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

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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 C o l u m b i a , 1988 A THESIS SUBMITTED I N PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (The S c h o o l o f N u r s i n g )  accepX^tnTsTt^iesis  as conforming t o t h e r e q u i r e d  THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1997 © Patricia  Anne Rodney, 1997  standard  in  presenting  degree  at the  this  thesis  in  partial  University of  fulfilment  of  of  department  this thesis for or  by  his  scholarly purposes may be  or  her  representatives.  permission.  of  (^Q(^<,t rU(V-  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  A p f TI  Off  V ^ T  •  for  an advanced  Library shall make  it  agree that permission for extensive  It  publication of this thesis for financial gain shall not  Department  requirements  British Columbia, I agree that the  freely available for reference and study. I further copying  the  is  granted  by the  understood  that  head of copying  my or  be allowed without my written  Abstract TOWARDS CONNECTEDNESS AND TRUST: NURSES' ENACTMENT OF THEIR MORAL AGENCY WITHIN AN ORGANIZATIONAL CONTEXT This study generates  an understanding  o f how n u r s e s  enact  t h e i r m o r a l 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 context i n which they p r a c t i c e . Using a f e m i n i s t ethnographic design, the i n v e s t i g a t o r undertook approximately  180 h o u r s o f  f i e l d w o r k o n a n a c u t e m e d i c a l u n i t i n a community h o s p i t a l , a n d approximately  38 h o u r s o f f i e l d w o r k o n a s e c o n d a c u t e m e d i c a l  unit  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 w o r k e d 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 time, and i n c l u d e d formal 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  c l i n i c i a n s / n u r s e managers f r o m t h e h o s p i t a l s , and,  five  i n order t o  f u r t h e r e x t e n d h e r 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 care nurses  from d i f f e r e n t communities.  I t was f o u n d t h a t n u r s e s e n a c t t h e i r m o r a l a g e n c y 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 t h e h e a l t h c a r e team, a n d t h a t t h i s matrix i s strengthened  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 o f n u r s e s ' work was p o r t r a y e d a s 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 a n d m o r a l d i s t r e s s f o r n u r s e s . T h e r e 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 n u r s e s ' work, i n c l u d i n g g u i l t , and p e r s o n a l  fatigue,  risk.  Moreover, the c u l t u r e o f the o r g a n i z a t i o n a l context f o r n u r s i n g p r a c t i c e a n d p a t i e n t c a r e was p o r t r a y e d a s 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 a n d  Abstract, t h e i r f a m i l i e s was d e p a r t m e n t s and  (Cont'd)  f r a g m e n t e d , as was  t h e communication between  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  the  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 the d i s v a l u i n g of n u r s e s ' work, t h e d i s v a l u i n g o f a c u t e m e d i c i n e as a n u r s i n g  practice  context,  and  the d i s v a l u i n g of 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 s u b s t a n c e use The  problems.  i n v e s t i g a t o r c o n c l u d e s 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  problematic  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 c a n be  f u r t h e r a d d r e s s e d . She  claims  practice  that t r u s t should  f o s t e r e d i n h e a l t h c a r e teams by m a k i n g t h e v a r i o u s 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 other.  F i n a l l y , she  be  members more notes  that  t h e e t h i c a l mandate o f p r o f e s s i o n a l s must encompass a b r o a d e r n o t i o n o f s o c i e t a l good i f t h e d o m i n a n t s o c i o p o l i t i c a l a r e t o be  challenged.  ideologies  iv Table  of Contents  Abstract  p. i i  Table o f Contents  p. i v  Acknowledgments  p. v i i i  Dedication  p. i x  CHAPTER ONE: S i t u a t i n g t h e S t u d y : L i s t e n i n g t o N u r s e s ' Voices Introduction  p. 1  D e v e l o p i n g a Focus f o r t h e Study L o o k i n g a t E t h i c a l Problems and Situational Constraints Understanding M o r a l D i s t r e s s and M o r a l Agency Generating a Problem Statement  p. 4  S e t t i n g Up t h e S t u d y D e l i n e a t i n g Research Questions Locating a Meta-Theoretical Context Sketching the Study Design  p. p. p. p.  A r t i c u l a t i n g Relevance Developing E t h i c a l Theory 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 . 16 p. 16 p. 18  CHAPTER TWO:  Exploring  the Meta-Theoretical  p. 4 p. 8 p. 9 11 11 11 14  Context  Introduction  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 Which P a r a d i g m ( s ) ? N e g o t i a t i n g t h e Postmodern  p . 21 p. 21 p. 27  Understanding the Contributions 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 F e m i n i s t Research as P r a x i s  p. 30 p. 30 p. 33  Horizons  CHAPTER THREE: S u r v e y i n g T h e o r e t i c a l T e r r a i n on M o r a l A g e n c y and The C u l t u r e o f t h e Organizational Context Introduction  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 What C o u n t s ? What A b o u t O r g a n i z a t i o n a l C u l t u r e ? A Culture of Blindness?  p. p. p. p.  37 37 43 46  Table of Contents,  (Cont'd) 48 48 51 51 52 55 58 61  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 D o m i n a t i o n 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 Casuistry Care P r i n c i p l i s m vs Contextualism? 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  pppppp. pp.  T h e o r e t i c a l Work o n M o r a l A g e n c y  p- 62  Culture  p- 65  as Context Moral  es '  Agency  Introduction  P- 69  Conceptual  P- 70  Issues  Nurses' I d e n t i f i c a t i o n o f 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 a n d R e f l e c t i o n s  P- 72 P- 72 P- 77  Nurses' Moral Reasoning and E t h i c a l D e c i s i o n - M a k i n g Early Studies More R e c e n t Work Moral Distress i n Nursing Practice Summary a n d R e f l e c t i o n s  PPPPP-  CHAPTER F I V E : I m p l e m e n t i n g  the Study: Seeking  80 80 82 85 87  Meanings  Introduction  P- 95  Understanding Feminist Ethnographic Methodology Ethnographic Features Feminist Features  P. 96 P- 96 P- 100  How I L e a r n e d A c c e s s i n g Nurses' E x p e r i e n c e s and the Culture o f t h eOrganizational Context From where a n d f r o m whom I l e a r n e d Earning t r u s t i n study r e l a t i o n s h i p s Learning t o observe Learning t o l i s t e n C o n s t r u c t i n g Meanings  P- 103  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  PPPPPP-  103 103 108 114 119 121  vi Table of Contents,  (Cont'd)  W r i t i n g With I n t e g r i t y Rigor Narrative Integrity CHAPTER S I X : M o r a l A g e n c y E n a c t e d i n a R e l a t i o n a l  p . 131 p . 131 p . 136 Matrix  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 My I n i t i a l U n d e r s t a n d i n g Connected I n d i v i d u a l s Supportive Matrices? Transdisciplinarity Authentic Presence Trust  p. 140 p . 140 p . 141 p. 144 p. 148 p. 154 p . 160  Summary a n d R e f l e c t i o n s  p . 162  CHAPTER SEVEN: M o r a l A g e n c y i n t h e C o n t e x t o f N u r s e s ' Work Introduction  p. 166  The M o r a l C o n t e x t o f N u r s e s ' Work E t h i c a l Problems Moral Ambiguity Moral Distress  p. 167 p. 167 p. 168 p. 172  How N u r s e s M e d i a t e T h e i r Work Knowing t h e P a t i e n t Actively Negotiating G e t t i n g Around t h e System  p . 173 p . 173 p. 177 p. 178  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 Work Fatigue Guilt Personal Risk  p . 182 p. 182 p . 186 p . 188  Summary a n d R e f l e c t i o n s  p. 190  CHAPTER EIGHT: N u r s e s ' Work: The O r g a n i z a t i o n a l  Context  Introduction  p. 192  Fragmented Teams a n d Systems Levels o f Fragmentation Impact  p. 193 p. 193 p. 200  Fragmented D e c i s i o n - M a k i n g Incompatible Perspectives P a t i e n t s a n d T h e i r F a m i l y Members? The C o m p l e x i t y o f O p t i o n s  p . 205 p . 205 p . 207 p . 211  vii Table  of Contents,  (Cont'd)  Problems i n V a r i o u s Contexts CHAPTER  p . 218  NINE: The O r g a n i z a t i o n a l C o n t e x t : Ideologies  Sociopolitical  Introduction  p . 220  The V a l u e s T h a t S t r u c t u r e H e a l t h C a r e D e l i v e r y The ( D i s ) V a l u i n g o f N u r s e s ' Work 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 The ( D i s ) V a l u i n g o f Those i n Need  p. p. p. p.  