Pat Anderson
Women Across Cultures, Masters in Liberal Studies 441, Spring 1995
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 nurse’s 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
No Where 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 it’s origination, the result has been that nursing’s ethics of caring has 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, is what has 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 nurse’s oppression in its discourse, its 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, but they also 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, 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. The 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 exploitive 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 Noddings 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 care givers to care for themselves, the lack of care toward the nurse caregivers is not acknowledged. No matter how much I can theoretically see that Noddings 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 Nodding’s 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 an 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 is 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 which 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 nurse’s 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, 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). The conflict between men and women, such as power and authority is also at stake in the nurse-physician relationship (Aroskar, 1985).
One health care model that Aroskar (1985) discusses relates an image of a hospital as a doctor’s workshop with other health professionals accountable to follow 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 the physician as the 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 nurses 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 mindsets functioning at the same time.
No Where 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 lose 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 practice.
Another dilemma for her is teaching students that their role is one of collegiality with physicians, knowing the realities about 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 remains 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 functions to perpetuate caregivers 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? Nurse 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, 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 effect 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, 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, 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 there being only seventy-seven percent of the population (Glenn, 1994). This dysfunctional family set up functions to maintain doctors’ power over patients, nurses, women, and minorities.
Psychology of the System
Summers (1993) refers to health care 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 doctor’s 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, anger, as they would be a liability in a system that doesn’t provide an environment to express or experience them. Without acceptance for 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-racked 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 that 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 workloads prevents 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, non-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 the 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 health care institution. Nurses are asking themselves these questions every day 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 the battered woman’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 nurses 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. 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, listen to ourselves and regular folks. (Warren, 1992). “If knowledge is power, `life precedes theory’ is social revolution” (Warren, 1992, p. 42).
Warren (1992) claims to pose 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 aid, 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’s 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 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 nurses 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 that 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 the 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” which 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 second best, and of lacking faith in one’s self (Backer et al, 1993).
By valuing our voices we can create a new world view 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 policymaking 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 policymaking (Backer et al, 1993).
I think that persons actively involved in practicing nursing should be involved in formulating nursing’s 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 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.
References
Aroskar, M. A. (1985). Ethical relationships between nurses and physicians: Goals and realities—a nursing perspective. In A. H. Bishop & J. R. Scudder Jr (Eds.), Caring, curing, coping nurse physician-patient relationships (pp. 44-61). Alabama: University of Alabama Press.
Backer, B. A., Nikitas, D. Costello., Mason, D. J., McBride, A. B., & Vance, C. (1993,
Summer). Power at the policy table when women and nurses are involved. Revolution The Journal of Nurse Empowerment. 3, (2), 68-76.
Benner, P. (1991). In A. H. Bishop., & J. R. Scudder Jr (Eds.), Nursing: The practice of caring. (pp. xi-xii). New York: National League for Nursing Press.
Bishop, A. H., & Scudder, J. R. Jr (Eds.). (1991). Nursing: The practice of caring. New York:
National League for Nursing Press.
Boyer, R. J., & Nelson, L. J. (1990, Fall). A comment on Fry’s `The role of caring in a theory of nursing ethics’. Hypatia, 5, (3), 153-158.
Buchanan, S., & Cook, L. (1992, August). Nursing ethics committees: The time is now.
Nursing Management 23, (8), 40-41.
Curzer, H. J. (1993). Fry’s concept of care in nursing ethics. Hypatia, 8 (3), 174-183.
Fry, S. T. (1989, July). Toward a theory of nursing ethics. Advances in Nursing Science. pp.
9-22.
Fry, S. T. (1992). The role of caring in a theory of nursing ethics. In H. Berquaert Holmes &
L. M. Purdy (Eds.), Feminist perspectives in medical ethics (pp. 93-106). Bloomington: Indiana University Press.
Gilligan, C. (1982). In a different voice: Psychological theory and women’s development.
Cambridge: Harvard University Press.
Glenn Nakano, E. (1994). From servitude to service work: Historical continuities in the racial division of paid reproductive labor. In E. C. Dubois & V. L. Ruiz (Eds.), Unequal Sisters (2nd ed.) (pp. 405-435). New York: Routledge.(Reprinted from Signs, 1992, 18, (1))
Hine-Clark, D. (1989). Black women in white racial conflict and cooperation in the nursing profession 1890-1950. Bloomington: Indiana University Press.
Hoagland, S. L. (1991). Some thoughts about `Caring’. In C. Card (Ed.), Feminist ethics (pp.
246-263). Lawrence: University Press of Kansas.
Klebanoff, N. A. (1991). Codependency: Caring or suicide for nurses and nursing? In R. M.
Neil & R. Watts (Eds.), Caring and nursing: Explorations in feminist perspectives (pp.
151-161). New York: National League for Nursing.
Miller, K. L. (1991). A study of nursing’s feminist ideology. In R. M. Neil & R. Watts (Eds.),
Caring and nursing: Explorations in feminist perspectives. (pp. 43-56). New York: National League for Nursing.
Noddings, N. (1989). Women and evil. Berkley: University of California Press.
Parker-Spreen, R. (1990). Measuring nurses’ moral judgments. IMAGE: Journal of Nursing
Scholarship, 22 (4), 213-217.
Pulitzer, L. B. (1993). Short-staffed and working scared-Can nurses just say “No”? Revolution
the Journal of Nurse Empowerment, 3 (2), 10-13, 98-100, 102.
Rounds, K. (1993). Report from the ward–The nurse’s side. MS, 3 (4), 33-39.
Sherwin, S. (1992). No longer patient feminist ethics and health care. Philadelphia: Temple
University Press.
Sichel, B. A. (1992). Ethics of caring and the institutional ethics committee. In H. Berquaert
Holmes & L. M. Purdy (Eds.). Feminist perspectives in medical ethics (pp. 113-123). Bloomington: Indiana University Press.
Summers, C. (1993). Nurse — Heal thyself the dysfunctional hospital family: How nurses can support its healing. Revolution The Journal of Nurse Empowerment, 3, (2), 86-91, 121.
Thompson, J. E., & Thompson, H. O. (1985). Bioethical decision making for nurses.
Norwalk, CT: Appleton-Century-Crofts.
Toufexis, A. (1990, Fall). Coming from a different place. Time, pp 64-66.
Warren, V. L. (1992). Feminist directions in medical ethics. In H. Bequaert Holmes & L. M.
Purdy (Eds.), Feminist perspectives in medical ethics. (pp. 32-45). Bloomington: Indiana University Press.