A fundamental ethical approach to nursing: some proposals for ethics education

The purpose of this article is to explore a fundamental ethical approach to nursing and to suggest some proposals, based on this approach, for nursing ethics education. The major point is that the kind of nursing ethics education that is given reflects the theory that is held of nursing. Three components of a fundamental ethical view on nursing are analysed more deeply: ( 1) nursing considered as moral practice; ( 2) the intersubjective character of nursing; and ( 3) moral perception. It is argued that the fundamental ethical view on nursing goes together with a virtue ethics approach. Suggestions are made for the ethics education of nurses. In particular, three implications are considered: ( 1) an attitude versus action-orientated ethics education; ( 2) an integral versus rationalistic ethics education; and ( 3) a contextual model of ethics education. It will also be shown that the European philosophical background offers some original ideas for this endeavour. Key words: ethics education; ethics of care; moral perception; moral sensitivity; nurse-patient relationship; nursing; nursing ethics; virtue ethics Introduction Ethics is taking an increasingly prominent place in nursing education.[13] It has been generally accepted that nurses are confronted with unique nursing ethical problems that arise from their involvement in patient care. Specific nursing ethics consultations (e.g. ethics rounds) have been implemented in some health care institutions to discuss these issues.[ 4, 5] Besides the specific nursing (intradisciplinary) ethical dialogue, nurses have an increasingly greater role to play in the interdisciplinary ethics consultations that are being implemented in many health care institutions. [68] In most countries, ethics rounds and ethics committees are probably the most important channels through which intra- and interdisciplinary ethics consultations take place at local and national levels. A true intra- and interdisciplinary ethical debate can take place only if all those involved, in all the relevant professions, participate with the requisite (also ethical) knowledge. Against this background, the participation of the nursing profession in ethical dialogue already constitutes an important reason to provide nurses with an educational grounding in ethics. This article is primarily focused on the kind of basic ethics education all nurses should receive if they are to provide good care. Owing to the double focus on ethics and nursing, a dialogue between nursing models and theories of ethics will be developed throughout the whole length of the article, which has two aims. The first aim is to sketch broad outlines for a foundational ethical view on nursing, within which fundamental reflection about basic ethics education for nurses can take place. Special attention will be given to the intersubjective character of nursing and the role of ethical sensitivity in nursing practice. The second aim is to present some theoretical proposals for the ethics education of nurses. Attention will also be paid to some aspects of an integral and contextual model of ethics education. The exploration of the practical consequences of applying this approach to nursing practice do not fall within the scope of this article. A fundamental ethical view on nursing

The development of a view on nursing ethics education requires a consensus regarding what nursing practice means. The kind of nursing ethics education that is given depends on the theory that is held of nursing. What is the essence of nursing? In this article, the view of nursing held is based on some thoughts of Anne Bishop and John Scudder, according to whom nursing can be defined as an ethical practice based on the ethical requirement to promote the well-being of the patient by caring for him or her by a personal relationship (p. 104).[ 9] The fact that I base my view of nursing on the ideas of Bishop and Scudder implies some limitations in the scope of my analysis. These authors set the personal nurse-patient relationship at the heart of nursing. Following this relational perspective on nursing, the caring relationship is described in this contribution as a foundational condition of nursing practice. As a consequence, I do not deal with nursing practice that does not involve direct patient contact. Nevertheless, this domain of nursing practice also has a moral significance, as it too is based on the moral requirement of promoting the well-being of the patient. The first section deals with the characterization of nursing as an ethical practice. Thereafter, two components of the ethical practice of nursing (i.e. the intersubjective character of nursing practice on the one hand, and moral perception on the other) will be examined more closely. Nursing considered as ethical practice The fact that a firm ethics education for nurses is considered to be important supports the claim that providing care is an ethically laden practice. Alasdair MacIntyre defines practice as any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized (pp. 18788).[ 10] In the performance of these activities one tries to achieve those standards of excellence that are appropriate to that form of activity.[ 10] When MacIntyre's concept of practice is applied to nursing, nursing can be defined as the totality of skills and attitudes (caring behaviour) that are applied in the context of a particular caring relationship, with the intention of providing good care (the goal) to the (usually sick) fellow person (p. 45).[ 11] To describe the content of the practice of nursing, it is not at all sufficient to restrict oneself to enumerating a few technical nursing functions and skills, such as, for example, the diagnostic function and administering and monitoring therapeutic interventions and regimens. In addition to the technically manageable nursing functions (clinical competence), Patricia Benner[ 12] cites others that require something apart from a purely technical approach. These would include, among other things, providing comfort and preserving human dignity in the face of pain and extreme breakdown, presencing (being with the patient), and providing comfort and communication through touch. These functions require the ability to be sensitive to and engage with another human being in a situation of vulnerability, stress or distress.[ 13] Noteworthy in this definition is the goal-orientated character of nursing practice. Whatever nurses do must always be related to the final goal that is set. Generally, the goal of nursing activity is described as the promotion of the well-being of the patient by providing good care in the wider meaning of the word (i.e. on the physical as well as the psychological, relational, social, moral and spiritual levels[ 11]). Nurses participate in an ethical practice. In each particular situation, they have to make personal choices and decisions based on the good that nursing practice sets as a goal.

