Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Towards connectedness and trust : nurses’ enactment of their moral agency within an organizational context Rodney, Patricia Anne 1997

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_1997-196488.pdf [ 16.37MB ]
Metadata
JSON: 831-1.0099208.json
JSON-LD: 831-1.0099208-ld.json
RDF/XML (Pretty): 831-1.0099208-rdf.xml
RDF/JSON: 831-1.0099208-rdf.json
Turtle: 831-1.0099208-turtle.txt
N-Triples: 831-1.0099208-rdf-ntriples.txt
Original Record: 831-1.0099208-source.json
Full Text
831-1.0099208-fulltext.txt
Citation
831-1.0099208.ris

Full Text

TOWARDS CONNECTEDNESS AND TRUST: NURSES' ENACTMENT OF THEIR MORAL AGENCY WITHIN AN ORGANIZATIONAL CONTEXT by PATRICIA ANNE RODNEY B.Sc.N., The U n i v e r s i t y o f A l b e r t a , 1977 M.Sc.N., The U n i v e r s i t y o f B r i t i s h Columbia, 1988 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES (The School o f Nursing) accepX^tnTsTt^iesis as conforming t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1997 © P a t r i c i a Anne Rodney, 1997 in presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of (^Q(^<,t rU(V-The University of British Columbia Vancouver, Canada Date A p f TI Of f V ^ T • DE-6 (2/88) A b s t r a c t TOWARDS CONNECTEDNESS AND TRUST: NURSES' ENACTMENT OF THEIR MORAL AGENCY WITHIN AN ORGANIZATIONAL CONTEXT T h i s study generates an un d e r s t a n d i n g o f how nurses enact t h e i r moral agency w i t h i n t h e c u l t u r e o f the o r g a n i z a t i o n a l c o n t e x t i n which t h e y p r a c t i c e . U s i n g a f e m i n i s t e t h n o g r a p h i c d e s i g n , t h e i n v e s t i g a t o r undertook a p p r o x i m a t e l y 180 hours o f f i e l d w o r k on an acute m e d i c a l u n i t i n a community h o s p i t a l , and app r o x i m a t e l y 38 hours o f f i e l d w o r k on a second acute m e d i c a l u n i t i n a t e r t i a r y h o s p i t a l . The i n v e s t i g a t o r worked c l o s e l y w i t h s i x s t a f f nurses d u r i n g t h i s t i m e , and i n c l u d e d f o r m a l r e s e a r c h i n t e r v i e w s w i t h t h e s e s i x nurses t o supplement her o b s e r v a t i o n s . She a l s o i n c l u d e d o b s e r v a t i o n o f and r e s e a r c h i n t e r v i e w s w i t h f i v e c l i n i c i a n s / n u r s e managers from t h e h o s p i t a l s , and, i n o r d e r t o f u r t h e r extend her a n a l y s i s , r e s e a r c h i n t e r v i e w s w i t h t h r e e home c a r e nurses from d i f f e r e n t communities. I t was found t h a t nurses enact t h e i r moral agency i n a r e l a t i o n a l m a t r i x w i t h o t h e r members o f the h e a l t h c a r e team, and t h a t t h i s m a t r i x i s s t r e n g t h e n e d by a u t h e n t i c presence and t r u s t between a l l p r o f e s s i o n a l s / p r o v i d e r s and p a t i e n t s and t h e i r f a m i l i e s . The c o n t e x t of nurses' work was p o r t r a y e d as f r a u g h t w i t h everyday e t h i c a l problems t h a t generated s i g n i f i c a n t moral a m b i g u i t y and moral d i s t r e s s f o r n u r s e s . There were s i g n i f i c a n t p e r s o n a l c o s t s a s s o c i a t e d w i t h nurses' work, i n c l u d i n g f a t i g u e , g u i l t , and p e r s o n a l r i s k . Moreover, th e c u l t u r e o f th e o r g a n i z a t i o n a l c o n t e x t f o r n u r s i n g p r a c t i c e and p a t i e n t c a r e was p o r t r a y e d as p r o b l e m a t i c . The communication between p r o f e s s i o n a l s / p r o v i d e r s and p a t i e n t s and A b s t r a c t , (Cont'd) t h e i r f a m i l i e s was fragmented, as was t h e communication between departments and a g e n c i e s . F i n a l l y , a number o f dominant s o c i o p o l i t i c a l i d e o l o g i e s seemed t o be embedded i n t h e o r g a n i z a t i o n a l c u l t u r e , i n c l u d i n g t h e d i s v a l u i n g o f n urses' work, t h e d i s v a l u i n g o f acute medicine as a n u r s i n g p r a c t i c e c o n t e x t , and t h e d i s v a l u i n g o f those i n n e e d — p a r t i c u l a r l y e l d e r l y p a t i e n t s and p a t i e n t s w i t h substance use problems. The i n v e s t i g a t o r concludes by c a l l i n g f o r more f e m i n i s t e t h n o g r a p h i c work so t h a t t h e i n f l u e n c e o f p r o b l e m a t i c o r g a n i z a t i o n a l c u l t u r e s on t h e e t h i c s o f p r o f e s s i o n a l p r a c t i c e can be f u r t h e r addressed. She c l a i m s t h a t t r u s t s h o u l d be f o s t e r e d i n h e a l t h c a r e teams by making the v a r i o u s members more a u t h e n t i c a l l y a c c e s s i b l e t o each o t h e r . F i n a l l y , she notes t h a t t h e e t h i c a l mandate of p r o f e s s i o n a l s must encompass a broader n o t i o n o f s o c i e t a l good i f t h e dominant s o c i o p o l i t i c a l i d e o l o g i e s a r e t o be c h a l l e n g e d . iv Table of Contents A b s t r a c t p. i i T a b l e o f Contents p. i v Acknowledgments p. v i i i D e d i c a t i o n p. i x CHAPTER ONE: S i t u a t i n g the Study: L i s t e n i n g t o Nurses' V o i c e s I n t r o d u c t i o n p. 1 Dev e l o p i n g a Focus f o r t h e Study p. 4 Lo o k i n g a t E t h i c a l Problems and S i t u a t i o n a l C o n s t r a i n t s p. 4 Understanding M o r a l D i s t r e s s and Mo r a l Agency p. 8 Ge n e r a t i n g a Problem Statement p. 9 S e t t i n g Up the Study p. 11 D e l i n e a t i n g Research Questions p. 11 L o c a t i n g a M e t a - T h e o r e t i c a l Context p. 11 S k e t c h i n g t h e Study Design p. 14 A r t i c u l a t i n g Relevance p. 16 Deve l o p i n g E t h i c a l Theory p. 16 S t r e n g t h e n i n g t h e H e a l t h Care System p. 18 CHAPTER TWO: E x p l o r i n g the M e t a - T h e o r e t i c a l Context I n t r o d u c t i o n p. 21 T h i n k i n g About t h e P h i l o s o p h y o f S c i e n c e p. 21 Which Paradigm(s)? p. 21 N e g o t i a t i n g t h e Postmodern p. 27 Understanding t h e C o n t r i b u t i o n s of F e m i n i s t Theory p. 30 Feminism and E t h i c a l / P o l i t i c a l H o r i z o n s p. 30 F e m i n i s t Research as P r a x i s p. 33 CHAPTER THREE: Surveying T h e o r e t i c a l T e r r a i n on Moral Agency and The C u l t u r e of the O r g a n i z a t i o n a l Context I n t r o d u c t i o n p. 36 A S o c i a l H i s t o r y o f H e a l t h Care E t h i c s p. 37 What Counts? p. 37 What About O r g a n i z a t i o n a l C u l t u r e ? p. 43 A C u l t u r e o f B l i n d n e s s ? p. 46 Table of Contents, (Cont'd) A T h e o r e t i c a l H i s t o r y o f H e a l t h Care E t h i c s The Domination o f P r i n c i p l e s The Emergence o f C o n t e x t u a l i s t E t h i c s C a s u i s t r y Care P r i n c i p l i s m vs Co n t e x t u a l i s m ? R e l a t i o n s h i p s and C h a r a c t e r Towards T h e o r e t i c a l D i v e r s i t y T h e o r e t i c a l Work on M o r a l Agency C u l t u r e as Context Moral Agency I n t r o d u c t i o n C onceptual Issues Nurses' I d e n t i f i c a t i o n of E t h i c a l Problems Problems i n a V a r i e t y o f P r a c t i c e Contexts Summary and R e f l e c t i o n s Nurses' M o r a l Reasoning and E t h i c a l D e c i s i o n - M a k i n g E a r l y S t u d i e s More Recent Work M o r a l D i s t r e s s i n N u r s i n g P r a c t i c e Summary and R e f l e c t i o n s CHAPTER FIVE: Implementing the Study: Seeking Meanings p- 48 p- 48 p- 51 p- 51 p- 52 p. 55 p- 58 p. 61 p- 62 p- 65 es ' P- 69 P- 70 P- 72 P- 72 P- 77 P- 80 P- 80 P- 82 P- 85 P- 87 I n t r o d u c t i o n U nderstanding F e m i n i s t E t h n o g r a p h i c P- 95 Methodology P. 96 E t h n o g r a p h i c Features P- 96 F e m i n i s t F eatures P- 100 How I Learned P- 103 A c c e s s i n g Nurses' E x p e r i e n c e s and th e C u l t u r e o f t h e O r g a n i z a t i o n a l Context P- 103 From where and from whom I l e a r n e d P- 103 E a r n i n g t r u s t i n study r e l a t i o n s h i p s P- 108 L e a r n i n g t o observe P- 114 L e a r n i n g t o l i s t e n P- 119 C o n s t r u c t i n g Meanings P- 121 P r o t e c t i n g I n d i v i d u a l s and I n s t i t u t i o n s p. 126 vi Table of Contents, (Cont'd) W r i t i n g With I n t e g r i t y p. 131 R i g o r p. 131 N a r r a t i v e I n t e g r i t y p. 136 CHAPTER SIX: Moral Agency Enacted i n a R e l a t i o n a l M a t r i x I n t r o d u c t i o n : C o n s t r u c t i n g Meanings p. 138 Connectedness and T r u s t p. 140 My I n i t i a l U nderstanding p. 140 Connected I n d i v i d u a l s p. 141 S u p p o r t i v e M a t r i c e s ? p. 144 T r a n s d i s c i p l i n a r i t y p. 148 A u t h e n t i c Presence p. 154 T r u s t p. 160 Summary and R e f l e c t i o n s p. 162 CHAPTER SEVEN: Moral Agency i n the Context o f Nurses' Work I n t r o d u c t i o n p. 166 The M o r a l Context of Nurses' Work p. 167 E t h i c a l Problems p. 167 Mo r a l Ambiguity p. 168 Mo r a l D i s t r e s s p. 172 How Nurses Mediate T h e i r Work p. 173 Knowing t h e P a t i e n t p. 173 A c t i v e l y N e g o t i a t i n g p. 177 G e t t i n g Around t h e System p. 178 P e r s o n a l Costs A s s o c i a t e d With Work p. 182 F a t i g u e p. 182 G u i l t p. 186 P e r s o n a l R i s k p. 188 Summary and R e f l e c t i o n s p. 190 CHAPTER EIGHT: Nurses' Work: The O r g a n i z a t i o n a l Context I n t r o d u c t i o n p. 192 Fragmented Teams and Systems p. 193 L e v e l s o f Fragmentation p. 193 Impact p. 200 Fragmented D e c i s i o n - M a k i n g p. 205 Inc o m p a t i b l e P e r s p e c t i v e s p. 205 P a t i e n t s and T h e i r F a m i l y Members? p. 207 The Complexity o f Options p. 211 Table of Contents, (Cont'd) vii Problems i n V a r i o u s Contexts p. 218 CHAPTER NINE: The O r g a n i z a t i o n a l Context: S o c i o p o l i t i c a l I d e o l o g i e s I n t r o d u c t i o n p. 220 The Val u e s That S t r u c t u r e H e a l t h Care D e l i v e r y p. 222 The ( D i s ) V a l u i n g o f Nurses' Work p. 222 The ( D i s ) V a l u i n g o f S p e c i a l i z a t i o n p. 229 The ( D i s ) V a l u i n g o f Those i n Need p. 233 CHAPTER TEN: Responding t o Nurse' V o i c e s I n t r o d u c t i o n p. 237 M e t h o d o l o g i c a l R e f l e c t i o n s p. 239 S u b s t a n t i v e R e f l e c t i o n s p. 243 Enhancing Mo r a l Agency p. 243 Reshaping Nurses' Work Contexts p. 246 C h a l l e n g i n g The O r g a n i z a t i o n a l Context p. 248 I n t e r r o g a t i n g S o c i o p o l i t i c a l I d e o l o g i e s p. 250 REFERENCES p. 253 APPENDICES: Appendix A: A b s t r a c t : Emergency N u r s i n g Study p. 293 Appendix B: F i e l d w o r k Calendar p. 295 Appendix C: P a r t i c i p a n t B i o g r a p h i c Summary p. 297 Appendix D: P a r t i c i p a n t B i o g r a p h i c Form p. 299 Appendix E: I n f o r m a t i o n f o r P a r t i c i p a n t Forms p. 301 Appendix F: P a r t i c i p a n t Consent Form p. 308 Appendix G: I n f o r m a t i o n f o r S t a f f p. 312 Appendix H: I n f o r m a t i o n f o r P a t i e n t s and F a m i l i e s p. 315 Appendix I : Sample I n t e r v i e w Notes p. 318 Appendix J : Sample T r i g g e r Questions p. 321 Appendix K: F i n a l I n t e r v i e w Segment p. 323 Appendix L: T r a n s c r i p t i o n i s t Agreement p. 339 Appendix M: A n a l y t i c S t r u c t u r e p. 341 viii Acknowledgments T h i s t h e s i s c o n t i n u e s a journey t h a t I began w i t h my Master's t h e s i s i n 1987-1988. I was aware then t h a t such a journey was by no means a s o l o accomplishment, and what I have l e a r n e d s i n c e has c e r t a i n l y r e i n f o r c e d t h a t c o n v i c t i o n . Any shortcomings i n t h i s f i n i s h e d p r o j e c t are my o w n — I have been t h e b e n e f i c i a r y o f a g r e a t d e a l o f p r o f e s s i o n a l and p e r s o n a l s u p p o r t . F i r s t , my h e a r t f e l t thanks go t o t h e f o u r t e e n nurses who p a r t i c i p a t e d i n t h i s study and gave so w i l l i n g l y o f t h e i r t i me and t h e i r i n s i g h t s . My thanks go as w e l l t o t h e members o f t h e h o s p i t a l a d m i n i s t r a t i o n s from S i t e One and S i t e Two who welcomed me t o t h e i r i n s t i t u t i o n s , and t o t h e p a t i e n t s , f a m i l y members, and o t h e r s t a f f a t both s i t e s who h e l p e d me t o understand. I n a d d i t i o n , I would l i k e t o extend my thanks t o t h e e l e v e n emergency nurses who p a r t i c i p a t e d i n the study t h a t I completed j u s t p r i o r t o t h i s one. Secondly, I would l i k e t o acknowledge t h e Canadian N a t i o n a l H e a l t h Research and Development Program f o r p r o v i d i n g f u n d i n g t o support t h i s r e s e a r c h . I have a p p r e c i a t e d t h e i r commitment t o h e a r i n g from t h e nurses whose v o i c e s are p r o f i l e d i n t h i s s t u d y . Thanks a l s o t o Sue Humphreys, who l o o k e d a f t e r t h e t r a n s c r i p t i o n o f r e s e a r c h m a t e r i a l s . Furthermore, I would l i k e t o acknowledge th e o u t s t a n d i n g i n t e l l e c t u a l and p e r s o n a l support t h a t I have r e c e i v e d from my D i s s e r t a t i o n S u p e r v i s o r y Committee. My C h a i r , Dr. Joan Anderson from t h e U n i v e r s i t y o f B r i t i s h Columbia (UBC) School o f N u r s i n g , has been a mentor f o r me i n a l l t h e b e s t senses of t h e word. She i n v i t e d me on t h i s j o u r n e y , and has been t h e r e f o r me a t e v e r y i m p o r t a n t j u n c t u r e . Together w i t h Joan, Dr. B e t t y Davies and Dr. S a l l y Thome from t h e UBC S c h o o l o f N u r s i n g and Dr. M i c h a e l McDonald from the UBC Centre f o r A p p l i e d E t h i c s have made up a team t h a t I have f e l t f o r t u n a t e t o have been a p a r t o f . I have a l s o had t h e o p p o r t u n i t y t o l e a r n from and w i t h a t e r r i f i c network of c o l l e a g u e s (from a v a r i e t y o f d i s c i p l i n e s ) a t UBC, t h e U n i v e r s i t y o f V i c t o r i a , and t h e Canadian B i o e t h i c s S o c i e t y . E a r l y on i n my s t u d i e s (1992) t h i s i n c l u d e d t h e o p p o r t u n i t y t o t a k e a course w i t h Dr. Sara F r y , who was i n s t r u m e n t a l i n h e l p i n g me t o a r t i c u l a t e my focus on moral agency. I would l i k e t o thank Sara f o r her i n s p i r a t i o n . L a t t e r l y , as a f a c u l t y member a t t h e U n i v e r s i t y of V i c t o r i a S c h o o l o f N u r s i n g , t h e undergraduate stu d e n t s who I have been working w i t h have help e d me t o grasp t h e r e l e v a n c e of what I have l e a r n e d i n t h i s s t udy. I am g r a t e f u l f o r t h e h e l p of one of t h e s t u d e n t s , Roger A u t i o , who was a r e s e a r c h a s s i s t a n t f o r t h i s s t u d y . And thanks t o t h e D i r e c t o r o f t h e S c h o o l , Dr. Jan S t o r c h , who has supported me i n my new r o l e . F i n a l l y , I would l i k e t o express my g r a t i t u d e t o numerous f r i e n d s and f a m i l y members. I n p a r t i c u l a r , I have b e n e f i t e d from t h e f r i e n d s h i p o f two n u r s i n g c o l l e a g u e s , C a r o l i n e Howe and R o s a l i e S t a r z o m s k i . My thanks go t o my s t e p d a u g h t e r s , Meghan and S a l l y Thomasson, my c o u s i n , B r i e n G i l l e s p i e , and my f r i e n d , Hugh Craske, f o r h e l p i n g me t o p r o o f t h i s t h e s i s . S p e c i a l thanks t o my mother, Anne Y u i l e , who helped w i t h innumerable p r o j e c t s . And most s p e c i a l thanks t o my husband, John Thomasson, who has l i v e d t h i s j ourney w i t h me. D e d i c a t i o n I n l o v i n g memory of my f a t h e r , The Hon. M i c h a e l Rodney, QC June 26, 1926 — June 22, 1993 1 CHAPTER ONE: SITUATING THE STUDY: LISTENING TO NURSES' VOICES I n t r o d u c t i o n As n u r s e s , we s t r u g g l e t o a r t i c u l a t e t h e e t h i c a l concerns i n our p r a c t i c e but f i n d we a r e d i s c o u n t e d o r t r i v i a l i z e d o r s e n t i m e n t a l i z e d . T h i s has been damaging t o i n d i v i d u a l n u r s e s , t h e d i s c i p l i n e of n u r s i n g , and p a t i e n t s . I t i s time f o r change. We need a moral language t h a t w i l l p r e s e r v e a sense o f t h e t r a g i c reminding us a l l t h a t each of us i s v u l n e r a b l e t o t h e c o n t i n g e n c i e s o f human l i f e . We need a language t h a t w i l l enable us t o s u s t a i n our p a t i e n t s and each o t h e r ; t h a t w i l l s e r v e as t h e v e h i c l e f o r our e t h i c a l r e f l e c t i o n ; t h a t w i l l g i v e v o i c e t o our e t h i c a l concerns ( L i a s c h e n k o , 1993a, p. 9 ) . W i t h i n t h i s s t u d y , I hope t o c o n t r i b u t e t o a growing d i a l o g u e about our e t h i c a l concerns i n n u r s i n g and h e a l t h c a r e . I n p a r t i c u l a r , I w i s h t o p r o f i l e t h e v o i c e s o f nurses on t h e f r o n t l i n e s o f p a t i e n t c a r e , nurses who s t r u g g l e w i t h t h e c o n t i n g e n c i e s o f human l i f e and who have taught me a g r e a t d e a l about t h e i r own p r a c t i c e and t h e p r a c t i c e o f our p r o f e s s i o n as a whole. I n coming t o t h i s s t u d y , I am informed by my p r e v i o u s background as a nurse p