Embodied knowing? The constitution of expertise as moral practice in nursing

¿Conocimiento incorporado? La constitución de la expertise como práctica moral en la enfermería

Conhecimento incorporado? A constituição da expertise como prática moral na enfermagem

ARTIGO ORIGINAL

REFLEXÃO TEÓRICA

Embodied knowing? The constitution of expertise as moral practice in nursing

Conhecimento incorporado? A constituição da expertise como prática moral na enfermagem

¿Conocimiento incorporado? La constitución de la expertise como práctica moral en la enfermería

Sioban Nelson

PhD. Dean and Professor Faculty of Nursing, in The University of Toronto, Canadá

^Endereço

ABSTRACT

Prominent nursing authors, such as Patricia Benner, are influential in the increasing trend to conceptualize ethics as a contextual and embodied way of knowing, embedded in nursing expertise. It will be argued here that rather than revealing a moral truth manifest in practice, the idea of ethics as expertise constitutes nursing practice as a moral endeavour and the nurse as a practitioner who has acquired a particular moral deportment. In fact, the case will be made that the expert nurse as a moral and ethical category is the result of the elaboration of prestigious humanistic discourses in the educational and professional shaping of nurses. These discourses act on and are enacted by the individual nurse through his or her participation in specific ethical exercises that result in the constitution of the desired subjectivity. Of critical importance here is the widespread adoption in nursing pedagogy and professional literature of phenomenological perspectives on the body and nursing practice. This paper examines both the intellectual origins and contemporary implications of this trend for practicing nurses.

Keywords: Ethics. Professional practice. Morale. Nursing.

RESUMO

Autores proeminentes da enfermagem, como Patrícia Benner, têm influenciado a crescente tendência de conceituar ética como uma forma de conhecimento contextual embutido na expertise de enfermagem. Será discutido aqui que mais do que revelar um manifesto da verdade moral, a idéia de ética como expertise constitui a prática de enfermagem como um empenho moral e a enfermeira como uma profissional que tenha adquirido uma conduta moral peculiar. De fato, acontecerá que a enfermeira expert como categoria moral e ética, é resultado da elaboração de prestigiosos discursos humanísticos na formação educacional e profissional de enfermeiras. Estes discursos agem sobre as enfermeiras de forma individual e são desempenhados através da sua participação em exercícios éticos específicos, que resultam na constituição de uma subjetividade desejada. De suma importância aqui é a adoção difundida na pedagogia de enfermagem e na literatura profissional, de perspectivas fenomenológicas sobre o corpo da enfermagem e sua prática. Este artigo explora tanto as origens intelectuais como as implicações contemporâneas desta tendência para enfermeiras assistenciais.

Palavras-chave: Ética. Prática profissional. Moral. Enfermagem.

RESUMEN

Importantes autores del área de enfermería, como lo es Patricia Benner, han influenciado la creciente tendencia de conceptuar la ética, como siendo una forma de conocimiento contextual incorporado en la expertise de la enfermería. En el presente artículo se discute que la idea de la ética como expertise, más que revelar un manifiesto de la verdad moral, constituye la práctica de la enfermería como un empeño moral, y, la enfermera como siendo una profesional que ha adquirido una conducta moral peculiar. De hecho, sucede que la enfermera expert, como categoría moral y ética, es resultado de la elaboración de importantes discursos humanísticos en la formación educacional y profesional de enfermeras. Esos discursos actúan en las enfermeras de forma individual y son desempeñados a través de su participación en ejercicios éticos específicos, los cuales dan como resultado la constitución de una subjetividad deseada. Es de suma importancia la adopción de perspectivas fenomenológicas sobre el cuerpo de la enfermería y su práctica, las cuales se encuentran difundidas en la pedagogía de enfermería y en la literatura profesional. Este artículo examina los orígenes intelectuales así como las implicaciones contemporáneas de esta tendencia para las enfermeras asistenciales.

Palabras clave: Ética. Práctica profesional. Moral. Enfermería.

INTRODUCTION

This brief paper elaborates the theoretical underpinnings of a critique of embodied ethics. First published in the conference proceedings "Sickness and in health: ethics, power practice",¹ the argument developed here forms one of the organizing themes of "The complexities of care: nursing reconsidered" edited by myself and Suzanne Gordon and published by Cornell University Press in 2006.²

I begin with a quote from Patricia Benner from a recent paper entitled "The roles of embodied emotion and lifeworld in nursing practice".³

Good nursing practice minimally requires the following seven moral sources and skills: 1) relational skills in meeting the other in his or her particularity drawing on life-manifestations of trust, mercy and openness of speech; 2) perceptiveness, e.g. recognizing when a moral principle such as justice is at stake; 3) skilled know-how that allows for ethical comportment and action in particular encounters in a timely manner; 4)moral deliberation and communication skills that allow for justifications of and experiential learning about actions and decisions;⁴ 5) "an understanding of the goals or ends of good nursing practice";^5:191 6) participation in a practice community that allows for character development to actualize and extend good nursing practice; and last, but not least; 7) the capacity to love ourselves and our neighbours, and the capacity to be loved.³

There are a number of significant philosophical threads that manifest in this set of ethical imperatives – many of which – I have decided on reflection are beyond the reach of a single paper. It is clearly a paradigm heavily indebted to phenomenological ideas of embodied capacities and pre-subjective truths (Merleau-Ponty’s providing the theoretical ballast here). This is by now quite familiar thread in nursing discourse – through Heidegger much more than Merleau-Ponty, but this is not the trail I intend to follow in this paper (alluring though it is). My target here is the manner in which in this schema moral knowing/ethical comportment have elided to equate with nursing expertise.