CHAPTER  TEN: R e s p o n d i n g t o N u r s e '  222 222 229 233  Voices  Introduction  p . 237  Methodological Reflections  p. 239  Substantive Reflections E n h a n c i n g M o r a l Agency R e s h a p i n g N u r s e s ' Work C o n t e x t s 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 C o n t e x t Interrogating S o c i o p o l i t i c a l Ideologies  p. p. p. p. p.  REFERENCES  243 243 246 248 250  p . 253  APPENDICES: Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix Appendix  A: A b s t r a c t : Emergency N u r s i n g S t u d y B: F i e l d w o r k C a l e n d a r C: P a r t i c i p a n t B i o g r a p h i c Summary D: P a r t i c i p a n t B i o g r a p h i c Form 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 F: P a r t i c i p a n t C o n s e n t Form G: I n f o r m a t i o n f o r S t a f f H: I n f o r m a t i o n f o r P a t i e n t s a n d F a m i l i e s I : Sample I n t e r v i e w N o t e s J : Sample T r i g g e r Q u e s t i o n s K: F i n a l I n t e r v i e w Segment L: T r a n s c r i p t i o n i s t Agreement M: A n a l y t i c S t r u c t u r e  p. p. p. p. p. p. p. p. p. p. p. p. p.  293 295 297 299 301 308 312 315 318 321 323 339 341  viii Acknowledgments T h i s t h e s i s c o n t i n u e s a j o u r n e y t h a t I began w i t h my M a s t e r ' s t h e s i s i n 1987-1988. I was aware t h e n t h a t s u c h a j o u r n e y was by no means a s o l o a c c o m p l i s h m e n t , 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 s h o r t c o m i n g s i n t h i s f i n i s h e d p r o j e c t a r e 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 t h a n k s go t o t h e f o u r t e e n n u r s e s who p a r t i c i p a t e d i n t h i s s t u d y and gave so w i l l i n g l y o f t h e i r t i m e and t h e i r i n s i g h t s . My t h a n k s 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 f r o m 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 b o t h s i t e s who h e l p e d me t o u n d e r s t a n d . I n a d d i t i o n , I w o u l d l i k e t o e x t e n d my t h a n k s t o t h e e l e v e n emergency n u r s e s who p a r t i c i p a t e d i n t h e s t u d y t h a t I c o m p l e t e d j u s t p r i o r t o t h i s one. S e c o n d l y , 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 R e s e a r c h and Development P r o g r a m f o r p r o v i d i n g f u n d i n g t o s u p p o r t 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 f r o m t h e n u r s e s whose v o i c e s a r e 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 of research materials. Furthermore, I would l i k e t o acknowledge t h 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 s u p p o r t t h a t I have r e c e i v e d f r o m my D i s s e r t a t i o n S u p e r v i s o r y C o m m i t t e e . My C h a i r , Dr. J o a n A n d e r s o n f r o m t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a (UBC) S c h o o l o f N u r s i n g , has b e e n a m e n t o r f o r me i n a l l t h e b e s t s e n s e s o f t h e w o r d . 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 . T o g e t h e r w i t h J o a n , D r . B e t t y D a v i e s and Dr. S a l l y T h o m e f r o m t h e UBC S c h o o l o f N u r s i n g and D r . M i c h a e l M c D o n a l d f r o m t h e UBC C e n t r e f o r A p p l i e d E t h i c s have made up a t e a m 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 f r o m 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 of 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 C a n a d i a n 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 c o u r s e w i t h Dr. S a r a 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 f o c u s on m o r a l a g e n c y . I w o u l d l i k e t o t h a n k S a r a f o r h e r 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 o f 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 u n d e r g r a d u a t e s t u d e n t s who I have been w o r k i n g w i t h have h e l p e d me t o g r a s p t h e r e l e v a n c e o f what I have l e a r n e d i n t h i s s t u d y . I am g r a t e f u l f o r t h e h e l p o f one o f t h e s t u d e n t s , R o g e r 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 t h a n k s 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. J a n S t o r c h , who has s u p p o r t e d me i n my new r o l e . F i n a l l y , I w o u l d l i k e t o e x p r e s s 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 f r o m 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 t h a n k s 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 C r a s k e , 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 t h a n k s t o my m o t h e r , Anne Y u i l e , who h e l p e d w i t h i n n u m e r a b l e p r o j e c t s . And most s p e c i a l t h a n k s t o my h u s b a n d , J o h n Thomasson, who has l i v e d t h i s j o u r n e y w i t h me.  Dedication I n l o v i n g memory o f my f a t h e r , The Hon. M i c h a e l Rodney, QC J u n e 26, 1926 — J u n e 22, 1993  1  CHAPTER ONE: SITUATING THE STUDY: LISTENING TO NURSES' VOICES  Introduction 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 c o n c e r n s i n o u r p r a c t i c e b u t 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 h a s b e e n damaging t o i n d i v i d u a l n u r s e s , the d i s c i p l i n e o f n u r s i n g , and p a t i e n t s . I t i s time f o r c h a n g e . We need a m o r a l l a n g u a g e t h a t w i l l p r e s e r v e a s e n s e o f t h e t r a g i c r e m i n d i n g us a l l t h a t e a c h o f u s 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 l a n g u a g e t h a t w i l l enable us t o s u s t a i n o u r p a t i e n t s and each o t h e r ; t h a t w i l l serve as t h e v e h i c l e f o r o u r 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 o u r e t h i c a l c o n c e r n s ( L i a s c h e n k o , 1993a, p. 9 ) . Within t h i s study,  I hope t o c o n t r i b u t e t o a g r o w i n g  dialogue  about o u r 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 wish 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 , n u r s e s 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 a n d who have t a u g h t  me a g r e a t d e a l a b o u t 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 o u r 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 i n f o r m e d  b y 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 outpost,  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 coronary and by my b a c k g r o u n d a s a h o s p i t a l n u r s e e d u c a t o r c r i t i c a l care  1  n u r s i n g . I am a l s o i n f o r m e d  teaching undergraduate nursing students courses  b y my  care,  teaching experiences  i n t h e o r y and c l i n i c a l  i n two d i f f e r e n t u n i v e r s i t y p r o g r a m s . I n a d d i t i o n , I have  worked w i t h master's students  l e a r n i n g about advanced  nursing  C r i t i c a l c a r e i s a term t h a t i n c l u d e s i n t e n s i v e c a r e , c o r o n a r y c a r e , emergency, and a v a r i e t y o f o t h e r s p e c i a l t y p r a c t i c e areas where p a t i e n t s are s e r i o u s l y i l l , and where e x t e n s i v e b i o m e d i c a l t e c h n o l o g y i s commonplace. 1  practice i n c r i t i c a l  c a r e , and I have h a d 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 across  Canada as a n u r s i n g e t h i c s  T h r o u g h o u t my e x p e r i e n c e s ,  consultant.  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 n u r s e s o n t h e f r o n t l i n e s o f p a t i e n t care.  I have a l s o been s t r u c k b y t h e s e r i o u s c o n c e r n s o f n u r s e s  who w o r k 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  s u p p o r t t h o s e f r o n t l i n e n u r s e s . I have c o m p l e t e d 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 I n my f i r s t s t u d y , I l e a r n e d  perspective.  from c r i t i c a l care nurses about t h e  a n g u i s h t h a t t h e y e x p e r i e n c e when t h e y p a r t i c i p a t e i n a c t i v e treatment 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  only prolong the  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, 1 9 8 7 ) . And i n my s e c o n d s t u d y , I l e a r n e d discomfort  f r o m emergency n u r s e s a b o u t t h e i r  i n s e n d i n g p a t i e n t s home w i t h o u t a d e q u a t e home c a r e  s u p p o r t (Rodney, 1993; s e e a l s o A p p e n d i x A: A b s t r a c t : Nursing  Study).  