The Ethic of Care: a moral compass for Canadian nursing practice

The ethic of care or the moral imperative to act justly is offered as an ethical compass to guide nurses. Nurses are inspired to adopt the ethic of care into their practice and into their everyday lives as a lived virtue. A connection is drawn between the theoretical premises of feminism, humanism, phenomenology and the ethic of care, because they each pay attention to the contextual features of people’s lives. Critics of the ethic of care are respectfully challenged. A convincing argument is made that sensing the needs of others is as important as being able to use universal maxims to deal with moral issues. Something new is proposed that goes beyond what was previously believed to be central to this important subject matter. It is recommended that the practice of the ethic of care be informed by knowledge derived from additional sources. For example, the multi-faceted components of care, sound moral principles and the values and ethical responsibilities as laid out by the Canadian Nursing Association (CNA) Code of Ethics, are all considered as crucial and relevant to ethical decision making. Special attention is paid to the notions of compassion, generosity, unconditional positive regard and presencing and a heartfelt narrative is used to illustrate the lived practice of compassion. The chapter ends with a case study where a student nurse is assigned the challenge of caring for a client diagnosed with a catatonic type of schizophrenia. Critical thinking questions are posed in relation to this real life story.

The relationship between sound moral principles and care is presented. Although the ethic of care is relational, contextual and empathetic it also draws upon existing knowledge to inform decision-making. Additional tools such as the moral principles of integrity, veracity, fidelity, respect for selfworth, beneficence, non-maleficence, autonomy and courage are utilized in conjunction with the ethic of care. In this manner ethical action occurs in the context of nurturing the human being who is experiencing the problem within the framework of all that is going on. Integrity is proposed as the standard that guarantees all other values. Moral courage is portrayed as the ability to adhere to the fundamental law of integrity, ethics and perseverance even in the face of rejection or opposition. Client advocacy is deemed to be closely associated with the practice of moral courage. Not only are nurses encouraged to incorporate moral principles of high virtue into their way of being, they are also directed to strive to see the inherent good in every person, regardless of the circumstances. In this manner nurses are ethically obligated to offer competent and compassionate care even in the presence of less than desirable client behaviour. It is pointed out that this edict may sometimes present itself as a profound ethical test. Narratives are used to help illuminate the notions of morality in the context of a person’s story and the case study at the end of the chapter is particularly challenging when nurses are asked to care for a person who is accused of the brutal murder of a child.

Key aspects of the role of the Canadian Nurses Association (CNA) are presented as well as the purpose of the CNA Code of Ethics for Registered Nurses (RNs). Nurses are made aware that the ethical values and responsibilities as laid out in the CNA Code of Ethics are not discretionary but must be followed by all practicing nurses. Each value is discussed in terms of how they are played out in actual practice and narratives are used to emphasize important points. The role of Canadian law is explained because nurses who have a working knowledge of the Canadian legal system are better equipped to deal with legal issues that may arise, especially in trying situations. A brief overview of The Canadian Constitution and The Charter of Rights and Freedoms is also undertaken for similar reasons. Nurses are informed that although some laws are derived from ethics this is not necessarily consistently the case and the law always supersedes ethics. The commonalities between the ethic of care and the CNA Code of Ethics is presented. Other valid topics that directly relate to the CNA Code Ethics Part I include: the safety of research participants; the duty to report unsafe practice; the importance of ensuring informed consent for treatment, the role of advance directives and safe guarding the confidentiality of all client information. The chapter ends with an actual Coroner’s case where a nurse deliberately covers up a mistake that costs a client their life.

