Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics

By Daniel F. Chambliss

Vividly documenting the real world of the contemporary hospital, its nurses, and their moral and ethical crises, Dan Chambliss offers a sobering revelation of the forces shaping moral decisions in our hospitals.

Based on more than ten years' field research, Beyond Caring is filled with eyewitness accounts and personal stories demonstrating how nurses turn the awesome into the routine. It shows how patients, many weak and helpless, too often become objects of the bureaucratic machinery of the health care system and how ethics decisions, once the dilemmas of troubled individuals, become the setting for political turf battles between occupational interest groups. The result is a compelling combination of realism and a powerful theoretical argument about moral life in large organizations.

• Language: English
• Publisher: University of Chicago Press
• Release date: May 8, 1996
• ISBN: 9780226150505

Book preview

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INTRODUCTION

Nursing and Ethics in an Age of Organizations

Nursing is a noble profession but too often a terrible job. At its best, nursing is a calling, a physically and emotionally challenging, humanly fulfilling moral mission. Nurses encounter patients in their most vulnerable moments, sharing an intimacy found in few other human relationships. Sometimes they work with a personal commitment transcending technical performance, a commitment too rarely found in most careers. At the same time, nurses express frustration as their immediate, even dominant, emotional response to their work. I can’t do my job, they say. There is no support from the higher ups. Lack of time, of support, of supplies, of respect are mentioned again and again. In letters to nursing magazines, the theme is echoed: "I love nursing, but . . ." There is, in many nurses’ daily lives, the constant conflict between what nursing at its best could be—the ideal—and what too often it actually is—the reality. For many nurses, the tension is intolerable. By the late 1980s, despite historically high salaries, multithousand-dollar signing bonuses, wide-open career ladders, despite work that produces immediately tangible results, despite great opportunities for learning, and despite the virtual guarantee of employment for nurses who wanted to work,¹ nearly one-third of the registered nurses in the United States were not practicing nursing.

Working nurses often feel actively thwarted in their jobs, blocked from doing the meaningful work that was promised them. They feel that their professional birthright has been violated by administrators, by physicians, sometimes by government policies. Perhaps these nurses entered the profession with naive expectations. This younger generation, fresh from collegiate programs with broad classroom experience but little clinical experience, and imbued with an aggressive, independent theory of what nursing could be, comes into the hospital eager to serve, only to suffer the reality shock of limited resources, shortstaffing in the hospitals, and recalcitrant, chronic, incurable patients, who are not at all grateful or appreciative of the young nurse’s care.² Perhaps nurses suffer from the inherent contradiction, as Susan Reverby puts it, of being ordered to care:³ required by one’s job to do emotion work⁴ which needs to be felt spontaneously. Or perhaps they are feeling the clash as a clearly female (97 percent of all nurses are women) culture of personal relationships meets with the impersonality of a more traditionally male organizational world.⁵ And while women are rapidly entering the ranks of medical doctors, no comparable change is occurring in nursing. Whatever its source, the frustration and disappointment of many nurses is quite real, and it is often perceived in distinctly moral terms. One cannot be an ethical nurse, it may seem, in this setting where powerful others block what nurses see as their professional obligations.⁶ Studying nurses’ frustrations, we can learn lessons about the psychology of workers in any organization, and about the very possibility for being a moral individual in an organizational world of contending and sometimes divergent interests.

Like most working Americans, the hospital nurse is fundamentally an organization member; this profoundly affects nursing’s moral position. Nurses are subordinated to hospital authority in numerous ways, subject to its policies, directed by its head nurses, its supervisors, and its administrators. They are subordinate as well to the orders of numerous physicians and must work within doctors’ vision of the patient’s needs and their plans for the patient’s life, or death. But in this dual subordination to the hospital’s bureaucracy and the physician’s orders, nurses may forget their profession’s distinctive goals. As nurses tell it, nursing’s moral core, its commitment to the welfare of the patient as a whole person, has been buried under medical directives and the financial and administrative imperatives of the modern medical center. In a setting where one’s work is governed by others, how can one person claim her own moral integrity? Perhaps with the decline of nursing orders of religious nuns, the spiritual commitment that many nurses once felt has been replaced by a more secular, instrumentalist view of their profession. And perhaps, too, nursing is hidden behind medicine: witness the great prestige of the highly technological methods of the Intensive Care Unit, the mechanical heart and lung, the artificial kidneys of Dialysis Units, and the mystique and financial power of medical research, in which as much as $1,000,000 is spent on a single interesting case,⁷ while dozens of old people throughout the hospital lie in bed waiting for lunch. Nurses complain of this and say, in their own words, that nursing has lost its own moral footing.

