Philosophies, Models, and Theories

Moral Obligations

Pamela J. Grace

The end or purpose of nursing is the well-being of other people…it is a moral end. That is, it involves the seeking of a good, and it involves relationships with other human beings. The science learned and the technical skills developed are designed and shaped by this moral end.

(Curtin & Flaherty, 1982, p. 86)

This chapter explores the moral obligations that are inherent in nursing’s theoretical works. An underlying assumption of this chapter is that nursing is a moral undertaking. This assumption is defensible because of the nursing profession’s implicit and explicit promises to provide a vital service to society—services that propose to address, via the endeavors of its scholars and practitioners, certain needs associated with human functioning. A recent work has identified from several decades of nursing literature a consistent focus of, and for, nursing work. This central unifying focus is articulated as “facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (Willis, Grace, & Roy, 2008, p. E28). This focus is inherent in almost all (if not all) nursing’s theoretical works. Nursing furthers a good for individuals and for society. However, the idea that nursing is engaged in providing for a good makes nursing actions susceptible to moral criticism. We can say that actions are good or bad, praiseworthy or blameworthy, to the degree that they are aimed at advancing nursing’s purposes in regard to human functioning and flourishing or the relief of suffering. As a point of clarity the terms ethical and moral are used interchangeably in this chapter. Although in some settings a distinction is made between the terms good nursing actions, ethical nursing actions, and moral nursing actions, these terms are synonymous. They are representative of actions that are required of the nurse.

It follows then that there is a disciplinary responsibility for ongoing theorizing about the nature of nursing, the boundaries of practice, and the knowledge necessary for practice. This is because nursing does not take place in a static world.Knowledge about humans and their needs evolves in response to environmental and social changes, and these changes tend to be interrelated with scientific knowledge developments as well as sociopolitical movements. Thus a discipline such as nursing needs knowledge that continues to be effective in its provision of services and is continually and responsively evolving. The theoretical works of nursing must be able to account for and remain relevant to contemporary conditions of nursing practice. They provide a basis for understanding why nursing as a profession is necessary, what needs it serves, and what the essential nature of the profession entails. They also direct knowledge development and are influenced by knowledge developed in other fields. Since the publication of an article by Carper (1978) that was based on her dissertation work, it has become generally accepted that there are various types of knowledge used in nursing practice.

Nursing Ways of Knowing

Carper (1978) identified four patterns of knowledge used by nurses as a result of her review and synthesis. The four types of knowledge were empirical knowledge (the science), esthetic knowledge (the art), personal knowing (an ability to understand one’s relationship to another for whom one has assumed certain responsibilities, as in the nurse-patient relationship), and ethical knowing (understanding what constitutes good actions). These forms of knowing are interrelated and only distinguishable for the purposes of discussion. Take the following relatively simple example as an admittedly rough illustration. A patient suffers a gastrointestinal hemorrhage secondary to a duodenal ulcer. It is severe but not immediately life-threatening. Empirical knowledge gives us an understanding of the pathophysiology and what is necessary to restore homeostasis. In this case, a blood transfusion is needed. However, from previous theorizing we understand that human beings are complex individuals who differ in their needs and our job, in part, is to understand what those individual needs are. Personal knowledge is that knowledge of self that the nurse uses to form a therapeutic relationship with the patient and that permits the discovery of contextual details that are important to understanding “who” this particular person is (given the limits of any emergency situation). In this case, our patient has a fear of needles and is afraid of dying. Esthetic knowing involves creativity in tailoring interventions that are appropriate and effective for this patient’s needs. Ethical knowledge, in turn, is about conceptualizing what good actions are for this patient and determining how to achieve them, even when obstacles exist. The four types of knowledge are interrelated and all are essential for optimal nursing care.