This ethical practice becomes concrete through the personal relationship between the nurse and the patient.[ 9] The quality of nursing care must always be seen in the light of the relationship between a unique nurse and a unique patient. The patient cannot be considered as a passive object to which a care strategy is to be applied. On the contrary, caring activities presuppose a reciprocal interaction between human persons who enter into relationships with each other based on their uniqueness. To describe some proposals for the ethics education of nurses, a thorough analysis of two basic concepts, which up to now have remained implicit in the discussion, has to be given. In the following section, the intersubjective character of the view of persons and care on which this view of nursing is based will be analysed, then the concept of moral perception will be clarified. The intersubjective character of nursing An important fact connected with nursing considered as ethical practice is the intersubjective context in which nursing care must be situated. By providing care, and the attitudes and skills associated with this activity, the nurse enters as a person into a relationship with the patient. Nel Noddings remarks that the essential characteristics and the quality of the care phenomena are linked with the relationship between the one who is caring and the one who is cared for.[ 14] In many cases one speaks of a reciprocal relationship (i.e. both the one who is caring and the one who is cared for actively participate in the care activity in some respect). The fundamental reciprocity of a relationship of care can be found in the dynamic interaction of giving care and receiving care. A view of nursing in which the relationship between nurse and patient is regarded as central presupposes an intersubjective view of human beings, within which interpersonal relations are interpreted in terms of solidarity and responsibility. In Europe, the intersubjective view of human beings is exhaustively described in the framework of the personalistic tradition in ethics.[ 15, 16] As early as 1923, the Jewish philosopher Martin Buber wrote his pioneering work on being human, Ich und Du (I and Thou).[ 17] With this most valuable contribution, a new insight broke through: one can never be a human being alone. Humans essentially stand in an open relationship, involved with the reality in which they live and with other humans to whom they owe their existence and who continue to surround them. There has been a new contribution to the view of humans as intersubjective beings from a totally different perspective, namely the ethics of care.[ 18, 19] Care ethicists give a lot of attention to the anthropology that underlies ethical thinking in health care. Carol Gilligan writes that: The most basic questions about human living how to live and what to do are fundamentally questions about human relations, because people's lives are deeply connected, psychologically, economically, and politically (p. XIV).[ 19] In contrast to more individualistic views of people and community, care ethicists opt for a perspective according to which all individuals find themselves in a complex network of relationships that are often not the product of their own personal choices.[ 20] One person always holds something of the lives of others in his or her own hands, or has the lives of others temporarily placed in his or her hands. Every day, always with new variations, people are

dependent on others and others are dependent on them. In short, everyday interaction between persons is a complicated network of mutual dependencies. In an intersubjective view of human beings, vulnerable dependency and self-sufficient autonomy are regarded as equally valuable and interwoven aspects of human life. Annelies van Heijst expresses interdependency as a human characteristic when she claims that people are people's concern.[ 21] This brief sketch of the intersubjective view of human beings that underwrites the practice of nursing implies that one should focus attention on nurses themselves. They are also part of an interpersonal network of people around them. Caregiving is a concrete form of interpersonal relationship. The care relationship is more than a technical relationship; it is an interpersonal interaction where the technical aspect of care rests on the successes and failures, and the open opportunities and vulnerable situation of nurses as persons.[ 22] In the following section, the nurse as person will be considered with the aid of the concept moral perception. Moral perception and the nurse as person Moral perception situates itself in the first phase of the caring process, as described by Joan Tronto.[ 18] During this exploratory phase, a caring person is morally sensitive to his or her surroundings. He or she is attentive to what happens around him or her and tries to detect situations where the life-sustaining web containing the others is weakened. Using this morally sensitive attitude (moral sensitivity) a caring person clears the path in order to be touched by and subsequently to be concerned by the situation of the other who is in need of care. According to the American philosopher, Laurence Blum, a sensitive moral perception determines to a large extent what from an ethical perspective is relevant to observe and think.