these questions
everyday while attempting to honor the ethics of care. The health care system
blames the nurse and the nurse blames herself for the system's behavior, giving
credit to the institution's desires and accusations, in the same way that a
battered woman does with her lover. Because I understand and see this
victim blaming and exploitation of nurses, I find it almost impossible to
function in the field of nursing.
It was difficult to understand battered women's syndrome until feminists researched the phenomenon and made it
clear how the abuse worked to keep women in its clutches. Nurse abuse will
continue until the intricate mechanisms are brought to light. Under these
circumstances, the ethics of care is complicit in perpetuating the abuse,
despite the desperate need our clients have for our caring and despite the fact
that nurses really want to care. Our concentration on caring blinds us to our
own abuse. Nurses deny that they are not cared for at all. They frequently
leave one horrible job, only to end up in another horrible job - like an abused
woman who leaves one abuser and miraculously ends up with another.
Solutions
Warren (1992) questions the way we
conduct ethics itself and challenges us to pose philosophical questions from
various perspectives, not only from a doctor's vantage point. She further
suggests that ethicists leave their "philosophical armchairs" and go
beyond asking what a Hispanic woman needs from ethics by actually going to the
barrio and asking the women about their problems (Warren, 1992, p. 40). Warren
(1992) realizes this kind of inquiry would involve a lot of listening, but thinks
this is what ethics has to do.
We definitely need to find a way to
incorporate diverse perspectives and values into nursing's ethical framework -
much knowledge and appreciable insights will be gained. Sisterhood, in
actuality, is not global. A myriad of different perspectives can be found among
nurses and women themselves. Our challenge is to holistically include
contextual experience.
I think nursing would be a good place
to initiate Warren's (1992) recommendation. There is no other way to correct
historic non-listening. Listening to nurse's would not only benefit the
profession, but would also provide valuable insights about caring for patients.
The inclusion of nurse's ethical issues would approach a true ethics of caring.
Warren (1992) discusses how those in
academia relate to each other and suggests that this very discourse be
dissected to bring out its moral dimension. The ethics game sometimes includes
attempts to one-up each other; arguments are used as weapons that don't resolve
morally complicated issues. Ulterior motives and competition run the risk of
harming others (Warren, 1992). The intellectual forest prevents one from seeing
the trees. From my bedside perspective, it's as if the academics are looking
down at the forest, obviously not seeing the trees that I work in every day as
a nurse.
Warren (1992) recommends
co-authorship of philosophical papers, especially those relating to
relationship issues. Warren (1992) also suggests anonymous authorship to bypass
reputation and concentrate on ideas. I think there would be much to be learned
if a feminist philosopher and myself were to co-author a paper on nursing
ethics, chocked full of practical data obtained from the trenches.
Another suggestion Warren (1992)
poses is to appeal to the entire reader's personality, not just their
intellect. We might inspire others by writing about people's lives, encouraging
them to express their ambivalence which could lead to self-knowledge. A feminist theory should not come from on high by "experts", even feminist
experts, it should be constructed from life experience (Warren, 1992, p. 42).
No matter what the books tell us, we should trust our own judgment, and listen to
ourselves and regular folks. (Warren, 1992). "If knowledge is power, `life
precedes theory' is social revolution" (Warren, 1992, p. 42).
Warren (1992) poses a
radical question in asking whether our goal should be to find a small set of
moral principles or values for everyone at all times in their lives. I don't
see this suggestion as radical. However, including non-traditional values might
sound radical to traditional thinkers.
Nursing could serve as a model of
inclusion, it's an ideal place for feminist ethics to become reality. Women
must include themselves in moral matters - whether traditionalists like it or
not. I imagine an ethical framework that is alive with the context of all our
voices, allowing diverse values to breathe through it, freely and naturally.
Empowerment
Ethics
All levels of nursing must find
empowerment from its ethics, whether a nurse's aide, staff nurse, manager,
administrator, or academic. Nursing must reject its hierarchal setup that
mirrors male stratification models. True self-esteem and personal power will
not come from a stratification spot. If nurse aides are devalued, all of
nursing is devalued. Men frequently find power in the layered system that
places them at the top. Real power is the ability to empower all participants
in health care to feel important, involved, appreciated, and cared for. Nursing
ethics needs to be practical and available for each nurse to use for her
patients and for herself.
Nursing Consciousness Raising
Patriarchy's ideology continues in
health care because nurses are not aware of their internalized oppression.
Miller (1991), in a quote from Ashley, says that nurses are not only the most
conservative of conservatives but are rarely feminist. Miller (1991) agrees
with Ashley that this failure has led to nursing's inability to liberate its
education and practice. We must get beyond the internalization by deprogramming
with feminism.
Nurses need to do their own ethics.
Radical feminists think that we have to think for ourselves and not think in
terms of what men have taught us to think. In the future, I would like to
develop programs to raise nurse's consciousness about feminist ethics. Hopefully, once the seeds of feminist consciousness are planted, methods will be developed
and time would be allocated for nurses to become involved in the process of
developing the profession's ethics.
