Caring as a slave morality: Nietzschean themes in nursing ethics

Self-Deception in Clinical Nursing Practice: A Concept Analysis

In this paper, we explore the phenomenon of "self-deception" within the context of nursing, focusing on how nurses employ this coping mechanism when faced with dissonance, distress, and conflicting situations in clinical settings. Our primary objective is to examine the phenomenon of self-deception using Rodgers' evolutionary method of concept analysis. Focusing on nurses' experiences in challenging situations, our analysis highlights how self-deception is often employed as a coping strategy. According to our conceptual analysis, self-deception in nursing clinical practice highlights tensions between different paradigms and expectations in healthcare settings. These tensions stem from the power dynamics and subservience that nurses often face, which can hinder their ability to advocate for themselves, their patients, and the nursing profession.

Caring as the unacknowledged matrix of evidence-based nursing

In this article, we explicate evidence-based nursing (EBN), critically appraise its framework and respond to nurses' concern that EBN sidelines the caring elements of nursing practice. We use resources from care ethics, especially Vrinda Dalmiya's work that considers care as crucial for both epistemology and ethics, to show how EBN is compatible with, and indeed can be enhanced by, the caring aspects of nursing practice. We demonstrate that caring can act as a bridge between 'external' evidence and the other pillars of the EBN framework: clinical expertise; patient preferences and values. Drawing on an influential EBN handbook, section 1 presents the aims and features of EBN, including the normative principle that EBN should take place within a 'context of caring'. We aim to understand this context and whether it can be neatly detached from the EBN framework, as the handbook seems to suggest. In section 2, we highlight the grounds for resistance to EBN from the nursing community, before mounting the argument that nursing practices can be understood fruitfully through feminist care ethics and/or virtue ethics lenses. In section 3, we deepen that analysis using Dalmiya's concepts of care-knowing and care as a hybrid ethico-epistemic virtue, which are ideally suited to the complex practices of nursing. In section 4, we bring this rich understanding of care into conversation with EBN, showing that its framework cannot be adequately theorised without paying proper attention to care. Caring can be neither an innocuous background assumption of nor an afterthought to the EBN framework.

Patient perspectives on the role of nurses in HIV pre-exposure prophylaxis care (PrEP-RN)

INTRODUCTION

In response to ongoing new HIV diagnoses among gay, bisexual, and other men who have sex with men (gbMSM) and limited access points for HIV pre-exposure prophylaxis (PrEP) care, we established Canada's first nurse-led HIV prevention service in Ottawa, Canada-PrEP-RN. As part of this service, registered nurses became the primary provider in PrEP delivery and monitoring.

OBJECTIVES

To (1) gather patients' sentiments and experiences related to nurse-led PrEP and (2) identify the implications for nurses working in sexual healthcare.

METHODOLOGY

Qualitative interviews were conducted with 14 gbMSM participants who had received, or were presently enrolled in, HIV prevention care from nurses in the PrEP-RN clinic. Interview transcripts were reviewed and analyzed using thematic analysis.

RESULTS

Our analysis revealed two major themes of: The Sexual Health Nurse as the Expert and Patients Reliance on Nurses. The first theme discussed patients' positive attitudes toward nurses, in terms of the knowledge nurses possessed and the kind and efficient services they. The accommodating nature of nurses, however, led patients to become dependent on their care, which was the focus of the second theme. This reliance on nurses created challenges when patients transitioned from PrEP-RN to alternate providers for ongoing care.

CONCLUSION

These findings were examined to understand the effect of patients' perceptions of nurses on nursing practice. Despite patients' confidence in nurses' ability to provide PrEP care, the expectations they placed onto nurses to address the totality of their needs created competing demands for nurses to be both a leader in HIV prevention care-and fulfill the image of the caring, healthcare 'hero', which created feelings of moral distress among nurses. As increasing initiatives focus on task-shifting of healthcare roles to nurses, understanding the patients' perspective is essential in maintaining effective nurse-patient relationships.

I Am Not Just a Nurse: The Need for a Boundaried Ethic of Care in the Context of Prolific Relationality

The Ethics of Care (EoC) theory has been widely applied in the field of management, and there is a growing consensus that it is important to recognise the value and practice of care in the workplace. In this paper, we consider the implications of the EoC at work, and in particular the risks unboundaried care demands may pose to employees who encounter unmanageable 'calls to care'. We present findings from interviews with 27 nurses in Malaysia, which suggest that the demand to care at work, in addition to demands made in the non-work sphere, may be unmanageable. We argue for a more boundaried approach to the EoC at work with a view to ensuring that in valuing care we do not over-burden the carer.