Emergency  I n t h e words o f one o f t h e emergency n u r s e s :  ...a l o t o f p e o p l e come i n , q u o t e , "as p l a c e m e n t p r o b l e m s " , and i t u s e d t o be t h a t a p l a c e m e n t p r o b l e m s i m p l y meant t h a t somebody was e l d e r l y and what t h e y needed was a n u r s i n g home, and t h e r e was, t h e r e was a l w a y s a s h o r t a g e o f 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 t h o s e 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 p l a c e m e n t p r o b l e m s we're s e e i n g [ a r e ] 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 c o m p l e x s i t u a t i o n s , and I d o n ' t b e l i e v e t h a t there's the...access to...[the necessary] f a c i l i t i e s outi n t h e community...we're s e e i n g p a t i e n t s c o m i n g i n t h a t a r e much more a c u t e l y i l l t h a n t h e y e v e r u s e d t o b e , b u t t h e y ' r e being discharged s t i l l r e l a t i v e l y acutely i l l ( P a r t i c i p a n t Number T e n ; Rodney, 1 9 9 3 ) . N u r s e s and o t h e r s  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 a r e l e f t t o  d e a l w i t h t h e consequences o f problems i n t h e h e a l t h c a r e i n t h e i l l u s t r a t i o n above, problems w i t h sweeping a c u t e h o s p i t a l cutbacks without concomitant resource care  system— care  s h i f t s t o community  ( A n d e r s o n , G r a c e , 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; O b e r l e & G r 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 , & L o n g -  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).  W i t h L i a s c h e n k o ( 1 9 9 3 a ) , I b e l i e v e t h a t n u r s e s ' v o i c e s have n o t b e e n h e a r d c l e a r l y enough i n c l i n i c a l ,  academic,  or policy  a r e n a s . The i n v i s i b i l i t y o f n u r s e s i n much o f t h e c o n t e m p o r a r y h e a l t h care 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 the literature s t i l l  f o c u s 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 a s s u m p t i o n t h a t most p r o f e s s i o n a l e t h i c a l c o n c e r n s a r e subsumed by t h o s e o f p h y s i c i a n s ( B a y l i s , Downie, Freedman, H o f f m a s t e r , & S h e r w i n , 1995; S h e r w i n , 1992; W a r r e n , 1992; s e e a l s o C h a p t e r T h r e e ) . T h i s i s n o t t o s a y 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 important, 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 f o c u s o n n u r s e s 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 c o n c e r n s 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 care workers, pharmacists, p h y s i o t h e r a p i s t s ,  respiratory  t h e r a p i s t s , a n d s o c i a l w o r k e r s . 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  health  c a r e p r o v i d e r s — f o r e x a m p l e , 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 , n u r s e s ' 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 health care ethics l i t e r a t u r e  (Sherwin, 1992). Moreover,  I do n o t  wish t o imply t h a t nurses a r e 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  d o m i n a n t f o c u s 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 n u r s e s 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 o b s c u r e s our understanding o f the e t h i c a l concerns o f the health care which includes p a t i e n t s , t h e i r f a m i l i e s ,  2  team,  and a d m i n i s t r a t i v e  p e r s o n n e l , a s w e l l a 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 . Hence my  f o c u s i s o n t h e e t h i c a l c o n c e r n s o f n u r s e s a n d my i n t e r e s t i s  i n the o r g a n i z a t i o n a l context w i t h i n which the health care 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  Developing Looking  a Focus  team  study.  f o r t h e Study  a t E t h i c a l P r o b l e m s and S i t u a t i o n a l  Constraints  Upon s t e p p i n g b a c k 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 serious, recurring e t h i c a l problems  3  i n their practice  (Rodney &  S t a r z o m s k i , 1993; s e e a l s o C h a p t e r F o u r ) . These e t h i c a l p r o b l e m s include prolongation of l i f e ,  lack o f informed consent, v i o l a t i o n s  of c o n f i d e n t i a l i t y , questionable practices o f professionals  within  and o u t s i d e o f 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 i n a d e q u a t e 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; B e n n e r , T a n n e r , & C h e s l a , 1996; B e r g e r , W i t h i n t h i s study, I am u s i n g t h e term " f a m i l y " q u i t e b r o a d l y . I agree w i t h contemporary f a m i l y t h e o r i s t s t h a t " i t i s q u i t e p o s s i b l e f o r p e o p l e t o have a f a m i l y e x p e r i e n c e ( i n c l u d i n g t h e f e e l i n g s o f i n t i m a c y , connectedness, commitment, and so f o r t h ) w i t h p e o p l e who a r e n o t i n one's a c t u a l f a m i l y . " ( H a r t r i c k & L i n d s e y , 1995, p. 154) T h e r e f o r e , I take i t t h a t t h e "most u s e f u l d e f i n i t i o n o f f a m i l y [ i s ] 'Who t h e f a m i l y says i t i s . ' Furthermore, who 'counts' as f a m i l y may v a r y depending on t h e h e a l t h concern." (Robinson, 1995, p . 119) z  By e t h i c a l problem, I mean a problem t h a t (a) cannot be r e s o l v e d s o l e l y through an appeal t o e m p i r i c a l data, (b) i n v o l v e s c o n f l i c t o f v a l u e s and u n c e r t a i n t y about t h e amount o r type o f i n f o r m a t i o n needed t o make a d e c i s i o n , and (c) t h e answer f o r which w i l l have profound r e l e v a n c e f o r s e v e r a l areas o f human c o n c e r n ( C u r t i n , 1982, pp. 3 8 - 3 9 ) . I am c a u t i o u s o f t h e use o f t h e term e t h i c a l dilemma, as i t i m p l i e s a c h o i c e 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 t h a t a r e u s u a l l y seen as m u t u a l l y e x c l u s i v e . I n my e x p e r i e n c e , t h e r e a l w o r l d o f c l i n i c a l p r a c t i c e i s r a r e l y t h a t two d i m e n s i o n a l . Instead, t h e r e a r e u s u a l l y m u l t i p l e , c o n f l i c t i n g , and sometimes o v e r l a p p i n g a l t e r n a t i v e s . 3  S e v e r s e n , & C h v a t a l , 1991; C a s s e l l s & Redman, 1989; 1988;  1989; Duncan, 1992;  H o l l a n d s , 1994;  F e n t o n , 1987;  D a v i s , 1981;  Haddad, 1988; 1992;  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; O b e r l e & G r a n t , 1994; Ornery & C a s s w e l l , 1988;  P e n t i c u f f , 1989;  S c a n l o n , 1996/1997; S e l l i n , L o n g - M i d d l e t o n , 1996;  1991;  Rodney, 1987; 1 9 9 3 ;  Shindul-Rothschild, Berry, &  S i b b a l d , 1997;  Solomon, O ' D o n n e l l ,  Jennings,  G u i l f o y , W o l f , N o l a n , J a c k s o n , Koch-Weser, & D o n n e l l e y ,  1993).  T h r o u g h o u t t h i s r e s e a r c h , n u r s e s r e p o r t t h a t t h e y a r e hampered b y situational constraints within their practice contexts. S i t u a t i o n a l c o n s t r a i n t s c a n be u n d e r s t o o d a s a s p e c t s o f n u r s e s ' s t r u c t u r a l a n d i n t e r p e r s o n a l work e n v i r o n m e n t s  that are perceived  t o impede t h e i m p l e m e n t a t i o n o f p r o f e s s i o n a l s t a n d a r d s o f n u r s i n g and t h u s 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 . 2 4 ) . S i t u a t i o n a l c o n s t r a i n t s a r e m a n i f e s t e d i n interpersonal c o n f l i c t s with other individuals  ( f o r e x a m p l e , when  nurses d i s a g r e e w i t h t h e 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 t r e a t m e n t f o r a p a t i e n t who h a s r e q u e s t e d t h a t i t be w i t h d r a w n [ 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, t h e assignment b e l i e v e are e x c e s s i v e workloads F l e n t j e , & Bashor,  o f what n u r s e s  [Robinson, Roth, Keim,  Levenson,  1991]).  As I commenced my s t u d y , I f o u n d t h a t i n o r d e r t o u n d e r s t a n d nurses' r e p o r t s o f the s i t u a t i o n a l c o n s t r a i n t s that they when t r y i n g t o d e a l w i t h e t h i c a l p r o b l e m s , the 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  encounter  I needed t o a p p r e c i a t e 4  w i t h i n which  their  By o r g a n i z a t i o n , I mean a formal s t r u c t u r e f o r h e a l t h c a r e d e l i v e r y . T h i s can be p a r t o f a h o s p i t a l , long-term c a r e f a c i l i t y , h e a l t h c l i n i c , home c a r e agency, o r a v a r i e t y o f o t h e r i n s t i t u t i o n s . I w i l l say more about t h e culture 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 n Chapter Three. 