Gilligan's different voice: a perspective for nursing

This article proposes that Carol Gilligan's ethic of care provides for nursing a paradigm for moral deliberation that demonstrates compatibility with nursing's historical and philosophical traditions of relational caring and furnishes empirical support for the value of caring as a moral activity. The appropriateness of Gilligan's theory for nursing is further illustrated by an elucidation of the similarities between Gilligan's theory and nurse theorist Jean Watson's claims that caring constitutes both a necessary and a fundamental component of nursing. It is argued that Gilligan's theory of moral deliberation more faithfully reflects the nursing experience than Kohlberg's contractual, Kantian theory, which currently dominates the nursing literature.     

Intercultural caring-an abductive model

The aim of this study was to increase the understanding of caring from a transcultural perspective and to develop the first outline of a theory. The theoretical perspective includes Eriksson's theory of caritative caring. Texts on caring by the transcultural theorists, including Campinha-Bacote, Kim-Godwin, Leininger and Ray, are analysed using content analysis. The overall theme that resulted from this analysis was that caring is a complex whole. Three main categories of caring emerged: inner caring, outer caring and the goal of caring. Inner caring consists of caring is a relationship, and caring and culture are seen in different dimensions. Outer caring refers to caring affected by educational, administrative and social and other structures. The goal of caring consists of caring leading to change towards health and well-being. The main categories include categories and subcategories that are compared with Eriksson's theory of caritative caring.
A model for intercultural caring is generated abductively. Caring and culture appear in three dimensions: caring as ontology independent of context; caring as a phenomenon emphasised differently in different cultures; caring as nursing care activities is unique. Caring alleviates suffering and leads to health and well-being. This model describes caring from an intercultural perspective as a mutual but asymmetric relationship between the nurse and the patient, including the patient's family and community. The patient's cultural background and acculturation influence caring. The cultural background, cultural competence and organisation of the nurse also influence caring. Caring is seen as a complex whole. This study integrates Campinha-Bacote's, Kim-Godwin's, Leininger's and Ray's views of caring with Eriksson's caritative caring and presents caring from a transcultural perspective in a new way as a model for intercultural caring, which can benefit nursing care, education, research and administration.     

Grief as a Social Emotion: Theoretical Perspectives

The article explores a sociological perspective on grief as a social emotion. Focusing on the social bond with the deceased, the self-concept of the survivor or the power of feeling rules, general sociological theories of emotions (symbolic interactionism, structural theory, behavioral theory) have the potential to deepen the understanding of grief as a social emotion. The article concludes by presenting a cognitive-structural model of grief that integrates the different theoretical elements.     

Understanding the importance of values and moral attitudes in nursing care in preserving human dignity

The purpose of this investigation was to explore when nursing becomes an art, and to develop a theory/model of nursing as art. The overall design of the investigation was qualitative, and phenomenological-hermeneutic. The five substantial categories in the theory/model are: Invitation and confirmation, encounter, values, moral attitude and demeanor, the act of good will, and aesthetic communication. One main finding of this nursing investigation based on the caring perspective was that values and a thoroughly moral attitude and demeanor are central when nursing becomes an art.     

Caring in nursing: a different interpretation

AIM: To apply Habermas' (1995) Theory of Moral Consciousness and Communicative Action to the nurse-patient relationship, offering a different interpretation to the nurse-patient relationship that is caring in nursing. RATIONALE: Many authors have described the nurse-patient relationship, but Habermas' theory synthesizes the components into a complex matrix that is caring in nursing. FINDINGS: The theory offers three claims to normative validity: the claim to truth which is the factual objective knowledge; the claim to truthfulness which refers to the intrasubjective self; and the claim to right which is the intersubjective interaction. The validity claims explain the patient's personal and illness self, the nurse's personal and professional self, and the interaction/discourse. The interaction is situation specific, and is identified as moral because dialogue/discourse requires a 'considerateness' of each for the other. 'Considerateness' in discourse requires certain rules, including that each participant has an equal voice, be followed in order for the Principle of Universalization to occur. Habermas draws on Kohlberg's (1981), and Selman's (1980) work to develop three levels of moral maturity of communication. These are preconventional, conventional, and postconventional. Initial moral maturity is egocentric, subjective, and obedient to authority. Maturity develops with recognition of other and reciprocity. At the postconventional level there is mutuality and the ability for abstract reasoning. There is a third person objectivity combining speaker and addressee/listener perspectives. Norms are not just accepted, they are reasoned through. This leads to justification of the norm, which is then accepted as valid. When the three validity claims are met and there is genuine 'considerateness' in the interaction there is communicative action. The reverse is strategic action, where the communication is coercive. When there is communicative action both patient and nurse are validated with a sense of fulfillment or . CONCLUSION: Habermas' (1995) theory offers a new paradigm for caring in nursing.     