Jacobs-Kramer and Chinn (1988) subsequently expanded on this model of nursing knowledge and White (2009, 1995) provided a critique of the work both of Carper and of Jacobs-Kramer and Chinn. She recognized the absence of sociopolitical knowing, which “represents a fifth pattern of knowing essential to an understanding of all the others” (p. 403) and consequently to appropriate (or optimally beneficial) actions. Sociopolitical knowing, labeled emancipatory by Chinn and Kramer (2008), permits us to see that the roots of many ethical problems are buried within the contexts in which nursing care is provided or in the environments of ourpatients. It facilitates a broader understanding of our professional responsibilities as continuing beyond resolution of the immediate situation. In accord with White’s critique this chapter takes ethical knowledge in nursing as a broad concept. Ethical knowing in nursing must inevitably encompass the evaluation and critique of environments of practice that obstruct good nursing care as this is conceptualized by nursing philosophers and theorizers. That is, ethical knowing at the theory development level inevitably requires an understanding of the discipline’s obligations to the broader society given the nurse theorist’s—albeit tentative—answers to the following question: What is nursing and what does it do?

Ethical Knowing: Broadening the Scope

Flaming (2004) has argued that, insofar as theories assert what nursing is (ontology), they might be said to represent ethical imperatives. For example, it is generally agreed that one role of nursing is to promote health (however, this is ultimately defined by the nursing philosopher/theorist). Given this claim, then, we ought to be able to promote health by identifying, developing or acquiring, and using the necessary knowledge and skills. Further, when nursing actions to facilitate health are obstructed by environmental conditions, there are ethical obligations to address such obstacles. Barriers to good actions are most effectively addressed when individual professionals are not working alone. Obstructions often require educated, concerted, and coordinated efforts to tear them down. Such efforts depend on both the ability to identify the source of barriers and an understanding that an obligation exists to develop strategies that address the barriers. Theorizing and knowledge development necessarily incorporate the recognition that there are professional responsibilities for optimal practice (Chinn & Kramer, 2010).

Of course, there may be many reasons why a particular theoretical work is inadequate to direct ethical (good) practice, including that it is in an early stage of development. The assumptions of the work may be at too high a level of abstraction and development of propositions or principles may be too immature for decision making in a variety of settings or for particular situations, or important aspects of the theory have not been tested for soundness. With this proviso in mind, it can nevertheless be asserted that theory used as a guide for practice beyond determining what is generally “good” practice should also be able to assist the individual nurse in deciding appropriate courses of action in a variety of diverse situations. In addition, it should give explicit or implicit directions for the nurse when obstacles to good practice arise (Kenney, 1999).

In this way a particular theoretical work assists the individual nurse with clinical reasoning, judgment, and ensuing action (clinical decision making) as well as with ethical reasoning, judgment, and ensuing action (ethical decision making). In this sense, clinical and moral reasoning in nursing are intimately related if not synonymous because the best clinical action or actions are those that are ethically warranted. However, further ethical reasoning may be needed to determine the best courses of action when the “good” clinical action is blocked by environmental conditions of varying sorts (e.g., institutional restrictions, health care delivery system problems, interpersonal conflicts).

The Moral Endeavor

As noted, an examination of nursing viewed as a moral endeavor is appropriately addressed via the explications of nursing’s theorists and scholars. This is so because theorizing in nursing is aimed at the following two main ends:

1. To describe and explain nursing

2. To provide a structure or framework that facilitates practice, research, and practitioner education

Within each of the theoretical works are moral implications and imperatives for the student, practitioner, researcher, or educator. Additionally, implications exist for the profession as a whole related to structuring environments in a way that enable theory-derived practice as described later.

The moral concerns of nursing as a practice profession are derived primarily from the works of these original thinkers, who realistically can be considered nursing’s philosophers. Whereas general philosophy engages in the search for knowledge or wisdom about humans and the world in which they find themselves, nursing philosophy has a more particular focus. Nursing philosophies attempt to answer the question “What is nursing?” as well as the following related significant question: “Why is nursing important to human beings?” It is the task of other parts of this book to look at practice directed by various philosophical and theoretical frameworks; the purpose of this book’s companion text—Alligood and Marriner Tomey (2010)—is to delineate more clearly the formulations of nursing’s theorists and the distinctions among them. This chapter draws on such literature in an effort to clarify the moral responsibilities and obligations that accompany philosophically founded practice.

