Loyalty and freedom of the nursing profession
Prof. Dr. Gonzalo Herranz, group de Trabajo de Ética biomédica, Universidad de Navarra.
Lecture given at the Pomeriggio di Studio per il Personale Paramedico.
Lugano, 27 March 1987.
I. Deontology of freedom and loyalty
II. The daily defence of freedom
III. Some points for consideration
1. Freedom and loyalty to oneself
2. Loyalty and independence towards the patient
3. Loyalty and independence vis-à-vis the doctor
4. Freedom and loyalty to the profession
Our topic for reflection is Professional Loyalty and Freedom of the Nurse. It goes without saying that I am of the opinion that medical ethics and nursing ethics have a lot to do with learning and practising the specific virtues of each profession. It is true that, in recent times, the ethics of our professions are being dragged, not without risk, into the gravitational field of law. It is therefore appropriate from time to time to talk about how to practise the professional virtues: their theory and their practice.
Loyalty drives us to keep promises, to hate pretence, to reject betrayal. It makes us sincere, honest, capable of suffering in defence of our convictions, so as not to give them up. But it also makes us generous, because loyalty, which makes it easier for us to fulfil the duties to which we have committed ourselves, also inspires us to create other voluntary, uncodified duties. It is these supererogatory duties that ultimately mark the difference between people who live their profession as a vocation and those who perform it as a mercenary job.
Freedom, in a professional context, is the ability to judge and act without external violence, guided by the ethical principles and scientific commitments of the profession. Professional independence is therefore not arbitrariness or capricious indeterminacy: it is a voluntary and constant adherence to certain principles and values chosen autonomously, in conscience, on the basis of their ethical superiority.
In the ability to create voluntary duties make contact loyalty and freedom. A truly free person claims for himself the right to do things better, to serve more intelligently and with more dedication. But this is not the only point of contact. I hope to show in the course of my talk that there are many ethical places where loyalty and freedom come together.
I. Deontology of freedom and loyalty 
Loyalty and freedom occupy an important place in nursing ethics. Freedom usually appears in deontological documents in the form of professional independence. The Code for Nurses of the committee International Nurses, which is intended to be the basic text of universal validity, states in its preamble that the nurse has four fundamental responsibilities: promote health, prevent disease, restore health and alleviate suffering. (Let me make a parenthetical criticism of the repetition of the word health: promote health, restore health. I do not do this to reproach the committee International Nurses' Association for its poor lexicon, but to remind us that, before the 1973 reform, we spoke of a triple commitment, more to my taste: preserve life, alleviate suffering and promote health). Let us continue. The Code, after regaling our ears with the comforting prophecy that nurses will always and everywhere be needed, affirms that respect for life, dignity and human rights is consubstantial to nursing and that the profession cannot be restricted by considerations of nationality, race, creed, skin colour, age, sex, political affiliation or class social affiliation.
These clauses tell us that the nurse has certain vocational commitments which she must fulfil responsibly and that, in order to carry out her profession with human quality and ethical dignity, she must be independent in her work, she cannot be interfered with by outside influences.
This is all very reasonable. Freedom is an indispensable condition for professional work to be ethical: without freedom there is no moral merit, no room for generous dedication. Without freedom, loyalty suffocates.
But it is also very interesting. The nurse's responsibilities look simultaneously to several fronts: to the patient, to her/his professional skill , to society, to the doctor and, finally, to her/his colleagues. This creates a broad grid of loyalties that may interact synergistically or may, at times, create conflicts that are very difficult to resolve.
II. The daily defence of freedom
The deontological documents indicate that the nurse's primary commitment is to provide the patient with the best service she is capable of, as dictated by her professional skill and her conscience. However, in today's apparently pluralistic and tolerant society, the nurse is not free from administrative or political pressures that sometimes tend to limit her autonomy and prevent her from providing this qualified service.
It is therefore necessary to proclaim obstinately that the nurse cannot abdicate her professional independence. Firstly, because this is a fundamental right that the nurse has as a human being, as a responsible moral agent, because professional freedom is, after all, an absolute prerequisite for a truly moral life. Secondly, however, I believe that the freedom of paramedical staff is also a right of the patient, who cannot reasonably be deprived of being cared for by a competent and conscientious nurse who does not give in to pressures that might in any way harm the patient or unfairly restrict the care he or she should receive. Third, the professional freedom and independence of the nurse is a right of those who work with the nurse in the promotion of health and the treatment of illness. In particular, it is in the physician's interest to have competent and conscientious nurses who do not give in to abusive pressures from the family, to the ill-advised demands of the patient himself or to carelessness on the part of the physician.
