ANS Ethics Collection – Entry 4
Available for free download
September 29 – October 29

The majority of the articles that comprise the ANS Ethics Collection appeared in the last 3 years of the 1980s, reflecting a period of growing awareness and understanding of the nature of nursing ethics. The title of Bishop and Scudder’s article characterized the challenge as one of controversy and debate, and the remaining articles reflect this tone. However, as the blogs related to each of the articles in this collection will show, there was also a thread of consistency – the conviction that there is a distinct ethic that underpins, characterizes, and guides nursing as a discipline. The debates lent greater clarity, and leave a legacy of understanding that remains relevant today.

In the article authored byAnne Bishop, Professor of Nursing, and John Scudder, Professor of Philosophy and Education at Lynchburg College in Virginia, took issue with Yarling and McElmurry’s argument. They acknowledged the importance of the need for reform that Yarling and McElmurry advanced, but they believed that the reform that is needed is greater excellence in nursing and expansion of nursing’s legitimate authority to care. They stated:

“According to Yarling and McElmurry, reform of the health care system is more morally significant than individual care for patients. Of course, nurses should seek reform that would change such conditions as those described [in their article], but labeling excellent care as merely personal moral action misses the moral sense inherent in nursing practice.” (p. 37)

Bishop and Scudder posited that the real challenge for nursing practice is a clear understanding of the nature of nursing ethics from a “care vs. cure” perspective. “Curing” demands ongoing advancement of technology and increasing specialization. “Caring” demands cooperation between physicians and nurses to accommodate the growing demands of technology and specialization, but that maintains the essential nature of healthcare.  Nurses practice from a caring model in which nurses have a privileged “in-between” position from which they fulfill their moral obligation to care. This “in-between” position is a privileged one that contributes to a cooperative process for reaching moral decisions. In contrast to a perspective that seeks autonomy for nurses and hospital reform, an in-between position focuses on the well-being of the person cared for, not the role of the provider or the exclusive rights of the patient.  They explained this as follows:

“In short, the nurse, rather than being a facilitator of compromise, is an advocate of communal decisions that bring together expert medical advice and treatment, sound hospital policy and procedure, and the realizable hopes and aspirations of the patient into the concrete practice of health care that fosters the well-being of the patient.” (page 42)

Bishop and Scudder cite their research exploring nurses’ sense of fulfillment and nonfulfillment in their practice, which revealed that nurses felt most fulfilled when the moral sense of their practice became evident through an experience with a particular patient. In order to achieve full autonomy, nurses would need to practice independently of institutions. Bishop and Scudder explore in some detail the challenges involved in practicing nursing as an employee of an institution.

They note that institutions that hire nurses provide protection, salaries and facilities in which to practice, but this requires some degree of sacrifice of autonomy. It also requires considerable cooperation with hospital administrators, institutional policies, physicians, and other practitioners within the walls of the institution. From Bishop and Scudder’s perspective, the commitment to the moral good for the patient is not unique to nurses, but is shared within this structure. Each discipline has its own particular kind of moral authority, with nurses exercising authority over the day-to-day care of the patient. This authority, exercised within the complex structure of the institution, is what creates the “in-between” position.

Bishop and Scudder are clear that this “in-between” position does not compromise or reduce the nurses moral agency. Rather, they believe that it enhances the nurse’s role in negotiating what is best for the patient by assuring that all who share the responsility for the patient’s care are well represented. They state

“The special in-between position places nurses where they can better contend for the needed cooperation because they share the medical side of the decision with the physician, the hospital policy side with hospital administration, and the personal side with the patient. Thus, the nurse is in a more privileged position for fostering the communal decisions that the moral sense requires. In short, the nurse, rather than being a facilitator of compromise, is an advocate of communal decisions that bring together expert medical advice and treatment, sound hospital policy and procedure, and the realizable hopes and aspirations of the patient into the concrete practice of health care that fosters thewell-being of the patient.” (p. 42)

Bishop and Scudder conclude with a strong statement regarding the moral practice of caring for those who need help restoring, maintaining and promoting good health. They affirm that nursing ethics derives from the practice of nursing – not from ethical theory or principles. They cite Patricia Benner’s focus on the practice of nursing, which gives concrete direction in the fulfillment of a moral sense of practice (Benner, 1984).

Next in this collection is Mary Carolyn Cooper’s 1988 article, published in July, 1988. The theme of this issue of ANS was the “Politics of Knowing.” Cooper acknowledged the important contributions of both Yarling and McElmurry and Bishop and Scudder, but pointed out the fact that neither of these publications addressed the nature of the nurse-patient relationship and the fundamental experience of moral agency of the nurse within the relationship. She proposed that the covenantal relationship between the nurse and the patient is the proper foundation for nursing ethics (Cooper, 1988).

Sources

Benner, P. A. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley.

Bishop, A., & Scudder, J. (1987). Nursing ethics in an age of controversy. ANS. Advances in Nursing Science, 9, 34–43. https://doi.org/10.1097/00012272-198704000-00011

Cooper, M. C. (1988). Covenantal relationships: grounding for the nursing ethic. ANS. Advances in Nursing Science, 10(4), 48–59. https://doi.org/10.1097/00012272-198807000-00008