Nursing
Ethics Committees
Nurses need their own ethics
committees. Multidisciplinary ethics committees have not addressed the unique
concerns of nurses; the focus and missions of nurses and physicians are
different (Buchanan & Cook, 1992). A few dilemmas Buchanan and Cook (1992)
suggest for nursing ethics committees are: withholding treatment,
communication, the use of technology, inadequate resources, and working
conditions that threaten safe practice.
Most ethical dilemmas involve patient
care nurses assume most of the responsibility for, but nurses are outside
of the decision-making process (Buchanan & Cook, 1992). When ethical
dilemmas are unresolved it leads to frustration and conflict which leads to
inefficient care, burn-out, and staff turnover. A nursing ethics committee could
provide a forum for: avoiding burn-out from passive administration of
another's orders, facilitating nurses' discussion of their concerns, and an
opportunity to strategize about solutions. Nursing ethics committees could also
benefit administration by fostering work satisfaction and motivation, thus
lessening turnover which is cost-effective (Buchanan & Cook, 1992).
The only thing I disagree with
Buchanan and Cook (1992) about is they suggest that nurses should become
knowledgeable about ethical principles and theories. I think nurses have to
inform the theories and principles through their contextual, relational experiences.
I think nursing ethics committees would be an ideal place to initiate feminist
consciousness raising and begin the deprogramming process. Nursing's
non-feminist, patriarchal values block their ability to challenge the health
care system.
Revolution
One great solution already in
progress is a new and different nursing journal called Revolution: Journal
of Nurse Empowerment. Rounds (1993) quotes its publisher, Laura Gasparis
Vonfrolio:
Why should we be well-adjusted to a
maladjusted situation? Silence means
consent. We must put a stop to passive obedience, self-effacing dedication, and
loyalty to institutions. Nursing education must consist of finance and
economics and be grounded in a historical perspective on sexism (Rounds, 1993,
p. 38).
Rounds (1993) discussed a favorite
term of Gasperis's, "horizontal violence" that describes how a
hospital pits nurses against each other with things like, "primary
nursing", "shared governance", and "career ladders"
(p. 38).
Policy
Making
Backer, Nikitas, Costello, Mason,
McBride, and Vance (1993) say that nurses have the potential to transform
public policy by instilling an ethic of caring into health policies; nurses
with feminist values will bring new skills to the formation of policies and
their implementation. Women have had to struggle to bring their voices to
policy tables, but are beginning to realize that their work and values have
been demeaned and devalued (Backer et al, 1993).
Devaluing has led to oppressed modes
of behavior, such as shame, self-hatred, isolation, horizontal violence, and
passivity. Patriarchy has perpetuated nursing's attitude of being second best, and of
lacking faith in one's self (Backer et al, 1993).
By valuing our voices we can create a
new worldview that would value caring, integrating diverse values. Nurses need
to reformulate work, relationships, and leadership from feminist values. The
feminist model of caring encompasses values of wholeness, process, support,
interconnectedness, equality, collaboration, and diversity, contrasting
patriarchal values of individualism, inequality and competition (Backer et al,
1993).
Caring in nursing includes being
responsive rather than judgmental and hierarchal, in a system that is not only
disease management (Backer et al, 1993). It includes a range of nurturing,
protective acts devoted to assessing and responding to patients and being
involved at the macro (social values and policies) and micro (interpersonal
processes and caring acts) levels. It involves a system that empowers nurses
and patients in a "web of inclusion" model that affirms relationships
(Backer et al, 1993, p. 73-74). Collaboration is encouraged and diversity and
equality are highly valued. Improvisation combines familiar and unfamiliar
components sensitive to context, process and intuition, not excluding objective
approaches (Backer et al, 1993).
The conflict of doing work that is
not valued by society has taken its toll on nursing (Backer et al, 1993).
Backer et al (1993) suggest that nurses suggest a redistribution of power among
diverse voices, rather than taking power away. Nurses' voices can be especially
effective in policy making because the ethics of care encompasses both
instrumental (objective, rational) and expressive (affective values, belief
components of an issue); feminist and traditional voices should be heard in
policy making (Backer et al, 1993).
I think that persons actively
involved in practicing nursing should be involved in formulating nursing
ethics. Its origins should not only come from academia, administrators, or even
feminist philosophers. Our ethics must be informed from the bedside and from
nursing's unique diversity.
Conclusion
The idea of an ethics of caring looks
nice on paper and sounds nice in conversation, but the practical reality is that
it sets up impossible expectations, and perpetuates the exploitation of nurses.
Before nurses can make their voices
heard they must first be made aware of the danger their caring poses in a male
dominated world that has devalued caring. We must raise the consciousness of
nurses, deprogramming their internalized oppression. We must find ways to
infuse nursing's exhaustion with hope from feminism. Society has a stake in
nurses not sacrificing themselves to care for others. At one time or another,
each of us is likely to be dependent on nursing's care.
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