To facilitate respect for differences in opinions, the “how to” of the values clarification process is clearly articulated. People are often unaware of what some of their values consist of because values are so entrenched into how a person thinks and behaves. Subsequently, values are frequently acted upon in an automatic fashion. When a nurse is not aware of their values, especially when it comes to precarious subject matter, they may inadvertently impose their point of view onto others. From an ethical perspective, this type of response can be extremely problematic. The association and difference between moral agency, moral residue and moral disengagement is made evident as well as what to do when they occur. Nurses are advised of the importance of getting help when moral residue leads to moral disengagement. An effective strategy is suggested as a way for nurses to own their personal and professional strengths as a means to deal with moral issues in practice. A case study portrays how the client’s right to choose not to receive treatment, ends in moral residue for the nurse. An additional exercise is presented as a way for nurses to enhance their awareness of their personal opinions on heated issues like: abortion; stem cell research; in-vitrofertilization; organ donation; euthanasia; and capital punishment. In order to gain a better understanding of values that collide with their own, nurses are prompted to intentionally debate the opposite side of each argument.

A new ethical model that stems from an ethic of care is introduced that is called, The Mosaic Model for Ethical Decisions. The goal of this ethical tool is to ensure that during the process of moral reasoning nothing essential gets left out, especially what is crucially important to the individual who is at the centre. Even though this model utilizes caring notions as a guide, it also takes into account the law; sound moral principles; the CNA Code of Ethics values and responsibilities; and any additional knowledge as deemed appropriate. Due to the fact that issues in practice often differ, not every segment of the model is needed in all settings. Therefore, strategies for decisionmaking are carefully designed as five key components with subcategories that are presented in an algorithm form. Each segment is supported by rational. The aim of Part I is to identify what matters to the client and others who have a stake in the case. Part II focuses on determining the key ethical and/or legal issues. Part III draws from other sources of knowledge for support. Part IV considers any possible course of action that may be taken, as well as the associated risks that may arise. Part V deals with additional considerations, like problems for the client’s family and healthcare professionals, in addition to relevant societal issues of concern. Exciting features of this model is that it is user friendly and applicable in diverse situations. Nurses are encouraged to carry the condensed version with them in the clinical setting.

Professional behaviours and values that are associated with ethical nursing practice are carefully articulated in this chapter. Society grants a profession a monopoly over their area of expertise because the implicit assumption is that these people can meet the needs of the public better than any other group. In order for any set of individuals to refer to themselves as a profession four standards must be present: they must possess a specialized body of knowledge; they have to be accountable; they are required to be selfgoverning; and they are obligated to abide by a code of ethics. Because the profession of nursing requires more of their members than just the basic criteria, specific responsibilities are clearly presented. Crucial components of the profession of nursing include, but are not limited to: accountability; competent applicant of knowledge; provision of services; setting professional boundaries; and the role of nursing leadership. Nurses are encouraged to look for creative ways to impart their knowledge to others in the form of: attending conferences and educational forums; being published in nursing journals; as well as becoming involved in research clubs and communities of practice. Although skills, knowledge and accountability are important aspects of the profession of nursing, other components are equally as valid. The discussion, therefore, concludes with specific suggestions for how a nursing career can be lived as a call to care. The case study that is presented at the closing of the chapter is derived from an actual Coroner’s case and reveals how the intention to cover-up a mistake is discovered.

Nursing accountability involves being responsible and answerable to someone outside of ourselves for what we do. Nurses are not only accountable to their clients, they are also answerable to their client’s families, their communities, and society at large. This discussion demonstrates how accountability aligns nicely with the ethic of care because they each embrace caring action; responsibility for others; universal connectedness; and the protection of vulnerable people. The assertion is made that nursing accountability is grounded in the following four moral principles: fidelity, respect for dignity, respect for worth and respect for self-determination of clients. The specific way that each of these constructs are played out in the clinical setting is clearly articulated. A crucial order of priorities in nursing accountability is proposed and the argument is made that a client’s welfare supersedes all other responsibilities. Nurses are also responsible to the profession of nursing. The expectation is that nurses strive to maintain competency to practice, and that their practice will be guided by the Canadian Nurses Association (CNA) Code of Ethics and practice standards as dictated by their specific regulatory body. If an institution’s policies violates nursing values and ethical responsibilities as laid out in the CNA Code of Ethics, the delivery of safe, competent, compassionate and ethical care comes first. Explicit strategies are suggested for nurses to follow when they encounter an ethical conflict with institutional policy. The case study at the end of the chapter reveals how a nurse becomes morally distressed when she is asked to withhold crucial information from her clients that will potentially result in serious harm.

