The ethics of care still appeals to many in spite of penetrating criticisms of it which have been presented over the past 15 years or so. This paper tries to offer an explanation for this, and then to critically engage with three versions of an ethics of care. The explanation consists firstly in the close affinities between nursing and care. The three versions identified below are by Gilligan (1982 ), a second by Tronto (1993 ), and a third by Gastmans (...) (2006 ), see also Little (1998 ). Each version is described and then subjected to criticism. It is concluded that where the ethics of care is presented in a distinctive way, it is at its least plausible; where it is stated in more plausible forms, it is not sufficiently distinct from nor superior to at least one other common approach to nursing ethics, namely the much-maligned 'four principles' approach. What is added by this paper to what is already known: as the article tries to explain, in spite of its being subjected to sustained criticism the ethics of care retains its appeal to many scholars. The paper tries to explain why, partly by distinguishing three different versions of an ethics of care. It is also shown that all three versions are beset with problems the least serious of which is distinctiveness from other approaches to moral problems in health care. (shrink)

Nurse educators, like many of their health care professional colleagues, frequently face moral dilemmas when they identify a student as presenting an unacceptable risk to public safety. In this situation, the statutory requirement of nurse educators to protect the public, under the Health Practitioners Competence Assurance Act , competes with the rights of the student to receive education under the Education Act . Using the different moral voices of justice and care, identified by Gilligan , this moral dilemma is examined (...) within the context of one school of nursing in a New Zealand tertiary education organisation. Overall, the justice voice dominated within the tertiary education organisation. Academic committees, and appeal panels, operating within the educational statutory framework, used democratic processes to reach decisions. The individual committee members, acting as autonomous moral agents, made decisions using universal principles and abstract moral reasoning. The focus was on individual rights, natural justice and due process. Nurse educators articulated both justice and care moral voices. Those with care voices described how they agonised between their duty to protect the public, and their wish to facilitate students, with whom they had built relationships, to succeed. The education management process did not acknowledge the statutory obligations of nurse educators, as registered nurses, or the implications of this within the education context. The moral dilemmas were either ignored, or rendered invisible. As a result of this, nurse educators engaged in various survival strategies, and the broader educational context remained intact and unchallenged. (shrink)

In this article I discuss the little examined relationship between time and patient autonomy. Using the findings from a study on the experience of premenopausal cancer patients making fertility preservation decisions during their treatment, I focus on how the patients in the study understood time, and how this understanding interacted with and influenced their decision-making. I then analyse in more depth the importance of time in patient decision-making, and the relationship of time to concepts of patient autonomy and decision-making in (...) the field of bioethics more generally. Focusing on the relational conception of autonomy, I conclude that time is an integral part of patient autonomy which warrants further research, such that it can be better integrated into concepts of patient autonomy, and the policy and guidelines that they inform and influence. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Elder abuse is a significant social issue in society. Although this area has generated an increasing research base, there is scant literature on elder abuse viewed through the lens of ageism and its sway on human rights and citizenship. These three perspectives on the topic allow for a meaningful and equitable benchmark from which elder abuse may be considered. Ageism influences the way human rights and citizenship are articulated for older people and is conceptualised as stereotypical views of older people (...) leading to prejudiced attitudes, actions and societal marginalisation. Such attitudes function to both disadvantage and devalue older people providing a covert basis for societal tolerance of elder abuse. This paper reviews pertinent literature in the area of elder abuse, human rights, citizenship and ageism, and argues that although society aspires to certain ideals in terms of equality and valuing the human individual, these aspirations may often be questionable in terms of older people and abuse. (shrink)

Psychological research has shown that cognitive illusions, of which visual illusions are just a special case, are systematic and pervasive, raising epistemological questions about how error in all forms of research can be identified and eliminated. The quantitative sciences make use of statistical techniques for this purpose, but it is not clear what the qualitative equivalent is, particularly in view of widespread scepticism about validity and objectivity. I argue that, in the light of cognitive psychology, the ‘error question’ cannot be (...) dismissed as a positivist obsession, and that the concepts of truth and objectivity are unavoidable. However, they constitute only a ‘minimal realism’, which does not necessarily bring a commitment to ‘absolute’ truth, certainty, correspondence, causation, reductionism, or universal laws in its wake. The assumption that it does reflects a misreading of positivism and, ironically, precipitates a ‘crisis of legitimation and representation’, as described by constructivist authors. (shrink)

The ethics of care, adopted in much of the nursing literature, is usually framed in opposition to the Kantian ethics of principle. Irrespective of whether the ethics of care is grounded in gender, as with Gilligan and Noddings, or inscribed on Heidegger's ontology, as with Benner, Kant remains the philosophical adversary, honouring reason rather than emotion, universality rather than context, and individual autonomy rather than interdependence. During the past decade, however, a great deal of Kantian scholarship – including feminist scholarship (...) – has rendered this series of oppositions questionable, challenging the view that an ethics of care and Kant's moral law are irreconcilable. This paper therefore re‐examines Kant's writings, drawing on recent scholarship, and argues both that they provide the care ethicists with everything they require, and that they offer something beyond an ethics of care, something that repairs the deficits in philosophies of caring. It concludes by suggesting that a Kantian ethics of care has significant implications for the construction of nursing knowledge. (shrink)