As noted, the question of whether there is or can be a central unifying focus for nursing given differences in philosophical beliefs and conceptual approaches of nursing’s scholars was revisited recently (Willis, et al., 2008). A synthesis of historical and contemporary theoretical works points to a central unifying focus. Embedded in most if not all of nursing’s theoretical works is the idea that nursing practice involves “facilitating humanization, meaning, choice, quality of life, and healing in living and dying” (p. e28). Thus regardless of differing methods and approaches to knowledge development, implicit in almost all of nursing’s theoretical works is this underlying focus that in turn can, arguably, serve as a touchstone for the ethical appraisal of nursing actions.

Guided Practice

It has been noted that nurses who believe they are not practicing according to theory are in fact using some sort of internalized guide. That is, individual nurses are using a personal philosophy or theory that directs their practice. Such frameworks also have inherent moral components. The tenets or assumptions of a personal or nonnursing framework used for nursing practice require examination for congruency with nursing’s purpose. Critics have rightly questioned the capacity of such personal frameworks to adequately accomplish nursing’s purposes. Moreover, insights from moral and cognitive psychology research reveal that actions, even the reasons given for actions, can be inconsistent depending on whether one is reacting “in-the-moment” orpurposefully deliberating (Doris & Moral Psychology Research Group, 2010; Eagleman, 2011). It is unlikely that individual nurses have engaged in the sort of rigorous investigation and analysis undertaken by nursing theorists in formulating their views; therefore, the capacity of such practice to be consistent is questionable. Thus the following discussion is appropriate for nurses who are openly using the ideas of a theorist to guide practice and to those who are not—or at least are not at present.

The bases for nursing practice have been explicated in one or more of the following forms: philosophies, conceptual models, and/or theories. For simplicity and from this point forward in the chapter, when it is necessary to refer simultaneously to the terms philosophies, models, and theories, they will be grouped under the term theoretical works. An elucidation of the distinctions and relationships among these terms is discussed in the writings of Fawcett (2005), Higgins and Moore (2000), and Alligood and Marriner Tomey (2010). Discussions regarding the validity of these distinctions have appeared in the nursing theory literature; however, it is generally understood that where distinctions are made, the conceptual progression of the theoretical works is from more abstract to less abstract. Philosophies are more abstract than conceptual models, which in turn are more abstract than theories. It should also be understood that each of the theorists developed their conceptual model and theory or theories from a foundational philosophy or from a synthesis of one or more philosophies.

Professional Goals

The use of philosophies, models, and theories as guides for nursing practice and the reverse influence of practice experiences on theory development are factors critical to the development of nursing’s knowledge base and thus to the maturation and evolution of the discipline. However, as noted, it is the discipline’s explicit aim of contributing both to the health of individuals and to the overall health of society that makes nursing itself a moral endeavor. The discipline’s broad goal of promoting health includes restoring health, preventing illness, and relieving suffering (International Council of Nurses [ICN], 2006). Health is a human good in that it is necessary for optimal functioning. It is a state of being that is generally (if not universally) valued by individuals and societies. This objective of the profession—to further overall health or well-being—constitutes nursing’s promise to society. The objective, along with guidelines for the ethical conduct of practicing nurses, is publicly articulated in codes of practice such as the American Nurses Association’s (ANA) Code of Ethics for Nurses with Interpretive Statements (ANA, 2001; Fowler, 2010), the ICN’s (2006) Code of Ethics for Nurses, and a variety of codes that have been developed in other countries, and thus more specifically address the cultural norms of that country. Codes of ethics, as noted elsewhere, might be conceived as the tentative end results of an evolving profession’s political process (Grace, 1998, 2001). This is because codes of ethics are formulated as a result of a given profession’s intradisciplinary conversations over time; they publicly articulate the purpose and the manner in which its services will be furnished to society. Therefore, the formulation of codes of ethics for a discipline is influenced by both scholars and practitioners of nursing and, more indirectly, by society.