4  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 the  w o r k 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  empirical  limit  n u r s e s ' 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  the contexts  r e s p o n s i b i l i t y and circumscribes world  w i t h i n which nurses e x e r c i s e  a c c o u n t a b i l i t y only  i n terms of  their  constraints  our understanding of the r e a l i t i e s of the  practice  i n which nursing i s l o c a t e d . S o c i o l o g i c a l studies portray  h i e r a r c h i c a l c a s t e s y s t e m as e x i s t i n g i n h o s p i t a l s . T h i s  a  creates  c e n t r a l i z e d d e c i s i o n m a k i n g 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 n u r s e s (Anderson e t a l . , i n p r e s s ; S t r e e t , 1992;  C a m p b e l l , 1987;  unappreciated" constraints  features  of  1996;  T o r r a n c e , 1 9 8 7 ) . I n f a c t , n u r s e s on t h e f r o n t  o f p a t i e n t c a r e have been d e s c r i b e d  the  Chambliss,  (Mauksch, 1990, that  the  organizational  nurses  p. 4 8 5 ) .  experience  environment, context  as f e e l i n g " b e t r a y e d  but  in which  are  J came to are  part  not of  they practice  and  understand  just  the  lines  that  external  culture  of  (Jameton,  the  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 r e v i e w e d , i t seemed c l e a r t h a t  o f t h e most p r o b l e m a t i c organizational context  features of the c u l t u r e of i s the  h e a l t h c a r e team members Schmitt, 1988;  1988;  and  1995;  Fiorelli,  Northouse & Northouse,  P r e s c o t t & Bowen, 1 9 8 5 ) . The  research  ( H o l l y , 1989;  S c h e r e r , M i l l e r , & B a t t i s t a , 1993;  1992;  indicates  e n t a i l s inadequate involvement of  t h e i r family i n treatment decisions  Jezewski,  between  ( A n d e r s o n e t a l . , i n p r e s s ; Baggs &  M a r s d e n , 1990;  that t h i s fragmentation  the  communication  E r i c k s e n , Rodney, & S t a r z o m s k i ,  J o n e s , 1994;  O ' T o o l e , 1992;  fragmented  one  patients  1993;  Kuuppelomaki,  1993;  Miya e t a l . ,  1 9 9 1 ; Solomon e t a l . ,  1993), as w e l l as i n a d e q u a t e  i n v o l v e m e n t 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 s h u t o u t o f d e c i s i o n - m a k i n g p r o c e s s e s ( C o r l e y , S e l i g , & F e r g u s o n , 1993; E r l i n & F r o s t , 1991; M a r t i n , 1989; Rodney, 1989; 1 9 9 4 ) . My u n d e r s t a n d i n g o f t h i s f r a g m e n t e d team c o m m u n i c a t i o n 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 a n d 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 study. I found t h e f o l l o w i n g f r o m one o f t h e emergency n u r s e s p a r t i c u l a r l y  story  illuminating:  ...the reason i t ' s p r o b a b l y n o t u n i f i e d i s because each d e p a r t m e n t i s s o s e g r e g a t e d we a l m o s t w o r k a g a i n s t e a c h o t h e r . . . . f o r e x a m p l e , t h e l a s t week I was w o r k i n g 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 t w o and t h e n i n b e d 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 h u n d r e d and t w e n t y , r e a l c o l d a n d clammy, i l l , I was one on one w i t h h e r w h i l e we s t a r t e d m a s s i v e a n t i b i o t i c s . . . e v e r y t h i n g [ t r e a t m e n t commenced] on h e r , and s h e was a n ICU [ I n t e n s i v e C a r e U n i t ] p a t i e n t , r e a d y f o r t r a n s f e r [ t o ICU] a t two i n t h e m o r n i n g , b u t , s e e , t h i s i s an e x a m p l e , [ I C U ] w e r e 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 a n 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 t w o o t h e r p e o p l e p l u s whoever may have w a l k e d 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 b e c a u s e [ I C U ] was, needed a n 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 p e o p l e i n on d o u b l e t i m e t o s a v e 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, 1 9 9 3 ) . What I h e a r d f r o m t h i s n u r s e was t h a t f r a g m e n t e d 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 t e a m members, b u t a l s o between  entire  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 m i s c o m m u n i c a t i o n t o o k p l a c e between  h o s p i t a l d e p a r t m e n t s and  community a g e n c i e s . I a l s o h e a r d a w a r n i n g t h a t f i s c a l  restraints  a r e n o t m a k i n g t h e c o m m u n i c a t i o n p r o b l e m s any b e t t e r . I n t h i s e x a m p l e , t h e c o m m u n i c a t i o n p r o b l e m s were w o r s e n e d when i n d i v i d u a l d e p a r t m e n t s a c t e d " t o s a v e t h e i r b u d g e t s " . A s a r e s u l t o f my s t u d y  w i t h emergency n u r s e s 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 believe that the c u l t u r e of the organizational context w i t h i n w h i c h n u r s e s 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 n o t 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 p r o b l e m s . I n f a c t , i t may  e x a c e r b a t e 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  Distress  and  Moral  Agency  I t a l s o became c l e a r t o me t h a t b e c a u s e 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 the o r g a n i z a t i o n a l context, nurses are o f t e n unable t o i m p l e m e n t t h e m o r a l c h o i c e s t h e y w i s h t o make w i t h behalf of) p a t i e n t s . This creates moral d i s t r e s s C l a r k e , Connaughty,  ( o r on  ( A p p l e t o n , 1993;  Cook, D a v i e s , M c C o r m i c k , M a c k e n z i e , 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; F e n t o n , 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; R u s h t o n , 1992;  Wilkinson,  1987/88; Yeo & F o r d , 1 9 9 6 ) . By d e f i n i t i o n , m o r a l d i s t r e s s o c c u r s when a m o r a l c h o i c e c a n n o t be t r a n s l a t e d i n t o m o r a l (Jameton, 1 9 8 4 ) — w h e n , f o r example,  action  an emergency n u r s e makes a  moral c h o i c e t o prepare a f a m i l y f o r the death of a p a t i e n t ,  but  d e p a r t m e n t a l s t r u c t u r e s make i t a l m o s t i m p o s s i b l e f o r h e r t o g e t t h e f a m i l y t o t h e b e d s i d e (Rodney, o c c u r s when a n u r s e i s " p u l l e d "  1994). M o r a l d i s t r e s s  also  (sent without 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 n o t b e e n a d e q 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 administering u n f a m i l i a r treatments (Wilkinson,  1985,  p. 6 5 ) . I n o t h e r w o r d s , he i s u n a b l e t o i m p l e m e n t h i s m o r a l c h o i c e t o p r o v i d e competent  care. Moral d i s t r e s s i s associated with  f e e l i n g s o f g u i l t , a n g e r , 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 b e e n c a l l i n g p r o f e s s i o n a l burnout 1989;  Rodney, 1988;  (Cameron, 1986; 1994;  C a r p e n t e r , 1988;  Fowler,  Rodney & S t a r z o m s k i , 1993; W i l k i n s o n ,  1985). Moreover,  the 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 m o r a l a c t i o n , and t h e i r s u b s e q u e n t  m o r a l d i s t r e s s , means t h a t  n u r s e s a r e 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 nurses are l i m i t e d i n t h e i r enactment 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 Ormond, 1988;  That i s ,  moral  ( E r l e n & F r o s t , 1991; K e t e f i a n &  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 ,  Rodney & S t a r z o m s k i , 1993; & McElmurray,  agency.  1986;  i n t e r v i e w e d i n my  Yeo  1990;  S t o r c h , 1992; W i l k i n s o n , 1989;  & F o r d , 1996).  One  Yarling  o f t h e n u r s e s who  I  study w i t h c r i t i c a l care nurses underscored the  s e n s e o f p o w e r l e s s n e s s 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: [ S p e a k i n g o f 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 [ t h e 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 w h a t . . . t h e 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 C o m m i t t e e was v a c i l l a t i n g a b o u t what t o do w i t h t h i s c h i l d , w h e t h e r t h e y s h o u l d t a k e h i m o f f t h e v e n t i l a t o r , and t h e r e w e r e a l s o f a m i l y p r o b l e m s a s s o c i a t e d w i t h i t , and I g u e s s as a b e d s i d e n u r s e you n e v e r r e a l l y g o t t o h e a r , 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 w h a t e v e r , b u t you know we n e v e r r e a l l y g o t an i d e a o f e x a c t l y why we had t o k e e p l o o k i n g a f t e r t h i s c h i l d and why t h e y 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. 1 2 8 ) .  