From what I have just said it could be deduced that the nurse lives in a world potentially fraught with ethical conflicts, which put his or her freedom and different loyalties at test from time to time. Reading the American nursing journals, one sometimes gets the impression that in the United States nurses live a life of constant turmoil. The nurse is under attack on several fronts. It seems to me that, in reality, the situation is not so dramatic.
So I prefer to talk to you about how the freedom and loyalty of the nurse manifests itself in more usual and ordinary things. I am not saying that it may not happen at times that a nurse has to face tremendous moral dilemmas, subject of the kind published in the American Journal of Nursing. Nor am I denying that there are not problems where professional independence is compromised in the face of political pressures. But I think my time and yours is best spent discussing freedom and loyalty in the day-to-day actions of a good nurse and considering them as part of the ethical essence of the profession.
III. Some points for consideration
The preservation of loyalty and the growth of professional independence need, like the cultivation of all virtues, a system, psychological and moral, of monitoring. We need to constantly monitor the level they reach in our behaviour, to see whether they grow or diminish. For this we need to examine our actions and our conscience. Plato said a very strong thing in this regard: that a life without examination is not worth living. The professional, careful of his independence and loyalty, examines himself because he is striving to maintain and increase virtues or ideals that are not easily attained and needs to renew his ethical programme every day. This is not easy. Certain environments seem to be dominated by routine or, what is worse, by a minimum effort plot. In these environments, those who do not share the moral tone of obligatory mediocrity are subjected to a policy of retaliation that discourages ethical leadership. Often, there is no choice but to swim against the tide. This mercenary atmosphere is partly one of the adverse consequences of the advent of labour law in hospitals, of the need to describe the functions of each work space, to avoid interference between the different categories of staff, or to fix contracts. On the one hand, this has helped to promote order and control in hospital management. On the other hand, however, it has made personal initiative increasingly difficult. It has reduced the risk of unfair exploitation of health care workers, but it has led to an atrophy of generosity.
In order to systematise in some way the description of professional independence and loyalty and to assist in this examination, it seems to me most appropriate to deal with four different aspects, as if they were source of duties to the nurse herself, to the patient, to the doctor and to the profession itself.
1. Freedom and loyalty to oneself
Is it possible for one to have conflicts of freedom and loyalty to oneself? At first glance, it seems that ethical autonomy is a permanent affirmation of independence and loyalty. I and my freedom always go together. I may suffer attacks from outside, constrictions on my freedom, violence towards the values I hold dear. But it does not seem likely that I am capable of developing a kind of autoimmune disease, attacking my freedom, being disloyal to my own convictions.
And yet it is within myself and against myself that some decisive moral battles are fought. It is true that independence and loyalty are made up of fidelity to the ethical principles of the profession, but the validity of these principles, their active influence on the life of each individual, their inspirational force, vary enormously from one to another. For the nurse, respect for the life and personal dignity of the patient and the promotion of an environment rich in professional skill and human values mark the field of her freedom and loyalty. But these ideals only grow in a climate of ethical demands. A morality of minimum effort, to which I alluded earlier in passing, is unfortunately and for some a very useful procedure to anaesthetise their own responsibility. My criticism of this morality of minimum effort is not exclusively based on the analysis of poor performance at work, which is in itself a fraud and an injustice. I think the harshest criticism is that it replaces the ethical ideals of generosity and altruism with a capricious subjectivism, which is the death of true moral autonomy.
What is the symptomatology of this unfair subjectivity? The health worker then discriminates between people, breaking his commitment not to discriminate. They classify the sick as kind or hateful. To the former, he dedicates smiles and attentions in Degree proportional to their social affinities, to their money. The others are subjected to refined forms of punishment and neglect.
Loyalty should inoculate us against these weaknesses and prejudices, against the terrible capacity for partisanship in each of us. And also against the thirst for flattery, gratification and rewards, however unjust, with which envy sometimes torments us. These are very difficult temptations to resist. It is often more bearable to firmly resist the persecution that comes from outside than to oppose the "reasoned" disloyalties that arise from within us.
