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Chapter 2 The Nurse as Moral Agent Jean-Marc Larouche and Tim Flaherty INTRODUCTION This chapter considers the profession of nursing as it is exercised in the field of pediatric chronic illness.Webegin with a general sociohistorical sketch from which we observe the emergence of indicators that form the dimensions of the "implicit ethics" of three ideal types of nurses. This is followed by an illustration of how each of the ideal types addresses the four ethical themes of concern in this study: autonomy,economics, location of care and decision making. The chapter concludes with a synthesis that presents the nurse as moral agent and with concludingstatements. In order to provide the general situation and context of the professionals involved in health care, this chapter is more detailed and lengthy than those that follow on the physician and the social worker. The details provided here will not be repeated in subsequent chapters but their importance will become evident. SOCIOHISTORICAL PERSPECTIVE: THE TENSION BETWEEN CARING ANDEXPERTISE To focus on the aspects of nursinghistory that are significantfor this chapter, the following sketch will be presented by observing the tension between two poles that define nursing.1 The first is nursing care and the second is nursingskill or technical expertise. The literature suggests these poles are recognized as central points of orientation in a discussion of nursing practice. From our observation of the interplay of these poles, we For greater da.caa.caetail and further documentation, see T. J. Flaherty, "Nursing Ethics: T Transformation of an Ethical Field," Research Services, Saint Paul University, Ottawa , August 31, 1993. 35 IMPLICIT ETHICS OF PROFESSIONALS INTHE FIELD OF PEDIATRIC CHRONIC CARE note indicators that allow us to identify the dimensions of three portraits, or ideal types, of nurse practising in the field of pediatric chronic illness. Nursing has its origins in the art of caring practised as part of family living.2 It became organized under monastic communities and religious orders after the rise of the influence of Christianity in the fourth century. It largely functioned as part of the "hospitality" monasteries offered to pilgrims. The practice of the art of nursinggradually became recognized as a vocation with the religious or moral motivation of charity. Its practice extended beyond the family circle to include care for the infirm and the poor. In this vocational expression, nursing was essentially the work of women. Women were assigned the role of caregiver by virtue of an understanding of the natural order.3 Because of the social order of the time, the assignation of care as a feminine virtue devalued it as a form of subservience and as secondary to masculine virtues associated with power, authority and control. The valuing of care as a religious virtue, particularly in the exercise of charity, made remuneration for nurses inappropriate . As with all aspects of religious and monastic life, the virtue of obedience was highly valued. The nurse offered the patient comfort and care while following the direction of the physician and those in authority. This understanding of nursing and its attribute of care was largely unchallenged in any formal manner until the time of the Crimean War in the 1850s and the British military nurse Florence Nightingale. Nightingale insisted on the recognition of the cognitive as well as the moral aspects of nursing.She highlighted newly emerging nursing knowledge and capability to illustrate non-moral good.4 Nurses were to promote health as a science and engage in disease prevention. The cognitive aspect of nursing was an addition to the moral aspects of care that featured sacrifice, charity and pity. This is a benchmark in the gradual transformation of nursing from vocation to profession.5 It is significant to note here that although tremendous influence is credited to Nightingale for moving nursing forward as a profession, she maintained that nurses must be obedient to the physician, give self-sacrificing care to the patient , assist the physician in his task and grow in the knowledge of the 2. See especially Teresa A. Christy, "Historical Perspectives on Accountability," in Current Perspectives in Nursing Education, vol. 2, ed. Janet A. Williamson (St. Louis: C. V. Mosby, 1978), 1-7; and Winnifred Gustafson, "Motivational and Historical Aspects of Care and Nursing," in Care: The Essence of Nursing and Health, ed. Madeleine M. Leininger (Detroit: Wayne State University Press, 1988), 61-75. 3. Gustafson, "Motivational and Historical Aspects of Care and Nursing," 69. 4. Ibid., 67. 5. For a detailed discussion of this phenomenon, see Andre Petitat...

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