r a c t i c i n g i n a n o r t h e r n o u t p o s t , i n acute m e d i c a l / s u r g i c a l u n i t s , and i n i n t e n s i v e c a r e and co r o n a r y c a r e , and by my background as a h o s p i t a l nurse educator t e a c h i n g c r i t i c a l c a r e 1 n u r s i n g . I am a l s o informed by my ex p e r i e n c e s t e a c h i n g undergraduate n u r s i n g s t u d e n t s i n t h e o r y and c l i n i c a l c o urses i n two d i f f e r e n t u n i v e r s i t y programs. I n a d d i t i o n , I have worked w i t h master's s t u d e n t s l e a r n i n g about advanced n u r s i n g 1 C r i t i c a l care i s a term that includes intensive care, coronary care, emergency, and a v a r i e t y of other s p e c i a l t y p r a c t i c e areas where patients are s e r i o u s l y i l l , and where extensive biomedical technology i s commonplace. p r a c t i c e i n c r i t i c a l c a r e , and I have had t h e o p p o r t u n i t y t o l i s t e n t o nurses a c r o s s Canada as a n u r s i n g e t h i c s c o n s u l t a n t . Throughout my e x p e r i e n c e s , I have been s t r u c k by t h e p a s s i o n , commitment, and d i s t r e s s o f nurses on t h e f r o n t l i n e s o f p a t i e n t c a r e . I have a l s o been s t r u c k by t h e s e r i o u s concerns o f nurses who work i n c l i n i c a l , e d u c a t i o n a l , and a d m i n i s t r a t i v e p o s i t i o n s t o support those f r o n t l i n e n u r s e s . I have completed two s t u d i e s p r i o r t o t h i s one t h a t have s t r o n g l y r e i n f o r c e d t h i s p e r s p e c t i v e . I n my f i r s t s t u d y , I l e a r n e d from c r i t i c a l c a r e nurses about t h e anguish t h a t they e x p e r i e n c e when they p a r t i c i p a t e i n a c t i v e t r e a t m e n t i n t e r v e n t i o n s t h a t they b e l i e v e w i l l o n l y p r o l o n g t h e s u f f e r i n g o f d y i n g p a t i e n t s and t h e i r f a m i l i e s (Rodney, 1987). And i n my second s t u d y , I l e a r n e d from emergency nurses about t h e i r d i s c o m f o r t i n sending p a t i e n t s home w i t h o u t adequate home c a r e support (Rodney, 1993; see a l s o Appendix A: A b s t r a c t : Emergency N u r s i n g S t u d y ) . I n t h e words o f one o f t h e emergency nurses: ...a l o t o f people come i n , quote, "as placement problems", and i t used t o be t h a t a placement problem s i m p l y meant t h a t somebody was e l d e r l y and what they needed was a n u r s i n g home, and t h e r e was, t h e r e was always a shortage of t h a t , and d i f f i c u l t y i n g e t t i n g them i n t o those k i n d s o f f a c i l i t i e s . . . n o w t h e k i n d s o f placement problems we're s e e i n g [are] p a t i e n t s b e i n g d i s c h a r g e d i n t o t h e community w i t h much more complex s i t u a t i o n s , and I don't b e l i e v e t h a t t h e r e ' s t h e . . . a c c e s s t o . . . [ t h e n e c e s sary] f a c i l i t i e s out i n th e community...we're s e e i n g p a t i e n t s coming i n t h a t a re much more a c u t e l y i l l than they ever used t o be, but t h e y ' r e b e i n g d i s c h a r g e d s t i l l r e l a t i v e l y a c u t e l y i l l ( P a r t i c i p a n t Number Ten; Rodney, 1993). Nurses and o t h e r s on t h e f r o n t l i n e s of p a t i e n t c a r e a re l e f t t o d e a l w i t h t h e consequences of problems i n t h e h e a l t h c a r e s y s t e m — i n t h e i l l u s t r a t i o n above, problems w i t h sweeping acute c a r e h o s p i t a l cutbacks w i t h o u t concomitant r e s o u r c e s h i f t s t o community c a r e (Anderson, Grace, Helms, James, & Rodney, i n p r e s s ; Helms, James, & Rodney, 1996; L i n d s e y & A t t r i d g e , 1989; Oberle & Gr a n t , 1994; S c a n l o n , 1996/1997; S h i n d u l - R o t h s c h i l d , B e r r y , & Long-M i d d l e t o n , 1996; S i b b a l d , 1997; S t a r z o m s k i & Rodney, 1997). With L i a s c h e n k o (1993a), I b e l i e v e t h a t n urses' v o i c e s have not been heard c l e a r l y enough i n c l i n i c a l , academic, o r p o l i c y arenas. The i n v i s i b i l i t y o f nurses i n much o f t h e contemporary h e a l t h c a r e e t h i c s d i s c o u r s e i s remarkable. D i s c u s s i o n s i n t h e l i t e r a t u r e s t i l l f o cus p r i m a r i l y on p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s , w i t h t h e i m p l i c i t assumption t h a t most p r o f e s s i o n a l e t h i c a l concerns are subsumed by those o f p h y s i c i a n s ( B a y l i s , Downie, Freedman, Hoffmaster, & Sherwin, 1995; Sherwin, 1992; Warren, 1992; see a l s o Chapter T h r e e ) . T h i s i s not t o say t h a t p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s a r e not i m p o r t a n t , nor i s t o say t h a t nurses and o t h e r s i n t e r e s t e d i n h e a l t h c a r e e t h i c s s h o u l d focus on nurses e x c l u s i v e l y . We a l s o need t o know much more about t h e e t h i c a l concerns o f an a r r a y o f o t h e r h e a l t h c a r e p r o f e s s i o n a l s — f o r example, d i e t i t i a n s , o c c u p a t i o n a l t h e r a p i s t s , p a s t o r a l c a r e workers, p h a r m a c i s t s , p h y s i o t h e r a p i s t s , r e s p i r a t o r y t h e r a p i s t s , and s o c i a l workers. And we need t o know a t l e a s t something about t h e e t h i c a l concerns o f a host o f a l l i e d h e a l t h c a r e p r o v i d e r s — f o r example, d i a l y s i s t e c h n i c i a n s , home c a r e a i d e s , nurses' a i d e s , o r d e r l i e s , p r a c t i c a l n u r s e s , and r a d i o l o g y t e c h n i c i a n s . T h i s l a t t e r group i s almost never addressed i n t h e h e a l t h c a r e e t h i c s l i t e r a t u r e (Sherwin, 1992). Moreover, I do not w i s h t o i m p l y t h a t nurses a re not ( a t l e a s t i n p a r t ) c u l p a b l e f o r e t h i c a l problems i n h e a l t h c a r e . What I am s a y i n g i s t h a t t h e dominant focus on p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s i n h e a l t h c a r e e t h i c s d i s c o u r s e obscures t h e e t h i c a l concerns o f nurses as w e l l as o t h e r p r o f e s s i o n a l s and h e a l t h c a r e p r o v i d e r s . I t a l s o obscures our u n d e r s t a n d i n g o f the e t h i c a l concerns o f t h e h e a l t h c a r e team, which i n c l u d e s p a t i e n t s , t h e i r f a m i l i e s , 2 and a d m i n i s t r a t i v e p e r s o n n e l , as w e l l as h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s . Hence my focus i s on the e t h i c a l concerns of nurses and my i n t e r e s t i s i n t h e o r g a n i z a t i o n a l c o n t e x t w i t h i n which t h e h e a l t h c a r e team o p e r a t e s . L e t me f u r t h e r e x p l i c a t e how I came t o t h i s s tudy. Developing a Focus f o r the Study Looking at E t h i c a l Problems and S i t u a t i o n a l C o n s t r a i n t s Upon s t e p p i n g back t o examine r e s e a r c h i n t h e f i e l d o f n u r s i n g e t h i c s and h e a l t h c a r e e t h i c s , I found t h a t nurses r e p o r t s e r i o u s , r e c u r r i n g e t h i c a l p roblems 3 i n t h e i r p r a c t i c e (Rodney & S t a r z o m s k i , 1993; see a l s o Chapter F o u r ) . These e t h i c a l problems i n c l u d e p r o l o n g a t i o n o f l i f e , l a c k o f informed consent, v i o l a t i o n s o f c o n f i d e n t i a l i t y , q u e s t i o n a b l e p r a c t i c e s o f p r o f e s s i o n a l s w i t h i n and o u t s i d e of n u r s i n g , team c o n f l i c t , a l l o c a t i o n o f s c a r c e r e s o u r c e s , and inadequate n u r s i n g s t a f f i n g ( A l l e n , 1974; A p p l e t o n , 1993; A r o s k a r , 1989; Benner, Tanner, & C h e s l a , 1996; B e r g e r , z Within t h i s study, I am using the term "family" quite broadly. I agree with contemporary family t h e o r i s t s that " i t i s quite possible for people to have a family experience (including the feeli n g s of intimacy, connectedness, commitment, and so forth) with people who are not i n one's actual family." (Hartrick & Lindsey, 1995, p. 154) Therefore, I take i t that the "most us e f u l d e f i n i t i o n of family [ i s ] 'Who the family says i t i s . ' Furthermore, who 'counts' as family may vary depending on the health concern." (Robinson, 1995, p. 119) 3 By e t h i c a l problem, I mean a problem that (a) cannot be resolved s o l e l y through an appeal to empirical data, (b) involves c o n f l i c t of values and uncertainty about the amount or type of information needed to make a decision, and (c) the answer for which w i l l have profound relevance f o r several areas of human concern (Curtin, 1982, pp. 38-39). I am cautious of the use of the term e t h i c a l dilemma, as i t implies a choice between two c o n f l i c t i n g a l t e r n a t i v e s that are usually seen as mutually exclusive. In my experience, the r e a l world of c l i n i c a l p r a c t i c e i s r a r e l y that two dimensional. Instead, there are usually multiple, c o n f l i c t i n g , and sometimes overlapping a l t e r n a t i v e s . Seversen, & C h v a t a l , 1991; C a s s e l l s & Redman, 1989; D a v i s , 1981; 1988; 1989; Duncan, 1992; Fenton, 1987; Haddad, 1988; 1992; H o l l a n d s , 1994; H o l l y , 1993; Lamb, 1985; L i a s c h e n k o , 1993a; M i y a , Boardman, H a r r , & Keene, 1991; O b e r l e , 1993; Oberle & Grant, 1994; Ornery & C a s s w e l l , 1988; P e n t i c u f f , 1989; Rodney, 1987; 1993; Sca n l o n , 1996/1997; S e l l i n , 1991; S h i n d u l - R o t h s c h i l d , B e r r y , & Long-Middleton, 1996; S i b b a l d , 1997; Solomon, O'Donnell, J e n n i n g s , G u i l f o y , Wolf, Nolan, Jackson, Koch-Weser, & Do n n e l l e y , 1993). Throughout t h i s r e s e a r c h , nurses r e p o r t t h a t t h e y are hampered by s i t u a t i o n a l c o n s t r a i n t s w i t h i n t h e i r p r a c t i c e c o n t e x t s . S i t u a t i o n a l c o n s t r a i n t s can be understood as asp e c t s o f nur s e s ' s t r u c t u r a l and i n t e r p e r s o n a l work environments t h a t a r e p e r c e i v e d t o impede th e implementation o f p r o f e s s i o n a l standards o f n u r s i n g and thus j e o p a r d i z e t h e q u a l i t y o f p a t i e n t c a r e (Rodney & S t a r z o m s k i , 1993, p.24). S i t u a t i o n a l c o n s t r a i n t s are m a n i f e s t e d i n i n t e r p e r s o n a l c o n f l i c t s w i t h o t h e r i n d i v i d u a l s ( f o r example, when nurses d i s a g r e e w i t h the f a m i l y and p h y s i c i a n about c o n t i n u i n g treatment f o r a p a t i e n t who has re q u e s t e d t h a t i t be withdrawn [ H o l l y , 1993]), and a d m i n i s t r a t i v e a c t i o n s t h a t are p e r c e i v e d by nurses as u n s u p p o r t i v e ( f o r example, the assignment o f what nurses b e l i e v e are e x c e s s i v e workloads [Robinson, Roth, Keim, Levenson, F l e n t j e , & Bashor, 1991]). As I commenced my stud y , I found t h a t i n o r d e r t o understand nurses' r e p o r t s of t h e s i t u a t i o n a l c o n s t r a i n t s t h a t t h e y encounter when t r y i n g t o d e a l w i t h e t h i c a l problems, I needed t o a p p r e c i a t e t h e c u l t u r e o f the o r g a n i z a t i o n a l c o n t e x t 4 w i t h i n which t h e i r 4 By organization, I mean a formal structure for health care d e l i v e r y . This can be part of a h o s p i t a l , long-term care f a c i l i t y , health c l i n i c , home care agency, or a v a r i e t y of other i n s t i t u t i o n s . I w i l l say more about the culture of the organizational context i n Chapter Three. p r a c t i c e i s l o c a t e d . There i s a g e n e r a l consensus i n t h e e m p i r i c a l work t h a t I have c i t e d t o t h i s p o i n t t h a t c o n s t r a i n t s l i m i t n u r s es' e x e r c i s e o f t h e i r r e s p o n s i b i l i t y and a c c o u n t a b i l i t y . However, v i e w i n g t h e c o n t e x t s w i t h i n which nurses e x e r c i s e t h e i r r e s p o n s i b i l i t y and a c c o u n t a b i l i t y only i n terms of c o n s t r a i n t s c i r c u m s c r i b e s our u n d e r s t a n d i n g o f the r e a l i t i e s o f t h e p r a c t i c e w o r l d i n which n u r s i n g i s l o c a t e d . S o c i o l o g i c a l s t u d i e s p o r t r a y a h i e r a r c h i c a l c a s t e system as e x i s t i n g i n h o s p i t a l s . T h i s c r e a t e s c e n t r a l i z e d d e c i s i o n making w i t h r e s u l t a n t c o n f l i c t and a l i e n a t i o n f o r many h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s — p a r t i c u l a r l y nurses (Anderson e t a l . , i n p r e s s ; Campbell, 1987; C hambliss, 1996; S t r e e t , 1992; T o r r a n c e , 1987). I n f a c t , nurses on t h e f r o n t l i n e s o f p a t i e n t c a r e have been d e s c r i b e d as f e e l i n g "betrayed and u n a p p r e c i a t e d " (Mauksch, 1990, p. 485). J came to understand that the constraints that nurses experience are not just external features of the environment, but are part of the culture of the organizational context in which they practice (Jameton, 1990; L i a s c h e n k o , 1993b). From t h e r e s e a r c h t h a t I reviewed, i t seemed c l e a r t h a t one o f t h e most p r o b l e m a t i c f e a t u r e s o f t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t i s t h e fragmented communication between h e a l t h c a r e team members (Anderson e t a l . , i n p r e s s ; Baggs & S c h m i t t , 1988; E r i c k s e n , Rodney, & S t a r z o m s k i , 1995; F i o r e l l i , 1988; Jones, 1994; Marsden, 1990; Northouse & Northouse, 1992; O'Toole, 1992; P r e s c o t t & Bowen, 1985). The r e s e a r c h i n d i c a t e s t h a t t h i s f r a g m e n t a t i o n e n t a i l s inadequate involvement of p a t i e n t s and t h e i r f a m i l y i n treatment d e c i s i o n s ( H o l l y , 1989; 1993; J e z e w s k i , S c h e r e r , M i l l e r , & B a t t i s t a , 1993; Kuuppelomaki, 1993; Miya e t a l . , 1991; Solomon e t a l . , 1993), as w e l l as inadequate involvement o f n u r s e s , who r e p o r t t h a t t h e y f e e l shut out o f d e c i s i o n - m a k i n g processes ( C o r l e y , S e l i g , & Ferguson, 1993; E r l i n & F r o s t , 1991; M a r t i n , 1989; Rodney, 1989; 1994). My u n d e r s t a n d i n g o f t h i s fragmented team communication was e n r i c h e d by my i n t e r v i e w s w i t h and o b s e r v a t i o n s o f emergency nurses p r i o r t o s t a r t i n g t h i s s t udy. I found t h e f o l l o w i n g s t o r y from one o f t h e emergency nurses p a r t i c u l a r l y i l l u m i n a t i n g : ...the reason i t ' s p r o b a b l y not u n i f i e d i s because each department i s so segregated we almost work a g a i n s t each o t h e r . . . . f o r example, t h e l a s t week I was working n i g h t s , I was i n [ c u b i c l e s ] one t o f o u r , I had two c a r d i a c p a t i e n t s i n bed one and two and then i n bed f o u r we had a [ p a t i e n t w i t h ] s e p t i c shock, [blood] p r e s s u r e o f seventy s y s t o l i c , h e a r t r a t e a hundred and twenty, r e a l c o l d and clammy, i l l , I was one on one w i t h her w h i l e we s t a r t e d massive a n t i b i o t i c s . . . e v e r y t h i n g [treatment commenced] on her, and she was an ICU [ I n t e n s i v e Care U n i t ] p a t i e n t , ready f o r t r a n s f e r [ t o ICU] a t two i n t h e morning, b u t , see, t h i s i s an example, [ICU] were s h o r t s t a f f e d , t h e r e f o r e t h e y had t o keep t h e p a t i e n t i n Emerg, t h e r e f o r e I had an e x t r a l o a d w i t h t h a t one p a t i e n t p l u s two o t h e r people p l u s whoever may have walked i n t o t h e department w i t h c h e s t p a i n , so I had t o t a k e t h e e x t r a l o a d because [ICU] was, needed an e x t r a s t a f f p e r s o n , and t h e y d i d n ' t want t o p u l l one o f t h e i r own people i n on double time t o save t h e i r b u d g e t . . . ( P a r t i c i p a n t Number E l e v e n ; Rodney, 1993). What I heard from t h i s nurse was t h a t fragmented team communication e n t a i l s not j u s t c o n f l i c t o r miscommunication between i n d i v i d u a l team members, but a l s o between e n t i r e departments i n t h e h o s p i t a l . I n o t h e r s i t u a t i o n s , c o n f l i c t o r miscommunication t o o k p l a c e between h o s p i t a l departments and community a g e n c i e s . I a l s o heard a warning t h a t f i s c a l r e s t r a i n t s a r e not making t h e communication problems any b e t t e r . I n t h i s example, t h e communication problems were worsened when i n d i v i d u a l departments a c t e d " t o save t h e i r budgets". As a r e s u l t o f my study w i t h emergency nurses and my r e v i e w o f o t h e r r e s e a r c h , I came t o b e l i e v e t h a t t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t w i t h i n which nurses and o t h e r p r o f e s s i o n a l s / p r o v i d e r s p r a c t i c e does not n e c e s s a r i l y promote t h e r e s o l u t i o n o f e t h i c a l problems. I n f a c t , i t may e xacerbate e t h i c a l problems because of fragmented team communication o r fragmented departmental communication o r b o t h . Understanding Moral D i s t r e s s and Moral Agency I t a l s o became