Towards democratic institutions: Tronto's care ethics inspiring nursing actions in intensive care

Care as a concept has long been central to the nursing discipline, and care ethics have consequently found their place in nursing ethics discussions. This paper briefly revisits how care and care ethics have been theorized and applied in the discipline of nursing, with an emphasis on Tronto's political view of care. Adding to the works of other nurse scholars, we consider that Tronto's care ethics is useful to understand caring practices in a sociopolitical context. We also contend that this vision can be used specifically to politicize nurses, by encouraging them to think critically about the context in which they work and how they can participate to change the status quo, notably by prompting the democratization of care in institutional settings. We illustrate this by demonstrating how moral distress that can occur with aggressive or futile treatments in the intensive care unit can be reduced if nurses are systematically included in the decision-making process. By showing some ways in which nursing political actions can begin to change the status quo as it pertains to futile treatments at the end of life, we can help empower nurses to strive to be included in political spaces and voice their concerns to have their professional needs met.

A Foucauldian discourse analysis of media reporting on the nurse-as-hero during COVID-19

This study uses a Foucauldian discourse analysis to explore media reporting on the role of nurses as being consistently positioned ‘heroes’ during COVID‐19. In so doing, it highlights multiple intersecting discourses at play, with the caring discourse acting as a central one in negatively impacting nurses' ability to advocate for safe working conditions during a public health emergency. Drawing on media reports during the outbreak of COVID‐19 in Ontario, Canada in the spring of 2020 and on historical information from SARS, this study seeks to establish caring as a discourse and examine if the caring discourse impedes nurses' ability to protect themselves from harm. The results of this analysis explicate how public media discourses that position nurses as caring, sacrificial and heroic may have impacted their ability to maintain their personal safety as a result of the expectations put upon the nursing profession.

Come and say what you think: reducing employees' self-censorship through procedural and interpersonal justice

BACKGROUND

Self-censorship in an organization may be defined as a conscious decision by employees to refrain from expressing opinions, criticism or suggestions in situations of perceived irregularities. There are at least two reasons for this decision: firstly, the fear that speaking up would prompt negative consequences, and secondly, the belief that it would not bring about a change in the situation. Procedural justice in an organization may encourage employees to limit that silence, thereby diminishing fear and undermining the belief that change is impossible.

PARTICIPANTS AND PROCEDURE

A set of three studies (total number of participants N = 710) was conducted in order to determine whether procedural justice predicts self-censorship and also to define the role of interpersonal justice in this relationship. It was assumed that procedural justice, while useful in the formation of an impartial and rigid legal system within an organization, is constrained by its disregard for personal relations.

RESULTS

It was found that when employees perceive a work environment as providing influence over procedures, they declare less self-censorship motivated by fear and resignation. In high interpersonal justice conditions the role of procedural justice in predicting employee self-censorship as well as employee silence beliefs increases.

CONCLUSIONS

Both fair treatment of all employees and the contextual and need-centered nature of such treatment should be integrated if self-censorship is to be reduced. The results confirm this conclusion for self-censorship (decision) and employee silence beliefs (belief that relations within the organization do not encourage people to speak up).

Caring leadership as Nietzschean slave morality

In this paper, I respond to calls for more critical reflection on the power dynamics of caring leadership. I consider how a combination of care and impotence might unfold as Nietzsche’s ‘slave morality’, crystallised in the phenomenon of ressentiment. At the heart of slave morality is an inversion of values in which everything represented by the Other is denigrated so that the slave can find meaning and solace in his own place in the world. The Nietzschean inversion transforms impotence, inferiority and submission into virtue, identity and accomplishment. In contrast to recent elaborations of ressentiment in followers, I argue that slave morality is something to which leaders, especially caring leaders, are also vulnerable. When caring leadership awakens or exposes the slave-within, we are unable to take charge of – or responsibility for – ourselves, because we have ceded control of the self to forces beyond the self. This is the risk of ‘care ethics’ as a systemic inversion of values which constructs an ideology out of letting others define who and what we are. It creates a breeding ground for ressentiment, feeding off unspoken and unspeakable grievances about the injustices of one’s lot, especially those involving a clash between the rhetoric of empowerment and the experience of impotence. The Nietzschean warning is: Be wary of leadership models which might look and even feel nice, but which turn self-sacrifice into virtue and silence into necessity.