[ 23] In this way, an accurate perception of the ethical components of a specific situation wherein a person is embedded is a necessary condition to ensure an adequate clarification of the situation of the other. According to Blum, a sensitive moral perception is characterized by the capacity of the agent to interpret the concrete situation of the other in terms of the other's well-being. For example, one can interpret the situation of a woman who does not have a place to sit on a bus as: A woman carrying a shopping bag is standing in the bus. This neutral perception in itself does not motivate the moral agent to perform altruistic actions. What is perceived is experienced as morally irrelevant. The situation changes dramatically when one redescribes the same woman as follows: An old woman has no place to sit on the bus, and is therefore forced to stand and carry her heavy shopping bag. The latter description in contrast to the first allows for an interpretation of the situation of the woman in terms of her well-being. The misfortune of the woman is an essential part of the description of her situation. This morally relevant perception of the woman's particular circumstances includes a motivation necessary for altruistic conduct.[ 24] In Blum's analysis of moral perception, attention to the particular is considered especially important. A discerning insight into a particular situation should put the agent in a position to tell which ethically relevant factors are present.[ 25] Sensitivity to the particularity of every situation cannot be detached from our knowledge of ethical principles and norms. On the contrary, the right application of ethical principles and norms in concrete situations presupposes precisely the capacity to be attentive to the ethical features inherent in a particular context. Moral perception is a capacity that should be associated not only with the intellect but also with the moral person in his

or her totality. Diverse aspects of the agent's ethical personality are called into play when he or she perceives, interprets and responds to the morally relevant reality.[ 24] These aspects include, among others: the person's implicit, intuitive moral ideas (about quality of life, suffering, death, human dignity); his or her emotional, relational and communicative abilities (empathy, emotional intelligence); his or her personality traits (altruistic, introverted); and his or her moral background (personal set of values, ethics education, experience with ethical dilemmas). From the perspective of nursing ethics education, Blum's view of the agent who exercises moral perception is of special interest. Not the human intellect or any other more or less distinct human capacity, but the whole person of the nurse as an ethical subject perceives and interprets his or her surrounding world from an ethical standpoint. The nurse, with his or her psychological and moral repertoire, takes in what is going on in the surrounding world, identifies the ethically relevant aspects, and tries to form an attitude (whether supported by concrete actions or not) that realizes the inherent ethical possibilities of the particular situation to the greatest possible extent. This whole process requires the ability to cultivate a deep sensitivity for what is ethically significant in a particular situation, and then to act appropriately in accordance with that perception.[ 26, 27] This is not a matter of gaining an intellectual understanding, but a sort of ethical know-how, or a sense of what behaviour is most appropriate in a given situation. A virtue ethics approach The fundamental ethical view on nursing, which has been presented in the previous sections of this article, reflects a so-called virtue ethics approach.[ 10, 28] An ethics of virtue differs from Kantian and utilitarian approaches to ethics primarily in terms on its distinct emphasis on the primacy of good character over right conduct. (The virtue ethics approach argued in this article is not intended to replace exclusively other approaches to ethical conduct. It would be very interesting to analyse in greater depth the supposed opposition between the ethics of virtue and Kantian and utilitarian approaches to ethics. Perhaps the opposition is less sharp than is sometimes thought. This fundamental analysis did not fall within the scope of this article.) Virtue ethics can be defined as a systematic and coherent account of virtues. Virtues can be characterized as acquired human qualities (character traits, attitudes) that are for some important reason desirable or worth having.[ 29] Virtues allow the attainment of a good that is inherent in a particular practice.[ 10] It would be the aim of a virtue ethics approach to identify certain traits as desirable, to analyse and classify such traits, and to explain their moral significance.[ 30] According to a virtue ethics approach, questions about the quality or the nature of the ethical agent do not come after questions concerning morally correct actions. On the contrary, the question of what qualities a person must have in order to be ethically good is considered as the primary factor, because the ethical quality of actions is largely determined by the ethical qualities of the agents whose actions they are.[ 31] For example, the ethical quality of a caring attitude, which issues from an adequate moral perception of a particular care situation, should not be measured only by the value of the concrete actions performed. It is precisely the other way around: particular care actions acquire their ethical value in the light of the quality of the caring attitude of which they are the expression. In a comparable manner, the professional goodness of a nurse is not simply a question of acting according to professional standards. A good nurse is one who, through practice,