c l e a r t o me t h a t because o f s i t u a t i o n a l c o n s t r a i n t s i n t h e o r g a n i z a t i o n a l c o n t e x t , nurses are o f t e n unable t o implement t h e moral c h o i c e s t h e y w i s h t o make w i t h ( o r on b e h a l f o f ) p a t i e n t s . T h i s c r e a t e s moral d i s t r e s s ( A p p l e t o n , 1993; C l a r k e , Connaughty, Cook, D a v i e s , McCormick, Mackenzie, O'Loane, & S t u t z e r , 1992; E r l e n & F r o s t , 1991; E r i c k s e n , Rodney, & S t a r z o m s k i , 1995; Fenton, 1988; G a u l , 1995; H o l l y , 1993; Rodney, 1988; 1994; Rodney & S t a r z o m s k i , 1993; Rushton, 1992; W i l k i n s o n , 1987/88; Yeo & Ford, 1996). By d e f i n i t i o n , moral d i s t r e s s o c c u r s when a moral c h o i c e cannot be t r a n s l a t e d i n t o moral a c t i o n (Jameton, 1984)—when, f o r example, an emergency nurse makes a moral c h o i c e t o prepare a f a m i l y f o r t h e death o f a p a t i e n t , but departmental s t r u c t u r e s make i t almost i m p o s s i b l e f o r her t o get t h e f a m i l y t o t h e bedside (Rodney, 1994). M o r a l d i s t r e s s a l s o o c c u r s when a nurse i s " p u l l e d " (sent w i t h o u t h i s consent) t o p r o v i d e c a r e t o p a t i e n t s on a u n i t where he has not been adeq u a t e l y o r i e n t e d , and where he knows t h a t he i s l i k e l y t o make mistakes i n a d m i n i s t e r i n g u n f a m i l i a r t r e a t m e n t s ( W i l k i n s o n , 1985, p. 65). I n o t h e r words, he i s unable t o implement h i s moral c h o i c e t o p r o v i d e competent c a r e . M o r a l d i s t r e s s i s a s s o c i a t e d w i t h f e e l i n g s o f g u i l t , anger, f r u s t r a t i o n , and p o w e r l e s s n e s s , and may be an i m p o r t a n t c o n s t i t u e n t o f what we have been c a l l i n g p r o f e s s i o n a l burnout (Cameron, 1986; C a r p e n t e r , 1988; Fowler, 1989; Rodney, 1988; 1994; Rodney & S t a r z o m s k i , 1993; W i l k i n s o n , 1985). Moreover, t h e i n a b i l i t y of nurses t o t r a n s l a t e moral c h o i c e s i n t o moral a c t i o n , and t h e i r subsequent moral d i s t r e s s , means t h a t nurses are l i m i t e d i n t h e e x e r c i s e o f t h e i r moral agency. That i s , nurses are l i m i t e d i n t h e i r enactment of t h e i r moral r e s p o n s i b i l i t y and a c c o u n t a b i l i t y ( E r l e n & F r o s t , 1991; K e t e f i a n & Ormond, 1988; L i a s c h e n k o , 1993b; M i l l e t t e , 1994; M u n h a l l , 1990; Rodney & S t a r z o m s k i , 1993; S t o r c h , 1992; W i l k i n s o n , 1989; Y a r l i n g & McElmurray, 1986; Yeo & F o r d , 1996). One o f t h e nurses who I i n t e r v i e w e d i n my study w i t h c r i t i c a l c a r e nurses underscored t h e sense o f powerlessness t h a t goes a l o n g w i t h t h i s l i m i t e d moral agency: [Speaking of a c r i t i c a l l y i l l c h i l d ] . . . i t seemed t h a t [the m e d i c a l s t a f f ] weren't a b l e t o get a r e a l l y c l e a r p i c t u r e o f what...the e t h i c a l s i t u a t i o n was, and t h e E t h i c s Committee was v a c i l l a t i n g about what t o do w i t h t h i s c h i l d , whether t h e y s h o u l d t a k e him o f f t h e v e n t i l a t o r , and t h e r e were a l s o f a m i l y problems a s s o c i a t e d w i t h i t , and I guess as a b e d s i d e nurse you never r e a l l y got t o hear, i t was j u s t s o r t o f c o f f e e room t a l k o r whatever, but you know we never r e a l l y got an i d e a o f e x a c t l y why we had t o keep l o o k i n g a f t e r t h i s c h i l d and why they c o u l d n ' t make t h i s d e c i s i o n ( P a r t i c i p a n t Number One; Rodney, 1987, p. 128). Generating a Problem Statement Thus, as I approached my c u r r e n t study, I understood t h a t nurses r e p o r t t h a t s i t u a t i o n a l c o n s t r a i n t s l i m i t t h e i r enactment o f t h e i r moral agency as they encounter s e r i o u s , r e c u r r i n g e t h i c a l problems i n t h e i r p r a c t i c e . A major s i t u a t i o n a l c o n s t r a i n t a r i s i n g from t h e c u l t u r e o f the o r g a n i z a t i o n a l c o n t e x t i n which nurses p r a c t i c e i s fragmented team and/or departmental communication, which i t s e l f e x a cerbates t h e s e e t h i c a l problems. However, I knew t h a t t h e r e s e a r c h r e l a t i n g t o e t h i c s i n n u r s i n g p r a c t i c e t h a t I reviewed a t the o u t s e t o f my s t u d y 5 was by no means c o n c l u s i v e ( C a s s i d y , 1991; Jameton & Fowler, 1989; K e t e f i a n , 1989; Ornery, 1989). There i s a p a u c i t y of r e s e a r c h e x p l a i n i n g how nurses deal with e t h i c a l problems i n t h e i r p r a c t i c e (Fowler & F r y , 1988; F r y , 1987; K e t e f i a n & Ormond, 1988; P e n t i c u f f , 1991; Swider, McElmurray & Y a r l i n g , 1985). The r e s e a r c h ( i n c l u d i n g my own two p r e v i o u s s t u d i e s ) c o n s i s t s p r i m a r i l y o f s e l f - r e p o r t s o f nu r s e s , s e l f - r e p o r t s t h a t have been gathered m o s t l y through d e s c r i p t i v e surveys and q u a l i t a t i v e i n t e r v i e w s . A l t h o u g h i t was c l e a r t o me t h a t nurses e x p e r i e n c e e t h i c a l problems, and t h a t t h e s e problems are confounded by t h e c u l t u r e o f th e o r g a n i z a t i o n a l c o n t e x t w i t h i n which they p r a c t i c e , i t was not c l e a r what nurses a c t u a l l y do i n a t t e m p t i n g t o d e a l w i t h e t h i c a l problems. I m p o r t a n t l y , t h i s means t h a t t h e r e i s a poor u n d e r s t a n d i n g o f how nurses themselves may c o n t r i b u t e t o e t h i c a l problems i n p a t i e n t c a r e , o r o f what happens when nurses' moral c h o i c e s c o n f l i c t w i t h those o f p a t i e n t s and/or f a m i l i e s . 6 3 I completed my i n i t i a l research review for the study proposal i n 1993. Given that t h i s study i s being written i n 1997, I have continued to update the research l i t e r a t u r e . The conclusions that I arri v e d at about the research l i t e r a t u r e i n 1993 s t i l l hold true. 6 See Mueller (1995) for an exploration of how unshared meanings create boundaries between patients and nurses, and Purkis (1993) f o r an exploration of how power i s exercised by nurses through i n s t i t u t i o n a l i z e d "practices". 11 S e t t i n g Up the Study D e l i n e a t i n g Research Questions Given t h e c o n c l u s i o n s above, I f e l t t h a t a study d i r e c t e d toward u n c o v e r i n g knowledge about nurses' enactment o f t h e i r moral agency w i t h i n t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t was i n d i c a t e d . More s p e c i f i c a l l y , t h e r e s e a r c h q u e s t i o n s t h a t I d e l i n e a t e d were as f o l l o w s : (1) What are nurses' understandings o f t h e e t h i c a l problems t h e y c o n f r o n t i n t h e i r p r a c t i c e ? (2) What are nurses' e x p e r i e n c e s i n e n a c t i n g t h e i r moral agency? That i s , how do they d e a l w i t h t h e e t h i c a l problems i n t h e i r p r a c t i c e ? (3) How does t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t a f f e c t n u r ses' e x p e r i e n c e s ? L o c a t i n g a M e t a - T h e o r e t i c a l Context I n o r d e r t o more f u l l y s i t u a t e my study, I would l i k e t o p r o v i d e an o r i e n t a t i o n t o t h e m e t a - t h e o r e t i c a l c o n t e x t t h a t supports my work. 7 My i n t e r e s t i n t h e c u l t u r e o f t h e o r g a n i z a t i o n s w i t h i n which nurses work l e d me t o g r a p p l e w i t h l o n g - s t a n d i n g gendered power r e l a t i o n s . As I developed and implemented my s t u d y , I was t h e r e f o r e informed by t h r e e major areas o f f e m i n i s t s c h o l a r s h i p . 8 F i r s t , my u n d e r s t a n d i n g o f t h e e p i s t e m o l o g y and 7 By meta-theoretical, I mean "broad issues r e l a t e d to theory" such as the "philosophical ferment about the nature and method of science" (Walker & Avant, 1995, pp. 5-7) . In a r t i c u l a t i n g a meta-theoretical context, I am i n the company of a growing cadre of contemporary t h e o r i s t s who are i n t e r e s t e d i n the p h i l o s o p h i c a l underpinnings of nursing theory (for example, A l l e n , 1992; Anderson, 1991a; Benner & Wrubel, 1989; Bishop & Scudder, 1990; Donaldson, 1995; Fry, 1992; 1995; Kikuchi & Simmons, 1992; 1994; Reed, 1989; Riegal, Ornery, C a l v i l l o , Elsayed, Lee, Shuler, & Siegal, 1992; Walker & Avant, 1995; Ward, 1995; Watson, 1995; Yeo, 1989). 8 Feminist theory can be defined as "the struggle of i n d i v i d u a l women questioning c e n t r a l assumptions of male-generated, -oriented and -dominated theories and creating a l t e r n a t i v e approaches to s o c i a l r e a l i t y " ( E i c h l e r , 1985, p. 619). I t has a long but often i n v i s i b l e history, and has only become recognized i n academic c i r c l e s over the past 20 years ( E i c h l e r , p. o n t o l o g y 9 u n d e r l y i n g my r e s e a r c h was informed by feminist standpoint theory. Harding (1991) d e s c r i b e s t h i s t h e o r y as f o l l o w s : The dominant c o n c e p t u a l schemes o f t h e n a t u r a l and s o c i a l s c i e n c e s f i t t h e e x p e r i e n c e t h a t Western men of t h e e l i t e c l a s s e s and ra c e s have o f themselves and t h e w o r l d around them. P o l i t i c a l s t r u g g l e and f e m i n i s t t h e o r y , [ f e m i n i s t s t a n d p o i n t t h e o r i s t s ] say, must be i n c o r p o r a t e d i n t o t h e s c i e n c e s i f we are t o be a b l e t o see beneath t h e p a r t i a l and f a l s e images o f t h e w o r l d t h a t t h e s c i e n c e s generate. By s t a r t i n g r e s e a r c h from women's l i v e s [my emphasis], we can a r r i v e a t e m p i r i c a l l y and t h e o r e t i c a l l y more adequate d e s c r i p t i o n s and e x p l a n a t i o n s — a t l e s s p a r t i a l and d i s t o r t e d ones (p. 48). T h i s means t h a t my study s t a r t e d from th e p e r s p e c t i v e o f women (nurses) who have h i s t o r i c a l l y worked w i t h i n a c o n t e x t imbued w i t h p a t r i a r c h a l power ( A s h l e y , 1976; K a l i s c h & K a l i s c h , 1982; Muff, 1982). L e t me be c l e a r t h a t I s t u d i e d women because o f t h e profound impact o f t h e female gender on n u r s i n g , not because I b e l i e v e t h a t male nurses a r e not a l s o d i s e m p o w e r e d — u n d e r s t a n d i n g t h e n a t u r e o f t h e i r disempowerment i s a q u e s t i o n f o r another study. Furthermore, I agree w i t h Harding (1991) and Morra and Smith (1995) t h a t men can be f e m i n i s t s , and, o f c o u r s e , t h a t not a l l women a r e . L i s t e n i n g t o t h e v o i c e s o f men i n n u r s i n g i s t h e r e f o r e an im p o r t a n t p r o j e c t ; i t i s j u s t not one t h a t I have undertaken i n t h i s s tudy. Two o f t h e c h a r a c t e r i s t i c f e a t u r e s o f f e m i n i s t s c h o l a r s h i p a r e i t s i n t e r d i s c i p l i n a r i t y and emphasis on t h e o r e t i c a l s y n t h e s i s 619). Despite t h i s recent acceptance, feminist theory has p r o l i f e r a t e d i n a multitude of t h e o r e t i c a l f i e l d s — " h i s t o r y , l i t e r a t u r e , anthropology, psychology, and sociology, to name a few" (Wallace, 1989, p. 8). 9 Epistemology i s concerned with "the nature and d e r i v a t i o n of knowledge, the scope of knowledge, and the r e l i a b i l i t y of claims to knowledge" (Flew, 1979, p. 109). Ontology i s the branch of metaphysics "concerned with the study of existence i t s e l f " and the "assumptions about existence underlying any conceptual scheme or any theory or system of ideas" (Flew, pp. 255-256). (Tuana & Tong, 1995; W a l l a c e , 1989). Thus, I have been a b l e t o draw on t h e o r i s t s from a v a r i e t y o f d i s c i p l i n e s f o r d i f f e r e n t areas o f f e m i n i s t s c h o l a r s h i p . My approach t o r e s e a r c h methodology and methods was i n f l u e n c e d throughout by f e m i n i s t s o c i o l o g i s t s (Oakley, 1981; D. Smith, 1987; 1989; 1990), f e m i n i s t s c h o l a r s i n e d u c a t i o n ( L a t h e r , 1991; Roman & A p p l e , 1990), and f e m i n i s t n u r s i n g s c h o l a r s (Anderson, 1991b; Campbell & B u n t i n g , 1991; H a l l & Stevens, 1991; MacPherson, 1983; P a r k e r & McFarlane, 1991). As Dorothy Smith (1989) e x p l a i n s , such methodologies and methods "seek from p a r t i c u l a r e x p e r i e n c e s i t u a t e d i n t h e m a t r i x o f t h e e v e r y d a y / e v e r y n i g h t w o r l d t o e x p l o r e and d i s p l a y t h e r e l a t i o n s , powers, and f o r c e s t h a t o r g a n i z e and shape i t " (p. 34). I wanted t o understand how nurses' e x p e r i e n c e s were a f f e c t e d by o r g a n i z a t i o n a l s t r u c t u r e s and p r o c e s s e s , o r r u l i n g r e l a t i o n s . And I wanted t o make the r e s u l t s 1 0 a c c e s s i b l e t o t h e nurses w i t h whom I s t u d i e d so t h a t t hey might use them t o f o s t e r o r g a n i z a t i o n a l change. F i n a l l y , my approach t o e t h i c a l t h e o r y i n t h e i n i t i a l c o n c e p t u a l i z a t i o n o f my study and i n t h e a n a l y s i s o f my s t u d y r e s u l t s has been informed by f e m i n i s t e t h i c s and t h e r e l a t e d f i e l d o f moral t h e o r y ( B a i e r , 1994; G i l l i g a n , 1982; Mann, 1994; Sherwin, 1992; Warren, 1992; Wolf, 1994). As a branch o f f e m i n i s t p h i l o s o p h y , f e m i n i s t e t h i c s i s p a r t o f t h e f o l l o w i n g p r o j e c t : Focused as t h e y are on women's e x p e r i e n c e s , f e m i n i s t p h i l o s o p h e r s have become p a i n f u l l y aware of the degree t o which t r a d i t i o n a l p h i l o s o p h y o v e r l o o k s o r t r i v i a l i z e s women's i U "Results" implies that there was something e s s e n t i a l or objective (Bernstein, 1983) to d i s c o v e r — a p o s i t i v i s t term that i s incongruent with the q u a l i t a t i v e and feminist t h e o r e t i c a l perspectives informing t h i s study (see also Chapter Two). Thus, I use the term "constructions" instead of r e s u l t s , which acknowledges that what I a r r i v e d at i n my study was something that was constructed between myself and the research p a r t i c i p a n t s . i n t e r e s t s , i s s u e s , c o n c e r n s , and persons. They have a l s o come t o see t r a d i t i o n a l p h i l o s o p h y ' s tendency f i r s t t o i d e n t i f y women w i t h t h e l e s s v a l u e d h a l f o f i t s major d i c h o t o m i e s ( f o r example, mind/body, s e l f / o t h e r , and reason/emotion) and the n t o s y s t e m a t i c a l l y n e g l e c t t h a t l e s s v a l u e d h a l f o f r e a l i t y throughout t h e course o f i t s own development. Thus, f e m i n i s t p h i l o s o p h e r s have observed t h a t among t h e n e g l e c t e d "female-a s s o c i a t e d " elements i n many of t r a d i t i o n a l p h i l o s o p h y ' s c a n o n i c a l t e x t s a re the c o n c r e t e , p a r t i c u l a r , and s u b j e c t i v e , which a re viewed as t h e enemies o f t h e a b s t r a c t , u n i v e r s a l , and o b j e c t i v e ; t h e emotions and t h e body, which a re s e t i n o p p o s i t i o n t o reason and t h e mind; t h e human need f o r c o o p e r a t i o n and community, which i s viewed as f a r l e s s u r g e n t t h a n t h e human d e s i r e t o compete and t o a s s e r t one's i n d i v i d u a l i t y ; and, f i n a l l y , t he judgement t h a t t h e l i n e s between t h e d i s c i p l i n e s , as w e l l as between t h e o r y and p r a c t i c e and v a l u e and f a c t , s h o u l d be b l u r r e d , hazy, and permeable as opposed t o c l e a r , d i s t i n c t , and i m p e n e t r a b l e (Tuana & Tong, 1995, p. 2 ) . F e m i n i s t e t h i c s i s a t t e n t i v e t o "contemporary e t h i c a l i s s u e s on t h e one hand and t h e c r i t i c i s m o f t r a d i t i o n a l e t h i c a l t h e o r y on th e o t h e r " (Jaggar, 1990/1991, p. 81). Thus, f e m i n i s t e t h i c a l l i t e r a t u r e o f f e r s me a p e r s p e c t i v e on contemporary e t h i c a l i s s u e s t h a t i s d i f f e r e n t from t h e c a n o n i c a l h e a l t h c a r e e t h i c s l i t e r a t u r e , and i t h e l p s me t o t h i n k about e t h i c a l and moral t h e o r y i n a d i f f e r e n t way. That i s , ( t o use Tuana and Tong's d e s c r i p t o r s ) i t h e l p s me t o d i s c o v e r t h e c o n c r e t e , t h e p a r t i c u l a r , t h e s u b j e c t i v e , t h e emotions, t h e body, t h e human need f o r c o o p e r a t i o n and community, and, f i n a l l y , i n t e r d i s c i p l i n a r y i n s i g h t s . S k e t c h i n g the Study Design The n a t u r e o f my r e s e a r c h q u e s t i o n s meant t h a t I needed t o understand t h e s u b j e c t i v e e x p e r i e n c e s o f nurses as th e y were l o c a t e d w i t h i n t h e r e a l w o r l d o f t h e i r p r a c t i c e c o n t e x t . T h i s l e d me t o