Moral Ecology in Nursing: A Pluralistic Approach

Moral dilemmas are present in all settings in which nurses work. Nurses are moral agents who must make moral decisions and take moral action in very complex social systems. Nurses are accountable for their actions, and it is therefore imperative that they have a solid foundation in ethics. There are multiple ethical frameworks nurses can utilize to justify their actions. A theory of moral ecology is presented here as a way to conceptualize the relationships between these frameworks. The first two steps of moral action, moral sensitivity and moral judgment, are explored in a pluralistic context. Specifically, multiple ethical frameworks that inform the practice of nursing are presented using an ecological model. Nurses work in a variety of practice environments, with different populations, across a spectrum of situations. An ecological model acknowledges that nurses are influenced by the complex social, and ethical, systems in which they find themselves taking moral action. When faced with ethical issues in practice, a nurse's moral sensitivity and moral judgment may be guided by ethical systems most proximal to the situation. Nurses bring individual moral beliefs to work and are influenced by the ethical directives of employers, the discipline's code of ethics, principles of bioethics, and various approaches to normative ethics (virtue, consequential, deontological, and care). Any of the frameworks presented may justifiably be applied in various nursing circumstances. I propose that the multiple ethical frameworks nurses utilize exist in a relationally nested manner and a model of moral ecology in nursing is provided.

Professional Stereotypes of Interprofessional Education Naive Pharmacy and Nursing Students

Objective. To assess and compare interprofessional education (IPE) naive pharmacy and nursing student stereotypes prior to completion of an IPE activity. Methods. Three hundred and twenty-three pharmacy students and 275 nursing students at Mercer University completed the Student Stereotypes Rating Questionnaire. Responses from pharmacy and nursing students were compared, and responses from different level learners within the same profession also were compared. Results. Three hundred and fifty-six (59.5%) students completed the survey. Pharmacy students viewed pharmacists more favorably than nursing students viewed pharmacists for all attributes except the ability to work independently. Additionally, nursing students viewed nurses less favorably than pharmacy students viewed nurses for academic ability and practical skills. There was some variability in stereotypes between professional years. Conclusion. This study confirms the existence of professional stereotypes, although overall student perceptions of their own profession and the other were generally positive.

A role for virtue in unifying the 'knowledge' and 'caring' discourses in nursing theory

A critical examination of contemporary nursing theory suggests that two distinct discourses coexist within this field. On the one hand, proponents of the 'knowledge discourse' argue that nurses should drop the 'virtue script' and focus on the scientific and technical aspects of their work. On the other hand, proponents of the 'caring discourse' promote a view of nursing that embodies humanistic qualities such as compassion, empathy and mutuality. In view of this, we suggest a way to reconcile both discourses despite the fact that they appear to be at odds theoretically and practically. To that end, we argue that nursing theory must give a prominent role to the Aristotelian conception of virtue, and we offer an account that includes both character and intellectual virtues. This account allows for a focus on moral competence but also accommodates the demands for discipline-specific knowledge. Our account incorporates the caring discourse by suggesting a way for individuals to cultivate the conditions within themselves that make 'caring in nursing' possible, while the knowledge discourse is accommodated via the acquisition of the intellectual virtues. The process for achieving both these ends is the same: an intention to consistently develop, hone and exercise certain character traits over time.

Simulated human patients and patient-centredness: The uncanny hybridity of nursing education, technology, and learning to care

Positioned within a hybrid of the human and technology, professional nursing practice has always occupied a space that is more than human. In nursing education, technology is central in providing tools with which practice knowledge is mobilized so that students can safely engage with simulated human patients without causing harm to real people. However, while there is an increased emphasis on deploying these simulated humans as emissaries from person-centred care to demonstrate what it is like to care for real humans, the nature of what is really going on in simulation-what is real and what is simulated-is very rarely discussed and poorly understood. This paper explores how elements of postcolonial critical thought can aid in understanding the challenges of educating nurses to provide person-centred care within a healthcare culture that is increasingly reliant on technology. Because nursing education is itself a hybrid of real and simulated practice, it provides an appropriate case study to explore the philosophical question of technology in healthcare discourse, particularly as it relates to the relationship between the human patient and its uncanny simulated double. Drawing on postcolonial elements such as the uncanny, diaspora, hybridity, and créolité, the hybrid conditions of nursing education are examined in order to open up new possibilities of thinking about how learning to care is entangled with this technological space to assist in shaping professional knowledge of person-centred care. Considering these issues through a postcolonial lens opens up questions about the nature of the difficulty in using simulated human technologies in clinical education, particularly with the paradoxical aim of providing person-centred care within a climate that increasingly characterized as posthuman.