Codes of ethics are subject to change over time and in response to societal needs (Grace & Gaylord, 1999). For this reason they are somewhat reflective of what society expects of the profession in question, although this influence is indirect. The public is generally not well informed about any given discipline’s code of ethics, which is predicated on disciplinary goals and focus, or about the implications of these codes for practitioners. Viens (1989) presents a good historical account of the development of the ANA code over the past century. The ANA periodically updates its code. The latest revision was published in 2001. An opportunity for input from the wider nursing community was provided during this process. Changes to this latest document include the idea that the nurse has responsibility for his or her personal integrity. Provision 5 states, “The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth” (ANA, 2001, p. 18). At first glance this seems a strange addition. However, a deeper look at the explanatory statements for this provision reveals the idea that personal empowerment is at issue. This involves both knowledge of self as an integrated being (Fowler, 2010), the strength to maintain integrity even in difficult situations, and the acquisition of knowledge necessary for competent practice. These qualities are seen as imperative in furthering nursing’s purposes especially in times of economic turmoil and chaotic environments. The relatively recently described concept of moral distress has been ascribed to the shaken sense of personal integrity that occurs when one has acted against one’s personal or professional values (Corley, 2002; Corley, Minick, Elswick, et al., 2005; Hamric, 2012; Jameton, 1984). Moral distress is a cause of harm to nurses but ultimately to patients. Nurses may leave the profession as a result of unresolved moral distress or distance themselves from the patients for whom they provide nursing care (Huffman & Rittenmeyer, 2012). Because moral distress results from a sense of powerlessness to act differently, one antidote to moral distress is taking action to resolve the problem. Although the ANA code provides guidelines for U.S. nurses, its pertinence to global nursing remains unclear even in the latest iteration. The ICN’s (2006) Code of Ethics for Nurses speaks more explicitly to the conduct of nurses practicing in a wide variety of countries.

Nurse philosophers/theorists, along with other influences, affect both the development and revisions of the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) and the conceptions of what constitutes ethical practice. Whereas the codes of ethics give broad guidelines related to the conduct of nurses, theoretical works might be expected to give more specific direction. The moral implications of practicing according to a given theorist’s works involve all of the following: individual, group, community, societal, and perhaps—although more debatably—global considerations. Therefore, the writings of nursing’s theorists, the profession’s codes of ethics, and the recognition of central unifying foci (Fawcett, 2000, 2005; Willis, et al., 2008) for the discipline each prove useful in clarifying the moral responsibilities of practice, including knowledge development needed for practice.

Health as a Metaparadigm Concept

Nursing’s metaparadigm also proves important to the present discussion because the metaparadigm concepts are those “that identify the phenomena of central interestto the discipline” (Fawcett, 2000, p. 4). They specify or identify the scope of concern for the profession. References to four concepts—(1) health, (2) person, (3) environment, and (4) nursing (viewed as a verb or action rather than as the discipline)—are explicitly or implicitly present in the writings of almost all of nursing’s philosophers and/or theorists. One of the metaparadigm concepts, health, is (although perhaps arguably) a designator for nursing’s main purpose with regard to the population of concern. How health is viewed and addressed depends, of course, on the particular theorist’s definition, which will stem from a philosophy regarding the nature of human beings and of the world in which they find themselves or of which they are parts. Because the metaparadigm concepts are at the highest level of abstraction, they do not guide action for the practitioner; rather, they clarify the boundaries of the action and subject matter of a discipline (Fawcett, 2005). In addition, as noted, the metaparadigm concepts delineate the scope of nursing’s foci of concern.

It is from the description or definition of health, along with those of environment, person, and nursing as given by the nursing scholars, that direction is provided for the practitioner. It remains to be seen whether the recently proposed central unifying focus (Willis, et al., 2008) will withstand criticism. As the proposal is considered, its facets could contribute to the refining of the goals of knowledge development and practice. The characteristics of the metaparadigm concepts may be explicit in the scholar’s writings, or they may be implicit. Thus actions taken by a nurse to further health may also vary in accordance with the philosophy, model, or theory used to guide practice, depending on a nurse’s personal philosophy or belief system. It becomes important, then, for nurses to understand not only the philosophical and theoretical implications but also the moral implications of practicing according to a certain perspective. Understanding is required because nursing actions that stem from a certain viewpoint may be inadequate for this purpose for a variety of reasons, although they are directed at fostering health.