Nursing advocacy entails taking action on behalf of others. The current discussion promotes advocacy as the driving force of nursing. The ethic of care relates well to the role of advocacy because it is concerned with taking responsibility for what happens to us and to other people. Advocacy can occur in the form of acting as a voice for an individual or by taking action in support of a larger issue. Both are closely aligned with nursing leadership. The expectation is that nurses act individually and collectively to eliminate social inequities. Whistle-blowing is a more drastic form of advocacy and should only be used as a last resort. A narrative is presented that carefully demonstrates how in one actual incident, whistle blowing became the only option left to ensure client safety. The discussion also quite poignantly points out that, nurses are not likely to advocate for a person or group of people that they have a bias toward. A review of the literature reveals the stark truth that nurses, as a general group, harbour stereotypical biases toward the mentally ill. Affirmative action is recommended to help to end discrimination. The greatest threat to the nurse who dares to do what they feel is right, is that of being morally silenced. Nurses are inspired to be as courageous as possible but to ensure that they are well supported before acting. The chapter ends with a compelling story of how a newly graduated psychiatric nurse advocates for her client who cannot speak English and who has been misdiagnosed.

The current discussion demonstrates how technological utility sometimes interferes with the moral sense of care and what to do about it. Caring as technology is viewed as the meaning of caring in relationship to technology. The virtual community, machines that support life, computers and robotics are included in this definition. It is pointed out that in modern health practices the nurturing aspects of caring for the ill or aged is increasingly viewed by some institutional bodies as less important than other more mechanistic aspects of service. Modern advances of science have also somewhat blurred the boundaries of when life begins and when it ends. When it comes to caring for premature babies, what was portrayed as most disturbing for nurses is the overuse of technology to try and save a life that cannot be saved. Another example of carrying out treatment that is destined to fail occurs when we use invasive procedures to save a life when death is imminent, like performing cardio-pulmonary resuscitation (CPR) on someone suffering from the end stages of a terminal diagnosis. No matter how many technological advances are developed, the challenge to the profession of nursing is not to lose its caring capacity. At the end of the chapter mindful listening is taught as a means for nurses to refocus mental energy back onto their clients. A narrative based on a real life case is shared by a distraught family member who felt left in the dark about the imminent death of her loved one.

The primary goal of this chapter is to assist nurses to engage in a morally inclusive practice. A morally inclusive practice celebrates what people have in common as well as their differences and involves the action of whole heartedly embracing diversity. Diversity reflects variations in belief systems and ways of living and includes many things such as: ethnicity, culture, gender, sexual orientation, age, religious and spiritual beliefs, socioeconomic position and health status. Culture is more that ethnicity and permeates everything that we do. Bullying is a negative but harsh reality of the culture of nursing. Witnesses of bullying are asked to intervene and not to participate in gossip. Returning kindness when confronted by aggression and standing up for oneself are presented as positive ways to combat vertical violence in the profession. Cultural competence is promoted as a way to help nurses when they are confronted with cultural issues. Rigid world views and ethnocentrism, or the view that one’s belief system or culture’s way of doing things is the right and natural way, are identified as barriers to implementing cultural competence into practice. Canadian residential schools are presented as a historical result of ethnocentrism that negatively impacted hundreds of Aboriginals. Cultural relativism is put forward as the polar opposite to ethnocentrism and is akin to building bridges rather than barriers. It is the attitude that other ways of doing things are different but equally valid. The practice of the ethic of care aligns closely with cultural relativism.