Professional identity in nursing: UK students' explanations for poor standards of care

Research concludes that professional socialisation in nursing is deeply problematic because new recruits start out identifying with the profession's ideals but lose this idealism as they enter and continue to work in the profession. This study set out to examine the topic focussing on the development of professional identity. Six focus groups were held with a total of 49 2nd and 3rd year BSc nursing students studying at a university in London, UK and their transcripts were subject to discourse analysis. Participants' talk was strongly dualistic and inflected with anxiety. Participants identified with caring as an innate characteristic. They described some qualified nurses as either not possessing this characteristic or as having lost it. They explained strategies for not becoming corrupted in professional practice. Their talk enacted distancing from 'bad' qualified nurses and solidarity with other students. Their talk also featured cynicism. Neophyte nurses' talk of idealism and cynicism can be understood as identity work in the context of anxiety inherent in the work of nurses and in a relatively powerless position in the professional healthcare hierarchy.

The Humanbecoming theory as a reinterpretation of the symbolic interactionism: a critique of its specific nature and scientific underpinnings

Discussions about real knowledge contained in grand theories and models seem to remain an active quest in the academic sphere. The most fervent of these defendants is Rosemarie Parse with her Humanbecoming School of Thought (1981, 1998). This article first highlights the similarities between Parse's theory and Blumer's symbolic interactionism (1969). This comparison will act as a counterargument to Parse's assertions that her theory is original 'nursing' material. Standing on the contemporary philosophy of science, the very possibility for discovering specific nursing knowledge will be questioned. Second, Parse's scientific assumptions will be thoroughly addressed and contrasted with Blumer's more moderate view of knowledge. It will lead to recognize that the valorization of the social nature of existence and reality does not necessarily induce requirements and methods such as those proposed by Parse. According to Blumer's point of view, her perspective may not even be desirable. Recommendations will be raised about the necessity for a distanced relationship to knowledge, being the key to the pursuit of its improvement, not its circular contemplation.

The relationship between emotional intelligence, previous caring experience and mindfulness in student nurses and midwives: a cross sectional analysis

BACKGROUND

Emotional Intelligence (EI), previous caring experience and mindfulness training may have a positive impact on nurse education. More evidence is needed to support the use of these variables in nurse recruitment and retention.

OBJECTIVE

To explore the relationship between EI, gender, age, programme of study, previous caring experience and mindfulness training.

DESIGN

Cross sectional element of longitudinal study.

SETTING AND PARTICIPANTS

938year one nursing, midwifery and computing students at two Scottish Higher Education Institutes (HEIs) who entered their programme in September 2013.

DATA

Participants completed a measure of 'trait' EI: Trait Emotional Intelligence Questionnaire Short Form (TEIQue-SF); and 'ability' EI: Schutte's et al. (1998) Emotional Intelligence Scale (SEIS). Demographics, previous caring experience and previous training in mindfulness were recorded.

METHODS

Relationships between variables were tested using non-parametric tests.

RESULTS

Emotional intelligence increased with age on both measures of EI [TEIQ-SF H(5)=15.157 p=0.001; SEIS H(5)=11.388, p=0.044]. Females (n=786) scored higher than males (n=149) on both measures [TEIQ-SF, U=44,931, z=-4.509, p<.001; SEIS, U=44,744, z=-5.563, p<.001]. Nursing students scored higher that computing students [TEIQ-SF H(5)=46,496, p<.001; SEIS H(5)=33.309, p<0.001. There were no statistically significant differences in TEIQ-SF scores between those who had previous mindfulness training (n=50) and those who had not (n=857) [U=22,980, z=0.864, p = 0.388]. However, median SEIS was statistically significantly different according to mindfulness training [U=25,115.5, z=2.05, p=.039]. Neither measure demonstrated statistically significantly differences between those with (n=492) and without (n=479) previous caring experience, [TEIQ-SF, U=112, 102, z=0.938, p=.348; SEIS, U=115,194.5, z=1.863, p=0.063].

CONCLUSIONS

Previous caring experience was not associated with higher emotional intelligence. Mindfulness training was associated with higher 'ability' emotional intelligence. Implications for recruitment, retention and further research are explored.

Why patients have a moral obligation to give care to clinicians

Progress is being made in transitioning from clinicians who are torn between caring for patients and populations, to clinicians who are partnering with patients to care for patients as people. However, the focus is still on what patients and others can do for patients, however defined. For clinicians whose interests must be similarly respected for their own sake and because they are integrally related to those of patients, what can and should patients do? Patients can be exempted from some normal social roles but are generally recognized to have moral obligations in health care. One of these obligations is caregiving to clinicians within the limits of each patient's capability. My paper moves this obligation beyond the ceremonial order of etiquette characterizing public statements on how patients should relate to others. It goes beyond a patient-centred ethic that is consumerist in nature, to a person-centred one that recognizes patients typically as moral agents who are dignified by recognizing the obligation to give as well as receive care as sincere benevolence. This obligation derives objective justification from divine command. It is also consistent, however, both with what people, if ignorant of their social role, would objectively produce for a hypothetical social contract, and with virtues constitutive of human nature and a relational and communitarian understanding of what it is to be a person. Including sentiment (intuition) and personal conscience, this relational identity makes caregiving intrinsically meaningful, yet caregiving also has an instrumental value to patients and clinicians. Its self-enforcement by patients will depend on their moral code and on society making caregiving achievable for them. A moral obligation for patient caregiving may then be specified to require patients to reflect on and invest in relationships in which they can feel and show care for others sincerely and respectfully.