Generating  a Problem  Statement  T h u s , as I a p p r o a c h e d  my c u r r e n t s t u d y , I u n d e r s t o o d  that  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 m o r a l a g e n c y as t h e y e n c o u n t e r s e r i o u s , r e c u r r i n g  ethical  problems  arising  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  from the c u l t u r e o f the o r g a n i z a t i o n a l context i n which p r a c t i c e i s fragmented  team a n d / o r d e p a r t m e n t a l  which i t s e l f exacerbates these e t h i c a l  nurses  communication,  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 r e v i e w e d a t t h e o u t s e t o f my s t u d y no means c o n c l u s i v e ( C a s s i d y , 1991; J a m e t o n & F o w l e r , K e t e f i a n , 1989;  5  was b y  1989;  Ornery, 1 9 8 9 ) . T h e r e i s a p a u c i t y o f r e s e a r c h  e x p l a i n i n g how n u r s e s deal ( F o w l e r & F r y , 1988;  with  F r y , 1987;  e t h i c a l problems  in their  K e t e f i a n & Ormond,  P e n t i c u f f , 1991; S w i d e r , M c E l m u r r a y  practice  1988;  & Y a r l i n g , 1 9 8 5 ) . 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 n u r s e s , s e l f - r e p o r t s t h a t have been g a t h e r e d m o s t l y t h r o u g h d e s c r i p t i v e s u r v e y s and q u a l i t a t i v e  interviews.  A l t h o u g h i t was c l e a r t o me t h a t n u r s e s e x p e r i e n c e e t h i c a l p r o b l e m s , and t h a t t h e s e p r o b l e m s  are confounded  by 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 w h i c h t h e y p r a c t i c e , i t was n o t c l e a r what n u r s e s 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 p o o r  u n d e r s t a n d i n g o f how n u r s e s t h e m s e l v e s 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 n u r s e s ' m o r a l  c h o i c e s c o n f l i c t w i t h t h o s e o f p a t i e n t s and/or  families.  6  I completed my i n i t i a l r e s e a r c h r e v i e w f o r t h e study p r o p o s a l i n 1993. G i v e n t h a t t h i s study i s b e i n g w r i t t e n i n 1997, I have c o n t i n u e d t o update the r e s e a r c h l i t e r a t u r e . The c o n c l u s i o n s t h a t I a r r i v e d a t about t h e r e s e a r c h l i t e r a t u r e i n 1993 s t i l l h o l d t r u e . 3  See M u e l l e r (1995) f o r an e x p l o r a t i o n o f how unshared meanings c r e a t e b o u n d a r i e s between p a t i e n t s and nurses, and P u r k i s (1993) f o r an e x p l o r a t i o n o f how power i s e x e r c i s e d by nurses through i n s t i t u t i o n a l i z e d " p r a c t i c e s " . 6  11 Setting Delineating  Research  Up  the  Study  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  directed  toward u n c o v e r i n g knowledge about n u r s e s ' enactment o f t h e i r 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  moral  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  follows:  (1) What a r e n u r s e s ' u n d e r s t a n d i n g s they confront i n t h e i r p r a c t i c e ?  of the e t h i c a l  problems  (2) What a r e n u r s e s ' 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 m o r a l a g e n c y ? T h a t i s , how do t h e y d e a l w i t h t h e e t h i c a l p r o b l e m s in their practice? (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 nurses' experiences?  Locating  a Meta-Theoretical  affect  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  to  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 s u p p o r t s my w o r k .  7  My  i n t e r e s t i n the c u l t u r e of the o r g a n i z a t i o n s  w i t h i n w h i c h n u r s e s work l e d me  t o grapple with long-standing  g e n d e r e d power r e l a t i o n s . As I d e v e l o p e d I was  and i m p l e m e n t e d my  study,  t h e r e f o r e i n f o r m e d by t h r e e m a j o r a r e a s o f f e m i n i s t  scholarship.  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  By m e t a - t h e o r e t i c a l , I mean "broad i s s u e s r e l a t e d t o t h e o r y " such as the " p h i l o s o p h i c a l ferment about the n a t u r e and method of s c i e n c e " (Walker & Avant, 1995, pp. 5-7). In a r t i c u l a t i n g a m e t a - t h e o r e t i c a l c o n t e x t , I am i n the company of a growing cadre of contemporary t h e o r i s t s who are interested i n the p h i l o s o p h i c a l u n d e r p i n n i n g s of n u r s i n g t h e o r y ( f o r example, A l l e n , 1992; Anderson, 1991a; Benner & Wrubel, 1989; Bishop & Scudder, 1990; Donaldson, 1995; Fry, 1992; 1995; K i k u c h i & Simmons, 1992; 1994; Reed, 1989; R i e g a l , Ornery, C a l v i l l o , E l s a y e d , Lee, S h u l e r , & S i e g a l , 1992; Walker & Avant, 1995; Ward, 1995; Watson, 1995; Yeo, 1989). 7  F e m i n i s t t h e o r y can be d e f i n e d as "the s t r u g g l e of i n d i v i d u a l women q u e s t i o n i n g c e n t r a l assumptions of male-generated, - o r i e n t e d and -dominated t h e o r i e s and c r e a t i n g a l t e r n a t i v e approaches t o 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 l o n g but o f t e n i n v i s i b l e h i s t o r y , and has o n l y become r e c o g n i z e d i n academic c i r c l e s over the p a s t 20 y e a r s ( E i c h l e r , p. 8  ontology standpoint  9  u n d e r l y i n g my r e s e a r c h was i n f o r m e d theory.  Harding  by  feminist  (1991) d e s c r i b e s t h i s t h e o r y a s  follows: The d o m i n a n t c o n c e p t u a l schemes o f t h e n a t u r a l a n d 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 W e s t e r n men o f t h e e l i t e c l a s s e s a n d r a c e s have o f t h e m s e l v e s a n d t h e w o r l d a r o u n d them. P o l i t i c a l s t r u g g l e a n d 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 ] s a y , 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 a r e t o be a b l e t o s e e b e n e a t h t h e p a r t i a l a n d 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 g e n e r a t e . 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 e m p h a s i s ] , we c a n a r r i v e a t e m p i r i c a l l y a n d t h e o r e t i c a l l y more a d e q u a t e 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 . 4 8 ) . T h i s means t h a t my s t u d y s t a r t e d f r o m t h e p e r s p e c t i v e o f women ( n u r s e s ) who have h i s t o r i c a l l y w o r k e d 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 , 1 9 8 2 ; M u f f , 1 9 8 2 ) . L e t me be c l e a r t h a t I s t u d i e d women b e c a u s e o f t h e p r o f o u n d impact o f t h e female gender on n u r s i n g , n o t because I b e l i e v e t h a t male n u r s e s a r e n o t 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 a n o t h e r study.  Furthermore, I agree w i t h Harding  (1991) a n d M o r r a a n d  S m i t h (1995) t h a t men c a n be f e m i n i s t s , a n d , o f c o u r s e ,  that 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 i m p o r t a n t undertaken i n t h i s  p r o j e c t ; i t i s j u s t n o t one t h a t I have  study.  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 e m p h a s i s o n t h e o r e t i c a l  synthesis  619). D e s p i t e t h i s r e c e n t acceptance, f e m i n i s t t h e o r y has p r o l i f e r a t e d 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 s o c i o l o g y , t o name a few" (Wallace, 1989, p. 8 ) .  in a  E p i s t e m o l o g y i s concerned w i t h "the n a t u r e and d e r i v a t i o n o f knowledge, the scope o f knowledge, and t h e r e l i a b i l i t y o f c l a i m s t o knowledge" (Flew, 1979, p. 109). Ontology i s t h e branch o f metaphysics "concerned w i t h t h e study o f e x i s t e n c e i t s e l f " and t h e "assumptions about e x i s t e n c e u n d e r l y i n g any c o n c e p t u a l scheme o r any t h e o r y o r system o f i d e a s " (Flew, pp. 255-256). 9  (Tuana & Tong, 1995; W a l l a c e , 1 9 8 9 ) . T h u s , I have b e e n a b l e t o d r a w on t h e o r i s t s f r o m 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 a r e a s o f f e m i n i s t s c h o l a r s h i p . My and methods was  approach t o r e s e a r c h  i n f l u e n c e d t h r o u g h o u t by f e m i n i s t  ( O a k l e y , 1981; D. S m i t h , 1987;  1989;  sociologists  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 , 1 9 9 0 ) , and nursing scholars  methodology  feminist  ( A n d e r s o n , 1991b; C a m p b e l l & B u n t i n g , 1991;  & S t e v e n s , 1991; M a c P h e r s o n ,  Hall  1983; P a r k e r & M c F a r l a n e , 1 9 9 1 ) .  As  D o r o t h y S m i t h (1989) e x p l a i n s , s u c h m e t h o d o l o g i e s and methods "seek f r o m 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 , p o w e r s , and f o r c e s t h a t o r g a n i z e and shape i t " ( p . 