Moral development: a differential evaluation of dominant models

This article examines and evaluates the supporting evidence from the prevailing models of moral development. Using the criteria of empirical relevance, intersubjectivity, and usefulness, the classical model from psychoanalytic theory, Kohlberg's and Gilligan's models from cognitive developmental theory, and the social learning theory model are reviewed. Additional considerations such as the theoretical congruency and sex role bias of certain models are briefly discussed before concluding with the current use of the models by nursing.     

Measuring Nurses' Moral Judgments

Studies of the moral reasoning of nurses yield inconsistent findings. Using Cronbach and Meehl's interpretive framework, the author demonstrates the lack of construct validity for Kohlberg's theory of moral development and related measures of moral reasoning. Gilligan's relational theory of moral orientations is proposed as an alternative theory worth testing in nurse samples.     

Concepts of caring and caring as a concept

If caring is to be retained as the "essence" of nursing, and if research in this area is to advance, then the various perspectives of caring must be clarified, the strengths and the limitations of these conceptualizations examined, and the applicability of caring as a concept and theory to the practice of nursing identified. Examination of the concept of caring resulted in the identification of five epistemological perspectives: caring as a human state, caring as a moral imperative or ideal, caring as an affect, caring as an interpersonal relationship, and caring as a nursing intervention. Two outcomes of caring were identified: caring as the subjective experience and as the physiologic responses in patients. The authors concluded that knowledge development related to caring in nursing is limited by the lack of refinement of caring theory, the lack of definitions of caring attributes, the neglect to examine caring from the dialectic perspective, and the focus of theorists and researchers on the nurse to the exclusion of the patient.     

Limitations and alternatives: ethical practice theory in nursing

Limitations in findings are encountered when a theoretical framework is selected prematurely to guide theory building. Kohlberg's theory, chosen by Ketefian as the framework for an ethical practice theory of nursing may not reflect the life experiences of nurses. While Kohlberg's theory calls for an ethic of justice, Gilligan's research suggests that most women make ethical decisions based on an ethic of care. An alternative to the premature selection of a guiding framework is first to describe the moral decision making of nurses and then to choose the framework that best fits the reality of nursing.     

Rethinking Moral Reasoning Theory

Many nursing studies on moral reasoning and ethics have used Kohlberg's theory of moral development. The body of knowledge that resulted from these studies indicated that nurses and nursing students had consistently lower than expected levels of moral reasoning. Educational offerings were developed to assist nurses to improve their moral reasoning. This article explores the cognitive-developmental theory of moral development as one way of determining the moral development of nurses. Since this theory of moral reasoning focuses on the rational thought of the individual and does not consider the impact of the environment, it is of limited applicability in nursing. A new theory of morality needs to be developed—a more holistic one that will include both universal principles and contextual issues.     

Ethical practice in nursing: working the in-betweens

BACKGROUND: While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. PURPOSE: With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. DESIGN AND METHODS: Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. FINDINGS: The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. CONCLUSIONS: Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.     

Value analysis: a method for teaching nursing ethics and promoting the moral development of students

In an investigation of junior-level baccalaureate nursing students, the value analysis teaching strategy was used to teach content related to nursing ethics. It was hypothesized that such a strategy, which emphasized the need for careful evaluation and weighing of facts preparatory to drawing conclusions, would impact on the student's level of cognitive moral development. Cognitive moral development was defined in accord with Kohlberg's theory of moral development. Control and experimental populations were derived from two groups of students sequentially enrolled in the same course. Pre- and post-testing using scores on Rest's Defining Issues Test (DIT) showed significant differences in gain between control and experimental subjects. There was a strong association between DIT score gains and self-report of peer discussion of ethical issues. The major implication of this study is that instructional intervention produces measurable change in some students' level of moral judgment.     

Construction and testing of the Moral Development Scale for Professionals (MDSP)

Moral development among students is central for nursing education, because nursing is informed by moral ends, and it is essential that professional nurses have a well developed ability for moral behaviour, ethical reasoning and decision making. The aim of this study was to construct a new instrument for measuring moral development according to Kohlberg's theory of moral development among students and professionals, and initially test it for reliability and validity among students in professional education. Thirty-two items following the conventional and postconventional stages in the theory were developed. Different actions for reducing the items were implemented. The final version of the instrument with 12 items was tested for reliability and validity among 326 conveniently chosen students. A Cronbach's alpha coefficient of 0.67 and support for construct validity was obtained.     