Slavery and jouissance: analysing complaints of suffering in UK and Australian nurses' talk about their work

Nursing has a gendered and religious history where ideas of duty and servitude are present and shape its professional identity. The profession also promotes idealized notions of relationships with patients and of professional autonomy both of which are, in practice, highly constrained or even impossible. This paper draws on psychoanalytic concepts in order to reconsider nursing's professional identity. It does this by presenting an analysis of data from two focus group studies involving nurses in England and Australia held between 2010 and 2012. The studies gave rise to data where extremely negative talk about nursing work seemed to produce, or to be expressed with, a high degree of energy, and a particular kind of enjoyment. In our analysis, we focus on the nurses' apparent enjoyment derived from their expression of a position of powerlessness in which they describe themselves as 'slaves' or 'martyrs' in the health care system. We interpret this as jouissance and suggest that the positions of slave or martyr provide a possible response to what we argue is the impossibility of the nurse's role. We argue that a remnant of a quasi-religious ethic within the profession makes it acceptable for nurses to talk about self-sacrifice and powerlessness as part of their working subjectivity. We further argue that this analysis offers a new consideration of the issue of power and professional identity in nursing that goes beyond seeing nurses as simply overpowered by, or engaged in, a gendered power struggle with other professional groups. We suggest that powerlessness and victimhood hold particular attractions and advantages for nurses and are positions that are more available to nurses than to other occupational groups. This research shows how psychoanalytic theory can help produce new insights into the problems and complexity of nursing and extend existing study of the professions.

Determinants of Nurses' Caring Behaviors (DNCB): Preliminary Validation of a Scale

INTRODUCTION

Nurses' Caring behaviors might be affected by many variables. The aim of this study was to develop and test a valid and reliable questionnaire to specify these determinants.

METHODS

Both qualitative and quantitative methods were applied to develop the questionnaire. The development process of the instrument was conducted in three phases. The first phase consisted of four steps: in-depth interviews, development of the preliminary version of the 38-item DNCB, expert panel review, and language revision. The second phase involved examining 143 qualified nurses for psychometric properties of the DNCB. The participants were selected, based on quota sampling approach, from four educational hospitals affiliated to Urmia University of Medical Sciences, Iran. The final phase involved testing of the revised instrument using exploratory factor analysis.

RESULTS

The results showed good CVI (0.89), test-retest correlation coefficient (0.91), internal consistency reliability (0.93), and acceptable face and construct validity. RESULTS of the factor analysis revealed a 6-factor solution, determined by Eigen values greater than 1, accounted for 77.736 of the total variance.

CONCLUSION

This instrument is a simple scale with a good reliability and validity that can provide comprehensive information about the determinants of caring behaviors in a short time.

Caring for attitudes as a means of caring for patients--improving medical, pharmacy and nursing students' attitudes to each other's professions by engaging them in interprofessional learning

INTRODUCTION

Negative attitudes between pharmacists, doctors and nurses can impact adversely on patients' medicines management. A seven-week interprofessional learning (IPL) intervention was delivered to foster positive attitudes.

METHODS

First-year pharmacy, nursing and medical students' attitudes were assessed using the Attitudes to Health Professionals Questionnaire before and after IPL intervention.

RESULTS

Students viewed pharmacists, doctors and nurses as more 'caring' after IPL. Nurses were viewed as most 'caring'. Nursing and pharmacy students perceived doctors as least 'caring' before and after IPL whereas medical students viewed pharmacists as least 'caring'. Students perceived their own profession as more 'caring' than others did. The three-way analysis of variance showed a significant difference between student groups (p<0.0001), professions (p<0.0001) and before-and-after IPL (p<0.005).

CONCLUSION

Findings suggest that students' attitudes are more positive after they have worked together during seven weeks of IPL. Each student group view their own profession more positively than others. Views become more aligned after this IPL intervention. Time may be an important factor in allowing for attitudes to change. IPL can help foster positive attitudes between doctors, pharmacists and nurses, which may facilitate effective collaboration and thus enhance patients' medicines management.