These days, discussions of what might be the ‘essence’ or the ‘core’ of nursing and nursing practice sooner or later end in a discussion about the concept of care. Most of the ‘newer’ nursing theories use this concept as a theoretical core concept. Even though these theoretical approaches use the concept of care with very different philosophical foundations and theoretical consistency, they concur in defining care as the essence of nursing and thereby glorify goodness as the decisive characteristic of nursing. (...) These theoretical approaches neglect the fact that nursing is above all a profession with a societal task and is characterized by an asymmetrical power relation between nurses and their patients. Based on the results of a research project that analysed the role nurses played in the killing of psychiatric patients in Germany during the Nazi regime, I demonstrate that an approach based on the concept of care is not able to explain how nurses were able to commit crimes of such atrocity. These crimes were bound to an emotional investment that sustained the production of ‘life unworthy of living’. In the case of nurses under the Nazi regime, certainly a kind of sadism was at issue that can only be explained if we recognize that the social bond is characterized by a certain tension; ‘goodness’ that caring theories assign to the social bond always coexists with the capacity for destruction. Using the Foucauldian theoretical framework of biopower and biopolitics enables one to analyse violence and power as integral parts of nurses' practice. Seen from this perspective, the killing of patients was part of a biopolitical programme and not a relapse into barbarism. The concept of care obscures the political agenda of nursing and does not provide a critical and political framework to analysing nursing practice. (shrink)

Abstract“Patient-centred care” is the recent response to the malaise produced in the field of health care from the point of view both of a technical mentality and the paternalistic model. The interest in the story-telling approach shown by both the humanities and the social sciences has favoured a “narrative turn” in medicine too, where the new ethics of therapeutic relationship consider the hermeneutic method a means by which to integrate evidence and subjectivity, scientific data and patient experience. The aim of (...) this paper is to show how Ricoeur’s theory of “threefold mimesis” makes a conceptual contribution to the use of narrative interviews in nursing and also be successfully transferred into and applied in the field of healthcare in general. First, the paper examines how this narrative approach might open up new possibilities for the acquisition of in-depth knowledge of patients’ life experiences, a condition indispensable for the improvement of the quality of care. Secondly, it highlights how this Ricoeurian method seems capable of provide an opportunity for healthcare professionals to review their own understanding of the caregiver-patient therapeutic relationship, beginning with their confrontation with the patient’s world as revealed by the narrative they provide. (shrink)

Recent discussions concerning the ethics of nursing care have gained added impetus from articulations of die so‐called ‘ethic of carersquo; in moral philosophy. This paper addresses the question of recognizing and elaborating the ethics of nursing care by exploring the problems and the possibilities of diese intersecting discourses. In the first part of the paper it is argued that appropriation of ‘the ethic of care’ by nursing theorists as the central value of nursing, in contradistinction to other moral values such (...) as beneficence or justice, runs the risk of reinforcing the conventional approaches to ethics that ‘the ethic of care’ seeks to overturn. Central to ‘the ethic of care’ is the recognition that caring entails a focus on the particularities and context of the relationships in which it is expressed. Accordingly die application of a unitary concept of care to the context of nursing relations may seriously distort dieir diverse and complex‐specific ediical possibilities. The dynamic complexity of nursing ethics may be more adequately understood by working through an array of specific examples of nursing practice highlighting the differences and similarities between them and other ethical practices of care. Experience of a set of examples in this way will draw attention to the multiplicity, ambiguity, and particularity of the ethics of nursing while facilitating the ability to recognize how other practices may or may not be understood as examples of ediical nursing care. In the second part of the paper a beginning is made on this project by addressing the work of several different theorists of care who have examined different practices of nursing from the overlapping perspectives of nurses, patients and the socio‐historical construction of their relationships. (shrink)

Modern British nursing developed from the mid‐nineteenth century and was seen as a morally purifying activity and as a potential force for social cohesion. It was also considered an activity fit for women. However, it embodied a fundamental tension within Victorian sensibility between a kind of rationalistic utilitarianism and a faith in transcendent values. This paper explores this tension and suggests that it can be detected in current debates about practice and evidence in nursing in the contemporary context of a (...) rise of managerialism in public services. (shrink)

Increasingly, nurses use the philosophy of hermeneutics, especially Heideggerian and Gadamerian hermeneutics, to inform interpretive research. However, application of the work of these philosophers to interpretive nursing research has proved problematic as it fails to recognise, or act upon, obligations inherent in their work. Through a review of hermeneutically informed nursing research, methodological implications regarding the use of hermeneutic philosophy are examined in relation to: (i) the need to address forestructures and pre-understandings; (ii) checking interpretations with research participants; (iii) seeking (...) objectivity, consensus and accuracy in textual interpretation; (iv) evaluating interpretations; and (v) gaining entry into the hermeneutic circle. This review suggests that despite obligations inherent in Heideggerian and Gadamerian hermeneutic philosophy, nurses fail to actualise these obligations in their research. In following Heidegger, nurses need to make the scientific theme secure by working out their forestructures in terms of the phenomenon under investigation. Those following Gadamer need to accept that interpretation seeks to manifest textual meanings rather than individual ones. And, whether following Heidegger or Gadamer, the way to make manifest textual meanings is to engage with the text within the hermeneutic circle by continuing to address forestructures and pre-understandings and by considering their influences upon the research. (shrink)