has learned to put both heart and soul into the job, and to do as a matter of course what is expected of a good nurse: to be concerned about the well-being of patients; and to be expert, honest, fair, cordial, reliable and more, and all at the right time, towards the right person, and so forth.[ 32] The concept of virtue has a long tradition in ethical theory. Yet it was almost considered suspicious, particularly in the experienced morality of the twentieth century. Since modern times, virtue has no longer formed the indisputable centre of ethics and has been considered as an important issue by fewer and fewer authors.[ 33] Robert Louden states that if one limits oneself to evaluate agents rather than acts, the theory will fail[ 34]: ( 1) to provide guidance for finding the way out of practical moral quandaries; ( 2) to make sense of cases in which good people do harmful actions; ( 3) to allow one to make the list of specific acts that for social reasons must be absolutely prohibited; and ( 4) to provide the way to notice when good persons have become bad, because we have nothing but the person's actual character to utilize. Recently, more authors have become convinced of the advantages of a virtue ethics approach.[ 10, 35, 36] The uneasiness with regard to other important positions (Kantian and utilitarian) in the ethics of our times is clearly explained in three points in a recent study on the rehabilitation of virtue ethics.[ 37] First, Wybo-Jan Dondorp[ 37] claims that, by restricting ethics to the rules governing society (in other words the way in which people live together), personal ambitions, character building, the ethical quality of the person, etc. remain beyond the scope of ethics. Virtue ethics concentrates precisely on these things. Secondly, according to Dondorp,[ 37] a great deal of present-day ethics is rationalistic as far as its notion of ethical judgement is concerned. Understanding ethical judgement as the application of general rules and principles to concrete, real-life situations wrongly ignores ethical sensibility as well as the receiving and creative sides of ethical experience. Virtue is precisely the ability to perceive the ethically relevant qualities of a situation (moral perception), judge them adequately and, on that basis, take the right decision. Thirdly, Dondorp[ 37] states that a great deal of present-day ethics is rather deontological. By speaking of ethics in terms of what should be done, the link becomes lost between the obligation to do something, the good that is the ultimate goal, and the motivation to act. Virtue is the concretely situated orientation towards the good that comes from within to such an extent that it is put into practice. In conclusion, one could say that there is no homogeneous version of virtue ethics, and that the revival of virtue ethics over recent decades offers a variety of theories that apparently seem united by their opposition to various strands of Kantian and utilitarian ethical theories. However, in view of the threefold uneasiness mentioned above, a virtue ethics approach appears to do more justice to the fundamental ethical view on nursing, which has been explained in this article. If this is so, virtue ethics could be regarded as offering more promising perspectives than other ethical approaches to the ethics education of nurses.[ 1] Some proposals for nursing ethics education

What can be concluded concerning nursing ethics education from these theoretical considerations about the essence of nursing and the status of virtue ethics? First of all, the primary goal of nursing ethics education can be derived from the internal aim of nursing and therefore should be defined as learning how to promote the well-being of patients. What kinds of knowledge and which practical, affective, communicative and reasoning skills do students have to learn in order to reach this goal? Inspired by this question, three important dimensions can be distinguished around which the development of nursing ethics education can be orientated: an attitude- versus an action-focused ethics education; an integral versus a rationalistic ethics education; and a contextual ethics education. An attitude- versus an action-focused ethics education According to a virtue ethics approach to nursing ethics education, the fundamental goals are: the transformation of the ethical agent; the orientation of his or her life; and the cultivation of virtuous attitudes and character, or excellence in his or her activity.[ 1, 38] Virtue is the condition that makes this possible: the acquired ability to adopt the correct position and to do the right thing in changing situations of life. These actions are not the core but rather the effects of what determines ethical quality in the most profound manner. Actions are not just called right or wrong, but someone is praised because of his or her courage, friendliness, honesty, loyalty, etc., in other words, because of attitudes or character traits that are more durable than just one simple action.[ 32] It should be the crucial task of ethics education to show the ways in which personal and professional life stands to be enriched or enhanced by the possession of such virtuous qualities and attitudes. With such a view, ethics education is more a matter of the cultivation of such virtuous excellences, bringing ethical agents to an appreciation of the worthwhileness of ethical and other enterprises for their own sakes, than of training in obligations or the imposition of prohibitions.