The desired moral attitude of the physician: (III) care

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired moral attitude of physicians. In a series of three articles, three of the discussed concepts are 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 the second article, the emotional and virtuous core of the desired professional attitude-compassion-has been presented. Compassion as a professional attitude has been distinguished from a spontaneous feeling of compassion, and has been related to a general idea of man as vulnerable and solidary being. Thus, the dignity of the patient is safeguarded in spite of the asymmetry of compassion. In this article, the third concept of the triad-"care"-is presented. Care is conceived as an attitude as well as an activity which can be directed to different objects: if it is directed to another sentient being, it is regarded as intrinsically morally valuable; implying (1) the acceptance of being addressed, (2) a benevolent inclination to help and to foster, and (3) activity to realize this. There are different forms of benevolence that can underlie caring. With regard to the professional physician's ethos, the attitude of empathic compassion as developed in the two previous articles is proposed to be the adequate underlying attitude of care which demands the right balance between closeness and professionalism and the right form of attention to the person of the patient. 'Empathic compassionate care' does not, however, describe the whole of the desired attitude of a physician, but focuses on the morally-emotive aspects. In order to get also the cognitive and practical aspects of biomedicine into the picture, 'empathic compassionate care' has to be combined with an attitude of responsibility that is more directed to decision-making and outcome than a caring attitude alone can be. The reconstruction of the desired professional attitude in terms of "empathic compassionate care" and "responsibility" 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.

Making the improbable probable: communication across models of medical practice

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas's theory of communicative action in order to suggest the kind of pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated.

Robot decisions: on the importance of virtuous judgment in clinical decision making

RATIONALE, AIMS AND OBJECTIVES

The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason an ideal physician, incarnating the required virtues, skills and knowledge is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule- and principle-based moral orientation and biomedical knowledge and skills.

METHODS

Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov.

RESULTS

Although prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways how the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, although less strictly, will more reliably keep at moral objectives, be understandable, be more flexible in case the rules come to their limits, and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to her own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible.

CONCLUSION

Although an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions like clinical practice the agency of a moral human person is more trustworthy. Furthermore, the understanding of the patient's emotions must remain insufficient for a non-emotional, non-human being. Because these are crucial preconditions for good clinical practice, enough attention should be given to develop these virtues and emotional skills, in addition to the usual attention on knowledge, technical skills and the obedience to moral rules and principles.

Humanistic Nursing Theory: application to hospice and palliative care

AIM

This article presents a discussion of the relevance of Humanistic Nursing Theory to hospice and palliative care nursing.

BACKGROUND

The World Health Organization has characterized the need for expert, palliative and end-of-life care as a top priority for global health care. The specialty of hospice and palliative care nursing embraces a humanistic caring and holistic approach to patient care. As this resonates with Paterson and Zderad's Humanistic Nursing Theory, an understanding of hospice nurses' experiences can be investigated by application of relevant constructs in the theory.

DATA SOURCES

This article is based on Paterson and Zderad's publications and other theoretical and research articles and books focused on Humanistic Nursing Theory (1976-2009), and data from a phenomenological study of the lived experience of Taiwanese hospice nurses conducted in 2007.

DISCUSSION

Theoretical concepts relevant to hospice and palliative nursing included moreness-choice, call-and-response, intersubjective transaction, uniqueness-otherness, being and doing and community.

IMPLICATIONS FOR NURSING

The philosophical perspectives of Humanistic Nursing Theory are relevant to the practice of hospice and palliative care nursing. By 'being with and doing with', hospice and palliative nurses can work with patients to achieve their final goals in the last phase of life.

CONCLUSION

Use of core concepts from Humanistic Nursing Theory can provide a unifying language for planning care and describing interventions. Future research efforts in hospice and palliative nursing should define and evaluate these concepts for efficacy in practice settings.

Nurses' and patients' perceptions of caring behaviours: quantitative systematic review of comparative studies

AIM

This paper is a report of a systematic review conducted to test the hypothesis that nurses and patients perceive the concept of caring in nursing differently.

BACKGROUND

Caring is viewed as the central focus of nursing. However, despite its fundamental place in clinical practice, researchers and scholars have failed in reaching a common definition. This failure has led to eliciting for nebulous interpretations of the concept often leading to perplexity and opposing views between patients and nurses.

DATA SOURCES

Extensive search was conducted using MEDLINE, CINAHL and EMBASE between March and May 2009 with no publishing time limit and the keywords 'care', 'caring', 'nurse', 'nursing', 'behavio(u)rs', 'patient', 'perception', 'quantitative' and 'comparative'.