Caring, patient autonomy and the stigma of paternalism

Caring, patient autonomy and the stigma of paternalism ¶This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that over-emphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.     

Ethical dilemmas in nursing: the role of the nurse and perceptions of autonomy

This study investigated decision making in ethical dilemmas and attitudes toward professional autonomy. It was based on Murphy's identification of three nurse-patient relationship models. The model identification was the result of Murphy's investigation of the levels of moral reasoning of nurse practitioners, from Kohlberg's theory of moral development. Autonomy is necessary for patient advocacy in Murphy's highest order model of nurse-patient relationship. 109 freshmen, 103 seniors, and 82 graduates (baccalaureate nursing) were examined for model selection, risk-taking, restrictions, and anxiety in the decision-making process in specific situations. Autonomy was measured independently. The most significant results indicated that freshmen were less likely to select the autonomous model of relationship, had lower attitudes toward professional nursing autonomy, and were less willing to take risks. Graduates were lower than either student group in their perceptions of restrictions and anxiety. The responses to each dilemma itself varied by situation in relation to the model preferred.     

Two portraits of caring: a comparison of the artists, Leininger and Watson

Two nursing leaders, Madeleine Leininger and Jean Watson, have devoted their careers to studying and evolving the meaning of caring. The theme of caring as presented by each theorist was explored along with their views of the nature of nursing, use of theory development strategies, and their individual contributions to the development of nursing knowledge. Both identify nursing as a humanistic science, with the concept of caring being the central unifying domain of nursing. Consistent with their belief that the humanistic sciences require a different research methodology to study that which is uniquely human, both have utilized qualitative research methodologies in their study of care. The evolution of each theorist perspective of care reflects their own background and experiences. Each theorist, therefore, has painted a different portrait of caring, demonstrating a differing emphasis on philosophical, cultural and empirical concerns. For Leininger, caring must be placed in a cultural context since caring patterns can differ transculturally. Watson has focused on the philosophic (existential--phenomenological) and spiritual basis of caring and sees caring as the ethical and moral ideal of nursing. Both Leininger and Watson have demonstrated their artistry in their individual portraits of caring and in their contributions to the development of nursing knowledge.     

Acting from the virtue of caring in nursing.

The author challenges the recently argued position of Helga Kuhse that caring is merely a preparatory stage to moral action and that impartial, principled thinking is required to make action moral, by suggesting a notion of caring as virtue. If caring is a virtue then acting from that virtue will be acting well. Acting from the virtue of caring involves eight features, which include not only that of being sensitive to, and concerned about, the patient, but also that of being aware of, and sensitive to, the relevant ethical principles. In this way, caring is seen as an overarching quality that gives action its moral character. The moral character of an action does not derive only from its having been performed in the light of principles.     

Family suffering related to war experiences: an interpretative synopsis review of the literature from a caring science perspective

The aim of this study was to conduct a synopsis review of findings from families' experiences related to combat and war events and to interpret these findings from the perspective of theories of suffering. The method used in the study was a synopsis review of 12 articles dealing with family suffering related to war or combat experiences and an interpretation of the articles from a caring science perspective. Findings from the synopsis review were that the dominant part of the articles viewed suffering in general and post-traumatic stress disorders (PTSD) in particular from a medical, psychiatric or psychologically behaviouristic perspective. PTSD and other distress-related conditions were mainly described in terms of their symptoms and dealt with in terms of pathology. The interpretation of the articles from a caring science perspective generated three significant themes: first, interdependence as a spiritual dimension of dependence, secondly, familial communion as sharing moral and spiritual values and thirdly, familial suffering visualized by compassion. The study's conclusion is that, from a caring science perspective, the appearance of family suffering should be comprehended in terms of expressed compassion and that any disturbance within familial communion is likely to have an emotional impact on all of the family members, as a result of their interdependence.     

Challenging misperceptions about nurses' moral reasoning.

Discussions in the nursing literature about the usefulness of Kohlberg's theory of moral reasoning for women and nurses, and assertions about the level of moral reasoning scores of nurses have been clouded by inaccuracies and misperceptions. In this article, theoretical and measurement issues related to moral reasoning are clarified and a critical review of the literature is provided about the moral reasoning of nursing students and nurses as measured by the Defining Issues Test (DIT). The review indicates the need for greater rigor in studies of moral reasoning among nurses and the need for accuracy in interpreting and reporting moral reasoning scores. The data show that the moral reasoning of nurses, like that of other groups, tends to increase with formal education. Nurses' scores are usually comparable to, and sometimes higher than, scores of their academic peers.