a q u a l i t a t i v e r e s e a r c h p e r s p e c t i v e , as I was i n t e r e s t e d i n s t u d y i n g q u e s t i o n s about human e x p e r i e n c e s "through s u s t a i n e d c o n t a c t w i t h persons i n t h e i r n a t u r a l environments...producing r i c h , d e s c r i p t i v e d a t a t h a t h e l p us t o understand t h o s e persons' e x p e r i e n c e s . . . . [ i n o r d e r t o ] open up new o p t i o n s f o r a c t i o n and new p e r s p e c t i v e s t h a t can change people's w o r l d s " (Boyd, 1993, pp. 69-70). I d e c i d e d on a q u a l i t a t i v e f e m i n i s t e t h n o g r a p h i c s t u d y d e s i g n i n o r d e r t o uncover knowledge about nurses' u n d e r s t a n d i n g o f , and e x p e r i e n c e s d e a l i n g w i t h , t h e e t h i c a l problems t h a t t h e y c o n f r o n t i n t h e i r p r a c t i c e . F e m i n i s t ethnography "works d i a l e c t i c a l l y on t h e r e l a t i o n between t h e phenomenal appearances o f s o c i a l l i f e and t h e o b j e c t i v e n a t u r e o f t h e s o c i a l r e l a t i o n s t h a t s t r u c t u r e them" (Roman & A p p l e , 1990, p. 54; see a l s o Smith, 1987). Thus, my study d e s i g n a l s o enabled me t o b e g i n t o account f o r t h e i n f l u e n c e o f t h e o r g a n i z a t i o n a l c u l t u r e (the s o c i a l r e l a t i o n s ) on nurses' e x p e r i e n c e s (the phenomenal appearances). More s p e c i f i c a l l y , a f e m i n i s t e t h n o g r a p h i c d e s i g n enabled me t o i n c l u d e both o b s e r v a t i o n and s e l f - r e p o r t ( i n t e r v i e w s ) i n o r d e r t o b e t t e r understand what nurses do i n a t t e m p t i n g t o d e a l w i t h e t h i c a l problems (see a l s o Chapter F i v e ) . Working c l o s e l y w i t h s i x s t a f f n u r s e s , I undertook a p p r o x i m a t e l y 180 hours o f f i e l d w o r k as a p a r t i c i p a n t - o b s e r v e r on an acute m e d i c a l u n i t i n a community h o s p i t a l , and a p p r o x i m a t e l y 38 hours of f i e l d w o r k as a p a r t i c i p a n t - o b s e r v e r on a second acute m e d i c a l u n i t i n a t e r t i a r y h o s p i t a l . I i n c l u d e d f o r m a l r e s e a r c h i n t e r v i e w s w i t h t h e s e s i x nurses t o supplement my o b s e r v a t i o n s . My f i e l d w o r k a l s o i n c l u d e d r e s e a r c h i n t e r v i e w s w i t h f i v e c l i n i c i a n s / n u r s e managers from t h e two h o s p i t a l s so t h a t I c o u l d b e t t e r understand t h e o r g a n i z a t i o n a l c o n t e x t w i t h i n which nurses' e x p e r i e n c e s were l o c a t e d . F i n a l l y , I i n t e r v i e w e d t h r e e home c a r e nurses i n o r d e r t o b e t t e r understand some of t h e broader community i s s u e s and i d e o l o g i e s . A r t i c u l a t i n g Relevance Developing E t h i c a l Theory Working from w i t h i n a f e m i n i s t t h e o r e t i c a l c o n t e x t , one o f my a s p i r a t i o n s has been t o c o n t r i b u t e t o t h e o r y development i n a p p l i e d e t h i c s ( h e a l t h c a r e e t h i c s and p r o f e s s i o n a l e t h i c s ) by g e n e r a t i n g e m p i r i c a l work on the moral agency of h e a l t h c a r e p r o f e s s i o n a l s . H e a l t h c a r e p r o f e s s i o n a l s such as nurses are c o n s i d e r e d t o have a p a r t i c u l a r k i n d o f moral agency because o f t h e unique knowledge and s k i l l s — a n d hence p o w e r — t h e y h o l d (Danis & C h u r c h i l l , 1991; Fowler, 1990b; J e n n i n g s , C a l l a h a n , & Wolf, 1987; P o f f & Waluchow, 1991). Yet our knowledge of t h e e t h i c s o f p r o f e s s i o n a l p r a c t i c e i s f a r from complete (Brunk, 1991; P e l l e g r i n o , V e a t c h , & Langan, 1991; Saks, 1995). As P e l l e g r i n o , V e a t c h , and Langan e x p l a i n , "...the whole e d i f i c e o f e t h i c s i n t h e p r o f e s s i o n s has become p r o b l e m a t i c . P r o f e s s i o n a l s themselves are confused about th e nature of t h e i r o b l i g a t i o n and t h e moral v a l u e s t h a t ought t o govern t h e i r r e l a t i o n s h i p s w i t h t h o s e who seek t h e i r h e l p " (p. v i i ) . Thus, we do not know a g r e a t d e a l about how nurses and o t h e r h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s enact t h e i r moral agency. We need t o have a b e t t e r sense of t h i s i f we are t o support t h e e t h i c a l p r a c t i c e o f nurses and our c o l l e a g u e s i n o t h e r d i s c i p l i n e s . How can t h e k i n d o f e m p i r i c a l work generated i n t h i s s tudy c o n t r i b u t e t o t h e o r e t i c a l work on moral agency? To b e g i n t o answer t h i s q u e s t i o n r e q u i r e s some r e f l e c t i o n on t h e shortcomings o f t r a d i t i o n a l p o s i t i v i s t c o n c e p t i o n s o f e t h i c s and m o r a l i t y (Hoffmaster, 1990). As one t h e o r i s t c l a i m s : I n t h e i r a n a l y s e s o f complex s i t u a t i o n s , e t h i c i s t s o f t e n appear g r a n d l y o b l i v i o u s t o t h e s o c i a l and c u l t u r a l c o n t e x t i n which t h e s e o c c u r , and indeed t o e m p i r i c a l r e f e r e n t s o f any s o r t . Nor do t h e y seem v e r y c o n s c i o u s o f t h e c u l t u r a l s p e c i f i c i t y o f many of t h e v a l u e s and procedures they u t i l i z e when making e t h i c a l judgements (Weisz, 1990, p. 3 ) . A growing number of e t h i c i s t s b e l i e v e t h a t t h e s o l u t i o n t o such d i s c i p l i n a r y problems l i e s i n a contextualist approach t o e t h i c s and m o r a l i t y , 1 1 which focuses on the r e a l w o r l d o f p r a c t i c e (Hoffmaster, 1990; 1993; W i n k l e r , 1993). And "understanding t h e p r a c t i c e o f m o r a l i t y r e q u i r e s t h a t t h i s p r a c t i c e be l o c a t e d i n i t s s o c i a l and h i s t o r i c a l c o n t e x t s " (Hoffmaster, 1990, p. 250). T h i s i s p r e c i s e l y what I am hoping t o a c h i e v e — t o l o c a t e nurses * enactment of t h e i r moral agency w i t h i n t h e s o c i a l and h i s t o r i c a l ( c u l t u r a l ) c o n t e x t o f t h e h e a l t h c a r e o r g a n i z a t i o n , and t h e n use t h e s e d a t a t o r e f l e c t back on p h i l o s o p h i c a l n o t i o n s o f moral agency. I n f a c t , Hoffmaster (1993) and a c o l l e a g u e ( J e n n i n g s , 1990) have p o i n t e d out t h a t e t h n o g r a p h i c s t u d i e s are p a r t i c u l a r l y s u i t e d f o r such a purpose. Some t h e o r i s t s have c a l l e d t h i s dual mode inquiry, whereby f a c t and v a l u e i n q u i r y a r e combined 1 2 t o 1 1 The major d i v i s i o n s of ethics as a d i s c i p l i n e include d e s c r i p t i v e e t h i c s , normative e t h i c s , and metaethics (Fowler, 1987; Fry, 1987; Yeo, 1991). Descriptive ethics e n t a i l s f a c t u a l descriptions of moral behavior and b e l i e f systems or b e l i e f s ; normative ethics e n t a i l s the formulation and defense of basic p r i n c i p l e s , values, v i r t u e s , and i d e a l s governing moral behavior; and metaethics e n t a i l s an analysis of meaning, j u s t i f i c a t i o n , and inferences of moral terms, concepts, and statements (Fowler, 1987, pp. 26-29). Whereas the term ethi c s usually r e f e r s to the above as a formal f i e l d of inquiry, morality usually r e f e r s to personal a t t r i b u t e s and actions. The terms are often used interchangeably, but I w i l l adhere to t h i s d i s t i n c t i o n whenever possible. 1 2 This implies that facts are separate from values, but the d i s t i n c t i o n between the two forms of inquiry may not be absolute (Jennings, 1990). Yeo (1994) warns that distinctions between f a c t s and values are "the wrong s t a r t i n g point for moral enquiry" (p. 90). He notes that the "description of the problem s i t u a t i o n [the facts] i s constructed, and constructed enhance t h e o r y development i n e t h i c s ( Fowler, 1990a; Jameton & Fowler, 1989). I n t e r e s t i n g l y , s c h o l a r s o f both moral t h e o r y ( B a i e r , 1994; Flanagan, 1991) and a p p l i e d e t h i c s ( Hoffmaster, 1990; 1991; 1993; J e n n i n g s , 1990; Stevenson, 1987; W i n k l e r , 1993) a r e c a l l i n g f o r more i n q u i r y o f t h i s genre. S t r e n g t h e n i n g The Health Care System One o f t h e c h a l l e n g e s t h a t I f a c e d a t t h e o u t s e t o f my st u d y was t o a r t i c u l a t e how t h e nurses' v o i c e s I am p r o f i l i n g would be o f b e n e f i t t o t h e h e a l t h c a r e s y s t e m . 1 3 C l e a r l y , t h i s i s something t h a t I w i l l r e t u r n t o i n t h e f i n a l Chapters o f t h i s t h e s i s . However, I would a l s o l i k e t o l a y out some o f my t h i n k i n g h ere. The Canadian h e a l t h c a r e system i s c u r r e n t l y undergoing a s i g n i f i c a n t p e r i o d o f r e f o r m and renewal (Evans, 1990; R a c h l i s & Kushner, 1994; S t o r c h & M e i l i c k e , 1994). T h i s has r e s u l t e d from v a r i o u s s o c i a l , p o l i t i c a l , p h i l o s o p h i c a l , and economic f o r c e s , such as t h e a g i n g o f t h e p o p u l a t i o n , t h e r i s e o f new t e c h n o l o g y , an emphasis on t h e determ i n a n t s o f h e a l t h , t h e consumer movement, and t h e changing c u l t u r a l and sociodemographic c h a r a c t e r i s t i c s o f t h e Canadian p o p u l a t i o n (Badets & C h u i , 1994; L e F o r t , 1993). These same f o r c e s have generated a number of e t h i c a l problems throughout t h e h e a l t h c a r e system (Buchanan, 1989; Denton & Spencer, 1988; F r y , 1988; Kluge, 1988; 1992; S t o r c h , 1992). I t f u r t h e r seems t h a t e t h i c a l problems of r e s o u r c e a l l o c a t i o n have come t o dominate o r d i f f e r e n t l y by d i f f e r e n t players. As such, i t i s not morally neutral" (Yeo, 1994, p. 92). Indeed, Yeo (1994) claims that f a c t s and values are "co-dependent" (p. 95). 1 3 I am g r a t e f u l to the Canadian National Health Research and Development Program for providing funding to support t h i s study. I am also g r a t e f u l to Dr. Joan Anderson of the University of B r i t i s h Columbia (UBC) School of Nursing for her encouragement to a r t i c u l a t e the relevance of the study. confound most o t h e r e t h i c a l problems (Rodney & S t a r z o m s k i , 1994; see a l s o S c a n l o n , 1996/1997; S i b b a l d , 1997; S t o r c h , 1992; Watson, 1994). The e x t e n t o f t h e c u r r e n t r e f o r m and renewal, which must g r a p p l e w i t h d i f f i c u l t i s s u e s o f c o s t containment and r e s o u r c e a l l o c a t i o n (Evans, 1990; R a c h l i s & Kushner, 1994; Yeo, 1993), i s r e f l e c t e d i n a s i g n i f i c a n t number of p r o v i n c i a l r e p o r t s and commissions on h e a l t h . These i n c l u d e , f o r example, Closer to Home: The Report of the B r i t i s h Columbia Royal Commission on Health Care and Costs ( B r i t i s h Columbia R o y a l Commission on H e a l t h Care and C o s t s , 1991), and Improving Health and Weil-Being in Quebec (Government of Quebec, 1989). Observers warn t h a t u n l e s s t h e Canadian h e a l t h c a r e system i s s u c c e s s f u l i n i t s r e f o r m and r e n e w a l , t h e f i v e p r i n c i p l e s under which i t operates ( u n i v e r s a l i t y , a c c e s s i b i l i t y , p o r t a b i l i t y , comprehensiveness, and p u b l i c a d m i n i s t r a t i o n ) w i l l be t h r e a t e n e d ( B e t k o w s k i , 1994; Helms, James, & Rodney, 1996; R a c h l i s & Kushner, 1994; S t o r c h , 1988). I n h e r e n t i n t h e s e f i v e p r i n c i p l e s i s t h e use o f c o n c e n t r a t e d p u b l i c a u t h o r i t y t o balance t h e power of h e a l t h c a r e p r o f e s s i o n a l s so t h a t they a c t on b e h a l f of t h e p u b l i c r a t h e r than on t h e b a s i s o f t h e i r s e l f - i n t e r e s t ( B a r e r & Evans, 1992). Strengthening the r e s p o n s i b i l i t y and a c c o u n t a b i l i t y of health care professionals i s thus central to reform and renewal. To a c h i e v e t h i s s t r e n g t h e n i n g , a f i r m f o u n d a t i o n i n t h e e t h i c s o f p r o f e s s i o n a l p r a c t i c e i s r e q u i r e d , p a r t i c u l a r l y as t h e r e i s e m p i r i c a l evidence o f t h e s e r i o u s n e s s and r e c a l c i t r a n c e o f t h e e t h i c a l problems w i t h i n t h e h e a l t h c a r e system. A b e t t e r u n d e r s t a n d i n g o f t h e e t h i c s of p r a c t i c e o f h e a l t h c a r e p r o f e s s i o n a l s i s needed, and e t h i c a l t h e o r y , e s p e c i a l l y i n terms o f moral agency, must be developed t o h e l p support t h a t p r a c t i c e . I t i s my b e l i e f t h a t t h i s study h e l p s t o a c h i e v e both t h e s e ends. By c o n t r i b u t i n g t o t h e u n d e r s t a n d i n g of t h e e t h i c s o f p r a c t i c e o f one group of h e a l t h c a r e p r o f e s s i o n a l s , i t s e t s t h e stage f o r a b e t t e r u n d e r s t a n d i n g of t h e e n t i r e team. And by a t t e n d i n g t o t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t w i t h i n which nurses and o t h e r h e a l t h c a r e p r o f e s s i o n a l s p r a c t i c e , t h i s study h e l p s t o e x p l a i n t h e s o u r c e s , and thus th e p o t e n t i a l f o r r e s o l u t i o n , o f problems such as fragmented team and/or departmental communication. Such a r e s o l u t i o n i s v i t a l , because r e s e a r c h i n d i c a t e s t h a t fragmented team communication may worsen p a t i e n t outcomes (Baggs & S c h m i t t , 1988; Baggs, Ryan, P h e l p s , R i c h e s o n , & Johnson, 1992; Busby & G i l c h r i s t , 1992; F i s h e r & P e t e r s o n , 1993; M i t c h e l l , Armstrong, Simpson, & L e n t z , 1989). O v e r a l l , I i n t e n d t h i s study t o c o n t r i b u t e t o t h e knowledge necessary t o make t h e c u l t u r e of h e a l t h c a r e o r g a n i z a t i o n s more conducive t o t h e e t h i c a l and e f f e c t i v e p r a c t i c e o f nurses and a l l o t h e r h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s . I n t h e words of an e t h i c i s t who i s , I b e l i e v e , p a r t i c u l a r l y c o g n i z a n t o f t h e r e a l i t i e s o f t h e p r a c t i c e w o r l d w i t h i n which n u r s i n g i s l o c a t e d , "we want, as p a r t i c i p a n t s i n i n s t i t u t i o n a l c u l t u r e , t o be a b l e t o n o t i c e our moral problems and t o cope w i t h them w i t h s e n s i t i v i t y and i n t e g r i t y and t o keep our h e a l t h c a r e i n s t i t u t i o n s r e s p o n s i v e t o t h e i r moral g o a l s " (Jameton, 1990, p. 450). CHAPTER TWO: EXPLORING THE META-THEORETICAL CONTEXT I n t r o d u c t i o n W i t h i n t h i s s t u d y , I am p r o f i l i n g t h e v o i c e s o f nurses on t h e f r o n t l i n e s of p a t i e n t c a r e , nurses who p r a c t i c e i n h e a l t h c a r e o r g a n i z a t i o n s w i t h a w e l l - e n t r e n c h e d c u l t u r e o f gendered power r e l a t i o n s h i p s . T h e r e f o r e , I have l o c a t e d t h e meta-t h e o r e t i c a l c o n t e x t f o r t h i s s tudy w i t h i n f e m i n i s t t h e o r y . As I e x p l a i n e d i n Chapter One, I am u s i n g f e m i n i s t s t a n d p o i n t t h e o r y ( p r o c e e d i n g from women's l i v e s ) t o i n f o r m t h e e p i s t e m o l o g y and on t o l o g y u n d e r l y i n g my r e s e a r c h . My approach t o r e s e a r c h methodology and methods i s i n f l u e n c e d throughout by f e m i n i s t s o c i o l o g i s t s , f e m i n i s t s c h o l a r s i n e d u c a t i o n , and f e m i n i s t n u r s i n g s c h o l a r s , and my approach t o e t h i c a l t h e o r y has been informed by f e m i n i s t e t h i c i s t s . Having l o c a t e d my meta-t h e o r e t i c a l c o n t e x t , I w i l l make use o f t h i s Chapter t o f u r t h e r e x p l o r e i t . Given t h e profound changes i n the p h i l o s o p h y o f s c i e n c e t o which every d i s c i p l i n e i s w i t n e s s today, and g i v e n t h a t f e m i n i s t t h e o r y has f l o u r i s h e d c o n c o m i t a n t l y w i t h t h e s e changes ( L a t h e r , 1991; Luke & Gore, 1992; Tuana & Tong, 1995), I w i l l b e g i n w i t h some comments about t h e p h i l o s o p h y o f s c i e n c e . T h i n k i n g About the Philosophy of Scie n c e Which Paradigm(s)? S i n c e Kuhn's (1970) landmark t e x t , r e v o l u t i o n s (or e v o l u t i o n s [Laudan, 1977]) i n t h e paradigms of s c i e n c e have become i n c r e a s i n g l y v i s i b l e i n d i v e r s e f i e l d s o f human i n q u i r y . Many of th e s e changes have been based on an e p i s t e m o l o g y which " r e j e c t s f o u n d a t i o n a l t r u t h s l o c a t e d i n d i s c i p l i n a r y knowledge and r e j e c t s t h e u n i t a r y r a t i o n a l i s t s u b j e c t as f o u n d a t i o n a l t o a l l knowledge" (Luke & Gore, 1992, p. 5 ) . T h i s epistemology has been d e f i n e d as n a t u r a l i z e d (Dancy, 1985, p. 235; K o r n b l i t h , 1985), and c l a i m s t h a t d e s c r i p t i v e ( f a c t u a l , " i s " ) q u e s t i o n s have an im p o r t a n t b e a r i n g on v a l u e (normative, " o u g h t " ) 1 4 q u e s t i o n s . 