In exploring phenomenological literature, it is evident that the term ‘phenomenology’ holds rather different meanings depending upon the context. Phenomenology has been described as both a philosophical movement and an approach to human science research. The phenomenology of Husserl, Heidegger, Gadamer, and Merleau-Ponty was philosophical in nature and not intended to provide rules or procedures for conducting research. The Canadian social scientist, van Manen, however, introduced specific guidelines for conducting human science research, which is rooted in hermeneutic phenomenology and this (...) particular method has been employed in professional disciplines such as education, nursing, clinical psychology, and law. The purpose of this paper is to explore the difference between the phenomenological method as described by van Manen and that of other philosophers such as Husserl, Heidegger, Gadamer, and Merleau-Ponty. In so doing, the author aims to address the blurred boundaries of phenomenology as a research method and as a philosophical movement and highlight the influence of these blurred boundaries on nursing knowledge development. (shrink)

This paper proceeds from examining the debate regarding the question of whether a systematic literature review should be undertaken within a qualitative research study to focusing specifically on the role of a literature review in a phenomenological study. Along with pointing to the pertinence of orienting to, articulating and delineating the phenomenon within a review of the literature, the paper presents an appropriate approach for this purpose. How a review of the existing literature should locate the focal phenomenon within a (...) given context is illustrated by excerpts from the first author’s literature review within a descriptive phenomenological study. Also discussed is the important issue of when the researcher should fully enter the attitude of the phenomenological reduction and how this may influence the study. (shrink)

This paper proceeds from examining the debate regarding the question of whether a systematic literature review should be undertaken within a qualitative research study to focusing specifically on the role of a literature review in a phenomenological study. Along with pointing to the pertinence of orienting to, articulating and delineating the phenomenon within a review of the literature, the paper presents an appropriate approach for this purpose. How a review of the existing literature should locate the focal phenomenon within a (...) given context is illustrated by excerpts from the first author’s literature review within a descriptive phenomenological study. Also discussed is the important issue of when the researcher should fully enter the attitude of the phenomenological reduction and how this may influence the study. (shrink)

The concept of ‘place’, and general references to ‘geographies of …’ are making gradual incursions into nursing literature. Although the idea of place in nursing is not new, this recent spatial turn seems to be influenced by the increasing profile of the discipline of health geography, and the broadening of its scope to incorporate smaller and more intimate spatial scales. A wider emphasis within the social sciences on place from a social and cultural perspective, and a wider turn to ‘place’ (...) across disciplines are probably equally important factors. This trend is raising some interesting questions for nurses, but at the same time contributes some confusion with regard to imputed meanings of ‘place’. While it is clear that most nurse clinicians and researchers certainly understand that place of care matters to their practices and patients, many diverse uses of ‘place’ are found within nursing literature, and contemporary understandings of the term ‘place’ within nursing are not immediately clear. It is in this context that this article plans to advance the discussion of place. More specifically, the aims of this paper are threefold: to critique ‘place’ as it appears in nursing literature, to explore the use of ‘place’ within health geography, whence notions of place and ‘geographies of’ have originated and, finally, to compare and contrast the use of ‘place’ in both disciplines. This critique intends to address a deficit in the literature, in this era of growing spatialization in nursing research. The specific questions of interest here are: ‘what is “place” in nursing?’ and ‘how do concepts of place in nursing compare to concepts of place in health geography?’. (shrink)

Professional medical ethics demands of health care professionals in addition to specific duties and rules of conduct that they embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired implied attitude of physicians. In a sequel of three articles, a set of three of these concepts is presented in an interpretation that is meant to characterise the morally emotional part of this attitude: “empathy”, “compassion” and “care”. In the first article of the (...) series, “empathy” has been developed as a mainly cognitive and morally neutral capacity of understanding. In this article, the emotional and virtuous core of the desired professional attitude—compassion—is elaborated. Compassion is distinguished from sympathy, empathy and pity. Several problems of compassion as a spontaneous, warm emotion for being a professional virtue are discussed: especially questions of over-demand, of justice and of concerns because of a possible threat to the patient’s dignity and autonomy. An interpretation of compassion as processed and learned professional attitude, that founds dignity on the general idea of man as a sentient being and on solidarity, not on his independence and capacities, is developed. It is meant to rule out the possible side effects and to make compassion as a professional attitude and as professional virtue attractive, teachable and acquirable. In order to reach the adequate warmth and closeness for the particular physician-patient-relation, professional compassion has to be combined with the capacity of empathy. If appropriate, the combination of both empathy and compassion as “empathic compassion” can demand a much warmer attitude towards the patient than each of the elements alone, or the simple addition of them can provide. The concept of “care” that will be discussed in a forthcoming article of this sequel is a missing necessary part to describe the active potential of the desired moral attitude of the physician more completely. The reconstruction of the desired professional attitude in terms of “empathic compassionate care” is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions. (shrink)

Conducting empirical research on gender in medical ethics is a challenge from a theoretical as well as a practical point of view. It still has to be clarified how gender aspects can be integrated without sustaining gender stereotypes. The developmental psychologist Carol Gilligan was among the first to question ethics from a gendered point of view. The notion of care introduced by her challenged conventional developmental psychology as well as moral philosophy. Gilligan was criticised, however, because her concept of ‘two (...) different voices’ may reinforce gender stereotypes. Moreover, although Gilligan stressed relatedness, this is not reflected in her own empirical approach, which still focuses on individual moral reflection. Concepts from social psychology can help overcome both problems. Social categories like gender shape moral identity and moral decisions. If morality is understood as being lived through actions of persons in social relationships, gender becomes a helpful category of moral analysis. Our findings will provide a conceptual basis for the question how empirical research in medical ethics can successfully embrace a gendered perspective. (shrink)