My topic here, then, is somewhat broader than ethics as usually conceived. Morality is the more general term, applying to human experiences of right and wrong in everyday life. Moral issues are often unformulated, even unconscious; morality can even refer to the general tone of a world. Ethics, on the other hand, refers to a more conscious reflection on our moral beliefs, and seems typically to be applied to specific cases in a setting as opposed to the nature of the setting itself. In professional settings such as hospitals, ethics usually refers to the codification of moral principles by an occupational group (as in medical ethics); often, the code reflects the group’s long-range self-interest in its image as a servant of the community.

This codification of moral values can have sociological effects: it frames debate in its own terms. Once an ethical vocabulary is adopted, subsequent arguments must fit into its terminology; thus, it controls the assumptions of debate. In medicine, the use of bioethical language has made moral debates more abstract (by continually referring to general principles), rights-driven, individualistic, and centered on discrete cases. Left aside, often, are discussions of the general routines or structures of medical services. Such language is legalistic in tone and sometimes indistinguishable from legal advice. An ethics consultation in American hospitals often includes the hospital lawyer, and decisions on what is right are regularly tempered by what the courts officially sanction as legal. Where the language of ethics frames debate, certain issues find no place in the conversation. At the same time, this language can be a weapon for those who know it: for nurses, the revolution of bioethics has provided words, phrases, and arguments to use in their conflicts with physicians and administrators.

Still, this language was not created with nursing in mind, and the discipline of bioethics, recently expanded from medical ethics, has for the most part bypassed nursing.⁸ Perhaps that is appropriate. Ethics aims to answer the question What should be done? Hence, in its practical applications, it is written for powerful people who make decisions, not the powerless who carry them out. Physicians are the ones who write informed consent protocols and Do Not Resuscitate orders, and perform abortions. Medical researchers suffer ethical dilemmas, choosing between the two worthy ends of knowledge and future benefits, on the one hand, and the health and comfort of the current patient on the other.⁹ Doctors ask, and can decide, How do we choose? Ethics provides well-considered answers for them which are logically derived from clear principles.

But perhaps in speaking to powerful decision makers, traditional ethics leaves the rest of us behind. Most people don’t exercise the power that physicians do. Certainly most health care workers don’t. A large proportion of the American labor force works in large bureaucracies, where their work is planned to the smallest detail by absent others. Discussions of the ethics of life and death pose difficult questions, but the answers given by most people won’t matter. How, a nurse may reasonably ask, should one act when one isn’t powerful?

In other respects, too, traditional bioethics has left aside the world in which nurses, and most other people, live. In 1979, when I first began research in this field, I read a series of publications by one of the better-known clearinghouses for bioethics literature. I was quickly frustrated by the detachment of it all from what actually happens in hospitals. Ethicists would fabricate difficult, even bizarre, hypothetical case scenarios designed to test their acuity in applying one or another principle and, balancing carefully, would then develop a series of possible resolutions to the case presented. Such exercises were framed by hypothetical questions, not real situations. They were designed, I thought, not to replicate crucial features of reality but to generate the toughest test of a philosopher’s logic.¹⁰ Too often, then, it seems that in asking What should be done? philosophers ignore a prior question: "What can be done? Much of bioethics assumes that people are autonomous decision makers sitting in a fairly comfortable room trying logically to fit problems to given solution-making patterns. The whole business is almost deliberately unreal—intellectually challenging but not very useful. And when bioethics does handle real issues, its solutions remain basically academic. Inside hospitals, by contrast, decisions are driven not by academic problem-solving techniques but by the routines of life in a professional bureaucracy. Efforts to teach powerless second-year medical students four principles of ethics"¹¹ do little to alter those routines.¹²

A more empirical approach to bioethics research, focusing on nursing, could shift the debate in several ways: (1) It would move discussions from the hypothetical scenarios to real settings. We understand the abstract logic of ethics, but the social and psychological realities of hospital life are only just beginning to emerge. (2) It would move ethics from a formal individualism to a broader organizational awareness. Nursing’s problems in particular reflect the organizational structures in which nurses work, and any serious discussion of ethics in nursing must deal with these realities. In looking at nurses’ ethical difficulties, we necessarily learn about life in organizations. (3) Finally, empirical study would move ethics from speaking only of the few people who are autonomous to speaking of the many relatively powerless who work in organizations; we will have to deal with politics.¹³ Nurses, being employees, deal not so much with tragic choices as with practical, often political, issues of cajoling, tricking, or badgering a recalcitrant system into doing what ought to be done. Nurses continue to admire Florence Nightingale because she did what should be done, and did so without being fired. Certainly the principles and methods of bioethics can clarify the issues and specify what choices are being faced. But sometimes clarification only makes obvious the opposed goals of the battling factions. And if that is so, then a seminar on great issues in bioethics won’t help much; lectures by prominent speakers miss the point; changing an individual’s consciousness, one individual at a time, won’t solve any problems. In fact, such efforts at ameliorating ethical lapses may well be a distraction, fostering a public impression that something is being done. The real problems then go untouched and remain where they always were, embedded in organizational routines and structures.