[ 13, 30] The argument in favour of the cultivation of virtuous attitudes can be connected with the importance of the caring presence in everyday professional practice.[ 39] The ethical value of a caring presence with the other must be connected with an ethically qualified attitude that manifests a deep respect for the value of the other. The Dutch philosopher Paul van Tongeren speaks in this connection of the cultivation of an attitude of ethical sensitivity in regard to everything we encounter. By this he intends to relativize the importance of ethical activity in the interest of promoting an ethical attitude informed by ethical virtues, which is sensitive to the ethical possibilities and unarticulated intimations of the good embedded in every particular context.[ 40] According to van Tongeren, this means being sensitive to the ethical value that is inherent in persons, relationships and experiences. According to Scott, raising awareness of the moral dimension of practice and supporting the development of moral sensitivity is one of the key reasons for teaching ethics to nurses.[ 1, 13] This somewhat abstract explanation can be clarified with an example of a nurse who treats his or her patient in a caring way. The concrete caregiving actions that the nurse performs are the expression of a virtuous attitude that has been acquired as a response to the understanding of the ethical value of the patient as a human being on the one hand, and the understanding of caring as ethical virtue on the other. The ethical significance of the patient and caring is not merely passed down to the nurse as part of general knowledge. It is rather an insight into what good care is, which

is acquired in concrete contexts. The nurse can respond to the patient's need for care in a justified manner only if he or she has been attentive to the ethical significance revealed by the patient and the particular context in which the patient finds himself or herself. In other words, by cultivating an attitude of ethical sensitivity, the nurse teaches himself or herself to be receptive to the ethical possibilities that are inherent in every particular context of care.[ 41] On the basis of the insight acquired through this process, the nurse tries to find an appropriate response to the patient's situation. It is clear from this plea for the cultivation of ethical attitudes that the ethical vocabulary normally used in ethics education has to be broadened. Along with rationalistic ethical concepts (ethical principles, ethical judgements, ethical methods of analysis, etc.), others such as character, virtues, intuition, personality, emotions, moral perception, moral sensitivity and so on, must be a conspicuous feature of the educational package. According to Scott, concepts such as moral sensitivity and moral perception could be linked to that which nursing students already know and are familiar with, namely the importance of observing their patients, of looking and seeing, and forming a clinical judgement on the basis of their perceptions (p. 129).[ 13] This connection with clinical practice could make ethics more real and more important for nursing students. An integral versus a rationalistic ethics education The integral character of ethics education means that rational argumentation, emotional involvement and contextual factors should never be completely separated from one another.[ 42] The integrating factors of ethical conduct are not only the cognitive factors, but also the affective and motivating factors: the capacity to imitate the good that attracts, the capacity to empathize with the other, which brings emotional solidarity, among other things.[ 38] Virtue education is, in no small part, education of the emotions. To teach virtue requires that we take seriously the idea that we can become (to a greater degree than we often imagine) agents of our emotional lives.[ 43] Virtue ethics regards ethical development as a matter of crucial interplay between the different dimensions of human being (rationality, emotions, etc.) and it has been of concern to give a coherent account of this interplay.[ 30] However, there is still an enormous amount of conceptual work to be done on the psychology of virtue, in order to reach a clearer understanding of the harmonization of reason, affect and behaviour in virtuous conduct, as well as, from an ethics educational viewpoint, what might constitute appropriate and effective ethics educational strategies for the promotion of such conduct.[ 44] When applied to nurse education, the integral view implies that human actions cannot be regarded as a mere summation of rational and emotional components. When a nurse acts, he or she acts as a totality, using both rational and emotional capacities.[ 45] The emotional faculties of nurses should be cultivated, because they play a double role in the process of ethics deliberation. First, emotions have an important role to play in the detection of ethical problems in nursing. Experiencing certain emotions is a vital part of broadening one's perspectives and deepening one's understanding of certain aspects of the human condition.[ 13] Emotions can be considered as modes of attention enabling nurses to notice what is morally salient, important, or urgent in themselves and their surroundings. They help nurses to track the morally relevant news. They are a medium by which nurses discern the particulars.[ 43] For example, gross neglect of elderly people provokes feelings of repulsion or horror in nurses. It is precisely that intuitive sense that motivates them to formulate