Recent work in clinical nursing ethics has been influenced by two main areas of insight associated with the challenge levelled by the women's movement to traditional thinking about morality and ethics. Broadly speaking these two realms have been distinguished as articulating ‘feminist’ socio‐political and ‘feminine’ ethic of care concerns. Often these two impulses are seen as pulling against each other, or worse, the ‘feminine’ emphasis on the ethics of care is seen as reinforcing the dynamics that elicit the ‘feminist’ concern. (...) In this paper I suggest how an expanded understanding of an ethic of care in clinical settings can provide resources for dealing with both concerns. A discussion of the way institutional relations can ride rough‐shod over the ‘feminist’ insights of ethical care, in the second part of the paper, provides evidence for my conclusion that ethical nursing care depends on recognizing that both areas of insight are imperative for its success. (shrink)

Agonizing care: care ethics, agonistic feminism and a political theory of care ‘Care’ is central to nursing theory and practice, and has been described in a variety of ways. Intense conversations about care have been developing in other fields of study as well, from the social sciences to the humanities. Care ethics has grown out of intellectual exchange between feminist thought, moral theory and the critique of traditional western political philosophy. However, care ethics is not without its critics, as these (...) accounts of care have also sparked vigorous challenges. This paper traces the construct of care through nursing theory, care ethics, feminist critiques of moral and political theory and agonistic feminism to outline a set of problematics that a political theory of care should engage. It discusses how care is conventionally posited in more or less essentialist, universalizing and naturalizing terms. It introduces the ideas of feminist theorists who resist dichotomizing care and the political, and situate care in the context of power and politics. The tensions between care feminism and agonistic feminism are highlighted in order to explore the potential of theorizing both care and nursing in political terms. (shrink)

The claim that, in some nontrivial sense, nursing can be identified with caring has prompted a search for the philosophical foundations of care in the nursing literature. Although the ethics of care was initially associated with Gilligan's ‘different voice’, there has more recently been an attempt – led principally by Benner – to displace the gender perspective with a Heideggerian one, even if Kant is the figure to whom both Gilligan and Benner appear most irretrievably opposed. This paper represents the (...) first half of a double-edged project: initially, to point out that Heidegger explicitly disowns any ethical implications for his ontological thinking, and to argue that no ethical theory (including an ethics of care) can be derived from Being and Time; and then to argue that Kant's categorical imperative is not only compatible with the ethics of care but actively entails it. In this, Heideggerian, part of the argument, I consider three attempts to wrest an ethics from Being and Time– those of Benner, Olafson and Guignon – suggesting that, for different reasons, they all fail. Benner systematically confuses the ontological with the ontic, not recognizing that care, concern and solicitude have ‘deficient’ modes as well as positive ones, and that Heidegger's ontology retrieves the possibility of an ethics-in-general without at any point implying an ethics-in-particular (whether of care or justice). Olafson does recognize this, and to that extent admits his failure, but his efforts to amplify Heidegger's thought in such a way as to generate an ethical theory involve both the importing of Kantian premises, and an appeal to some rather doubtful empirical observations. Guignon resorts to Heidegger's discussion of authenticity, and the idea that authentic Dasein ‘may choose its hero’, suggesting a morally reassuring list of heroes who might fit the bill. However, there is nothing in Heidegger's account of this choice that justifies his confidence, and I conclude by proposing that we should take Heidegger at his word when he says that ontology has ‘no result, no effect’. (shrink)

This paper explores the relationship between temporal continuity in nursing and temporal features of sickness. It is based on phenomenological and hermeneutical philosophy, empirical studies of sickness time, and the nursing theories of Nightingale, of Benner and of Benner and Wrubel. In the first part, temporal continuity is defined as distinct from interpersonal continuity. Tensions between temporal continuity and discontinuity are discussed in the contexts of care management, of conceptualisations of disease and of time itself. Temporal limitations to the methodological (...) concept of situation are discussed. The main part of this paper explores nurses' possibilities to relate to their patients' time, and how temporal features of sickness may warrant temporal continuity of nursing. Three temporal characteristics of sickness are discussed: the immediacy of patients' suffering, the basic continuity of life through sickness and health care, and the indeterminism and precariousness of sickness. The timing of nursing acts is discussed. The paper explores how sickness is both part of the continuity of life, and threatens this continuity. It concludes that this tension is implicitly recognised in the temporal continuity of nursing, which allows for discontinuous and continuous aspects of sickness time. Nurses accordingly perceive the sick person's time at several levels of temporality, and distinguish highly complex temporal processes in their patients' trajectory. Temporal continuity provides the time, flexibility, and closeness for nurses to perceive and act into time dimensions of individual sickness. The paper shows that temporal continuity of nursing is grounded in temporal characteristics of severe sickness. It suggests that temporal continuity is an important theoretical concept in nursing. (shrink)