Professional independence, loyalty to oneself, also has important intellectual consequences. At the same time that they make us part of a small but very important core of loyalties, they make us extremely free with respect to what is outside that core. Someone has said that the main factor that stands in the way of scientific progress and the application of new knowledge is a tenacious conservatism that we all carry within us, partly due to the intrinsic viscosity of the mind, which finds it difficult to replace one idea with another, partly due to a lack of curiosity and, above all, to a reluctance to correct defensible errors. One of the greatest joys of professional life should be to change, to say "I was wrong" and to rectify. This not only keeps life joyful, but makes it open and progressive. Professional freedom must make us truly free for anything other than the core of commitments to which loyalty binds us.
2. Loyalty and independence towards the patient
Nursing ethics textbooks refer to the well-known loyalty conflicts that sometimes dramatically complicate the relationship between patients and nurses, in particular when nurses are challenged in their loyalty by opposing demands of patients and doctors. Only a few prototype dilemmas, e.g. those related to ecommunicating-hiding information, could occupy us at length. I prefer to draw attention to some more everyday issues and Materials.
The primary responsibility of the nurse is to care for the patient. The patient's interests take precedence over all other interests. But, as we are well aware, there is sometimes a huge gap between the ideal patients of the deontological regulations and the flesh and blood patients who come to the consulting rooms or are admitted to the hospital services. I don't think I need to dwell on describing how degraded and impoverished in dignity the humanity of many is left as a result of illness of body or soul.
And yet, the nurse must serve everyone without distinction. I like to present to my students, so that they can analyse the quality of their own dispositions towards the patient, the case that Rubin offered to a group group of nurses participating in a course on geriatric care.
Loyalty lies in respecting the patient as he is: in him we must see in transparency the figure of the suffering Christ and serve him with skill and dedication. In respect for man, service acquires a high moral status. There are no humiliating operations for the nurse who makes respect the nerve of her service to the patient. For hers is not a mercenary servitude, but becomes a professional, intelligent and reasonable service.
Because of this stately character of patient service, the routine of the nurse's work is excluded, and with it the risk of dehumanisation. No matter how much automation, no matter how much bureaucracy, no matter how much technology there is in the hospital, the nurse who is loyal to her patient does not allow her humanity to be eclipsed. Technology serves us to serve the patient more effectively and must provide us with opportunities to treat them more humanely. The little protagonist in the novel To Kill a Mockingbird of that excellent doctor, Dr Reynolds, put it very accurately: "He never lost our confidence: he always told us what he was going to do to us". This is a formidable description of what loyalty to the patient should be: whatever his age, to tell him what we are doing to him, thus treating him as a human being and not as a thing.
There is one area of the nurse-patient relationship that is particularly dear to me. When, for example, I see in the hospital lift a patient being moved from one side to the other, with his intravenous line held in place by a mesh and his IV drip supported by a tripod on wheels, I think that the ability of good nurses to make the plight of the hospitalised patient pleasant is boundless. Loyalty has a splendid field here: to investigate and apply simple procedures which make the illness bearable, which give the patient maximum freedom and make him forget, as far as possible, that he is in a strange environment. There is a moral obligation to apply to nursing-specific research, this search for that essentially human technology that soothes, that gives freedom and that cares for the patient as a human being. The much talked about humanisation of hospitals is not a job of human relations experts, of putting in place an ombudsman to serve as a lightning rod for public anger, but that other task of loyalty to professional commitments which finds its greatest award in the satisfaction of serving human beings, soul and body. The nurse who has a strong sense of the ethical demands of her profession is an independent person, who thinks for herself and who is able to use and adapt many products of technical progress for the benefit of her patients.
At summary, the alliance between independence of judgement and loyalty to service creates an almost unlimited capacity to discover and meet patients' needs.
3. Loyalty and independence vis-à-vis the doctor
The role of independence and loyalty in nurse-physician relationships is particularly important. They are two allies pursuing the same purpose, the benefit of the patient. And while the history of the doctor-nurse alliance has a massively positive balance, even if we measure it only in the countless number of marital alliances between the two, it is also a history of more than a few conflicts. What nurse does not have a grievance against a doctor? How many are fully happy with the traditional hierarchical model that gives the doctor almost absolute control in decision-making?
