Can an ethic of caring be maintained?

Abstract

In her 1990 Guest Editorial for JAN, Lynda Law Harrison raised the question: ‘Can an ethic of caring in nursing be maintained?’ This is a provocative question to ponder once again as we move into a new era which witnesses the unravelling of timeless ethics and values that guide and sustain nursing as a moral endeavour which assures its universal professional covenant with the public. The current socio-political, medical-economic polemics of health (read sickness) care are arguably turning nursing away from human caring and its bedrock ethic of caring. The demands of modern medicine have turned nursing more towards technical-industrial, quantitatively time-bound, product-line, institutional demands of the job. Such westernized clinical views of humanity and compassionate, ethical, human caring services, leave little room for nurses to attend to the work that they love. The work nurses love, that calls them into nursing in the first place, is often the caring–healing relationships, the values, and the sense of purpose and meaning attached to the human dimensions of nursing. This deeper humanitarian, caring science endeavour and the work of caring–healing relationships, is grounded in the timeless ethic and ethos that guides the personal and professional life of nursing. Yet, this is the very ethic which has been and continues to be eroded by the dominant technical, medicalized, clinicalized, professionalized view of humans and nurses themselves. Ironically however, just as we can currently identify the dissonance between the caring ethic of nursing and the focus of the dominant system, we witness collapse and chaos from within, nationally and internationally. Harrison's (1990) JAN Editorial invites a revisit as we enter a new era of conflict with respect to ethics and values, and what is truly important in sustaining hospitals as well as the humanity of practitioners and patients alike. The concluding challenge of that editorial, 15 years ago, was to acknowledge that: ‘Nurse practitioners, administrators, educators, researchers and theorists must continue to work together to ensure that the ethic of caring remains an essential unique focus of our profession’ (p. 126). I could not agree more with Harrison's conclusion, but with an updated view for this new century. Since that editorial was published, some disturbing, yet paradoxical, dynamics are increasingly evident in the world of hospital nursing: for example, the growing shortage of nurses, exceeding any past shortages in Western countries, including shortage of nursing faculty; the rising tension between corporate models vs. professional models of health services; the institutional-scientific management tactics, driven by costs and economic gains; the continuing widespread stories of dispirited nurses; the breakdown of professional institutional standards for maintaining healthy and viable nurse-working conditions; and, in some instances, last-resort approaches towards quotas and nurse–patient ratios have now been selectively legislated. These growing dynamics within and without the profession, guided largely by economic imperatives, have hardened and shortchanged the ethic of caring. Nurses and nursing are detoured from the human caring mission towards demands to do more and more, but with less and less time and appreciation. At a deeper level, we have to acknowledge the dissonance between the disciplinary-ethical-moral foundation of human caring as ontology, and epistemology, as well as a philosophy and model of science that guides informed caring practices. Parker (2004) does not hesitate to name this dissonance by reminding us that every epistemology becomes an ethic. Thus, if nursing does not maintain its caring ethic, it and we suffer harmful consequences, which as Palmer puts it, can result in ethical formation or ethical deformation (italics added). Thus, critical issues and consequences are evident if we do not and cannot maintain the caring ethic in nursing, and if we are to sustain humanity itself. But do not despair! In the midst of all the difficulties of this era, consistent with chaos and complexity theory, a new order and pattern of hope and change seems to be emerging underneath the chaos at the surface. Perhaps because of, or in spite of, the tense dynamics and value-conflicts and growing dissonance, there is evidence of an ethic of caring re-emerging; indeed, having to be emerge, if the profession of nursing and the systems that require nursing care are to survive. To put things in another perspective regarding the broader standing of nursing in the world, once again, in the 2005 Gallup poll in USA, the public placed the nursing profession on top, with respect to honesty and ethics, above other major professions (http://www.gallop.com). This acknowledgement is a reinforcement of the importance of sustaining the caring ethic if we are to maintain our covenant with the public. The tension in the dominant approaches to hospitals and medical treatment is in stark contrast to the public's accelerating interest, if not demand, for professional integrity, honesty and ethics, along with complementary-alternative medicine and an increasing awareness of the relationship between spirituality and health (Watson 