an ethical problem concerning this neglect. They then obviously bring that feeling into the discussion and clarify its meaning. An affective involvement with the well-being of patients prevents blindness and hard-heartedness, latent mechanisms that can make nurses insensitive to the human side of caregiving. Secondly, emotions have an expressive function; the quality of ethical actions does not depend only on the content of the action, but equally on the way in which the action is performed.[ 24, 46] The manner in which one person approaches another shows a certain colour. Who we are and what we hold as important are reflected in our emotional communication. The presence or absence of certain emotions can be morally significant. To take one example, a helping action that is emotionally flat may not be received in the same way as an action conveyed through a more positive, affective expression. As recipients, we may judge that it lacks what is important for our well-being: namely, that others be engaged with us here and now and that they view that kind of attention and engagement as important in itself.[ 43] Besides education of nurses as persons, emotional involvement, imagination and the cultivation of virtuous attitudes require attention to the context in which an individual has to try to exercise these qualities in practice.[ 24] This leads to the contextual character of ethics education. A contextual ethics education Virtuous attitudes do not occur in a vacuum. They are embodied by a particular nurse who is a member of many groups and communities. The relational, cultural, social, institutional, political and religious links that the nurse forges with others form the context in which the attitudes of ethical life come into being and are experienced.[ 47, 48] The ethical character formation of nurses can best be regarded as a practical educational event that gradually takes shape within specific narrative communities, of which health care institutions are a clear example. In this section, these points will be illustrated by examining the influence of the institutional context (health care institution) on the rise and development of ethical attitudes, in particular the attitude of caring. At the beginning of this article, it was argued that the intersubjective context in which care is provided is an intrinsic part of the care situation. Through care, the nurse as a person enters into a relationship with the patient. However, there is not only the nurse-patient relationship. The care process itself usually takes place within the context of the co-ordinated activities of a team of caregivers (physicians, nurses, social workers, etc.) who are also part of a health care institution (hospital, nursing home).[ 38] The institutional context of the health care institution is partially outlined in the (non)existence of clear ethical opinions and policies about care, the (non)existence of structured interdisciplinary ethics consultations (e.g. ethics committees, ethics rounds), the position of power(lessness) between doctors and nurses, the working relationship within the team and the hospital, the relationship between nurses and hospital directors, etc. These contextual factors influence greatly the questions asked (or not), the problems signalled (or not), the solutions proposed (or not). A good observer of the ethical dialogue in health care will quickly note that the process and outcome of ethical reflection is influenced not only by institutional factors, but also by other external factors, such as the position of power between doctors and nurses, the working

relationship within the team and in the hospital, the relationship between nurses and hospital directors, etc. The influence of professional relationships and positions on ethical decision-making processes is expressed in the concept of the moral position of the nurse. This means that the actual position of nurses in an institution of care is crucially important for the way in which they deal with ethical problems and participate (or not) in ethics consultations. Ethical problems are predominantly anchored in institutional, professional and relational dimensions. Ethical problems occur in an atmosphere of power/helplessness, emotional concern, indifference, efficiency and cost-effectiveness, pressure at work, (in)competence etc. This atmosphere determines who expresses which moral convictions and the kind of influence they will have on care. This is an important aspect for the teaching of professional ethics to nurses. It has to be taken into account that nursing practice consists of having certain attitudes and initiatives within institutions in whose framework the nurse-patient relationship is effected. At this institutional level nurses are predominantly summoned to their responsibilities as employees of the institution. Basically, as members of a health care institution, nurses have to work toward the aims of the institution. According to Arie van der Arend, in real terms this mostly results in the incorporation of nurses into the prevailing business-like culture of hospitals, where matters of efficiency and savings become ever more predominant.[ 49] Yet one has to implement this policy in an environment where the well-being of patients comes first and foremost, and where patients approach nurses primarily because of their human and professional qualities. Being both employees and nurses, nurses are confronted with both sides of the organization. This makes them easy victims of conflicts between different responsibilities.