The primary goal of this chapter is to assist nurses to engage in a morally inclusive practice. A morally inclusive practice celebrates what people have in common as well as their differences and involves the action of whole heartedly embracing diversity. Diversity reflects variations in belief systems and ways of living and includes many things such as: ethnicity, culture, gender, sexual orientation, age, religious and spiritual beliefs, socioeconomic position and health status. Culture is more that ethnicity and permeates everything that we do. Bullying is a negative but harsh reality of the culture of nursing. Witnesses of bullying are asked to intervene and not to participate in gossip. Returning kindness when confronted by aggression and standing up for oneself are presented as positive ways to combat vertical violence in the profession. Cultural competence is promoted as a way to help nurses when they are confronted with cultural issues. Rigid world views and ethnocentrism, or the view that one’s belief system or culture’s way of doing things is the right and natural way, are identified as barriers to implementing cultural competence into practice. Canadian residential schools are presented as a historical result of ethnocentrism that negatively impacted hundreds of Aboriginals. Cultural relativism is put forward as the polar opposite to ethnocentrism and is akin to building bridges rather than barriers. It is the attitude that other ways of doing things are different but equally valid. The practice of the ethic of care aligns closely with cultural relativism.

The aim of this chapter is to encourage nurses to work with their clients’ religious and spiritual values and not to discriminate when they differ from their own. The desire to believe in God or something beyond the physical is deemed to be universal. Theology, religion and spirituality are integral parts of the search for something more, yet even though they have much in common they are not one and the same. What most religious and spiritual beliefs share is the notion that there is more to life than physical existence. The profession of nursing has a long and enduring history of a close association with spirituality and nursing has often been referred to as a mission or calling. It is argued that religious practices are still valid for present day nursing. The Canadian Nurses Association (CNA) supports this stand and recognizes parish nursing as valid. Religion and spirituality align well with the ethic of care and the emphasis on the relationships between people and all that exists. What is a nurse expected to do when their client does not believe in anything or is an atheist? The rule of thumb is that you must work with your client’s belief system. This directive applies because nurses are mandated by the CNA not to discriminate for any reason. It is also relevant because it is the caring, compassionate approach to what really matters to the client.

In this current discussion nurses are persuaded to take the lead toward preserving public health care for all people. This action is mandated by Part II of the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses. Canadians often site increased wait times for surgeries; not being able to have a family doctor; or long hours spent in the Emergency Room; as criticisms of our publicly funded health care. Many of these assessments are justified. However, even though our present system bears room for enhancement that does not mean that it is no longer working or that it should be abolished altogether. We need to be cognizant of the fact that everyone in this country can access basic health care without paying for it from their own pocket. In comparison to Canadians, millions of Americans don’t have any medical coverage, especially the poor, and so many more lose their coverage just because they get sick or go without medical care because of a preexisting medical ailment. But how do nurses begin to advocate for better access to health care services? They need to become involved. The following suggestions are recommended by the CNA: a greater emphasis on health prevention, health promotion and chronic disease prevention; earlier intervention in the treatment of chronic diseases; improving the social economic determinants of health; redirecting people who normally access Emergency Room (ER) services for non-urgent care, to out-patient clinics; and addressing the issue of bed blockers by better bed allocation planning.

Nurses as a group have the knowledge and possess the compassion that is needed to improve the lives of the underprivileged. As mandated by the (CNA) Code of Ethics Part II, thirteen specific ways to eliminate social inequities are presented as a means of addressing and/or eliminating social inequities. Poverty is a worldwide problem that has been growing instead of subsiding and has a negative impact on people’s health. Because socioeconomic determinants of health are closely tied to health outcomes, the poor use additional and more expensive health services. In order to positively impact populations that are suffering, one effective way to get the attention of policy makers is to build a business case that demonstrates cost saving measures. Homelessness is on the increase in Canada. The perception is that it is too expensive to provide housing and treatment for people who suffer from addictions and/or mental illness is not necessarily supported by fact. A review of a recent study commissioned by government provides evidence that a substantial amount of money could be saved if housing and treatment was made available for these people. Ideas are suggested that may help nurses to instigate other positive changes in the lives of others, not just for some people but for everyone.

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