Since the 1990s, numerous studies on the relationship between parents and their children have been reported on in the literature and implemented as a philosophy of care in most paediatric units. The purpose of this article is to understand the process of nurses' care for children in a paediatric setting by using Noddings's caring ethics theory. Noddings's theory is in part described from a theoretical perspective outlining the basic idea of the theory followed by a critique of her work. Important (...) conceptions in her theory are natural caring (reception, relation, engrossment, motivational displacement, reciprocity) and ethical caring (physical self, ethical self, and ethical ideal). As a nurse one holds a duty of care to patients and, in exercising this duty, the nurse must be able to develop a relationship with the patient including giving the patient total authenticity in a 'feeling with' the patient. Noddings's theory is analysed and described in three examples from the paediatrics. In the first example, the nurse cared for the patient in natural caring while in the second situation, the nurse strived for the ethical caring of the patient. In the third example, the nurse rejected the impulse to care and deliberately turned her back to ethics and abandoned her ethical caring. According to the Noddings's theory, caring for the patient enables the nurse to obtain ethical insights from the specific type of nursing care which forms an important contribution to an overall increase of an ethical consciousness in the nurse. (shrink)

The aim of this paper is to clarify what “phenomenological” means in the phenomenological researches of nursing and what “method” is or should beadopted in phenomenological researches of nursing. The essay first defines a traditional classification of the phenomenological researches of nursing by Cohen and Omery, and then gives a new attempt to classify the phenomenological approaches in the theories of nursing. On this basis, the essay reviews some representative “phenomenological” researches of nursing today and addresses critical comments to them. (...) Finally, the essay will make clear what “phenomenological” should mean in the phenomenological research of nursing and what kind of “method” should be adopted in those researches. (shrink)

Many of the activities of clinical practice happen to, with or upon vulnerable human beings. For this reason numerous nursing authors draw attention to or claim a significant moral domain in clinical practice. A number of nursing authors also discuss the emotional involvement and/or emotional labour which is often experienced in clinical practice. In this article I explore the importance of emotion for moral perception and moral agency. I suggest that an aspect of being a good nurse is having an (...) emotional sensitivity to other human beings (patients), because this emotional sensitivity allows the nurse to perceive more accurately the context and perspective of the patient. It is thus important to the moral agency of the nurse and to morally sensitive clinical practice. As such education of the emotions should be a feature of the moral education of the nurse. A useful conception of the role of educated emotion in the moral life can be discovered in Aristotelian ethics. (shrink)

This paper is concerned with aspects of responsibility in Norwegian public health nursing. Public health nursing is an expansive profession with diffuse boundaries. The Norwegian public health nurse does not perform ‘hands on’ nursing, but focuses on the prevention of illness, injury, or disability, and the promotion of health. What is the essence of ethical responsibility in public health nursing? The aim of this article is to explore the phenomenon based on the ethics of responsibility as reflected upon by the (...) philosopher Emanuel Levinas (1906–1995). From an ethical point of view, responsibility is about our duty towards the Other, a duty we have not always chosen, are prepared for, or can fully explain; but it is nevertheless a demand we have to live with. Interviews with five experienced Norwegian nurses provide the empirical base for reflection and interpretation. The nurses share stories from their practice. In interpreting the nurses’ stories, the following themes emerge: personal responsibility; boundaries; temporality; worry, fear, and uncertainty; and a sense of satisfaction. As the themes are developed further, it becomes apparent that, despite their diversity, they are all interrelated aspects of ethical responsibility. Responsibility for the Other cannot be avoided, ignored, or transferred. The nurses’ responsibility is personal and infinite. Levinasian ethics can help nurses understand the importance of accepting that being a responsive carer can involve not only contentment in the predictable, but also the fear, worry, and uncertainty of the unpredictable. (shrink)

This paper extends the dialogue of educational philosophy to the experience of beginners entering the teaching profession. Rather than impose the ideas of any specific philosopher or theorist, or indeed official standard, the exploration presented here owes its origins to phenomenology and the use of grounded theory. Working from a narrative data base and focussing on the knowing of name in the first instance, the authors develop their emergent ideas on self and identity in relation to children taught, through connection (...) to a wider literature that includes reference to Giddens, Illeris, Deleuze and Heidegger, for example. The paper is thus also an exercise in suggesting that research on practice by academics working in professional education, who are non-philosophers, can lead to constructive and relevant engagement with philosophy in developing theory from and about about practice, even though the approach, in the initial stages, may well be serendipitous and eclectic in nature. (shrink)

In this article a discussion of the phenomenon of wellness and its relevance to contemporary nursing practice is developed. Drawing on phenomenology, the research literature and the author's own wellness research, an exposition of the concept of wellness is presented. It is proposed that the experience of being well is lived as a continuity of time and that it involves both a taking-for-granted of the body and containment of the horizon of concern. The state of actually being well is also (...) clarified and contrasted with the more common understanding of wellness as an optimal or future state. This discussion has significance for nursing knowledge development, in terms of our understanding of the experience of wellness and illness. It also has implications for how nurses approach their practice, particularly in the area of health promotion. (shrink)

It is frequently claimed that nursing is vital to the safe, humane provision of health care and health service to our populations. It is also recognized however, that nursing is a costly health care resource that must be used effectively and efficiently. There is a growing recognition, from within the nursing profession, health care policy makers and society, of the need to analyse the contribution of nursing to health care and its costs. This becomes increasingly pertinent and urgent in a (...) situation, such as that existing in Ireland, where the current financial crisis has lead to public sector employment moratoria, staff cuts and staffing deficits, combined with increased patient expectation, escalating health care costs, and a health care system restructuring and reform agenda. Such factors, increasingly common internationally, make the identification and effective use of the nursing contribution to health care an issue of international importance. This paper seeks to explore the nature of nursing and the function of the nurse within a 21st century health care system, with a focus on the Irish context. However, this analysis fits into and is relevant to the international context and discussion regarding the nursing workforce. This paper uses recent empirical studies exploring the domains of activity and focus of nursing, together with nurses perceptions of their role and work environment, in order to connect those findings with core conceptual questions about the nature and function of nursing. (shrink)