1 5 ( K o r n b l i t h ; S t a r z o m s k i & Rodney, 1997). Paradigms i n t h e p h i l o s o p h y o f s c i e n c e a r e d i f f i c u l t t o d e l i n e a t e because they are c o n c e p t u a l i z e d d i f f e r e n t l y by d i f f e r e n t t h e o r i s t s , and because they are not s t a t i c . I have found i t u s e f u l t o c a t e g o r i z e them i n accordance w i t h Guba's (1990) o u t l i n e of t h e paradigms t h a t guide i n q u i r y because he makes e x p l i c i t t h e r e l a t i o n s h i p s between t h e paradigms, t h e i r u n d e r l y i n g e p i s t e m o l o g y and o n t o l o g y , and t h e r e s u l t a n t methodology and methods. 1 6 Guba o u t l i n e s f o u r paradigms, d i f f e r e n t i a t i n g them on the b a s i s o f o n t o l o g y (what i s t h e n a t u r e 1 4 I t i s worth noting here that the d i s t i n c t i o n between " i s " and "ought" has h i s t o r i c a l l y been important i n philosophy. Philosophers have warned of the " n a t u r a l i s t i c f a l l a c y " of arguing from i s to ought. We are cautioned not to deduce conclusions about what ought to be from premises that state only what i s the case; or the other way about....For instance, because a c e r t a i n kind of conduct i s natural to most of us, because that i s something to which most of us are n a t u r a l l y i n c l i n e d , therefore [we should not conclude] that i t i s l i c i t i f not p o s i t i v e l y obligatory (Flew, 1979, pp. 240-241). 1 5 In philosophy, "normative" has to do with questions of value. However, within the s o c i a l sciences, the word holds a somewhat d i f f e r e n t meaning— normative implies what i s standard, and hence normal. Given that philosophers and s o c i a l s c i e n t i s t s understand the word somewhat d i f f e r e n t l y , I w i l l favour the term "value" i n place of normative throughout t h i s t h e s i s . I would l i k e to thank Dr. Joan Anderson for bringing t h i s i n t e r d i s c i p l i n a r y conceptual issue to my attention. 1 6 Nonetheless, Guba (1990) notes that his i s only "one way to understand the paradigm issue" (p. 18). o f t h e knowable?), e p i s t e m o l o g y (what i s t h e n a t u r e o f t h e r e l a t i o n s h i p between t h e knower and t h e known?), and methodology (how s h o u l d t h e i n q u i r e r go about f i n d i n g out knowledge?) (p. 18). The f o u r paradigms t h a t he i d e n t i f i e s a re p o s i t i v i s m , p o s t p o s i t i v i s m , c o n s t r u c t i v i s m , and c r i t i c a l t h e o r y (Guba, pp. 19-27). Guba (1990) d e f i n e s p o s i t i v i s m as c o n v e n t i o n a l i n q u i r y , which i s r o o t e d i n a r e a l i s t o n t o l o g y ( r e a l i t y e x i s t s "out t h e r e " ) , a d u a l i s t / o b j e c t i v i s t e p i s t e m o l o g y (the i n q u i r e r stands back and puts q u e s t i o n s d i r e c t l y t o nat u r e and a l l o w s n a t u r e t o answer back d i r e c t l y ) , and an e x p e r i m e n t a l / m a n i p u l a t i v e methodology (pp. 19-20). Postpositivism i s a m o d i f i e d v e r s i o n o f p o s i t i v i s m , and has a c r i t i c a l r e a l i s t o n t o l o g y ( r e a l i t y e x i s t s out t h e r e but can never be f u l l y apprehended), a m o d i f i e d o b j e c t i v i s t e pistemology ( o b j e c t i v i t y remains a r e g u l a t o r y i d e a l , but can o n l y be approximated), and a m o d i f i e d e x p e r i m e n t a l / m a n i p u l a t i v e methodology ( i n q u i r y i s done i n more n a t u r a l s e t t i n g s , u s i n g more q u a l i t a t i v e methods, depending more on grounded t h e o r y , and r e i n t r o d u c i n g d i s c o v e r y ) (Guba, pp. 21-23). Constructivism i s founded on a r e l a t i v i s t o n t o l o g y ( r e a l i t i e s e x i s t i n t h e form o f m u l t i p l e mental c o n s t r u c t i o n s ) , a s u b j e c t i v i s t e p i s t e m o l o g y ( i n q u i r e r and i n q u i r e d a re f u s e d i n t o a s i n g l e e n t i t y ) , and a hermeneutic, d i a l e c t i c methodology ( i n d i v i d u a l c o n s t r u c t i o n s a r e e l i c i t e d and r e f i n e d h e r m e n e u t i c a l l y , and compared and c o n t r a s t e d d i a l e c t i c a l l y , w i t h t h e aim o f g e n e r a t i n g one, o r a few, c o n s t r u c t i o n s on which t h e r e i s s u b s t a n t i a l consensus) (Guba, pp. 25-27). The f o u r t h paradigm Guba c a l l s c r i t i c a l theory. Guba c l a i m s t h a t t h e c r i t i c a l t h e o r y paradigm has a c r i t i c a l r e a l i s t o n t o l o g y (as i n t h e case o f p o s t p o s i t i v i s m ) , a s u b j e c t i v i s t e p i s t e m o l o g y ( i n t h e sense t h a t v a l u e s mediate i n q u i r y ) , and a d i a l o g i c , t r a n s f o r m a t i v e methodology ( t h a t e l i m i n a t e s f a l s e c o n s c i o u s n e s s and e n e r g i z e s and f a c i l i t a t e s t r a n s f o r m a t i o n ) (pp. 24-25). I t i s i m p o r t a n t t o note t h a t Guba (1990) c o n s i d e r s t h e c r i t i c a l t h e o r y paradigm t o have a r e a l i s t o n t o l o g y because t h e phrase " f a l s e c o n s c i o u s n e s s " i m p l i e s t h a t t h e r e i s a " t r u e c o n s c i o u s n e s s " somewhere "out t h e r e " (p. 24). T h i s i s c o n t r a d i c t e d by a f e l l o w s c h o l a r w r i t i n g i n t h e same volume (Schwandt, 1990, p. 274), who c i t e s B e r n s t e i n (1978, p. 109) as c l a i m i n g t h a t "we can show the f a l s i t y o f an i d e o l o g y w i t h o u t c l a i m i n g t h a t we have a c h i e v e d a f i n a l , a b s o l u t e , ' t r u e ' u n d e r s t a n d i n g o f s o c i a l and p o l i t i c a l r e a l i t y " . 1 7 I t i s a l s o i m p o r t a n t t o note t h a t t h e term c r i t i c a l t h e o r y f o r t h i s paradigm i s not u n p r o b l e m a t i c . As Guba e x p l a i n s , t h e term i s : no doubt inadequate t o encompass a l l t h e a l t e r n a t i v e s t h a t can be swept i n t o t h i s c a t e g o r y o f paradigm. A more a p p r o p r i a t e l a b e l would be " i d e o l o g i c a l l y o r i e n t e d i n q u i r y " , i n c l u d i n g neo-Marxism, m a t e r i a l i s m , feminism, F r e i r e i s m , p a r t i c i p a t o r y i n q u i r y , and o t h e r s i m i l a r movements as w e l l as c r i t i c a l t h e o r y i t s e l f (p. 23). I wonder i f some f e m i n i s t t h e o r i s t s might o b j e c t t o b e i n g c a t e g o r i z e d w i t h t h e o r i s t s such as n e o - M a r x i s t s , 1 8 but I do t h i n k t h a t Guba's c l a s s i f i c a t i o n has some u t i l i t y . I w i l l t h e r e f o r e 1 7 I am i n c l i n e d to agree with Schwandt (1990). See my l a t e r discussion of Bernstein's (1991) horizons. 1 8 However, Lather (1991) appears to share t h i s type of c l a s s i f i c a t i o n . She states that "the various feminisms, neo-Marxisms and some of the poststructuralisms, then, become kinds of c r i t i c a l theories which are informed by i d e n t i f i c a t i o n with and i n t e r e s t i n oppositional s o c i a l movements." (p. 3) r e f e r t o t h i s paradigm as c r i t i c a l t o a v o i d c o n f l a t i o n w i t h Habermas' C r i t i c a l S o c i a l T h e o r y . 1 9 I n comparing t h e v a r i o u s paradigms, Guba (1990) s t a t e s t h a t none of them s h o u l d be seen as t h e paradigm o f c h o i c e — e a c h o f them has t h e i r own m e r i t s (p. 2 7 ) . Schwandt (1990), comparing t h e c o n s t r u c t i v i s t and c r i t i c a l paradigms, e x p l a i n s t h a t t h e c o n s t r u c t i v i s t methodologies are concerned w i t h t h e r e s t o r a t i o n o f t h e meaning of human e x p e r i e n c e , w h i l e c r i t i c a l methodologies are concerned w i t h s y s t e m a t i c a l l y i n v e s t i g a t i n g t h e manner i n which t h a t e x p e r i e n c e may be d i s t o r t e d by f a l s e c o n s c i o u s n e s s and i d e o l o g y (p. 268). When I f i r s t became aware o f Guba's (1990) d i s t i n c t i o n s , i t seemed t o me t h a t t h e r e was an o p p o r t u n i t y f o r me t o employ both paradigms s e p a r a t e l y . I n e p i s t e m o l o g i c a l terms, t h e c o n s t r u c t i v i s t (the " i s " ) paradigm would h e l p me w i t h t h e d e s c r i p t i v e work of my s t u d y , w h i l e t h e c r i t i c a l paradigm would h e l p me w i t h t h e v a l u e work (the "ought"). However, I have come t o l e a r n t h a t t h e boundaries between t h e two paradigms are not a b s o l u t e , and so I understand t h a t I am employing a synthesis o f th e two. /Another t h e o r i s t (Schwandt [T.A.], 1994) argues f o r " d i s s o l v i n g l o n g - s t a n d i n g d i c h o t o m i e s such as s u b j e c t / o b j e c t , knower/known, f a c t / v a l u e " (p. 132). He c l a i m s t h a t "we can 19 Habermas' (1984) project i n C r i t i c a l S o c i a l Theory i s to provide a reasoned c r i t i q u e of Western rationalism, with an assessment of the p r o f i t s and losses e n t a i l e d by "progress"(McCarthy, 1984, pp. v i i - v i i i ) . He wants to use both empirical and p h i l o s o p h i c a l i n q u i r y (McCarthy, p. ix) to construct a meaningful c r i t i q u e of society; thereby providing normative d i r e c t i o n f o r change. So f a r he has a r r i v e d at some admittedly tentative conclusions about the nature of p o l i t i c a l i n t e g r a t i o n i n p o s t l i b e r a l s o c i e t i e s , family s o c i a l i z a t i o n and ego development, mass media and mass culture, and p o t e n t i a l s for protest (Habermas, 1989, pp. 297-310). Habermas also t e l l s us that we must understand c u l t u r a l behavior i f d e l i b e r a t i o n of basic s o c i e t a l goals i s to take place (Wuthnow, Hunter, Bergesen, & Kurzweil, 1984, pp. 254-255). c o n t i n u e t o r e s p e c t t h e b i d t o make sense of t h e c o n d i t i o n s o f our l i v e s w i t h o u t c l a i m i n g t h a t e i t h e r i n q u i r e r o r a c t o r i s t h e f i n a l a r b i t e r o f u n d e r s t a n d i n g " (Schwandt, 1994, p. 132). Making a s i m i l a r p o i n t about i n q u i r y i n a p p l i e d e t h i c s , Yeo (1994) e x p l a i n s : F a c t s i n moral e x p e r i e n c e and debate are not t h e d i s c r e t e atoms o f t h e s c i e n t i s t . They are c o n f i g u r e d , as f a c t s , i n h o r i z o n s marked by what we v a l u e o r p r i z e . And v a l u e s are not t h e f r e e - f l o a t i n g p r i n c i p l e s o f t h e moral t h e o r i s t ; t h e y a r e grounded, as v a l u e s , i n our e m o t i o n a l and b o d i l y ways of e n v i s i o n i n g t h e w o r l d i n i t s f a c t i c i t y . The elementary c a t e g o r y i s n e i t h e r f a c t , nor v a l u e , but meaning [my emphasis]. To paraphrase Kant, v a l u e s w i t h o u t f a c t s a r e empty, f a c t s w i t h o u t v a l u e s are b l i n d (p. 95). I am i n t e r e s t e d i n t h e meaning t h a t nurses c o n s t r u c t about t h e i r e x p e r i e n c e s e n a c t i n g t h e i r moral agency, and I am i n t e r e s t e d i n how t h e o r g a n i z a t i o n a l c o n t e x t and i d e o l o g i e s a f f e c t nurses' e x p e r i e n c e s . Thus, I employed a f e m i n i s t e t h n o g r a p h i c methodology, which has elements o f both t h e c o n s t r u c t i v i s t and c r i t i c a l paradigms (see a l s o Chapter F i v e ) . 2 0 W h i l e I do not t h i n k t h a t t h e boundaries between f a c t s and v a l u e s s h o u l d be e r a d i c a t e d (a p o i n t t h a t Yeo [1994] a l s o makes), I do b e l i e v e i n making t h e boundaries permeable t o t h e e x t e n t t h a t i n t e r - s u b j e c t i v e l y c o n s t r u c t e d f a c t s inform i n q u i r y about v a l u e s . And t o t h e e x t e n t t h a t f a c t s and v a l u e s are understood as not a b s o l u t e , b u t , r a t h e r , as c o n s t r u c t e d out o f t h e meanings t h a t ^° I t seems to me that Geertz (1973) a r t i c u l a t e s the p o t e n t i a l dangers of using a c o n s t r u c t i v i s t paradigm alone and taking i t too l i t e r a l l y . He says: The besetting s i n of i n t e r p r e t i v e [ c o n s t r u c t i v i s t ] approaches to anything...is that they tend to r e s i s t , or to be permitted to r e s i s t , conceptual a r t i c u l a t i o n and thus to escape systematic modes of assessment. You e i t h e r grasp an i n t e r p r e t a t i o n or you do not, see the point of i t or you do not, accept i t or you do not. Imprisoned in the immediacy of its own detail [my emphasis], i t i s presented as s e l f -v a l i d a t i n g , or, worse, as validated by the supposedly developed s e n s i t i v i t i e s of the person who presents i t ; any attempt to cast what i t says i n terms other than i t s own i s regarded as a travesty .... (p. 24) . r e s e a r c h e r s , p a r t i c i p a n t s , and r e a d e r s b r i n g t o t h e c o n t e x t o f i n q u i r y . The f e m i n i s t e t h n o g r a p h i c methodology and methods t h a t I have used i n t h i s s tudy have been s e l e c t e d t o a c h i e v e t h e s e ends. N e g o t i a t i n g the Postmodern Why d i d I f e e l t h a t i t was imp o r t a n t t o use a s y n t h e s i s o f bot h t h e c o n s t r u c t i v i s t and c r i t i c a l paradigms? Answering t h i s means embarking on a more a b s t r a c t t e r r a i n t h a n t h a t l a i d out by Guba ( 1 9 9 0 ) — i t r e q u i r e s t h a t I n e g o t i a t e t h e postmodern. The postmodern c o n d i t i o n : i n v o l v e s t h e r e j e c t i o n o f a l l e s s e n t i a l i s t and t r a n s c e n d e n t a l c o n c e p t i o n s o f human n a t u r e ; t h e r e j e c t i o n o f u n i t y , homogeneity, t o t a l i t y , c l o s u r e and i d e n t i t y ; t h e r e j e c t i o n o f t h e p u r s u i t o f t h e r e a l and t h e t r u e . I n t h e p l a c e o f the s e i l l u s o r y i d e a l s we f i n d t h e a s s e r t i o n t h a t man i s a s o c i a l , h i s t o r i c a l o r l i n g u i s t i c a r t i f a c t ; t h e c e l e b r a t i o n o f f r a g m e n t a t i o n , p a r t i c u l a r i t y and d i f f e r e n c e ; t h e acceptance o f t h e c o n t i n g e n t and apparent ( S q u i r e s , 1993, p. 2 ) . Postmodernism "has been g i v e n t h e o r e t i c a l substance by t h e works o f t h e French p o s t s t r u c t u r a l i s t s (who themselves had l i t t l e use f o r t h e te r m . . . ) " (Marcus, 1994, p. 5 6 4 ) . 2 1 L a t h e r (1991) d e f i n e s postmodernism as "the l a r g e r c u l t u r a l s h i f t s o f a p o s t -i n d u s t r i a l , p o s t - c o l o n i a l e r a " and p o s t s t r u c t u r a l i s m as "the working out o f those s h i f t s w i t h i n t h e arenas o f academic t h e o r y " (p. 4 ) . I t i s impo r t a n t t o note, though, t h a t t h e r e a re a number o f v a r i a t i o n s i n how these "post" terms a r e used. W r i t i n g from an Z i One of the most i n f l u e n t i a l p o s t s t r u c t u r a l i s t s i s Foucault (although the nature of h i s work i s such that he would r e s i s t categorization i n a s p e c i f i c i n t e l l e c t u a l genre [Rabinow, 1984]). Foucault's project i s to examine knowledge and power; demonstrating that asymmetries of power tend to e x i s t i n the structure of knowledge i t s e l f (Wuthnow et a l . , 1984, p. 253). "The dictum 'knowledge i s power1 i s true i n the most l i t e r a l sense, according to Foucault" (Wuthnow et a l . , p. 253) Foucault sees "a form of c r i t i c a l h i s t o r i c i s m as the only road to preserving reason and the obli g a t i o n . . . t o forge an ascetic ethic of s c i e n t i f i c and p o l i t i c a l r e s p o n s i b i l i t y as the highest duty of the mature i n t e l l e c t u a l " (Rabinow, p. 27) . A u s t r a l i a n p e r s p e c t i v e , Luke and Gore (1992) o f f e r t h e f o l l o w i n g c l a r i f i c a t i o n : The p o s t s t r u c t u r a l i s t agenda focuses on t h e d e c o n s t r u c t i o n o f t a k e n - f o r - g r a n t e d h i s t o r i c a l s t r u c t u r e s o f s o c i o - c u l t u r a l o r g a n i z a t i o n s w i t h i n which v a r i o u s v e r s i o n s o f t h e " i n d i v i d u a l " have been i n s e r t e d and, i m p o r t a n t l y , on t h e language and t h e o r e t i c a l s t r u c t u r e s w i t h which t h e i n d i v i d u a l and t h e s o c i a l have been w r i t t e n . D e c o n s t r u c t i o n under t h e p o s t s t r u c t u r a l i s t banner i s most commonly r e f e r r e d t o as archaeology o f knowledge and has c h a r a c t e r i z e d much A u s t r a l i a n , B r i t i s h , and Canadian work. I n t h e U n i t e d S t a t e s , by c o n t r a s t , d e c o n s t r u c t i o n tends t o c l a i m a l l e g i a n c e w i t h what has been named postmodernism....Yet both p o s t s t r u c t u r a l i s m and postmodernism t a k e i s s u e w i t h t h e c e n t u r i e s - l o n g r u l e o f Enlightenment ep i s t e m o l o g y and t h e f i c t i o n s o f t h e i n d i v i d u a l t h a t i t spawned. Both r e j e c t t h e s e l f - c e r t a i n s u b j e c t , t h e t r u t h o f s c i e n c e and f i x i t y o f language, and t h e f u n c t i o n a l i s t o r d e r imputed t o t h e s o c i a l and t h e o r i e s o f t h e s o c i a l (p. 5 ) . However, "although l i b e r a t i n g , and even d e m o c r a t i s i n g , i n i t s r e f u s a l o f h i e r a r c h y and c e r t a i n t y , t h e postmodern c o n d i t i o n i s p a r a l y s i n g i n i t s d e c o n s t r u c t i o n o f a l l ' p r i n c i p l e d p o s i t i o n s ' " ( S q u i r e s , 1993, p. 1 ) . As another t h e o r i s t n o t e s , "the w r i t i n g s o f t h e s o - c a l l e d 'post-modern' i n t e l l e c t u a l s r a r e l y [ d e a l ] w i t h e t h i c a l - p o l i t i c a l i s s u e s , o r so i t [seems]" ( B e r n s t e i n , 1991, p. 5; see a l s o F r a s e r & N i c h o l s o n , 1990; L a t h e r , 1991; Watson, 1 9 9 5 ) . 