The paper follows Benner’s line of reasoning through the influential works of Alisdair McIntyre⁶ and Charles Taylor^7-9 (and others) in order to explore the modern application of Aristotle and Aquinas to the professions and to practice. It will be argued that this development in nursing ethics in heavily indebted to Taylor’s combination of neoaristotelian and German romanticist approach to knowledge, practice and subjectivity.

Following this discussion, two elements in Benner’s care ethic will be discussed in detail: first the anti-positivism, and second the emphasis on emotion. Here we discuss the manner in which this ethic of expertise in achieved through a set of exercises where the nurse attunes herself in a particular way to the clinical situation – the rejection of the primacy of reason and the focus on feeling are key elements in Benner’s constitution of the expert nurse. It will be argued that this view of nursing as a practice in which ethics is defined as belonging in the unworldly realm of embodied truth and moral knowing – the legacy of Enlightenment humanism and German romanticism – constitutes ethical practice as a highly elaborate form of conduct accessible only to elites. One cannot help but ask – What does it offer the millions of nurses working to get through the shift? I conclude with the question.

Is it not a more modes approach to ethics in nursing both possible and desirable?

Finally, let me acknowledge that a paper appearing to criticize the values of equality, self-realization and human connectedness is very much at risk of appearing to support their opposite. This is not the case. This paper is in no way a defence of insensitive or uncaring practice – what it does do is question the idea that expert clinical nursing is only possible when combined with exemplary ethical understanding.

SOME BACKGROUND

It would be difficult to overstate the influence of the work of American nurse Patricia Benner on contemporary nursing. Benner’s landmark work, her 1984 From Novice to Expert, radically resituated discussions of nursing practice – from the academy to hospital ward – away from abstract theorization or simple skill checklists, into a complex arena of contextualized learning and practice. Benner’s work adapted Dreyfus and Dreyfus’s skill acquisition model (originally developed with pilots) and delineated a widely accepted set of competencies that became the basis of work structure in San Francisco, national competency frameworks adopted by professional associations and regulatory authorities in Canada, Australia and the United States (and elsewhere) and became the basis for a professional development and work organization model that she now markets directly to health providers. (All in all, few would dispute that it has been a great success!) Even more importantly for today’s discussion Benner has provided a wealth or writings for undergraduate and graduate nursing curricula in North America and Australia and it is in this capacity that her work has, and continues to, influenced a new generation of nurses as to what is nursing practice, how knowledge and skill are developed, and what constitutes clinical expertise.

In recent years, however, Benner writings have taken a distinctive turn. The idea of practice as an essentially ethical enterprise has become an increasingly important feature of her work. In her most recent work, an utter conflation of expertise with ethical ‘knowing’ has taken place. It is this resisting of nursing practice as an essentially ethical form of conduct and the implications of this, so far unremarked, shift that this paper explores.¹⁰

The great influence in Benner’s shift to the ethical is that of the Canadian philosopher Charles Taylor. Taylor is an internationally acclaimed neoaristotlean philosopher.^7-9

Like the other prominent Catholic philosopher of the English-speaking world, Alisdair McIntyre,⁶ Taylor takes a radical stand on contemporary society, decrying individualism and the failures of community. but Taylor is more political than McIntyre and he is well known for his views on participatory politics and social action. Taylor thus broadly appeals to left critiques of advanced liberal societies and recalls communitarian and humanist values and a sense of connectedness, as essential features of a civilized society.

A second important aspect of Taylor’s wide appeal is his long-sustained critique of positivist science. The holistic and nonreductionist arguments that underpin Taylor’s analysis of knowledge and practice resonate strongly with both humanist and ‘New Age’ tendencies that deride reductionist medicine, scientific amorality and other demons of twentieth century.^7:93 A final important thread in Taylor’s philosophical anthropology^* relates to the previous nonreductionist conviction: it is that all social action is essentially about human ‘meaning’, and that meaning rests fundamentally upon the good. Taylor acknowledges the failures but reasserts the promise of modernity.⁸ In fact according to Nicholas Smith’s recent work on Taylor, for Taylor "it is the project of modernity, rather than anything like the project of Christianity, that promises a fuller realization of Christianity’s basic ideals".^11:236

In fact, Taylor claims that the direct apprehensions of the needs of another or the intuited sense of the requirements of a principle are key elements of moral subjectivity. Critically this awareness of the good, as a constituent element of subjectivity, arises from the idea of a pre-reflective moral life "shaping moral experience and motivating moral action".^7:213 Moreover, it is Taylor’s conviction that human beings rely on openness to the divine source of affirmation in order to accede to their moral subjectivity.