This paper analyses a situation where a patient's suffering provoked feelings of compassion in a student nurse, and distress at her patient's circumstances. The reported behaviour of qualified nurses within the situation suggests that they lacked compassion, had inadequate knowledge, and that they failed to understand their patient's plight. An account of the situation is followed by an exploration of the nature of moral agency, and understanding in nursing. Nurses' capacity for moral imagination is shown to be of crucial importance (...) to the care that patients receive. The extent of nurses' responsibility for their behaviour is considered, and in particular, the extent of nurses' responsibility during times when they experience strain. Argument leads to the conclusion that we are justified in holding nurses responsible for their behaviour in situations of patient care, although we must not judge a nurse's behaviour too hastily. Attention is drawn to the need for a moral climate to sustain those nurses who struggle to give good patient care, despite the strain that is ever present within today's world of health care. (shrink)

This paper situates the moral domain of practice within the context of a particular description of nursing practice – one that sees human interaction at the heart of that practice. Such a description fits not only with professional rhetoric but also with literature from patients and recent empirical work exploring the nature of nursing practice.Martha Levine in her 1977 description of ethics, within the context of nursing practice, indicated that what was important from an ethical perspective was how we interact (...) with each other, with patients and colleagues, on a daily basis. What enables such interaction to display moral sensitivity, insight into patient need, and a focus on the good for the patient? Of relevance when answering this question is the empirical evidence indicating that professional socialization, as a nurse or a doctor, may dull the individual’s moral sense. If this is the case, cognizance needs to be taken of such evidence when identifying theoretical approaches from mainstream ethics that may provide insight and value for nurse education. It is suggested that such insight and value can be gained from a consideration of the work of Aristotle, Murdoch, and Vetlesen. (shrink)

POHLMAN S, CIBULKA NJ, PALMER JL, LORENZ RA and SMITHBATTLE L. Nursing Inquiry 2013; 20: 71–81 The placebo puzzle: examining the discordant space between biomedical science and illness/healingThe placebo response presents an enigma to biomedical science: how can ‘inert’ or ‘sham’ procedures reduce symptoms and produce physiological changes that are comparable to prescribed treatments? In this study, we examine this puzzle by explicating the discordant space between the prevailing biomedical paradigm, which focuses on a technical understanding of diagnosis and treatment, (...) and a broader understanding of illness and healing as relational and embodied. Although biomedical achievements are impressive, the knowledge resulting from this paradigm is limited by its ontological and epistemological assumptions. When the body and world are objectified, illness meanings, therapeutic relationships, and healing practices are dismissed or distorted. In spite of a robust critique of the tenets of biomedicine for guiding practice, the biomedical paradigm retains a tenacious hold on evidence-based medicine and nursing, downplaying our clinical understanding of the sentient body, patients’ life-worlds, and illness and healing. In reality, skilled nurses rely on multiple forms of knowledge in providing high-quality care to particular patients. Clinically wise nurses integrate their experience and knowledge of patients’ priorities, fears, and illness trajectories along with biomedical findings to make astute judgments and promote health and healing. (shrink)

The idea of meaning plays, together with the notion of caring, a pivotal role in recent nursing theory, informing its approach to philosophy, research and practice. Unlike caring, however, it has received relatively little analytical attention – a fact that is surprising in view of the scepticism about meaning that is characteristic of much contemporary philosophy and social theory. This paper reviews the philosophical literature on meaning, highlighting sceptical currents in the Wittgensteinian corpus, neo‐behaviourism and poststructuralism. It also considers a (...) similar line of thought that has emerged in social theory, questioning the explanatory value of concepts such as ‘practice’, ‘culture’, ‘norms’, ‘tacit knowledge’, and ‘tradition’. All these perspectives suggest that there is something wrong with the common‐sense picture of a set of shared, implicit rules that account for our ability to understand and communicate; and they all point to an alternative picture which is naturalistic, materialist and causal, and which depicts ‘shared meaning’ as a rather mysterious quality, unable to explain the familiar regularities of verbal and nonverbal behaviour. In this picture, while the idea of meaning can be retained, it ceases to be something shared, and becomes something individual and idiosyncratic, a unique cluster of associations, concomitants, and other habits of thought. The paper closes with a brief interpretation of what the alternative implies for a research methodology in nursing. In particular, it proposes that certain well established approaches will have to be abandoned, and that qualitative strategies will have to be grounded in a rigorous scientific framework, rather than in techniques (such as phenomenology), which presuppose a misleading and inaccurate conception of what meaning is. (shrink)

Sara T. Fry maintains that care is a central concept for nursing ethics. This requires, among other things, that care is a virtue rather than a mode of being. But if care is a central virtue of ethics and medical ethics then the claim that care is a central concept for nursing ethics is trivial. Otherwise, it is implausible.