Political considerations touch directly onto questions of ethics. For instance, frequently arguments arise within the hospital regarding whether an issue is one of ethics, and hence moral debate, or of technical judgment, hence professional expertise. Ethics involves broadly human questions, answerable outside the confines of any particular discipline or specialty.¹⁴ While nurses may recognize a technique (say, the insertion of chest tubes for drainage) as being in the physician’s sphere of competence, the corresponding ethical question (whether chest tubes should be placed in a hopelessly ill patient) may be regarded as answerable more or less by any sensible human being. For the moral decision, technical training is irrelevant.

In questions of sustaining life, a physician may claim that, based on long training and an understanding of pathophysiology, he or she should decide when treatment will cease; while nurses in the same setting may contend that the question is rather one of the patient’s autonomy, dignity, and the like, and that all parties involved should participate in the decision. When treatment does cease and palliation begins, then nurses are in charge of the case. Such an argument is less a question of ethics than of power and of who will make the decision. What officially appears as an ethics argument is actually a thinly disguised turf battle.

An empirical approach to nursing ethics in particular would also recognize the central role of gender in such arguments. Both the people and the ethos of nursing are predominantly feminine, and this shapes the problems seen and solutions practiced. By now we have good evidence that men and women frequently conceive of moral problems in somewhat different ways. In nursing, I will argue, the structural features of the work may be more important than one’s gender or personal preferences for action, but even the structural requirements reinforce a female style. Even while avoiding any reification of the differences in masculine and feminine moral reasoning, we can still take note of these differences and see how they play out in the hospital. Because almost all nurses are women, it is hard to separate what is female from what is nursing, but we do find hints. And only an empirical study can make that distinction.

So this is a work of social science, not logical or moral philosophy. I will not begin with a philosophical definition of ethics or conclude with a prescription for nurses’ behavior. I am not trained in the dialectics of moral argument or in the propositions and truth tables of logic. This is sociology; my task is to describe in detail, and with defensible generalizations, how nurses define and respond to ethical problems in their daily work. I will describe the factors that shape the nurse’s experience of ethical difficulties, as she herself defines them. Although the literature on nursing and health care has been used here¹⁵, the findings rest primarily on my own fieldwork. The research has been empirical; the data are mostly events I have seen myself or have been told of by participants.¹⁶

The research was conducted between 1979 and 1990, in three discrete blocks: the first, from January 1979 until June 1980, in a large Northeastern medical center; the second, from June through August of 1982, in a mid-sized (300-bed) community hospital also in the Northeast; and the third, from January until June of 1990, in a large medical center in the Southwest. I also spent short periods in other hospitals, both in America and abroad. This totals over two years of full-time work, including some 110 formal interviews and countless days and nights of on-site observation of nurses at work.¹⁷ The research was thus extensive, covering a long period of time, across the geography of the United States, in many different units of a number of hospitals, and with a sizable number of nurses. During this eleven-year period, ethics committees became common in hospitals, the federal government began monitoring life-support decisions (in the Baby Doe regulations), Do Not Resuscitate policies became mandatory, and the spreading impact of the women’s movement came to be felt throughout the workplace. All of these changes were evident over the course of the research. Things were not in 1990 as they had been in 1979.

This book looks at the experience of nurses and how they live their moral lives. We will see that their moral feelings and daily actions are not separate entities and that a host of moral assumptions are embedded in their habitual modes of behavior.¹⁸ The individual nurse and her setting are integrally joined; indeed, the individual and her setting are reciprocally, mutually defining. A nurse is truly a nurse only if she has patients;¹⁹ similarly, a hospital nurse is irredeemably a part of the hospital of which she is a part. Neither the hospital nor the nurse can entirely distinguish itself from the other. In this context, we see how the nurse’s self and role are intertwined with her experience of the hospital, her patients, and her work. There may be, as we will see in Chapter Six, an effort to detach herself from the work she does; but these efforts are typically characterized by their continuing, relapsing failure. Simply, we will explore the moral geography of hospital nursing. In a broader sense we will be detailing what it means, in experiential terms, to be a member of an