REVIEW METHODS

This quantitative systematic review of comparative studies followed the guidance of the Centre for Reviews and Dissemination. A seven-item 'yes' or 'no' checklist was developed and used for appraising the quality status of the selected literature. Narrative summary technique was used to report outcomes.

RESULTS

Evidence of incongruence of perceptions between patients and nurses is mainly supported by the literature. Few studies, however, report aspects of congruence.

CONCLUSION

There is considerable evidence of the assertion that there is no congruence of perceptions between patients and nurses as regards to which behaviours are considered caring and intended caring is not always perceived as such by the patient. Further research is needed, however, to generate more knowledge on the relationship between caring behaviours, patient outcomes and health or nursing costs.

Inverting compliance, increasing concerns: aging, mental health, and caring for a trustful patient

Why, after 40 years of intensive research, is adherence to treatment still an issue? This paper suggests a possible solution to an apparently unsolvable problem: reconceptualizing adherence. To understand how adherence can affect key personnel in any western health system, this study focuses on community nurses working with older mental health patients in Quebec. When they spoke about adherence, nurses presented an idealized image of the nurse-patient relationship, namely, the caring nurse and the trustful patient. However, this idealization cannot be reduced only to questions of power and paternalism. By reconceptualizing adherence as a 'matter of concern', health professionals and researchers alike might come to understand individual care situations within a broader notion of conflicts in patient care.

Nietzsche's Genealogy of Morality and the changing boundaries of medicine, psychiatry and psychiatric and mental health nursing practice: a slave revolt?

The main constructions in Nietzsche's On the Genealogy of Morality (1994) are employed in order to explore the changes in mental health care that have been recently taking place. Characterized by boundaries that define the objectivity of scientific method, the biological stratum or the area of concern (disease and the disembodied being) and the professional distance that is maintained in the healthcare encounter, the noble morality of contemporary allopathic (Western) mental health care practice appears to be being challenged, in an act of ressentiment, by the slave morality of society, inverting values and beliefs that have previously been held. Mental health care paternalism may be in the process of giving way to consumer sovereignty, patient participation in decision making and the re-discovery of the embodied being at the centre of the healthcare encounter. Nietzsche warns that the dominance of slave morality and the inversion of moral values (what was a quality that was held by the nobles and regarded as good) - that is, objectivity and mental health care paternalism - becomes bad; and what was a quality held by the slaves and regarded as bad - subjectivity - becomes good, may ultimately be detrimental to the advancement of society.

No essence no self: using a Buddhist perspective to characterize the nature of nursing

A fresh perspective is needed on the historical roots and contemporary politics of the essentials of nursing. In the 21st century, the profession needs to move past separatist thinking and the pursuit of identifying what can be called a professional self. Two ways that nurses have tried to characterize a professional self is through claiming caring as the essence of nursing and using the esoteric taxonomy system of nursing diagnoses. The Buddhist teaching of nonself (anatman) is proposed as an alternative way of viewing the nature of the profession.

'Caring? It's the little things we are not supposed to do anymore'

This study explored the views of twenty-five qualified nurses in five hospitals to determine what they perceived as dominant values in clinical nursing work. Aspects of a grounded theory approach were used and this study formed the final one of three. The first two studies had student nurse samples and this study aimed to confirm and validate the data from the students' perceptions. The student nurses had implied that nurses communicated and 'cared' for patient's much less than they expected. Findings from this study reaffirm the students' perceptions and suggest that nurses may not be as caring as they would like to be. One significant issue to emerge, in conjunction with the realization that nurses were not being as caring as they would have liked, was that it mattered to them that caring was the 'little things' not 'supposed to be done anymore'.

Service user involvement and the restrictive sense of psychiatric categories: the challenge facing mental health nurses

The active involvement of those people who have at one time used, or who continue to use, mental health services has come to be seen as a central feature of both the policy and the practice of modern mental health care. However, while those people who use mental health services may face a variety of obstacles to active participation in their care and in the provision of mental health services more generally, this paper will draw on the work of Gilles Deleuze, arguably one of the most important philosophers of the late 20th century, to suggest that the language of psychiatry--and, in particular, the attendant valuations or 'sense' of psychiatry's diagnostic categories--serve to restrict the participation of people in their individual care and in the provision of mental health services. Accordingly, it will be suggested that the challenge, as well as the opportunity, that confronts mental health nurses is to facilitate greater, more active user participation by practising in a manner that elicits the resources, capabilities and potential that service users possess, thereby challenging the prevailing and restrictive sense of the diagnostic categories by which people are identified, and by which they come to identify themselves.