Recently the relevance of the philosophy of Martin Heidegger has been critiqued in nursing literature. However, this critique is based primarily upon an appropriation of Heidegger that does not reflect an understanding of meaning as grounded in temporality. Therefore, this paper aims to (1) explicate Heidegger's grounding of meaning, (2) briefly contrast Heidegger's and Husserl's notions of the origin of meaning, (3) describe how Heidegger was first introduced to nursing, and (4) illustrate through examples from a research study how the (...) philosophy of Heidegger might inform the phenomenological researcher. (shrink)

Nursing practice invites nurses to embody caring practices that meet, comfort and empower vulnerable others. Such a practice requires a commitment to meeting and helping the other in ways that liberate and strengthen and avoid imposing the will of the caregiver on the patient. Being good and acting well (phronesis) occur in particular situations. A socially constituted and embodied view of agency, as developed by Merleau‐Ponty, provides an alternative to Cartesian and Kantian views of agency. A socially constituted, embodied view (...) of agency is less mechanistic and less deterministic than Descartes' and Kant's radical separation of mind and body, and more responsive and generative than Kant's vision of moral agency as constituted by autonomous choice makers who are uninfluenced by emotion. The role of emotion in perception and judgement is explored in this paper. Distinctions between techne and phronesis are drawn. The role of emotion in market relationships and procedural ethics drawn for the abstract, general other are strategies for exchange of goods and services, but these same market relationships are dependent on well‐functioning nonmarket relations of noncalculated giving and receiving. (shrink)

The current reform of nursing education is resulting in major changes in the curricula of colleges of nursing. For the first time, ethical and moral issues are being seen as an important theme underpinning the entire course. The moral theorist with whose work most nurse teachers are acquainted is Kohlberg. In this paper, it is suggested that his work, and the conventions of morality which he exemplifies, may not be the most appropriate from which to address the moral issues facing (...) the nurse. The author suggests that the work of Carol Gilligan of Harvard university is of great significance, not only for nurses involved in the teaching of ethics, but for all nurses. Gilligan's emphasis on caring and relationships accords with the common experience of the nurse, and echoes the current revival of interest within nursing in examining, and valuing, the phenomenon of caring. (shrink)

This article highlights the distinction between the ‘art of nursing’ and ‘fine art’. While something in the nature of nursing can be described as ‘the art of nursing’, it is not to be misunderstood as ‘fine art’ or craft. Therefore, the term ‘aesthetic’ in relation to nursing should not be linked to the aesthetic of modern art, but instead to a broader and more general meaning of the word. The paper's main focus is the aesthetic experience, which is treated in (...) a hermeneutic way and elucidated from classical sources and the philosophy of nursing and from Art. The paper argues that the pioneers used the term ‘art of nursing’ in a metaphorical way to say something more specific on the nature of nursing. The term illustrates the nurse's ability to practise at the highest possible level of excellence. (shrink)

This paper forms part of a wider study examining the history and sociology of nursing education in England between 1860 and 1948. It argues that the question of whether nursing was an art, science and/or social science has been at die ‘heart’ of a wider debate on die occupational status and disciplinary identity of nursing. The view that nursing was essentially an art and a ‘calling’, was championed by Florence Nightingale. Ethel Bedford Fenwick and her allies insisted that nursing, like (...) other professions, was a ‘scientific’ and technical enterprise. Social scientists later came to challenge nursing's claim to professionalism by analysing nursing work first within die context of industrial psychology. But they also advocated a rapprochement between nursing, health services and social science research, a challenge which we are in nursing, still striving to meet This paper argues for a strong coalition of nursing with its former nineteenth century ally, social science, in die continuing struggle for change within nursing and health care policy. Rather than searching for some rarified and purified essence of nursing knowledge, it argues that nurses need to join forces with sociologists and economists in striving to shape die agenda for health services research and provide die evidential basis for health policy transformation more generally. (shrink)

The aim of the article is to illustrate concrete problems in the asymmetrical nurse–patient power relationship. It is an ethical demand that the nurse is faced with the challenges that the power in the relation is administered so that the patient's room for action is expanded and trust maintained. It is an essential message in care philosophy, but in clinical practice, success is not always achievable. A hidden and more or less unconscious restriction of the patient's room for action may (...) result in the excesses of care. Three selected aspects: dependence, trust, and power described by the Danish philosopher K.E. Løgstrup and the Norwegian nursing philosopher Kari Martinsen's care philosophy has inspired this empirically based examination of some current barriers in the asymmetrical nurse–patient relationship. On the basis of qualitative interviews with six patients and six nurses, the research thus provides an identifying and problem‐exploratory examination of some current obstacles in which the handling of trust and power reflects the excesses of care. The findings develop three themes. ‘Being a burden’ acknowledges that the balance of power will always tip to the nurse's advantage. The second theme, ‘Doing only what's absolutely necessary’, shows how a fixation with ‘technicalism’ creates a distance between people that may constrain the patient's room for action. The last theme is concerning the nurse's ability to navigate between closeness and distance is essential in avoiding ‘the excesses of care’, paternalism, and overprotectiveness. A situation in which distance takes the upper hand and care turns into paternalism. A different situation would arise if the nurse's emotions became sentimental or intimate with the result that closeness gets the upper hand. To avoid a harmful exercise of power and the excesses of care, the findings have demonstrated that a relationship‐based caring is a demand for situation‐specific sensitive attention skills. (shrink)