[ 50] For example, when decisions about the allocation of resources are made according to a utilitarian cost-benefit rationale, what is good for the economic efficiency of a hospital is not necessarily perceived as good by the individual patient.[ 51] This simple example shows in what way the institutional context of nursing can hinder and sometimes even obstruct the work of caring and the development of caring attitudes. A contextual model of nursing ethics education has to take into account that ethics is primarily concerned with a view of the good life and that nurses require not only norms and treatment protocols established by budget-conscious administrators but especially ends and values for which they can strive. Nurses want to be more than just people carrying out specific functions or fulfilling certain roles. They also want their work to have meaning; they want to be engaged in something worth while. Without a view of the fundamental goals of nursing care, it becomes difficult, if not impossible, to motivate nurses. A fundamental view of nursing cannot be reduced to a set of strategic aims such as preventing nursing errors or providing technically competent care. Managers need to provide nurses with a meaningful working environment in which they are transformed from passive, contractual employees into motivated members of an orientated and meaningful health care organization. We could state that, with the organizational-policy-based component of care, we are increasingly confronted with a third party, which, using its direct or indirect influence, orchestrates the ethical dialogue. A characteristic of this third party is that it deploys initiatives outside the nursepatient relationship that determine the circumstances and peripheral conditions of nursing practice. It is problematic that institutionalorganizational factors mostly do not become explicit as such, hence the absence of an ethical touchstone. Consequently, a development has taken place whereby an

increasingly important role is attributed to management in ethical care questions. Discussing ethics is no longer a matter for nurses or other caregivers alone, but also for institutions of care as a whole, including the policy makers. This means that those responsible for policy have to be explicit about ethical questions and the choices made. A solid contextual nursing ethics education could help to make nurses and managers in nursing more conscious of the organizational embeddedness of ethical practices. Conclusion The major point in this article is that the kind of nursing ethics education that is given follows on from the theory that is held of nursing. With the caring relationship as the ordering principle, nursing ethics education would have a different emphasis than it would have with more task- or product-orientated theories. A continuing dialogue between theories and models of nursing and ethics is a major task in the intellectual history of the nursing profession. On the basis of the views about the fundamental background of nursing that have been developed in this article, three guidelines for nursing ethics education can be summarized as follows: 1. The education of nurses should, first of all, promote the cultivation of an ethical sensitivity on the part of nurses. This refers to the capacity to discern the ethical meaning of a particular situation and to respond accordingly. 2. Integral ethics education is possible only if the ethical vocabulary used in education is broadened. Along with rationalistic ethical concepts (ethical principles, judgements, methods of analysis, etc.) there must also be room for concepts such as personality, virtues, attitudes, emotions and so forth. A broader ethical vocabulary obviously also requires a broader perspective for ethics education as a whole. Besides introducing nurses to essential ethical theoretical knowledge (e.g. the image of humanity that we presuppose when reflecting on ethical matters), greater attention should be devoted to the cultivation of virtuous attitudes and affective capacities. 3. Special attention should be paid to the contextual embeddedness of ethical behaviour. This implies that projects in ethics education should not be onesidedly focused on nurses alone, but also on the context in which nurses must manifest themselves as ethical agents. Educators are responsible for imparting knowledge to students and ensuring that they develop the needed skills to recognize moral considerations in the professional context. However, it is health care administrators who create conditions in the workplace that can either facilitate or prohibit an employee from making use of this training. References 1 Scott PA. Ethics education and nursing practice. Nurs Ethics 1996; 3: 5363. 2 Kanne M. Professional nurses should have their own ethics: the current status of nursing ethics in the Dutch curriculum. Nurs Ethics 1994; 1: 2533. 3 Fry S. Teaching ethics in nursing curricula. Nurs Clin North Am 1989; 24: 48597.

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Address for correspondence: Chris Gastmans, Associate Professor, Center for Biomedical Ethics and Law, Faculty of Medicine, Catholic University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium. E-mail: Chris.Gastmans@med.kuleuven.ac.be Copyright of Nursing Ethics is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Source: Nursing Ethics, 2002 Sep; 9(5) Item Number: 2002157698