3 4 ) . I w a n t e d to  u n d e r s t a n d how n u r s e s ' e x p e r i e n c e s w e r e 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 . I w a n t e d t o make t h e r e s u l t s  1 0  And  a c c e s s i b l e t o t h e n u r s e s w i t h whom  I s t u d i e d s o t h a t t h e y m i g h t u s e them t o f o s t e r  organizational  change. F i n a l l y , my a p p r o a c h t o e t h i c a l t h e o r y i n t h e c o n c e p t u a l i z a t i o n o f my  initial  s t u d y and i n t h e a n a l y s i s o f my  study  r e s u l t s has b e e n i n f o r m e d 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 of  m o r a l t h e o r y ( B a i e r , 1994; G i l l i g a n ,  1982; Mann, 1994;  1992; W a r r e n , 1992; W o l f , 1 9 9 4 ) . As a b r a n c h o f  field  Sherwin,  feminist  philosophy, feminist ethics i s part of the f o l l o w i n g  project:  F o c u s e d as t h e y a r e 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 o f t h e d e g r e e t o w h i c h 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 " R e s u l t s " i m p l i e s t h a t t h e r e was something e s s e n t i a l or o b j e c t i v e ( B e r n s t e i n , 1983) t o d i s c o v e r — a p o s i t i v i s t term t h a t i s i n c o n g r u e n t w i t h the q u a l i t a t i v e and f e m i n i s t t h e o r e t i c a l p e r s p e c t i v e s i n f o r m i n g t h i s study (see a l s o Chapter Two). Thus, I use the term " c o n s t r u c t i o n s " i n s t e a d of r e s u l t s , which acknowledges t h a t what I a r r i v e d a t i n my study was something t h a t was c o n s t r u c t e d between myself and the r e s e a r c h p a r t i c i p a n t s . i U  i n t e r e s t s , i s s u e s , c o n c e r n s , and p e r s o n s . They have a l s o come to see t r a d i t i o n a l philosophy'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 m a j o r d i c h o t o m i e s ( f o r e x a m p l e , mind/body, s e l f / o t h e r , and r e a s o n / e m o t i o n ) a n d t h e n to systematically neglect that less valued half of r e a l i t y t h r o u g h o u t t h e c o u r s e o f i t s own d e v e l o p m e n t . T h u s , f e m i n i s t p h i l o s o p h e r s have o b s e r v e d t h a t among t h e n e g l e c t e d " f e m a l e a s s o c i a t e d " e l e m e n t s i n many o f 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 r e t h e 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 , w h i c h a r e 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 e m o t i o n s and t h e b o d y , w h i c h a r e s e t i n o p p o s i t i o n t o r e a s o n and t h e m i n d ; t h e human need f o r c o o p e r a t i o n and community, w h i c h i s v i e w e d a s 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 a n d t o a s s e r t one's i n d i v i d u a l i t y ; a n d , f i n a l l y , t h e 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 a n d f a c t , s h o u l d be b l u r r e d , h a z y , 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 a n d 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 o n the other"  ( J a g g a r , 1990/1991, p. 8 1 ) . T h u s , 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 o n c o n t e m p o r a r y 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 care  ethics  l i t e r a t u r e , a n d i t h e l p s me t o t h i n k a b o u t e t h i c a l and m o r a l t h e o r y i n a d i f f e r e n t way. T h a t i s , ( t o u s e 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 , the 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, a n d , f i n a l l y ,  interdisciplinary  insights.  Sketching The  the Study Design  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 t h e y were  located w i t h i n the r e a l world of t h e i r practice context. This 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 , a s 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 a b o u t human e x p e r i e n c e s  "through  sustained  c o n t a c t w i t h persons  i n their natural  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 u n d e r s t a n d t h o s e e x p e r i e n c e s . . . . [ i n o r d e r t o ] open up new new  persons'  options for action  and  p e r s p e c t i v e s t h a t c a n change p e o p l e ' s w o r l d s " (Boyd, 1993,  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  d e s i g n i n o r d e r t o uncover  knowledge about n u r s e s '  pp.  study  understanding  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 p r o b l e m s 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  relations  t h a t s t r u c t u r e them" (Roman & A p p l e , 1990, 1 9 8 7 ) . T h u s , my  p. 54; see a l s o  s t u d y d e s i g n a l s o e n a b l e d me t o b e g i n t o  f o r the influence of the o r g a n i z a t i o n a l c u l t u r e  Smith,  account  (the s o c i a l  r e l a t i o n s ) on n u r s e s ' e x p e r i e n c e s ( t h e 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 e n a b l e d t o i n c l u d e b o t h o b s e r v a t i o n and s e l f - r e p o r t  me  (interviews) i n order  t o b e t t e r u n d e r s t a n d what n u r s e s 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 nurses, I undertook  a p p r o x i m a t e l y 180 h o u r s 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 a c u t e 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 h o u r s 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 a s e c o n d  acute medical u n i t i n a t e r t i a r y  h o s p i t a l . I included formal research interviews w i t h these s i x n u r s e s t o s u p p l e m e n t my o b s e r v a t i o n s . My  fieldwork also included  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 f r o m  the  two h o s p i t a l s s o t h a t I c o u l d b e t t e r u n d e r s t a n d 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 w h i c h n u r s e s ' 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 n t e r v i e w e d t h r e e home c a r e n u r s e s i n o r d e r t o b e t t e r  understand  I  some o f t h e b r o a d e r community i s s u e s and  Articulating Developing E t h i c a l  ideologies.  Relevance  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 , 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  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 generating  considered  professional ethics)  by  care  c a r e p r o f e s s i o n a l s s u c h as n u r s e s  are  t o have a p a r t i c u l a r k i n d o f m o r a l a g e n c y b e c a u s e o f  t h e u n i q u e k n o w l e d g e and  s k i l l s — a n d hence p o w e r — t h e y  ( D a n i s & C h u r c h i l l , 1991; W o l f , 1987;  hold  F o w l e r , 1990b; J e n n i n g s , C a l l a h a n ,  P o f f & Waluchow, 1 9 9 1 ) . Y e t o u r k n o w l e d g e o f  e t h i c s of 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 1991;  of  development i n  e m p i r i c a l work on t h e m o r a l a g e n c y o f h e a l t h  professionals. Health  one  P e l l e g r i n o , V e a t c h , & L a n g a n , 1991;  P e l l e g r i n o , V e a t c h , and  &  the  (Brunk,  Saks, 1995).  As  Langan e x p l a i n , "...the whole e d i f i c e  e t h i c s i n the professions  has  become p r o b l e m a t i c .  of  Professionals  t h e m s e l v e s a r e c o n f u s e d a b o u t t h e n a t u r e o f t h e i r o b l i g a t i o n and the moral values t h o s e who  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  seek t h e i r h e l p "  d e a l a b o u t how  n u r s e s and  professionals/providers  (p. v i i ) .  T h u s , we  other health  enact  do n o t know a  great  care  t h e i r m o r a l a g e n c y . We  need t o h a v e  a b e t t e r s e n s e o f t h i s i f we  are t o support the e t h i c a l p r a c t i c e  o f n u r s e s and  i n other  How  our c o l l e a g u e s  disciplines.  can t h e k i n d of e m p i r i c a l work g e n e r a t e d i n t h i s  study  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 m o r a l a g e n c y ? 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  morality  ( H o f f m a s t e r , 1 9 9 0 ) . 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 a p p e a r 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 w h i c h t h e s e o c c u r , and i n d e e d 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 o f t h e v a l u e s and p r o c e d u r e s t h e y u t i l i z e when m a k i n g e t h i c a l judgements ( W e i s z , 1990, p. 3 ) . A g r o w i n g number o f 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 d i s c i p l i n a r y p r o b l e m s l i e s i n a contextualist and m o r a l i t y ,  1 1  which  ( H o f f m a s t e r , 1990;  approach  f o c u s e s on t h e r e a l w o r l d o f  1993; W i n k l e r , 1 9 9 3 ) . And  such  to ethics  practice  "understanding  the  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 " ( H o f f m a s t e r , 1990,  p. 2 5 0 ) . T h i s  i s p r e c i s e l y what I am h o p i n g t o a c h i e v e — t o l o c a t e n u r s e s * e n a c t m e n t o f t h e i r m o r a l a g e n c y w i t h i n t h e s o c i a l and  historical  ( 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 t h e s e d a t a t o r e f l e c t b a c k on p h i l o s o p h i c a l n o t i o n s o f agency. I n f a c t , Hoffmaster 1990)  mode inquiry,  moral  (1993) and a c o l l e a g u e ( J e n n i n g s ,  have p o i n t e d o u t t h a t e t h n o g r a p h i c s t u d i e s a r e  s u i t e d f o r such a purpose.  