Until recently, the metaphor used to describe the doctor-nurse relationship was taken from military symbology. This was, to a certain extent, logical. Modern nursing was born on the battlefield, in the blood hospitals of the Crimean War. Its creator, Florence Nightingale, had the tough personality of a military man and the ethos of the profession was indelibly marked in a military style. Nursing as a profession is an army in a permanent struggle against pain, illness and death.
Outwardly, nurses wear uniforms. Attempts in the United States to abolish the uniform have failed. People do not accept a nurse in blue jeans. They are organised according to hierarchies: there are head nurses, supervisors, duty nurses, whose coifs show, by the number and colour of the stripes, the Degree they occupy. But all this internal hierarchy is under the supreme control of the doctor. The infirmary is an instrument at the doctor's service to treat his patients.
The military metaphor magnificently enshrines the value of loyalty and obedience. There are those who believe that male and female stereotypes have strongly contributed to fix this image and this state of affairs. The ordinary relationship is a power relationship: the doctor commands, the nurse complies.
But more and more voices are being raised against this situation. For a relationship to work well, many argue, it has to be based not on power, but on mutual understanding, on honesty. The nurse knows much more about nursing than the doctor. And often, the nurse knows much more about the problems of the sick than the doctor. While recognising that nursing can never become an independent profession, new models for the doctor-nurse relationship are now being sought to take the place of the already unsatisfactory military metaphor. Nowadays the nurse is increasingly referred to as the patient's advocate. The aim is to give the nurse a sufficient margin of independence and to replace the subordinate relationship of nursing to medicine with a more truly interdependent relationship.
Independence, I repeat again, is an absolute necessity for a person if he or she is to act as an adult and responsible moral being. Only with independence is it possible to accept the challenge of unresolved difficulties and to seek new solutions to them. Only with independence can there be creative criticism. I think that, under certain conditions, the relationship between truly independent doctors and nurses could be much more fruitful than the relationship between the same doctors and simply submissive and passive nurses. I also believe that the dialogue between independence and loyalty has unlimited ethical possibilities. Independence, in this context, is not about freedom from external coercion, but, as I noted at the outset, about the ability to create voluntary duties for oneself, not stipulated in Codes or contracts, but arising from the expansive force of loyalty.
What avenues are open to this cooperation? It could be thought, and this has been source of angry conflicts, that Nursing should engage in a war of conquest of territories so far submitted to the sovereignty of the doctor. There are areas of technology, patient care, and prevention that nurses can perform. The WHO has sponsored the hybrid figure of the Nurse-practitioner, the nurse substitute membe of the doctor. This is intended to facilitate health care in countries with a severe shortage of doctors. But more than a few health ministries in Western Europe have wanted to use these nurse-consultants as cheap labour in order to slow down the escalation of public health care costs. The unsatisfactory nature of some of these experiences tells us clearly that the nurse is not a cheap doctor. Their value lies in being a real nurse.
I believe that the way to future cooperation is not to be found in exotic places: it is clearly indicated to us by the Codes of Ethics. There is no shortage of those who dismiss the Codes as obsolete. Of course, some of them are old, but they are not lacking in prudence. The Spanish Code imposes the duty of good relations between doctors and nurses, based on respect for people and for the scope of each one's particular competences: the doctor cannot allow the nurse to invade the area of his own responsibility, but neither can he interfere in the nurse's own functions.
There is, therefore, a boundary that cannot be broken down and that marks out the specific duties and competences of each profession. The doctor has to carry his own non-transferable burden, which he cannot abdicate. The nurse also has her typical duties. But what is decisive for a boundary to be a real boundary is that it is very clearly marked and at the same time very permeable, allowing a lively and continuous intercommunication. Otherwise it becomes a Wall of Shame. A lot of information has to pass through the doctor-nurse boundary in both directions.
Conflicts are inevitable, as they occur on all borders. The ethical thing to do is to try to resolve them early through sensible negotiation. In my experience, conflicts between doctors and nurses almost always revolve around questions of what is best for the patient, i.e., they are charity-maximising conflicts. Other times, they are not. They are conflicts of personal incompatibility, which are not resolved and turn into a chain of mistakes, ending in traumatic and irrational decisions. It is very painful.