Negotiating 'depression' in primary care: a qualitative study

Psychiatry has provided primary care physicians with tools for recognising and labelling mild, moderate or severe 'depression'. General practitioners (GPs) in the UK have been guided to manage depression within primary care and to prescribe anti-depressants as a first-line treatment. The present study aimed to examine how GPs would construct 'depression' when asked to talk about those anomalous patients for whom the medical frontline treatment did not appear to be effective. Twenty purposively selected GPs were asked in an interview to talk about their experience and management of patients with depression who did not respond to anti-depressants. GPs initially struggled to identify a group, but then began to construct a category of person with a pre-medicalised status characterised by various deviant features such as unpleasant characters and personalities, manipulative tendencies, people with entrenched social problems unable to fit in with other people and relate to people normally. GPs also responded in non-medical ways including feeling unsympathetic, breaking confidentiality and prescribing social interventions. In effect, in the absence of an effective medical treatment, depression appeared to become demedicalised. The implications of this process are discussed in relation to patients' subsequent access or lack of access to services and the way in which these findings highlight the processes by which medicine frames disease.

Humanism and its critiques in nursing research literature

AIM

This paper raises for debate the issue of how humanist ideas have been taken up by nurse scholars, particularly in research literature.

BACKGROUND

Many nurses from the mid-1970s onwards have described and promoted humanism as an appropriate philosophical basis for nursing practice and research. This has been partly in an attempt to sharply differentiate the profession from medicine, and later, managerialism, which have been represented as reductionist and failing to adequately respond to the whole patient.

METHODS

A summary of definitions of humanism and critiques of humanism in broad philosophical literature is followed by an examination and critique of literature appearing in PubMed published within nursing scholarship from 1976 to 2007 which discusses or promotes humanism in nursing practice or research.

FINDINGS

Writers have attempted to enhance the importance of nursing by associating it with the humanistic project of accepting responsibility for realizing our human potential. They have promoted a version of research which is qualitative and centres on understanding individual lifeworlds of research participants because of a strong valuing of the experiences and perspectives of the individual. Much of the literature on this topic describes this humanism in dualistic contrast to medico-scientific reductionism and objectivity.

CONCLUSION

Some of the presentations of humanistic nursing lack rigour and can be seen as doing little more than reproducing professional ideology. Scholars and others in the field of nursing could take the trouble to submit these ideologies to proper scrutiny.

Facilitating recovery by making sense of suffering: a Nietzschean perspective

One of the most challenging figures in the history of ideas, the 19th century German philosopher Friedrich Nietzsche, exerts a powerful and enduring influence over modern thought. Indeed, while those working in the healthcare professions may have traditionally found Nietzsche's work largely inaccessible, there is now an emerging body of healthcare research that seeks to elucidate and explore the relevance of his ideas for the healthcare professions generally, and for the theory and practice of nursing in particular. Accordingly, this paper will seek to contribute to this emerging body of research by suggesting that Nietzsche's work can be employed to provide a productive understanding of how recovery from mental illness can be facilitated, and it will attempt to do this by focusing on what is arguably Nietzsche's most seemingly obscure notion, namely, the 'eternal return'. In particular, by drawing upon contemporary research into the concept and experience of recovery, the paper will suggest that the discovery of new meaning is central to that process and that, this being so, Nietzsche's notion of the eternal return can provide a productive theoretical framework that can be employed by mental health professionals to orientate and guide therapeutic interventions towards that end.

Meta-synthesis of caring in nursing

AIM

The aim of this investigation was to enhance the understanding of the concept of caring.

BACKGROUND

Despite many analyses and studies of caring, the concept is not fully understood. This lack of clarity is unsettling given that caring is suggested to be the essence of nursing and a component of nursing's guiding paradigm. Meta-synthesis methods offer a way to push the understanding of caring forward using existing research findings.

DESIGN

Qualitative meta-synthesis.

METHOD

Meta-synthesis and grounded theory strategies were adapted to synthesize findings from 49 qualitative reports and six concept analyses of caring.

RESULTS

Results from this work indicate that caring is a context-specific interpersonal process that is characterized by expert nursing practice, interpersonal sensitivity and intimate relationships. It is preceded by a recipient's need for and openness to caring, and the nurse's professional maturity and moral foundations. In addition, a working environment that is conducive to caring is necessary. Consequences include enhanced mental well-being among nurses and patients, and improvements in patients' physical well-being.

RELEVANCE TO CLINICAL PRACTICE

It appears that caring has the potential to improve the well-being of patients and nurses. It is recommended that healthcare agencies and educational institutions devote more resources to cultivate the caring among employees and students.

CONCLUSIONS

The findings explicate a cohesive process of caring. They provide insight into the human attributes and clinical milieu that are necessary for caring to emerge. They also offer clarity regarding the therapeutic benefits of caring.