use  particularly  Some t h e o r i s t s have c a l l e d t h i s  whereby f a c t and v a l u e i n q u i r y a r e c o m b i n e d  1 2  dual to  The major d i v i s i o n s of e t h i c s as a d i s c i p l i n e i n c l u d e 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 m e t a e t h i c s (Fowler, 1987; F r y , 1987; Yeo, 1991). Descriptive ethics e n t a i l s f a c t u a l d e s c r i p t i o n s of moral b e h a v i o r 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 f o r m u l a t i o n and defense of b a s i c p r i n c i p l e s , v a l u e s , v i r t u e s , and i d e a l s g o v e r n i n g moral b e h a v i o r ; and metaethics e n t a i l s an a n a l y s i s of meaning, j u s t i f i c a t i o n , and i n f e r e n c e s of moral terms, concepts, and statements (Fowler, 1987, pp. 2629). Whereas the term e t h i c s u s u a l l y r e f e r s t o the above as a f o r m a l f i e l d of i n q u i r y , m o r a l i t y u s u a l l y r e f e r s t o p e r s o n a l a t t r i b u t e s and a c t i o n s . The terms are o f t e n used i n t e r c h a n g e a b l y , but I w i l l adhere t o t h i s d i s t i n c t i o n whenever p o s s i b l e . 1 1  T h i s i m p l i e s t h a t f a c t s are s e p a r a t e from v a l u e s , but the d i s t i n c t i o n between the two forms of i n q u i r y may not be a b s o l u t e (Jennings, 1990). Yeo (1994) warns t h a t distinctions between f a c t s and v a l u e s are "the wrong s t a r t i n g p o i n t f o r moral e n q u i r y " (p. 90). He notes t h a t the " d e s c r i p t i o n of the problem s i t u a t i o n [the f a c t s ] i s c o n s t r u c t e d , and c o n s t r u c t e d 1 2  enhance t h e o r y d e v e l o p m e n t  i n ethics  ( F o w l e r , 1990a; J a m e t o n &  F o w l e r , 1989). I n t e r e s t i n g l y , s c h o l a r s o f b o t h moral t h e o r y ( B a i e r , 1994; F l a n a g a n , 1991) and a p p l i e d e t h i c s ( H o f f m a s t e r , 1990;  1991; 1993; J e n n i n g s , 1990; S t e v e n s o n , 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  S t r e n g t h e n i n g The  Health Care  genre.  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 s t u d y was t o a r t i c u l a t e how t h e n u r s e s ' v o i c e s I am p r o f i l i n g w o u l d be of benefit t o the health care system.  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 of t h i s  thesis.  However, I w o u l d a l s o l i k e t o l a y o u t some o f my t h i n k i n g h e r e . The C a n a d i a n h e a l t h c a r e s y s t e m i s c u r r e n t l y u n d e r g o i n g 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 r e n e w a l ( E v a n s , 1990; R a c h l i s & K u s h n e r , 1994; S t o r c h & M e i l i c k e , 1 9 9 4 ) . T h i s h a s r e s u l t e d 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 e c o n o m i c  from  forces,  s u c h a s 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 e m p h a s i s  on t h e d e t e r m i n a n t s o f h e a l t h , t h e consumer movement,  and t h e c h a n g i n g c u l t u r a l a n d s o c i o d e m o g r a p h i c c h a r a c t e r i s t i c s o f t h e C a n a d i a n p o p u l a t i o n ( B a d e t s & C h u i , 1994; L e F o r t , 1 9 9 3 ) . T h e s e same f o r c e s have g e n e r a t e d a number o f e t h i c a l p r o b l e m s t h e h e a l t h c a r e s y s t e m (Buchanan,  1989; Denton  throughout  & S p e n c e r , 1988;  F r y , 1988; K l u g e , 1988; 1992; S t o r c h , 1 9 9 2 ) . I t f u r t h e r seems t h a t e t h i c a l p r o b l e m s o f r e s o u r c e a l l o c a t i o n have come t o d o m i n a t e o r d i f f e r e n t l y by d i f f e r e n t p l a y e r s . As such, i t i s not m o r a l l y n e u t r a l " (Yeo, 1994, p. 92). Indeed, Yeo (1994) c l a i m s t h a t f a c t s and v a l u e s a r e "codependent" (p. 95). I am g r a t e f u l t o 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 study. I am a l s o g r a t e f u l t o Dr. Joan Anderson o f 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 f o r her encouragement t o a r t i c u l a t e t h e r e l e v a n c e of t h e s t u d y . 1  3  c o n f o u n d most o t h e r e t h i c a l p r o b l e m s (Rodney & S t a r z o m s k i , s e e 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;  1994; 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 r e n e w a l , w h i c h 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 c o n t a i n m e n t and allocation  (Evans,  1990;  R a c h l i s & K u s h n e r , 1994;  resource  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 o f p r o v i n c i a l r e p o r t s c o m m i s s i o n s on h e a l t h . These i n c l u d e , f o r e x a m p l e , Closer The  Report  and  Costs  of  the  B r i t i s h Columbia  Royal  Commission  and to Home:  on Health  Care  ( B r i t i s h C o l u m b i a R o y a l C o m m i s s i o n on H e a l t h C a r e  C o s t s , 1 9 9 1 ) , and  Improving  Health  and  (Government o f Quebec, 1 9 8 9 ) . O b s e r v e r s  Weil-Being  in  and  Quebec  warn t h a t u n l e s s  Canadian h e a l t h care system i s s u c c e s s f u l i n i t s reform  the and  renewal, 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, 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 James, & Rodney, 1996;  ( B e t k o w s k i , 1994;  R a c h l i s & K u s h n e r , 1994;  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  and  Helms,  S t o r c h , 1988). concentrated  p u b l i c a u t h o r i t y t o b a l a n c e t h e power 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 s o t h a t t h e y a c t on b e h a l f o f t h e p u b l i c r a t h e r t h a n on t h e b a s i s of t h e i r s e l f - i n t e r e s t r e s p o n s i b i l i t y and thus  central  ( B a r e r & E v a n s , 1 9 9 2 ) . Strengthening  a c c o u n t a b i l i t y of health  to reform  and  care  professionals  the is  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 i s e m p i r i c a l e v i d e n c e 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 e t h i c a l problems w i t h i n the h e a l t h c a r e system. A b e t t e r understanding  of the e t h i c s of p r a c t i c e of h e a l t h care  there the  p r o f e s s i o n a l s i s n e e d e d , and  e t h i c a l theory,  e s p e c i a l l y i n terms  o f m o r a l a g e n c y , must be d e v e l o p e d t o h e l p s u p p o r t 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 helps 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 o f 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 care p r o f e s s i o n a l s , i t s e t s the stage f o r 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 n t i r e team. And c u l t u r e of the o r g a n i z a t i o n a l context  by a t t e n d i n g  to  w i t h i n which nurses  and  other health care 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 helps e x p l a i n the sources,  and  the  to  thus the p o t e n t i a l f o r r e s o l u t i o n , of  p r o b l e m s s u c h as f r a g m e n t e d team a n d / o r d e p a r t m e n t a l c o m m u n i c a t i o n . Such a r e s o l u t i o n i s v i t a l , b e c a u s e i n d i c a t e s t h a t f r a g m e n t e d t e a m c o m m u n i c a t i o n may outcomes (Baggs & S c h m i t t , J o h n s o n , 1992;  1988;  Busby & G i l c h r i s t ,  research  worsen p a t i e n t  Baggs, Ryan, P h e l p s , 1992;  M i t c h e l l , Armstrong, Simpson, & L e n t z ,  Richeson, &  Fisher & Peterson, 1989).  O v e r a l l , I intend t h i s study t o c o n t r i b u t e t o the  knowledge  n e c e s s a r y t o make t h e c u l t u r e o f h e a l t h c a r e o r g a n i z a t i o n s c o n d u c i v e t o t h e e t h i c a l and  i s , I b e l i e v e , p a r t i c u l a r l y cognizant  of  r e a l i t i e s of the p r a c t i c e world w i t h i n which nursing "we  an  the i s located,  w a n t , 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  n o t i c e o u r m o r a l p r o b l e m s and and  more  e f f e c t i v e p r a c t i c e o f n u r s e s 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 o f e t h i c i s t who  1993;  i n t e g r i t y and  t o c o p e w i t h them w i t h  t o keep o u r h e a l t h c a r e  t o t h e i r moral goals"  ( J a m e t o n , 1990,  p.  sensitivity  institutions 450).  