2 2 What I t a k e from t h i s r e p r e s e n t a t i o n o f t h e postmodern t e r r a i n i s t h a t my commitment t o th e c o n s t r u c t i v i s t paradigm i s congruent w i t h postmodern c r i t i q u e s — i n t h a t knowledge i s seen as c o n s t r u c t e d — b u t my simultaneous commitment t o t h e c r i t i c a l paradigm may not b e — p a r t i c u l a r l y i f I want t o d e a l w i t h t h e e t h i c a l - p o l i t i c a l i s s u e s i n h e r e n t i n nurses' workplaces o r i f I want t o l o c a t e p r i n c i p l e d p o s i t i o n s from which t o generate change. See Marcus (1994) for a contrasting view. What I am i n need o f i s not j u s t knowledge of but a l s o knowledge for s o c i a l change; t h a t i s , praxis ( S t a n l e y , 1990, p. 15). Y e t , i n much o f t h e p o s t m o d e r n / p o s t s t r u c t u r a l d i s c o u r s e , t h e r e i s l i t t l e a t t e n t i o n t o p r a x i s ( B e r n s t e i n , 1991; L a t h e r , 1991) . I am thus drawn t o contemporary t h e o r i s t s who attempt t o r e c o n c i l e t h e t h e o r e t i c a l i n s i g h t s o f t h e postmodern w i t h a c a p a c i t y f o r s o c i a l change. Such t h e o r i s t s share a d e s i r e t o accept and r e t a i n some o f t h e g a i n s made by postmodernism, but a l s o r e c o g n i s e and attempt t o t r a n s c e n d t h e problems c r e a t e d by postmodern t e n d e n c i e s t o suppress v a l u e ( S q u i r e s , 1993, p. 5 ) . B e r n s t e i n (1991) d e s c r i b e s t h i s t r a n s c e n d e n t approach i n terms o f horizons o f v a l u e . He f e e l s t h a t t h e metaphor i s a p p r o p r i a t e because he does "not t h i n k t h a t t h e r e i s a s i n g l e a l l - e n c o m p a s s i n g e t h i c a l - p o l i t i c a l h o r i z o n o f 'modernity/postmodernity' but r a t h e r an i r r e d u c i b l e p l u r a l i t y o f h o r i z o n s " ( B e r n s t e i n , 1991, p. 10). Such h o r i z o n s aim t o "balance [my emphasis] a t h e o r e t i c a l r e j e c t i o n o f e s s e n t i a l i s m , o b j e c t i v i s m and u n i v e r s a l i s m w i t h a moral and p o l i t i c a l commitment t o non-oppressive, democratic and p l u r a l i s t i c v a l u e s " ( S q u i r e s , 1993, p. 6; see a l s o Luke & Gore, 1992; T a y l o r , 1991; 1992) . By t a k i n g a c o n s t r u c t i v i s t approach t o my stu d y , I have r e j e c t e d e s s e n t i a l i s m , o b j e c t i v i s m , and u n i v e r s a l i s m . I n o t h e r words, I do not b e l i e v e t h a t I c a p t u r e d one r e a l i t y t h a t i s "out t h e r e " . Rather, t o g e t h e r w i t h t h e nurses p a r t i c i p a t i n g i n my st u d y , I c o n s t r u c t e d one way o f u n d e r s t a n d i n g t h e i r e x p e r i e n c e s and t h e c o n t e x t w i t h i n which they p r a c t i c e . And t h a t way o f un d e r s t a n d i n g w i l l , I hope, open up p o s s i b i l i t i e s f o r change. By s i m u l t a n e o u s l y t a k i n g a c r i t i c a l ( f e m i n i s t ) approach t o my s t u d y , I made a moral and p o l i t i c a l commitment t o n o n - o p p r e s s i v e , d e m o c r a t i c , and p l u r a l i s t i c v a l u e s i n f a c i l i t a t i n g such change, and i n t h e way t h a t t h e study was conducted. Understanding the C o n t r i b u t i o n s of F e m i n i s t Theory Feminism and E t h i c a l / P o l i t i c a l Horizons A t t h i s p o i n t , I would l i k e t o say more about t h e abundant and v a r i e d c o n t r i b u t i o n s o f f e m i n i s t t h e o r y t h a t I have drawn on i n my c r i t i c a l approach. As I see i t , f e m i n i s t t h e o r y i s a l r e a d y v e r y much a p a r t o f t h e e t h i c a l - p o l i t i c a l h o r i z o n s t h a t B e r n s t e i n (1991) foreshadows. I t o f f e r s s i g n i f i c a n t d i r e c t i o n f o r p r a x i s because i t i s committed t o n on-oppressive, d e m o c r a t i c , and p l u r a l i s t i c v a l u e s . However, f e m i n i s t t h e o r y i s by no means a m o n o l i t h i c o r s t a t i c e n t i t y (Olesen, 1994). As L a t h e r (1991) e x p l a i n s : ...the v a r i e d moments i n t h e c o n j u n c t i o n o f feminism, neo-Marxism and p o s t s t r u c t u r a l i s m so e v i d e n t i n r e c e n t academic d i s c o u r s e f e e l t o me a h a r b i n g e r of a s h i f t i n t h e ways we t h i n k about what we know. While f u l l y acknowledging t h e amazing c a p a c i t y o f Western c u l t u r e t o absorb o p p o s i t i o n a l , counter-hegemonic movements..., we seem somewhere i n t h e m i d s t o f a s h i f t away from a view of knowledge as d i s i n t e r e s t e d and toward a c o n c e p t u a l i z a t i o n o f knowledge as c o n s t r u c t e d , c o n t e s t e d , i n c e s s a n t l y p e r s p e c t i v a l and p o l y p h o n i c (p. x x ) . " P o l y p h o n i c " i s an i m p o r t a n t a d j e c t i v e i n t h i s c o n t e x t . L a t h e r goes on t o e x p l a i n t h a t : ...the v a r i e d emancipatory p r o j e c t s are d e - s t a b i l i z e d from a v a r i e t y o f d i r e c t i o n s : f e m i n i s t s s k e p t i c a l o f Marxism, M a r x i s t s s k e p t i c a l o f i d e n t i t y p o l i t i c s f ocused on r a c e , gender o r s e x u a l o r i e n t a t i o n , p o s t s t r u c t u r a l s u s p i c i o n o f a l l who c l a i m t o be on t h e o u t s i d e o f regimes of t r u t h (p. 12). Feminism's c r i t i q u e o f male-dominated t h e o r i e s t h e r e f o r e i n c l u d e s c r i t i c i s m o f o t h e r t h e o r i e s o p e r a t i n g from a c r i t i c a l paradigm ( B r o d r i b b , 1992; F e l s k i , 1989; K y m l i c k a , 1990; Luke & Gore, 1992; W a l l a c e , 1989). As I w r i t e , t h e r e i s an emerging l i t e r a t u r e e x p l o r i n g t h e r e l a t i o n s h i p s and t e n s i o n s between t h e s e v a r i e d t h e o r i e s ( f o r example, feminism v i s - a - v i s Habermas [Meehan, 1995], and feminism v i s - a - v i s F o u c a u l t [Diamond & Quinby, 1988]). I m p o r t a n t l y , some f e m i n i s t s are c r i t i c a l o f f e m i n i s t t h e o r y i t s e l f ( F r a s e r & N i c h o l s o n , 1990; H i r s c h & K e l l e r , 1990). F e m i n i s t t h e o r y has been c r i t i c i z e d f o r l a c k i n g t h e c a p a c i t y t o i n i t i a t e s o c i a l change ( F e l s k i , 1989; Gore, 1992), and f o r i g n o r i n g t h e i n t e r s e c t i o n s o f c l a s s , r a c e , e t h n i c i t y , age, and s e x u a l o r i e n t a t i o n w i t h gender i n o p p r e s s i o n ( B a n n e r j i , 1993; C l a r k e , 1993; C o l l i n s , 1990; F e l s k i ; F r a s e r & N i c h o l s o n ; hooks, 1984; 1990; Jaggar, 1990/1991; James, 1993; Lugones, 1991; Lugones & Spelman, 1995; Ng, 1993; Olesen, 1994; Ramazanoglu, 1989). What t h i s means i s t h a t feminism i t s e l f does not speak i n a u n i f i e d v o i c e . Thus, as I engage w i t h f e m i n i s t t h e o r y i n my own work, I see i t as always i n p r o c e s s . However, I a l s o see i t as always w i t h t h e p o t e n t i a l t o address t h e s o c i a l i n j u s t i c e s t h a t plague s o c i e t y , and ( i n my a r e a o f i n q u i r y ) n u r s e s , t h e p a t i e n t s and f a m i l i e s who t h e y s e r v e , t h e i r f e l l o w h e a l t h c a r e team p r o f e s s i o n a l s / p r o v i d e r s , and t h e o r g a n i z a t i o n s w i t h i n which t h e y work. I n coming t o t h i s c o n c l u s i o n , I have embarked on what has come t o be termed t h e o r e t i c a l pragmatism. F r a s e r and N i c h o l s o n (1990) express t h e r e l a t i o n s h i p between feminism and t h e o r e t i c a l pragmatism n i c e l y : 2 3 " Note that Fraser and Nicholson (1990) speak i n the future tense—meaning, I take i t , that feminist theory has not yet arrived at the state that they describe. I n g e n e r a l , p ostmodern-feminist t h e o r y would be pragmatic and f a l l i b i l i s t i c . I t would t a i l o r i t s methods and c a t e g o r i e s t o t h e s p e c i f i c t a s k a t hand, u s i n g m u l t i p l e c a t e g o r i e s when a p p r o p r i a t e and f o r s w e a r i n g t h e m e t a p h y s i c a l comfort of a s i n g l e f e m i n i s t method o r f e m i n i s t e p i s temology. I n s h o r t , t h i s t h e o r y would l o o k more l i k e a tapestry composed of threads of many d i f f e r e n t hues than one woven in a s i n g l e color [my emphasis]. The most i m p o r t a n t advantage of t h i s s o r t o f t h e o r y would be i t s u s e f u l n e s s f o r contemporary f e m i n i s t p o l i t i c a l p r a c t i c e . Such p r a c t i c e i s i n c r e a s i n g l y a m atter o f a l l i a n c e s r a t h e r t h a n one o f u n i t y around a u n i v e r s a l l y shared i n t e r e s t o r i d e n t i t y (p. 35). T h e o r e t i c a l pragmatism means s e l e c t i n g t h e o r i e s i n o r d e r t o s o l v e r e a l problems i n p r a c t i c e r a t h e r than on t h e b a s i s o f an a p r i o r i commitment t o a p a r t i c u l a r t h e o r e t i c a l s c h o o l ( F r y , 1995; Laudan, 1977; Wolf, 1 9 9 4 ) . 2 4 I n t e r e s t i n g l y , i n a r e c e n t volume on n u r s i n g t h e o r y , Kasper (1995) w r i t e s o f what she sees as t h e down s i d e of pragmatism. She warns t h a t pragmatism s h i f t s our emphasis t o t h e "bottom l i n e " o f p a t i e n t outcomes, many of which are not known and/or measurable. She a l s o c a u t i o n s t h a t what gets measured as an outcome o f t e n r e f l e c t s an u n - a r t i c u l a t e d v a l u e d e c i s i o n . W h i l e I w h o l e - h e a r t e d l y agree w i t h K a s p e r 1 s concerns about an e c o n o m i c a l l y d r i v e n focus on t h e bottom l i n e and u n - a r t i c u l a t e d v a l u e s , I t h i n k t h a t she may have c o n f l a t e d t h e o r e t i c a l pragmatism w i t h pragmatism i n decision-making. I n o t h e r words, I do not see t h a t s e l e c t i n g t h e o r i e s on t h e b a s i s o f t h e i r a b i l i t y t o p r o v i d e d i r e c t i o n i n the r e a l w o r l d o f p r o b l e m - s o l v i n g n e c e s s a r i l y r e s u l t s i n an e c o n o m i c a l l y d r i v e n outcomes f o c u s . I n f a c t , I can see s e l e c t i n g from a v a r i e t y o f t h e o r i e s ( f o r example, f e m i n i s t t h e o r i e s on o p p r e s s i o n and power, e t h i c a l ^ 4 For a thoughtful and comprehensive discussion of pragmatism and philosophy, see Rorty (1987). t h e o r i e s on s o c i a l j u s t i c e , and moral t h e o r i e s on car e ) t o t a c k l e t h e v e r y i s s u e t h a t Kasper w o r r i e s about. F e m i n i s t Research as P r a x i s One d i s t i n c t i v e means by which f e m i n i s t t h e o r y has t h e p o t e n t i a l t o address s o c i a l i n j u s t i c e s i s through i t s a p p l i c a t i o n as a r e s e a r c h methodology. L a t h e r (1991) d e s c r i b e s t h i s as "an emancipatory approach t o r e s e a r c h i n t h e s o c i a l s c i e n c e s " (p. 50) . She e x p l a i n s : I base my argument f o r a r e s e a r c h approach openly committed t o a more j u s t s o c i a l o r d e r on two assumptions. F i r s t , we are i n a p o s t p o s i t i v i s t p e r i o d i n t h e human s c i e n c e s , a p e r i o d marked by much m e t h o d o l o g i c a l and e p i s t e m o l o g i c a l ferment. There has been, however, l i t t l e e x p l o r a t i o n o f t h e me t h o d o l o g i c a l i m p l i c a t i o n s o f t h e se a r c h f o r an emancipatory s o c i a l s c i e n c e . Such a s o c i a l s c i e n c e would a l l o w us not o n l y t o understand t h e m a l d i s t r i b u t i o n o f power and r e s o u r c e s u n d e r l y i n g our s o c i e t y but a l s o t o change t h a t m a l d i s t r i b u t i o n i n ways t h a t h e l p c r e a t e a more e q u a l w o r l d . My second argument i s t h a t r e s e a r c h t h a t i s e x p l i c i t l y committed t o c r i t i q u i n g t h e s t a t u s quo and b u i l d i n g a more j u s t s o c i e t y — t h a t i s , research as praxis [my e m p h a s i s ] — adds an impo r t a n t v o i c e t o t h a t ferment (pp. 50-51). Whi l e f e m i n i s t t h e o r y shares t h i s k i n d o f r e s e a r c h approach w i t h o t h e r s i n i t s c r i t i c a l paradigm (such as neo-Marxism, F r e i r e i s m , p a r t i c i p a t o r y i n q u i r y , and C r i t i c a l T h e ory), i t o f f e r s some unique f e a t u r e s t h a t have drawn me t o i t f o r my own s t u d y . 2 5 So what i s f e m i n i s t r e s e a r c h ? 2 3 Nursing scholars are also interested i n the research a p p l i c a t i o n of other "members" of the c r i t i c a l paradigm "family" (Allen, 1986; A l l e n , Benner & Diekelmann, 1986; Campbell & Bunting, 1991; Dzurec, 1995; Holter & Kim, 1995; MacPherson, 1983; McCormick & Roussy, 1997; Parker & McFarlane, 1991; Rasmussen, 1997). To i l l u s t r a t e , studies operating from t h e o r e t i c a l approaches such as Habermas' and Foucault's are designed to expose hidden power imbalances and to enlighten people about how they ought to r a t i o n a l l y act to r e a l i z e t h e i r own best i n t e r e s t s (Campbell & Bunting, p. 5). Together with feminist theory, these family members share a focus on emancipation. Given that there has s t i l l been l i t t l e exploration of the methodological implications of the family o v e r a l l , I have made use of only one of the members. Feminist theory i s p a r t i c u l a r l y suited the gendered context of my research focus, and i t s methodological implications have been reasonably well a r t i c u l a t e d . 34 Most w i d e l y , i t i s c o n c e i v e d as r e s e a r c h t h a t p r o v i d e s a b a s i s f o r c r i t i c a l l y r e a s s e s s i n g e x t a n t i d e o l o g y and t h e o r y where t h i s l e a v e s out women a l t o g e t h e r o r s i g n i f i c a n t l y d i s t o r t s o r devalues t h e i r a c t i v i t i e s and l i v e s as women. I n t h i s , i t s encompassing aim i s t o empower women by r e c o v e r i n g t h e d e t a i l s o f t h e i r e x p e r i e n c e and a c t i v i t i e s . . . . ( W y l i e , 1994, p. 612). What W y l i e ' s d e f i n i t i o n i n d i c a t e s i s t h a t f e m i n i s t r e s e a r c h i s f e m i n i s t by v i r t u e o f i t s c h a l l e n g e of dominant i d e o l o g i e s , not by v i r t u e o f predetermined methodologies o r methods (H a r d i n g , 1987/1995). 2 6 F e m i n i s t r e s e a r c h thus o f f e r s an "unmasking o f o p p r e s s i o n ; i t . . . c a l l s f o r a commitment t o c o n s t r u c t i n g a 's c i e n c e ' t h a t w i l l a l l o w women's [ v o i c e s ] t o be heard and [ t h e i r ] concerns t o be heeded" (Anderson, 1991b, p . 1 1 8 ) . A l t h o u g h f e m i n i s t t h e o r y i s not equated w i t h a predetermined methodology o r method, i t has a profound impact on both ( H a r d i n g , 1987/1995). F e m i n i s t s t u d i e s are done t o understand t h e everyday e x p e r i e n c e s o f women, and must empower them throughout t h e r e s e a r c h process (Anderson, 1991b; Campbell & B u n t i n g , 1991; L a t h e r , 1991; Oakley, 1981; P a r k e r & McFarlane, 1991; Smith, 1987). I n o r d e r t o a c h i e v e an u n d e r s t a n d i n g o f t h e e x p e r i e n c e s o f women, t h i s k i n d o f r e s e a r c h i s o f t e n q u a l i t a t i v e i n natu r e (MacPherson, 1983), but f e m i n i s t r e s e a r c h i s not by d e f i n i t i o n q u a l i t a t i v e r e s e a r c h (Harding, 1995/1987; Smith, 1989; W y l i e , 1994). What i s c e n t r a l t o f e m i n i s t r e s e a r c h i s t h e n o t i o n o f r e f l e x i v i t y (Anderson, 1991b; H a l l & Stevens, 1991; Ha r d i n g , 1 9 9 1 ) . 2 7 2 6 Harding (1987/1995) points out that a "research method i s a technique f or gathering evidence" (p. I l l ) , while methodology i s the "theory and analysis" of the ap p l i c a t i o n of d i s c i p l i n a r y knowledge (p. 112). 