This article highlights the distinction between the ‘art of nursing’ and ‘fine art’. While something in the nature of nursing can be described as ‘the art of nursing’, it is not to be misunderstood as ‘fine art’ or craft. Therefore, the term ‘aesthetic’ in relation to nursing should not be linked to the aesthetic of modern art, but instead to a broader and more general meaning of the word. The paper's main focus is the aesthetic experience, which is treated in (...) a hermeneutic way and elucidated from classical sources and the philosophy of nursing and from Art. The paper argues that the pioneers used the term ‘art of nursing’ in a metaphorical way to say something more specific on the nature of nursing. The term illustrates the nurse's ability to practise at the highest possible level of excellence. (shrink)

The nurse's moral competences in the management of situations which present ethical implications are less investigated in literature than other ethical problems related to clinical nursing. Phenomenology affirms that emotional warmth is the first fundamental attitude as well as the premise of any ethical reasoning. Nevertheless, it is not clear how and when this could be confirmed in situations where the effect of emotions on the nurse's decisional process is undiscovered. To explore the processes through which situations of moral distress (...) are determined for the nurses involved in nursing situations, a phenomenological–hermeneutic analysis of a nurse's report of an experience lived by her as a moral distress situation has been conducted. Nursing emerges as a relational doctrine that requires the nurse to have different degrees of personal involvement, the integration between logical–formal thinking and narrative thinking, the perception of the salience of the given situation also through the interpretation and management of one's own emotions, and the capacity to undergo a process of co‐construction of shared meanings that the others might consider adequate for the resolution of her problem. Moral action requires the nurse to think constantly about the important things that are happening in a nursing situation. Commitment towards practical situations is directed to training in order to promote the nurse's reflective ability towards finding salience in nursing situations, but it is also directed to the management of nursing assistance and human resources for the initial impact that this reflexive ability has on patients' and their families' lives and on their need to be heard and assisted. The only case analysed does not allow generalizations. Further research is needed to investigate how feelings generated by emotional acceptance influence ethical decision making and moral distress in nursing situations. (shrink)

The aims of this study were to present themes in nursing motifs as depicted in tattoos and to describe how it reflects upon nursing in popular culture as well as within professional nursing culture. An archival and cross‐sectional observational study was conducted online to search for images of nursing tattoos that were freely available, by utilizing the netnographic methodology. The 400 images were analyzed in a process that consisted of four analytical steps focusing on metaphors and meanings in the tattoos. (...) The findings present four themes: angels of mercy and domination; hegemonic nursing technology; embodying the corps; and nurses within the belly of the monster. The tattoos serve as a mirror of popular culture and the professional culture of nurses and nursing practice within the context of body art. Body art policy statements have been included in nursing personnel dress code policies. Usually these policies prohibit tattoos that are sexist, symbolize sex or could contribute and reproduce racial oppression. The results show that the tattoos can be interpreted according to several layers of meanings in relation to such policies. We therefore stress that this is an area highly relevant for further analyses in nursing research. (shrink)

Although we theorize that nurses ‘make a difference’ to patient outcomes and speculate that this happens because nurses ‘care’, there is so far little evidence to support this nebulous claim. Efforts to promote care as the defining characteristic of nursing, and an ‘ethic of care’ as the ethical basis of nursing, have sparked debate within the discipline. This debate has resulted in a polarization that has effectively stalled productive discourse on the issues. Moreover, the focus on care has been at (...) the expense of understanding the true nature of the relationship between caring and the broader base of ethical knowledge that underpins nursing and that must underpin nursing if it is a viable practice profession. This paper used the framework of philosophical argument to explore the moral and ethical foundations of nursing from the perspective of personal and public morals, and responsive nurse–patient relationships as the reflection of ethical nursing knowledge. The foundation of ethical nursing knowledge is the personal moral sense that resides within the individual and that nurses hold in common with others. Personal moral knowledge is transformed into disciplinary ethical knowledge specific to nursing through disciplinary consensus. Responsive relationships are conceptualized in the nursing literature as founded on three essential elements: respect, trust, and mutuality. These three elements are grounded in ethical nursing knowledge; therefore responsive nurse–patient relationships reflect both personal moral knowledge and disciplinary ethical knowledge. By facilitating the articulation of ethical nursing knowledge in practice, responsive relationships connect theory, ethical knowledge, and clinical outcomes. (shrink)

The notion of caring is extremely problematic in the way that it is defined, practised and promoted. In response to Gorovitz I have attempted to go beyond the discussion of how health care workers can promote care at an organisational level, and look at some of the paradoxical elements of caring as it is currently being described. These paradoxes arise, in part, from the current emphasis on individualism in Western society which has made the notion of ‘mass care’ unacceptable because (...) it fails to acknowledge individual differences in patients. If we acknowledge patients as individuals, however, we must also acknowledge practitioners as unique persons too, and we therefore need to be very careful about subjecting them to the same type of generalised prescriptions to which we have subjected patients in the past.A form of care which is not detached and impersonal is being advocated it seems, but it is unlikely that anyone would want health care workers to become inextricably emotionally entwined with their patients. Plotting out the middle ground, however, is difficult to do without recourse to generalised principles. These principles are extremely valuable in the way that they can shape policy and the planning of services, but they are difficult to apply to the relationships between individual staff and patients simply because they are generalised rather than specific. In using these principles, therefore, we can only determine the general context in which caring takes place, and not the nature of this caring.These problems and paradoxes seem, at the moment, to be inherent in caring as it has been recently portrayed. It may be possible to resolve them, or find ways out of these dilemmas, but this can only be done by a very careful examination of motivations and values. In the meantime we may have to be less ambitious in our aspirations, and think about how to define acceptable, rather than ideal standards of care. (shrink)