to  responsive  CHAPTER  TWO:  EXPLORING THE META-THEORETICAL  CONTEXT  Introduction 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 n u r s e s o n 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 , n u r s e s 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 m e t a 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 study 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 f r o m 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 a n d o n 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 a p p r o a c h t o r e s e a r c h m e t h o d o l o g y a n d methods i s i n f l u e n c e d t h r o u g h o u t  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 education, and f e m i n i s t n u r s i n g s c h o l a r s , a n d my a p p r o a c h t o e t h i c a l t h e o r y h a s been i n f o r m e d 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 u s e o f t h i s C h a p t e r explore i t . Given the profound  t o further  changes i n t h e 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 c h a n g e s ( L a t h e r , 1991;  L u k e & G o r e , 1992;  these  Tuana & Tong, 1 9 9 5 ) , I  w i l l b e g i n w i t h some comments a b o u t 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 Which  the Philosophy  of Science  Paradigm(s)?  S i n c e Kuhn's (1970) l a n d m a r k t e x t , r e v o l u t i o n s ( o r evolutions  [ L a u d a n , 1977]) i n t h e p a r a d i g m s o f 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 o f t h e s e c h a n g e s have been b a s e d on an e p i s t e m o l o g y w h i c h "rejects foundational truths located i n disciplinary  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 & G o r e , 1992, p. 5 ) . T h i s e p i s t e m o l o g y  been d e f i n e d a s n a t u r a l i z e d  has  (Dancy, 1985, p. 235; K o r n b l i t h ,  1 9 8 5 ) , and c l a i m s t h a t d e s c r i p t i v e  (factual,  " i s " ) q u e s t i o n s have  an i m p o r t a n t b e a r i n g on v a l u e ( n o r m a t i v e , " o u g h t " )  questions.  1 4  1 5  ( K o r n b l i t h ; S t a r z o m s k i & Rodney, 1 9 9 7 ) . 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 a r e 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 b e c a u s e t h e y a r e n o t s t a t i c .  I have  f o u n d i t u s e f u l t o c a t e g o r i z e them i n a c c o r d a n c e w i t h Guba's (1990) o u t l i n e o f t h e p a r a d i g m s t h a t g u i d e i n q u i r y b e c a u s e 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 p a r a d i g m s , 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 m e t h o d o l o g y and m e t h o d s .  16  Guba o u t l i n e s f o u r p a r a d i g m s ,  d i f f e r e n t i a t i n g them on t h e 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 I t i s worth n o t i n g here t h a t 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 p h i l o s o p h y . P h i l o s o p h e r s have warned of the " n a t u r a l i s t i c f a l l a c y " of a r g u i n g from i s t o ought. We are c a u t i o n e d not t o deduce c o n c l u s i o n s about what ought t o be from premises t h a t s t a t e o n l y what i s the case; or the o t h e r way about....For i n s t a n c e , because a c e r t a i n k i n d of conduct i s n a t u r a l t o most of us, because t h a t i s something t o which most of us are n a t u r a l l y i n c l i n e d , t h e r e f o r e [we should not conclude] t h a t i t i s l i c i t i f not p o s i t i v e l y o b l i g a t o r y (Flew, 1979, pp. 240-241). 1 4  In p h i l o s o p h y , "normative" has t o do w i t h q u e s t i o n s of v a l u e . However, w i t h i n the s o c i a l s c i e n c e s , the word h o l d s a somewhat d i f f e r e n t m e a n i n g — normative i m p l i e s what i s standard, and hence normal. Given t h a t p h i l o s o p h e r s 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 p l a c e of normative throughout t h i s t h e s i s . I would l i k e t o thank Dr. Joan Anderson f o r b r i n g i n g t h i s i n t e r d i s c i p l i n a r y c o n c e p t u a l i s s u e t o my a t t e n t i o n . 1 5  Nonetheless, Guba (1990) notes t h a t h i s i s o n l y the paradigm i s s u e " (p. 18). 1 6  "one  way  t o understand  of t h e knowable?),  epistemology  (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 a n d t h e k n o w n ? ) , and m e t h o d o l o g y (how  s h o u l d t h e i n q u i r e r go a b o u t f i n d i n g o u t k n o w l e d g e ? ) ( p .  1 8 ) . The f o u r p a r a d i g m s t h a t he i d e n t i f i e s a r e 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, p p .  19-27). Guba (1990) d e f i n e s p o s i t i v i s m a s c o n v e n t i o n a l i n q u i r y , which i s rooted i n a r e a l i s t ontology  ( 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 epistemology  (the inquirer  stands  b a c k a n d p u t s q u e s t i o n s d i r e c t l y t o n a t u r e and a l l o w s n a t u r e t o a n s w e r b a c k 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 m e t h o d o l o g y ( p p . 1 9 - 2 0 ) . Postpositivism  i s a modified version of  p o s i t i v i s m , a n d 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  (reality  exists  o u t t h e r e b u t c a n n e v e r be f u l l y a p p r e h e n d e d ) , a m o d i f i e d o b j e c t i v i s t epistemology  ( 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 ,  b u t c a n o n l y be a p p r o x i m a t e d ) ,  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 m e t h o d o l o g y ( 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, d e p e n d i n g more on g r o u n d e d 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. 2 1 2 3 ) . Constructivism  i s f o u n d e d on a r e l a t i v i s t  ontology  ( 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 epistemology  ( i n q u i r e r and i n q u i r e d a r e f u s e d i n t o a  s i n g l e e n t i t y ) , and a h e r m e n e u t i c ,  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 ,  with  t h e a i m o f g e n e r a t i n g o n e , o r a f e w , c o n s t r u c t i o n s on w h i c h t h e r e i s s u b s t a n t i a l c o n s e n s u s ) (Guba, pp. 2 5 - 2 7 ) . The f o u r t h p a r a d i g m 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  theory  p a r a d i g m 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 c a s e  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 epistemology  of  ( i n the sense t h a t  v a l u e s m e d i a t e 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 m e t h o d o l o g y ( 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 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.  energizes  24-25).  I t i s i m p o r t a n t t o n o t e 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 p a r a d i g m t o have a r e a l i s t o n t o l o g y b e c a u s e t h e phrase  "false consciousness" implies that there i s a "true  c o n s c i o u s n e s s " somewhere "out t h e r e " ( p . 2 4 ) . 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 ( S c h w a n d t , 1990, c l a i m i n g t h a t "we c l a i m i n g t h a t we  p. 2 7 4 ) , who  c i t e s B e r n s t e i n (1978, p. 109)  as  c a n show t h e 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 have a c h i e v e d a f i n a l ,  absolute,  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 " . important t o note t h a t the term c r i t i c a l  'true' I t i s also  1 7  theory f o r t h i s  paradigm  i s n o t 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 t e r m i s : no d o u b t i n a d e q u a t e 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 c a n be swept i n t o t h i s c a t e g o r y o f p a r a d i g m . A more a p p r o p r i a t e l a b e l w o u l d 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 . 2 3 ) . I wonder i f some f e m i n i s t t h e o r i s t s m i g h t 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 s u c h as n e o - M a r x i s t s , 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 am i n c l i n e d t o agree w i t h Schwandt (1990). See B e r n s t e i n ' s (1991) h o r i z o n s . 1 7  1 8  b u t I do t h i n k  I w i l l therefore  my  later discussion  However, L a t h e r (1991) appears t o share t h i s type of c l a s s i f i c a t i o n . s t a t e s t h a t "the v a r i o u s feminisms, neo-Marxisms and some of the p o s t s t r u c t u r a l i s m s , then, become k i n d s of c r i t i c a l t h e o r i e s which are informed by i d e n t i f i c a t i o n w i t h and i n t e r e s t i n o p p o s i t i o n a l s o c i a l movements." (p. 3) 1 8  of  She  r e f e r t o t h i s p a r a d i g m 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 In  Theory.  1 9  c o m p a r i n g t h e v a r i o u s p a r a d i g m s , Guba (1990) s t a t e s  that  none