2 7 R e f l e x i v i t y i s ce n t r a l to feminist research, but i t i s not unigue to i t . For an i n s i g h t f u l discussion of r e f l e x i v i t y i n anthropology, see Marcus (1994). R e f l e x i v i t y runs through f e m i n i s t r e s e a r c h methodology and methods, and, indeed, the e n t i r e process o f i n q u i r y . I t r e q u i r e s t h a t , as r e s e a r c h e r s , we s t a r t by a s k i n g o u r s e l v e s who we a r e and what we b e l i e v e ; "to examine c r i t i c a l l y t h e k i n d s o f . . . b e l i e f s t h a t shape our own thought and b e h a v i o r s , not j u s t t h e thought and b e h a v i o r o f o t h e r s " (Harding, 1991, pp. 149-150). As H a r d i n g (1991) f u r t h e r e x p l a i n s : A n o t i o n o f s t r o n g r e f l e x i v i t y would r e q u i r e t h a t t h e o b j e c t s o f i n q u i r y be c o n c e p t u a l i z e d as g a z i n g back i n a l l t h e i r c u l t u r a l p a r t i c u l a r i t y and t h a t t h e r e s e a r c h e r , through t h e o r y and methods, s t a n d behind them, g a z i n g back a t h i s own s o c i a l l y s i t u a t e d r e s e a r c h p r o j e c t i n a l l i t s c u l t u r a l p a r t i c u l a r i t y and i t s r e l a t i o n s h i p s t o o t h e r p r o j e c t s o f h i s c u l t u r e — m a n y of which...can be seen o n l y from l o c a t i o n s f a r away from th e s c i e n t i s t ' s a c t u a l d a i l y work (p. 163). From my r e a d i n g o f t h i s passage, r e f l e x i v i t y r e q u i r e s t h a t we h o l d up a m i r r o r t o o u r s e l v e s as w e l l as t o t h e p a r t i c i p a n t s i n (not o b j e c t s o f ) our i n q u i r y . And i t r e q u i r e s t h a t we h o l d t h e m i r r o r thus throughout our p r o j e c t — f r o m t h e i n i t i a l c o n c e p t u a l i z a t i o n o f t h e r e s e a r c h q u e s t i o n through t o our c h o i c e o f s u p p o r t i v e t h e o r y and e m p i r i c a l work, t o our c h o i c e o f r e s e a r c h methodology and implementation o f methods, and through t o t h e way t h a t we make our f i n i s h e d p r o j e c t a c c e s s i b l e t o o t h e r s . By s i t u a t i n g t h i s s tudy i n Chapter One and by e x p l o r i n g t h e m e t a - t h e o r e t i c a l c o n t e x t I have chosen i n t h i s Chapter, I have s t a r t e d such a r e f l e x i v e p r o c e s s . I w i l l attempt t o c a r r y i t through t h e remainder of t h e t h e s i s . 36 CHAPTER THREE: SURVEYING THEORETICAL TERRAIN ON MORAL AGENCY AND THE CULTURE OF THE ORGANIZATIONAL CONTEXT I n t r o d u c t i o n The next two Chapters move down a l e v e l o f a b s t r a c t i o n ; t h e y move from t h e m e t a - t h e o r e t i c a l t o t h e o r y and r e s e a r c h t h a t hover more c l o s e l y t o t h e "ground" o f nurses' e x p e r i e n c e s and t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t w i t h i n which t h e i r e x p e r i e n c e s a r e l o c a t e d . T h i s Chapter p r o v i d e s f u r t h e r t h e o r e t i c a l s upport f o r t h e p u r s u i t o f the r e s e a r c h q u e s t i o n s d i r e c t i n g my stu d y , w h i l e Chapter Four adds e m p i r i c a l s u p p o r t . Furthermore, both t h i s Chapter and Chapter Four p r o v i d e a f o u n d a t i o n f o r my subsequent a n a l y s i s o f t h e study r e s u l t s ( c o n s t r u c t i o n s ) . A l t h o u g h I do not see t h e d i s t i n c t i o n between t h e o r e t i c a l and e m p i r i c a l as a b s o l u t e , I have s e p a r a t e d t h e two t o make i t e a s i e r t o t r a c k t h e o r e t i c a l i s s u e s as w e l l as r e s e a r c h i s s u e s . G i v e n t h e r e s e a r c h q u e s t i o n s t h a t I d e l i n e a t e d i n Chapter One (What a r e nurses' understandings of t h e e t h i c a l problems t h e y c o n f r o n t i n t h e i r p r a c t i c e ? What are n u r s e s 1 e x p e r i e n c e s e n a c t i n g t h e i r moral agency? How does t h e c u l t u r e of t h e o r g a n i z a t i o n a l c o n t e x t a f f e c t nurses' e x p e r i e n c e s ? ) , I w i l l p r e s e n t my survey a c c o r d i n g t o l i t e r a t u r e r e l a t e d t o h e a l t h c a r e e t h i c s , l i t e r a t u r e r e l a t e d t o moral agency, and l i t e r a t u r e r e l a t e d t o t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t . Understanding t h e o r y r e l a t e d t o t h e moral agency o f h e a l t h c a r e p r o f e s s i o n a l s r e q u i r e s some r e f l e c t i o n on e t h i c a l t h e o r y w i t h i n h e a l t h c a r e . I w i l l d i s c u s s some o f t h e 37 i s s u e s here f i r s t , and then broaden my r e v i e w t o address i s s u e s i n e t h i c a l and moral t h e o r y t h a t a f f e c t our u n d e r s t a n d i n g o f moral agency per se. As I proceed, I w i l l a l s o be examining t h e i n t e r f a c e o f t h e o r y about c u l t u r e w i t h t h e o r y about e t h i c s , and I w i l l conclude w i t h a d i s c u s s i o n o f c u l t u r e as t h e c o n t e x t w i t h i n which moral agency i s enacted. A S o c i a l H i s t o r y of Health Care E t h i c s What Counts? The widespread a p p l i c a t i o n o f e t h i c a l t h e o r y t o h e a l t h c a r e i s a r e c e n t phenomenon. I n f a c t , t h e term " b i o e t h i c s " 2 8 appeared o n l y t w e n t y - f i v e y e a r s ago w i t h t h e p u b l i c a t i o n o f a t e x t about b i o l o g i c a l knowledge and human v a l u e s (Roy, W i l l i a m s , & D i c k e n s , 1994, pp. 3-4). The term " q u i c k l y became i d e n t i f i e d w i t h a l l academic and p r o f e s s i o n a l e f f o r t s t o address t h e e t h i c a l i s s u e s posed by developments i n t h e b i o l o g i c a l s c i e n c e s , and t h e i r a p p l i c a t i o n t o m e d i c a l p r a c t i c e " (Roy, W i l l i a m s , & D i c k e n s , p. 4). With r o o t s i n m e d i c a l e t h i c s , p h i l o s o p h i c a l e t h i c s , and r e l i g i o u s e t h i c s , b i o e t h i c s f l o u r i s h e d and d i v e r s i f i e d as a r e s u l t o f r a p i d advances i n m e d i c a l s c i e n c e and t e c h n o l o g y and s o c i e t a l changes (Fox, 1990; Roy, W i l l i a m s , & D i c k e n s , pp. 4-13). The l a t t e r i n c l u d e d "moral p l u r a l i s m , t h e human r i g h t s movement, and a t t i t u d e s towards death" (Roy, W i l l i a m s , & D i c k e n s , p. 12). B i o e t h i c s was i n i t i a l l y c l o s e l y a l i g n e d w i t h medicine and m e d i c a l e t h i c s , but t h i s has been changing. Roy, W i l l i a m s , and Dickens (1994) o f f e r t h e f o l l o w i n g account of t h e h i s t o r y o f d i s c i p l i n a r y involvement i n b i o e t h i c s : 2 8 The term biomedical ethics i s often used i n place of b i o e t h i c s . I consider them to be synonymous. 38 The t r a n s i t i o n from t r a d i t i o n a l m e d i c a l e t h i c s t o modern b i o e t h i c s has been marked by a power s t r u g g l e among d i s c i p l i n e s and p r o f e s s i o n s f o r c o n t r o l o f t h e f i e l d . D u r i n g t h e f i r s t s i x decades o f t h e t w e n t i e t h c e n t u r y , t h e o n l y groups, b e s i d e s d o c t o r s , who were i n t e r e s t e d i n t h e e t h i c a l a s p e c t s of h e a l t h c a r e were nurses and t h e o l o g i a n s . . . . A t t h e same t i m e , t h e i n f l u e n c e o f p h y s i c i a n s d e c l i n e d , as t h e y came t o r e a l i z e t h a t t h e i r approach t o e t h i c a l i s s u e s was no l o n g e r adequate i n t h e f a c e o f major changes i n m e d i c a l s c i e n c e and s o c i e t a l a t t i t u d e s . As b i o e t h i c s r a p i d l y developed i n t o a major academic e n t e r p r i s e , i t began t o a t t r a c t t h e p a r t i c i p a t i o n o f d i s c i p l i n e s t h a t had shown l i t t l e i n t e r e s t b e f o r e t h e n , e s p e c i a l l y p h i l o s o p h y . . . . So e n t h u s i a s t i c a l l y d i d p h i l o s o p h e r s embrace t h e newly emerging f i e l d o f b i o e t h i c s t h a t t h e y soon came t o dominate i t , a t l e a s t i n North America.... T h i s s t a t e o f a f f a i r s , however, was not t o l a s t . D u r i n g t h e 1980's, members o f t h e h e a l t h c a r e p r o f e s s i o n s , e s p e c i a l l y p h y s i c i a n s and nu r s e s , began t o r e a s s e r t t h e i r c l a i m t o e x p e r t i s e and a u t h o r i t y i n r e g a r d t o t h e e t h i c a l i s s u e s t h a t a f f e c t members o f t h e i r p r o f e s s i o n s . Other d i s c i p l i n e s , t o o , e n t e r e d t h e f i e l d , n o t a b l y law, s o c i o l o g y , a n t h r o p o l o g y , and even economics (pp. 19-20). These s h i f t s i n t h e s o c i a l h i s t o r y o f b i o e t h i c s a re i m p o r t a n t , because they have a f f e c t e d what counts as e t h i c a l t h e o r y i n h e a l t h c a r e . Traditional b i o e t h i c s can be d e s c r i b e d t h u s : The t a s k of b i o m e d i c a l e t h i c s i s t o r e s o l v e e t h i c a l problems a s s o c i a t e d w i t h t h e p r a c t i c e o f medicine [my emphasis] and/or t h e p u r s u i t o f b i o m e d i c a l r e s e a r c h . . . . The f o l l o w i n g q u e s t i o n s a re t y p i c a l l y r a i s e d i n b i o m e d i c a l e t h i c s . I s a p h y s i c i a n m o r a l l y o b l i g a t e d t o t e l l a t e r m i n a l l y i l l p a t i e n t t h a t he o r she i s dying? Are breaches o f m e d i c a l c o n f i d e n t i a l i t y ever m o r a l l y j u s t i f i a b l e ? I s a b o r t i o n m o r a l l y j u s t i f i a b l e ? I s e u t h a n a s i a m o r a l l y j u s t i f i a b l e ? (Mappes & Zembaty, 1991, p. 2) Mappes and Zembaty f u r t h e r note t h a t " b i o m e d i c a l e t h i c s must r e l y n ot o n l y on t h e t h e o r i e s o f g e n e r a l normative e t h i c s but a l s o on th e t h e o r i e s o f s o c i a l - p o l i t i c a l p h i l o s o p h y and p h i l o s o p h y o f law" (p. 2 ) . What are t h e i m p l i c a t i o n s o f t h e d i s c i p l i n a r y h i s t o r y and t h e t r a d i t i o n a l t h e o r e t i c a l focus o f b i o e t h i c s ? L e t me s t a r t by r e f l e c t i n g on t h e d e f i n i t i o n i n t h e c i t a t i o n above from Mappes and Zembaty (1991). Mappes and Zembaty d i s t i n g u i s h p h y s i c i a n s ' o b l i g a t i o n s from nurses' (and o t h e r p r o f e s s i o n a l s ' ) o b l i g a t i o n s i n t h e comprehensive anthology t h a t accompanies t h e c i t a t i o n , and the y devote a s e c t i o n o f a c h a p t e r t o papers from n u r s i n g . However, t h e c o n c e p t u a l focus i n t h e i r d e f i n i t i v e c i t a t i o n i s s t i l l on medicine, not h e a l t h c a r e . T h i s i s not an i d i o s y n c r a t i c focus i n t h e b i o e t h i c s l i t e r a t u r e ( B a y l i s e t a l . , 1995; Sherwin, 1992; Warren, 1992; Yeo, 1994). Moreover, t h e q u e s t i o n s t h a t Mappes and Zembaty (1991) and many o t h e r t h e o r i s t s i n b i o e t h i c s a r t i c u l a t e i m p l y t h a t e t h i c a l problems i n h e a l t h c a r e c o l l a p s e i n t o dichotomous (yes/no) q u e s t i o n s about what a p h y s i c i a n s h o u l d do w i t h a p a t i e n t . Such q u e s t i o n s presuppose t h a t an o b j e c t i v e , r a t i o n a l , a n a l y t i c process w i l l f u r n i s h a c o n c r e t e and c o r r e c t answer, and t h a t such answers a r e t o be found a p a r t from t h e f a m i l i a l , s o c i a l , c u l t u r a l , and p o l i t i c a l c o n t e x t s w i t h i n which t h e q u e s t i o n s o c c u r ( B a y l i s e t a l . ; B ishop & Scudder, 1990; Fox, 1990; Hoffmaster, 1990; Stephenson, 1995; Weisz, 1990; Yeo, 1994). E t h i c a l q u e s t i o n s t h a t nurses might ask ( f o r example, how t o d e a l w i t h t h e s u f f e r i n g o f d y i n g p a t i e n t s when t h e r e i s s e r i o u s f a m i l y c o n f l i c t ) , t h a t s o c i a l workers might ask ( f o r example, how t o f i n d r e s p i t e c a r e f o r d y i n g p a t i e n t s when f a m i l y members are exhausted and t h e r e a r e widespread h o s p i t a l c l o s u r e s ) , o r t h a t a d m i n i s t r a t o r s might ask ( f o r example, how t o i n v o l v e h o s p i t a l s t a f f i n p l a n n i n g f o r r a t i o n i n g o f s e r v i c e s ) r a r e l y get much c o n c e p t u a l o r p r a c t i c a l purchase. I n the s e k i n d s o f q u e s t i o n s , t h e emphasis i s not so much on what t o do, but r a t h e r on how t o do i t . 2 9 I m p o r t a n t l y , p h y s i c i a n s are not encouraged t o pursue s i m i l a r k i n d s o f q u e s t i o n s . Hence my d e s i r e t o p r o f i l e nurses' v o i c e s i n t h i s s tudy, and t o employ a methodology t h a t h e l p s us t o understand t h e c o m p l e x i t i e s and a m b i g u i t i e s t h a t a f f e c t everyone w i t h i n t h e o r g a n i z a t i o n a l c o n t e x t . R e f l e c t i n g on t h e preponderance o f o b j e c t i v e , r a t i o n a l approaches t o d e c i s i o n - m a k i n g w i t h i n b i o e t h i c s , i t seems t o me t h a t a n a l y t i c p h i l o s o p h e r s have l a r g e l y h e l d t h e i r own i n t h e power s t r u g g l e t h a t Roy, W i l l i a m s , and Dickens (1994) d e s c r i b e . The methodology f o r i n q u i r y t h a t t hey have been t r a i n e d i n remains dominant i n t h e f i e l d (Fox, 1990; Hoffmaster, 1990; Wolf, 1994). Moreover, I b e l i e v e t h a t t h e r e has been a c o n f l a t i o n o f m e d i c a l e t h i c s w i t h b i o e t h i c s . That i s , m e d i c a l e t h i c a l concerns ar e seen as t h e same as b i o e t h i c a l concerns. Some c o n c e p t u a l s o r t i n g i s needed here i f e t h i c s i s t o make a d i f f e r e n c e i n t h e r e a l w o r l d of c l i n i c a l p r a c t i c e . My own p r e f e r e n c e i s t o use t h e term health care ethics ( i n s t e a d o f b i o e t h i c s o r b i o m e d i c a l e t h i c s ) t o r e f e r t o e t h i c a l concerns t h a t a f f e c t t h e h e a l t h c a r e s y s t e m — c o n c e r n s e x p e r i e n c e d by p a t i e n t s , f a m i l i e s , h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s , h e a l t h c a r e o r g a n i z a t i o n s , and s o c i e t y as a w h o l e . 3 0 W i t h i n h e a l t h c a r e e t h i c s , t h e r e a r e concerns t h a t 2 9 I would l i k e to thank Dr. Michael McDonald from the UBC Centre f o r Applied E t h i c s for pointing out t h i s d i s t i n c t i o n to me. 3 0 In using t h i s term, I depart from Roy, Williams, and Dickens (1994), who would l i k e to keep i n s t i t u t i o n a l , p r o fessional, and feminist ethics separate from b i o e t h i c s . Although I appreciate the thoughtfulness of t h e i r discussion, I do not think that ethics i n c l i n i c a l p r a c t i c e can be compartmentalized i n t h i s manner. For example, questions about treatment withdrawal (bioethics) w i l l necessarily include questions about nurse-physician communication (professional ethics) and questions about the a v a i l a b i l i t y of p a l l i a t i v e care resources (organizational e t h i c s ) . Moreover, r e l a t e d questions about the character and conduct of health care a r e p a r t i c u l a r t o each o f t h e p r o f e s s i o n s ( m e d i c a l e t h i c s , n u r s i n g e t h i c s , pharmacy e t h i c s , and so on, a l l o f which I understand as subsets o f p r o f e s s i o n a l e t h i c s ) , and concerns t h a t a r e p a r t i c u l a r t o o r g a n i z a t i o n s (which I see as a subset o f b u s i n e s s e t h i c s ) . 3 1 Some o f the s t r o n g e s t c h a l l e n g e s t o t h e d i s c i p l i n a r y h i s t o r y and t h e t r a d i t i o n a l t h e o r e t i c a l f ocus o f b i o e t h i c s have been r a i s e d by f e m i n i s t e t h i c i s t s ( B a y l i s e t a l . , 1995; Roy, W i l l i a m s & D i c k e n s , 1994; Wolf, 1994; Yeo, 1994). As I e x p l a i n e d i n Chapter One, f e m i n i s t e t h i c s o f f e r s an a l t e r n a t e v i e w o f contemporary e t h i c a l i s s u e s and t r a d i t i o n a l e t h i c a l t h e o r y (Jaggar, 1990/1991). Susan Sherwin i s an imp o r t a n t contemporary v o i c e i n t h i s a r e a . I n her book, No Longer Patient: Feminist Ethics and Health Care (1992), she d e s c r i b e s t h e i n t e n t o f f e m i n i s t approaches t o h e a l t h c a r e e t h i c s as f o l l o w s : Feminism expands the scope of b i o e t h i c s , f o r i t proposes t h a t a d d i t i o n a l c o n s i d e r a t i o n s be r a i s e d i n t h e e t h i c a l e v a l u a t i o n o f s p e c i f i c p r a c t i c e s : i t demands t h a t we c o n s i d e r t h e r o l e o f each a c t i o n o r p r a c t i c e w i t h r e s p e c t t o th e g e n e r a l s t r u c t u r e s o f o p p r e s s i o n i n s o c i e t y . Thus m e d i c a l and o t h e r h e a l t h c a r e p r a c t i c e s s h o u l d be reviewed not j u s t w i t h r e g a r d t o t h e i r e f f e c t s on t h e p a t i e n t s who are d i r e c t l y i n v o l v e d but a l s o w i t h r e s p e c t t o t h e p a t t e r n s o f d i s c r i m i n a t i o n , e x p l o i t a t i o n , and dominance t h a t surround them.... I n a d d i t i o n , feminism encourages us t o e x p l o r e t h e p l a c e o f medicine i t s e l f i n s o c i e t y . M e d i c i n e has become one of our most p o w e r f u l and s i g n i f i c a n t i n s t i t u t i o n s ; g e n e r a l l y , i t i s t r e a t e d as an u n q u a l i f i e d good, because i t professionals embed health care eth i c s i n moral philosophy, and r e l a t e d questions about the just a l l o c a t i o n of resources embed health care eth i c s i n p o l i t i c a l philosophy. My use of the term health care eth i c s i s , however, congruent with B a y l i s et a l . (1995). 