2006). A new model of expectation is now emerging from the professions and the public alike, inviting a new order to emerge. What is bringing me hope, is that I am currently witnessing an increasing number of hospitals, nursing and hospital executives giving greater and greater attention, dignity, voice, recognition and action towards transforming nursing from inside out. These transformation efforts are resulting in nursing returning to its timeless ethic and practices of human caring, in that these ethical, theory-guided professional practice models seek to make explicit the caring relationships, the knowledge, values, philosophy, theory and therapeutics that guide advanced professional practice. These developments are transforming the practitioners as well as conventional systems (Watson 2006). For more information and selected examples of these progressive organizations and their caring-guided projects, visit the Watson website (http://www.uchsc.edu/nursing/caring). Thus, what is emerging under the chaos is an internal shift whereby individual nurses, nurse leaders and the profession of nursing are together bringing forth its timeless paradigm of caring as a hopeful ethic for this time of erosion and despair. There appears to be a momentum to develop theory-guided practice models in the midst of current hospital reorganizations. This turn is consistent with the widely-heralded American Nurses Credentialing Center Magnet Hospital initiative in USA, inviting hospitals and nursing administrators and leaders to achieve national Magnet recognition (http://ana.org/ancc/magnet/index.html). This development, if done with integrity and authenticity for deep change, is heartening. It gives nursing a professional pride and theoretical model to excel in its most cherished human caring practices, guided by an underlying caring ethic. It also promotes clinical research, and nurses as clinical scholars and knowledge workers, which the system requires for its ethic and integrity as well as its commitment and accountability to its public. The 1990 JAN editorial by Harrison identified steps that administrators in healthcare organizations can take to minimize institutional barriers to caring, by ‘implementing policies that reflect respect and care for nurses’ (p. 126). Further, these policies would involve nurses in decision-making so that they could determine how to implement caring; could establish programmes that facilitate nurses meeting their personal, as well as professional responsibilities. Administrators need to support education and therapeutic communication of caring which have ‘significant economic benefits for healthcare organizations’ (p. 126). It seems that with the current turn towards having to maintain the caring ethic in nursing, as well as new views from informed nurse administrators and leaders and visionaries, we see Harrison's challenges being met within a new context for change. In conclusion, the challenges of Harrison remain, but with the need for renewed attention and articulation. Some of the work by Nyberg (1998) a nurse administrator and leader of one of the original Magnet hospitals in the USA, provided an early voice for some responsibilities of the Nurse Administrator within a Caring Model which are congruent with Harrison. However, these responsibilities have expanded, and have increasing importance if nursing is to sustain its caring ethic. They include some of the following (Watson 2006, p. 54): Understanding and communicating caring as philosophy and ethic for organizational processes, structures and relationships; Developing skills of caring behaviours, caring presence in formal–informal relationships with individuals and groups; Being alert and responsive to situation for modelling, creating, and articulating theoretical–philosophical–ethics of caring with staff and colleagues; Providing leadership in implementing and evaluating experimental-demonstration models of caring–healing theory-guided practices; Promoting and supporting research on caring and healing/health outcomes; Exploring relationships between and among data which document connections between caring theory-guided practice models, nurse retention, patient–nurse satisfaction, healing outcomes and costs; Serving as stewards of caring-economics-costs, by incorporating caring as a valuable economic resource and caring as the foundational ethical variable in cost–benefit ratios. Finally, nursing and medical systems are in a new era of having to reconstruct new models that are based on hope and possibilities that transcend old paradigm thinking – thinking that is still lingering from an industrial-product-line mindset, silent with respect to the human spirit as the source for change. However, as nursing matures, and as it realigns its responsibilities and ethical caring covenant directly with the public, it stands as a beacon of light for a new ethic and ethos that transcends all that has come before and informs the healthcare system at large as well as society as a whole. So, in addressing the rhetorical question: ‘Can an ethic of caring be maintained?’, my response – knowing what we know now – is: ‘How can the discipline and profession of nursing, in good faith to itself and its public, bear to NOT maintain and act on an ethic of caring?’