I am persuaded, however, that there are resources to maintain good relations and to rebuild them when they have been damaged. We all make mistakes, but it is ethical to prevent them from becoming irreversible. It is necessary to know how to take a step back in time. From error, as from sin, one can only get out of it through a sincere examination of conscience, humble confession and an optimistic intention to make amends.
I insist: there are resources to prevent and heal conflicts between doctors and nurses. It is wise to have a prejudice that is usually favourable to the doctor: to assume that he or she is the skill professional and ethical. The nurse may faithfully follow his orders because she assumes that the doctor knows better, which is sometimes true.
When the nurse suspects that the doctor is in error, she should point this out to him gently and clearly and without hurting his reputation. It is often enough simply to ask whether the order, as expressed, is correct; whether it has been understood correctly. Skilled nurses know how to do this masterfully. They manage to rectify the error without offending, with elegance.
When faced with an order that is believed to be wrong or ethically unacceptable and the doctor does not agree to change it, it is preferable to appeal to someone in a hierarchical position above the doctor and the nurse: appeal to the Hospital Ethics Committee, for example, in which, incidentally, a nurse cannot be absent.
4. Freedom and loyalty to the profession
Loyalty to the profession, as well as freedom, manifests itself first and foremost in the preservation of ethical values, professional traditions of service and technical quality. It consists in showing a strong personal appreciation of the past, in not hiding the pride of belonging to a profession that has worked quietly for the good of mankind and that constitutes one of the most ethically elevated groups in society. I believe that no one can aspire to live high ethical ideals without being somehow rooted in a tradition, without having some models to imitate. Mimicry, both in psychology and ethics, may seem unoriginal, but it is inevitable. It is impossible, and also stupid, to pretend to be original always and in everything. Imitation is a quantitatively very considerable source of human behaviour. That is why it is so crucial to choose the right model(s) to follow. There is no lack of imitable figures either in the great universal tradition (which is why it is useful to know the History of Nursing) or at the local level, because in all climates the profession has given the lives of some nurses an extraordinary moral quality.
Loyalty to the profession and freedom oblige us to favour progress and innovation. Logically, I exclude from this progress that which is related to that area for which nurses are exclusively responsible: research and innovation in nursing care, because I referred to it when discussing loyalty to the patient. I want, however, to make a brief reference to how to deal with certain very revolutionary movements that, from time to time, seem to shake the foundations of the professions.
From time to time, trumpets of liberation seem to be heard. There seems to be an atmosphere of crisis. Nothing from the past is valid. Everything that has been built up to now must be demolished in order to build the new profession from scratch. In addition to the demands for social status, there is a sense of the mission of a new gospel. At last, everything will be possible! The enthusiasts of the Nursing process, of Systemic nursing tell us that they already have the core topic so that nurses can start to think, to decide, to be independent, to act. They will finally find out why they are doing what they are doing. They will even learn the true identity of nursing. They show us some beautiful diagrams that make us see their message which, surprisingly, includes liberation from routine, repetitive tasks. The nurse will be an executive who makes original decisions, who leads a life of inexhaustible creativity, as intense as that of a Florentine renaissance knight or a leader of revolutionary France.
All this, I know, is an exaggerated caricature. But I have read articles written by representatives of the militant tendency of the Nursing process movement that have reminded me of some of the productions of the most radical representatives of liberation theology or revolutionary philosophy.
There is a moral obligation of aggiornamento. And there is also a moral obligation to preserve the values of the profession. Sometimes, it seems that the battlefield where the future of the professions is being fought out is in the discussion sessions of the Congresses or in the stormy meetings of the Boards of Directors of the National Associations. But where the fate of the professions is really being fought out is in the soul of each of its members. For nurses, the inner dialogue between loyalty and freedom, between the commitment to innovate in order to better serve and the commitment to preserve the ethical essence of the profession in order to be able to welcome progress, constitutes the nerve of their professional ethics.
This is what a physician, concerned with the professional ethical values of medicine, can say to nurses: that the good practice of medicine depends critically on how nurses live their ethical commitment to freedom and loyalty.
Thank you very much for your patient attention.