31 This i s by no means a well standardized nomenclature. However, many th e o r i s t s see health care ethics (or b i o e t h i c s ) , business e t h i c s , and professional ethics as subsets of the larger f i e l d of applied ethics (for example, Beauchamp & Childress, 1989; Fowler, 1987; Mappes & Zembaty, 1991; Singer, 1986). I t i s worth noting that Roy, Williams & Dickens (1994) warn that the concept of applied ethics i t s e l f i s problematic. i s almost u n i v e r s a l l y regarded as t h e b e s t i n s t r u m e n t f o r p r o t e c t i n g and r e s t o r i n g h e a l t h (pp. 4-5). F e m i n i s t h e a l t h c a r e e t h i c s t h e r e f o r e s u b s t a n t i a l l y broadens what has o t h e r w i s e been an o v e r l y c i r c u m s c r i b e d t r a d i t i o n a l f o c u s . The k i n d s o f i s s u e s t h a t have been p r o f i l e d i n f e m i n i s t h e a l t h c a r e e t h i c s l i t e r a t u r e i n c l u d e such t h i n g s as a b o r t i o n (Sherwin, 1991/1995), A c q u i r e d Immune D e f i c i e n c y Syndrome (HIV/AIDS) ( B e l l , 1989/1992b), a g i n g and h e a l t h c a r e r a t i o n i n g ( B e l l , 1992a), b i o m e d i c a l r e s e a r c h (Marquis, 1989/1992; Rosser, 1989/1992; Sherwin, 1992), competence and mental i l l n e s s ( R i t c h i e , 1989/1995), d i s a b i l i t y (Wendell, 1989/1992), new r e p r o d u c t i v e t e c h n o l o g i e s ( L o r b e r , 1989/1992; Morgan, 1992; Murphy, 1992; Sherwin, 1992; Wertz & F l e t c h e r , 1992), and s u r r o g a t e motherhood (Ketchum, 1989/1992; Nelson & Ne l s o n , 1989/1992; O l i v e r , 1989/1992). Susan Wolf (1994) notes t h a t w h i l e t h e e a r l y focus i n f e m i n i s t h e a l t h c a r e e t h i c s was on r e p r o d u c t i v e i s s u e s , "more r e c e n t l y , f e m i n i s t work has t a k e n on t h e f u l l range o f . . . i s s u e s , not j u s t those t h a t have t o do w i t h women's r e p r o d u c t i v e c a p a c i t i e s " (pp. 404-405). Such a range i s c e r t a i n l y r e f l e c t e d i n th e l i s t above. A l t h o u g h f e m i n i s t e t h i c i s t s a r e by no means t h e o n l y e t h i c i s t s t o t a c k l e t h e s e i s s u e s , t h e i r a t t e n t i o n has been i n s t r u c t i v e . U n f o r t u n a t e l y , the use o f a f e m i n i s t e t h i c a l l e n s t o view e t h i c a l problems w i t h i n n u r s i n g has been m i n i m a l . A l t h o u g h nurses have been i n t e r e s t e d i n t h e a p p l i c a t i o n o f a f e m i n i s t e t h i c o f c a r e f o r p a t i e n t s and t h e i r f a m i l i e s ( f o r example, Benner & Wrubel, 1989; Cooper, 1991; 1993; F r y , 1989; 1991; O l s e n , 1992), t h e r e has been l i t t l e a t t e n t i o n i n t h e f e m i n i s t e t h i c s l i t e r a t u r e t o problems o f powerlessness and gender i n e q u i t y f o r n u r s e s , o r , f o r t h a t m a t t e r , o t h e r h e a l t h c a r e p r o f e s s i o n a l s / p r o v i d e r s . 3 2 To my knowledge, L i a s c h e n k o (1993a; 1993b), a nurse w r i t i n g w i t h i n t h e f i e l d o f f e m i n i s t e t h i c s , has been one of t h e f i r s t t o c a l l f o r t h o s e of us i n n u r s i n g t o embrace a f e m i n i s t e t h i c i n o r d e r t o enact our moral a g e n c y . 3 3 I n t h e meanwhile, because m e d i c a l e t h i c s has been c o n f l a t e d w i t h b i o e t h i c s , n urses' e t h i c a l concerns are r a r e l y addressed o u t s i d e o f n u r s i n g e t h i c s l i t e r a t u r e ( L i a s c h e n k o , 1993a). G i v e n t h a t h e a l t h c a r e e t h i c s has always attended t o c r i s e s more th a n everyday e t h i c a l problems, t h e near i n v i s i b i l i t y o f n u r s i n g i s not s u r p r i s i n g (Warren, 1992; Yeo, 1994). For i n s t a n c e , not enough n u r s i n g s t a f f a v a i l a b l e t o p r o v i d e s a f e o r competent c a r e t o a c u t e l y i l l p a t i e n t s i s an "everyday" i s s u e t h a t has been w e l l documented i n a t l e a s t t h r e e decades of r e s e a r c h (Rodney & S t a r z o m s k i , 1993), but i t has c e r t a i n l y not g o t t e n t h e a t t e n t i o n i n e t h i c s t h a t has been a f f o r d e d e u t h a n a s i a . As Yeo (1994) e x p l a i n s , "whether one does o r does not see something as a moral problem o r s i t u a t i o n i n t h e f i r s t p l a c e i s an a f f a i r o f i n t e r p r e t a t i o n " (p. 91). For d i f f e r e n t i n t e r p r e t a t i o n s t o be a v a i l a b l e , t h e v o i c e s o f nurses and o t h e r p r o f e s s i o n a l s / p r o v i d e r s need t o be more r e a d i l y a c c e s s i b l e i n contemporary h e a l t h c a r e e t h i c s d i s c o u r s e . What About O r g a n i z a t i o n a l C u l t u r e ? The everyday e t h i c a l problems t h a t nurses e x p e r i e n c e a r e , I have argued i n Chapter One, p a r t o f t h e c u l t u r e o f t h e 3 2 Sherwin (1992) and Warren (1992) are notable exceptions. 3 3 See also Rafael (1996). o r g a n i z a t i o n a l c o n t e x t w i t h i n which they p r a c t i c e . Y e t , as I d i s c u s s e d e a r l i e r i n t h i s Chapter, t r a d i t i o n a l h e a l t h c a r e e t h i c s tends t o be o b l i v i o u s t o t h e f a m i l i a l , s o c i a l , c u l t u r a l , and p o l i t i c a l c o n t e x t s w i t h i n which e t h i c a l problems o c c u r . So a l t h o u g h Roy, W i l l i a m s , and Dickens (1994) note t h a t t h e d i s c i p l i n e s o f s o c i o l o g y and anthropology have e n t e r e d t h e f i e l d o f h e a l t h c a r e e t h i c s , i t i s f a i r t o say t h a t t h e i r presence i s o n l y b e g i n n i n g t o make an impact (Fox, 1 9 9 0 ) . 3 4 Indeed, w i t h i n n u r s i n g we c o u l d use t h e i r h e l p . A s o c i o l o g i c a l p e r s p e c t i v e on i s s u e s such as n u r s i n g power and n u r s i n g workload has been e n l i g h t e n i n g ( f o r example, Campbell, 1987; Chambliss, 1996; C o r l e y & Mauksch, 1988; Mauksch, 1990; S t r e e t , 1992). S i m i l a r work on how t h e c u l t u r e o f the o r g a n i z a t i o n a l c o n t e x t a f f e c t s t h e e t h i c s o f n u r s i n g p r a c t i c e would be b e n e f i c i a l (Jameton, 1990; L i a s c h e n k o , 1993b). I t i s w i t h t h i s i n mind t h a t I have employed a r e s e a r c h methodology t h a t i s used i n t h e s o c i a l s c i e n c e s f o r my own stu d y . W i t h i n t h e f i e l d o f h e a l t h c a r e e t h i c s , Weisz (1990) makes an argument f o r more s u b s t a n t i v e c o n t r i b u t i o n s from a n t h r o p o l o g i s t s and s o c i o l o g i s t s : F i r s t , t h ey can p r o v i d e e t h i c i s t s w i t h d a t a , r a n g i n g from d e s c r i p t i o n s o f the h i s t o r i c a l o r i g i n s o f c u r r e n t e t h i c a l debates t o i n f o r m a t i o n about how people i n d i f f e r e n t c u l t u r e s and a t d i f f e r e n t s o c i a l l e v e l s a c t u a l l y behave i n e t h i c a l l y p r o b l e m a t i c s i t u a t i o n s . . . . Second, the p e r s p e c t i v e s t h e y u t i l i z e may i n f a c t s u b v e r t t r a d i t i o n a l schemas of e t h i c a l a n a l y s i s . . . . S e e i n g an e t h i c a l problem i n i t s broad s o c i a l c o n t e x t may n e c e s s i t a t e i t s r e c a t e g o r i z a t i o n from t h e e t h i c a l t o t h e p o l i t i c a l domain.... T h i r d , s u b j e c t i n g m e d i c a l e t h i c s and i t s p r a c t i t i o n e r s (as opposed t o i s s u e s and dilemmas) t o ex a m i n a t i o n and a n a l y s i s by o u t s i d e r s may f o s t e r t h e k i n d o f c r i t i c a l s e l f -r e f l e c t i o n n ecessary f o r t h e i n t e l l e c t u a l development o f any J 4 For a compelling account by two s o c i o l o g i s t s who have made a s i g n i f i c a n t impact, and then decided to leave the f i e l d , see Fox and Swazey (1992). new f i e l d , p a r t i c u l a r l y i f i t has grown as r a p i d l y as t h i s one (pp. 5-6). A l t h o u g h I do not share some of Weisz's m e t a - t h e o r e t i c a l p o s i t i o n s i n t h e c i t a t i o n a b o v e , 3 5 I t h i n k t h a t he has made some good p o i n t s . So f a r , I have been a r g u i n g i n f a v o u r o f h i s second and t h i r d p o i n t s . I agree t h a t we need t o see e t h i c a l problems i n t h e i r broader s o c i a l c o n t e x t s , and I agree t h a t those o f us working w i t h i n h e a l t h c a r e e t h i c s and/or h e a l t h c a r e o r g a n i z a t i o n s s h o u l d engage i n c r i t i c a l s e l f - r e f l e c t i o n . As one a n t h r o p o l o g i s t (Stephenson, 1995) warns, " i t i s t h e dominant c u l t u r e ( t h a t o f t h e r e s e a r c h e r s , p h y s i c i a n s , e t h i c i s t s , a n t h r o p o l o g i s t s , e t c . ) which may be most d i f f i c u l t t o a n a l y z e and comprehend" (p. 1 ) . Our c o l l e a g u e s i n t h e s o c i a l s c i e n c e s are w e l l p o s i t i o n e d both t h e o r e t i c a l l y and m e t h o d o l o g i c a l l y t o h e l p us i n such a n a l y s i s and comprehens i o n . Weisz's (1990) f i r s t p o i n t begins t o extend t h e d i s c u s s i o n beyond t h e c u l t u r e o f t h e o r g a n i z a t i o n a l c o n t e x t t o t h e c u l t u r e o f persons w i t h i n s o c i e t y . T r a d i t i o n a l h e a l t h c a r e e t h i c s has a l s o been l a r g e l y i n s e n s i t i v e t o t h e c u l t u r a l c o n t e x t s o f p a t i e n t s and t h e i r f a m i l y members, t o t h e c u l t u r a l c o n t e x t s o f groups w i t h i n s o c i e t y , and t o the c u l t u r a l c o n t e x t s o f g l o b a l h e a l t h problems (Fox, 1 9 9 0 ) . 3 6 Stephenson (1995) c a u t i o n s : j : > As a c o n s t r u c t i v i s t and feminist, I do not think that I "show" how people from " d i f f e r e n t cultures" ( d i f f e r e n t from whose?) "actually behave"; as a feminist, I would not "recategorize" a problem from e t h i c a l to p o l i t i c a l , but would instead look for the p o l i t i c a l within the e t h i c a l ; and as a feminist and a nurse I would not equate "medical" with health care e t h i c s . 3 ^ I have the good fortune to be part of an i n t e r n a t i o n a l (Thailand-Canada) i n t e r d i s c i p l i n a r y research team currently exploring t h i s very issue. The research project i s t i t l e d A Cross-Cultural Approach to Bealth Care Ethics, and i s headed by Dr. Harold Coward from the University of V i c t o r i a Centre for Studies i n R e l i g i o n and Society. I t i s a three year project (1994-1997) funded by the Canadian S o c i a l Sciences and Humanities Research Council and the Ford Foundation. Scholarly publications, p o l i c y reports, and p u b l i c presentations w i l l be forthcoming. 46 C u l t u r e can not be reduced t o a r e s i d u a l c a t e g o r y , o r a v a r i a b l e c a l l e d " c u l t u r a l b e l i e f s " w i t h o u t c o n s i d e r a b l e c o l l a t e r a l damage b e i n g done t o t h e people t o whom t h e narrowed concept i s a p p l i e d . I n t h i s narrow c o n s t r u c t i o n t h e s u b j e c t p o p u l a t i o n — p a t i e n t s o r c l i e n t s — h a v e h e a l t h c a r e b e l i e f s ( c u l t u r e ) , w h i l e p r o f e s s i o n a l s a r e t h e b e a r e r s o f M e d i c i n e — a supposedly v a l u e f r e e e n t i t y which i s v a l o r i z e d as e n t i r e l y "good" and o b j e c t i v e l y " t r u e " ( s c i e n c e ) . I n t h e many h e a l t h c o n t e x t s o f i n t e r n a t i o n a l development, immigrant and refugee i s s u e s , o r t h e s t r u g g l e s o f A b o r i g i n a l People around the w o r l d , t h i s . . . i s where h e a l t h y r a t i o n a l i s m i s expected t o t riumph over i g n o r a n c e and d i s e a s e because b i o m e d i c i n e i s b e l i e v e d t o be n e u t r a l , s c i e n t i f i c , and an o b j e c t i v e d e s c r i p t i o n o f r e a l i t y u n i n f l u e n c e d by s o c i a l p r o c e s s e s . What concerns me deeply i s that t h i s widespread view i s not recognized as part of the reproduction of inequity [my e m p h a s i s ] . . . i n c l u d i n g i n e q u i t i e s i n t h e p r o v i s i o n o f h e a l t h c a r e i t s e l f . We a l s o need t o q u e s t i o n how a n a r r o w l y f o c u s s e d e t h i c s might c o n t r i b u t e t o t h i s p r o c e s s (p. 2 ) . The k i n d o f q u e s t i o n i n g about i n e q u i t y t h a t Stephenson i s c a l l i n g f o r has b a r e l y begun ( F o x ) . "As new as gender a n a l y s i s i s i n b i o e t h i c s , a t t e n t i o n t o r a c e and e t h n i c i t y i s even newer" (Wolf, 1994, p. 406). A C u l t u r e of B l i n d n e s s ? What t h i s means i s t h a t t r a d i t i o n a l h e a l t h c a r e e t h i c s i s l a r g e l y b l i n d t o i s s u e s of c u l t u r e , o r r e l a t e d i s s u e s o f r a c e and e t h n i c i t y , w i t h i n s o c i e t y and t h e w o r l d a t l a r g e . And, g i v e n t h a t r a c e and e t h n i c i t y i n t e r s e c t w i t h c l a s s , age, and s e x u a l o r i e n t a t i o n as w e l l as gender i n o p p r e s s i o n ( B a n n e r j i , 1993; C a s s i d y , L o r d , & M a n d e l l , 1995; C l a r k e , 1993; C o l l i n s , 1990; F r a s e r & N i c h o l s o n , 1990; hooks, 1984; 1990; Jaggar, 1990/1991; James, 1993; Lugones, 1991; Lugones & Spelman, 1995; Ng, 1993; Ramazanoglu, 1989), t h i s means t h a t h e a l t h c a r e e t h i c s i s l a r g e l y I am g r a t e f u l to Dr. Peter Stephenson, Professor at the U n i v e r s i t y of V i c t o r i a ' s Department of Anthropology, for permission to c i t e from an unpublished manuscript (1995) that he has prepared for the research p r o j e c t . b l i n d t o o p p r e s s i o n as w e l l as i n e q u i t y . 3 7 Sherwin (1992) puts i t t h i s way: I t i s w i d e l y r e c o g n i z e d throughout t h e f i e l d o f b i o m e d i c a l e t h i c s t h a t people's h e a l t h c a r e needs u s u a l l y v a r y i n v e r s e l y w i t h t h e i r power and p r i v i l e d g e w i t h i n s o c i e t y . . . . I t i s not s u f f i c i e n t , however, j u s t t o n o t i c e t h e e f f e c t s o f p o v e r t y on h e a l t h ; i t i s a l s o n e c e ssary t o c o n s i d e r who i s a t r i s k o f becoming t h e v i c t i m o f p o v e r t y . I n a h i e r a r c h i c a l s o c i e t y such as t h e one we l i v e i n , members o f groups t h a t a r e oppressed on t h e b a s i s o f gender, r a c e , s e x u a l i t y , and so f o r t h a re t h e people who are most l i k e l y t o be poor. Moreover, not o n l y does b e i n g oppressed l e a d t o p o v e r t y and p o v e r t y t o poor h e a l t h but b e i n g oppressed i s i t s e l f a l s o a s i g n i f i c a n t d e t e r m i n i n g f a c t o r i n t h e areas o f h e a l t h and h e a l t h c a r e (p. 222). Oppression thus c r e a t e s a v i c i o u s c i r c l e t h a t i s l a r g e l y unattended t o i n t r a d i t i o n a l h e a l t h c a r e e t h i c s . Oppressed people become impoverished and i l l , which worsens t h e i r p o v e r t y , and worsens t h e r e a c t i o n o f o t h e r s ( i n c l u d i n g members of t h e h e a l t h c a r e system) t o t h e m — t h a t i s , worsens t h e i r o p p r e s s i o n (Sherwin, 1992, p. 223). I n f a c t , Sherwin (1992) adds i l l n e s s , d i s a b i l i t y , and p h y s i c a l appearance t o t h e c o n s t e l l a t i o n o f r a c e , e t h n i c i t y , c l a s s , age, gender, and s e x u a l o r i e n t a t i o n i n o p p r e s s i o n . A t a s o c i e t a l l e v e l , t h e impact o f o p p r e s s i o n on groups o f people can be d e v a s t a t i n g , and t h i s impact i s not j u s t t o be found i n t h e " T h i r d World" (Sherwin, 1992, p.225). Stephenson (1995) makes t h i s c l e a r . C i t i n g t h e " a p p a l l i n g m o r t a l i t y " o f c h i l d r e n i n N a t i v e communities i n B r i t i s h Columbia (pp. 6-10), he a s k s : Do our d i s t r a c t i o n s and enthusiasms c o n t r i b u t e t o t h e p o l i t i c a l economy of a w o r l d f u l l o f s t a r v i n g c h i l d r e n l i v i n g i n a b j e c t p o v e r t y who d i e i n droves o f common c h i l d h o o d 6 1 Inequity can be defined as unfairness (Webster's Ninth New Collegiate Dictionary, 1985, p. 618). Oppression has a somewhat d i f f e r e n t meaning. Working from F r e i r e (1970), McLaren and Lankshear (1994) define oppression as "a constraint to l i v i n g more f u l l y , more humanly: constraint born of s o c i a l contingencies of power; of d i s c u r s i v e regulation through i n t e r e s t e d and contrived s o c i a l p ractices c a r r i e d out so as to p r i v i l e g e some at the expense of others" (p. 1). d i s e a s e s l i k e c h i c k e n pox, because we f a i l t o c o n s t r u e t h e i r s u f f e r i n g as more th a n an a b s t r a c t i o n , o r even as an e t h i c a l i s s u e ? (p. 10). So w h i l e I have