Taylor’s work is a highly effective resurrection of Thomasist views on reason and faith. St. Thomas Aquinas (1225-1274), was the most famed authority (of all time no doubt) on Aristotle and his exegeses carried forward the master’s framework on goods, action, knowledge, virtue and reason.⁸

Briefly, and crudely, underpinning all the social and material goods to which we are anchored rests the essential moral order of the universe, and this moral order under Aquinas became a Christian one. Paramount in the Thomasist view is that no demonstrated truth (rational science) can stand above ‘revealed’ truth – truth accessed through divine revelation. Put simply, God and all creation is essentially good, man through original sin is the corruptor of God’s good. One way to re-attain this goodness is through practice. As Nicholas Smith explains: ‘Taylor’s thesis "is that the unity of a life must be articulated in a quest-like narrative that situates the self in relation to the good".^11:240

But how does one identify the good and right in every situation? The answer is through faith.

FAITH PRESERVES REASON FROM ERROR

As Aquinas argued Reason is not a sufficient guide for men, they need revelation. Faith preserves men from error.

Taylor’s philosophical anthropology, along with Alisdair McIntyre’s famous Aritostotelian formulation of practice in which the function of virtue is to "resist the corrupting power of institutions",^6:181 form the basis of Benner’s collapsing of the distinction between moral and clinical reasoning.

To take McIntyre first, an activity can only be considered a practice if virtues historically flourish. He explains: "to enter into a practice is to enter a relationship not only with its contemporary practitioners, but also with those who have preceded us in the practice, particularly those whose achievements extended the reach of the practice to its present point. It is thus the achievement, and a fortiori the authority, of a tradition which I then confront and from which I have to learn. And for this learning and the relationship to the past which it embodies the virtues of justice, courage and truthfulness are prerequisite in precisely the same way and for precisely the same reasons as they are in sustaining present relationships within practices".^6:181

To transpose this view to nursing, Benner argues that as a ‘practice’ in this Aristotelian sense, nursing not only embodies virtues (pre-reflectively) and these virtues of justice, courage and truthfulness are a stable historical prerequisite for sustaining relationships within the practice – but that nursing functions to defend the patient against the essentially corrupting power of the institutions within which the practice flourishes.

Benner’s project, then, as she puts it, is to aid the ‘recovery’ of "an understanding of the nature of clinical and ethical comportment and reasoning lodged in a practice".^10:55 This goal is given further impetus in the juxtaposition that Benner poses, this time from Taylor and others, between the legitimacy of scientific reasoning versus the craft, judgement, relationships and moral virtues of clinicians.¹⁰ In Benner’s view, the practitioner must develop the moral art of attentiveness, and willingness to be with patients who are suffering.¹⁰ The expert nurse – as opposed to the experienced nurse – has faith in her intuitive confidence to go against reason, the ability to trust her instincts as opposed to data. To lack this faith is to fall victim to rationalist science and to close oneself off to the practice wisdom accessible only through an embodied connection with the patient.

ROMANTICISM: OR FINDING ONE’S MORAL COMPASS

The key for the nurse to resist the rational and accede to the truth underlying every situation, Benner believes, is through the emotions. In her view the emotional response: "contains within it a vision of habits of skills, thought and relationship. Emotions are more than noise that trouble our cognitive processing; they create the possibility of rational action. "Emotional response can act as a moral compass in responding to the other person".^10:54

From her extensive studies of nursing expertise Benner concludes that: "the nurse’s skills of involvement with the situation and interpersonally with patients and families were crucial to developing expertise. Indeed emotional engagement allows one’s body to gear into situations. Nurses who did not experientially learn skills of involvement that allowed attentiveness but not over-involvement did not go on to become expert nurses".^10:53

Furthermore (and critically) "nurses (who) did not experience their own moral agency in making qualitative distinctions or taking responsibility for their choices were experienced but not expert nurses"(emphasis added).^10:53 Thus the expert nursing is constituted through a refined exercise where the nurse develops a repertoire of skills to engage in practice at a level that privileges faith over reason, and follows her well calibrated moral compass through attunement to her own emotional responses. But this is not simply an opportunity to extend one’s clinical range through emotional engagement – it is a prerequisite for expert practice!

But what then is the problem with an approach that positions nursing knowledge and practice, in fact defines expertise, through a particular and, it must be said, highly religious perspective?

Well I believe that are many – I will offer two here and discuss potential alternatives to this highly specialized path to ethical and clinical expertise. The first issue is to highlight an omission – what is wrong with the picture presented of the expert nurse and her transcendent ethical capacity?

This is the issue identified by Daniel Chambliss in his book "Beyond caring".¹³ Chambliss, a Harvard sociologist (at the time), conducted an important study on nursing and ethics. His work has been widely ignored by the large American nursing ethics literature – this is not surprising because one of the unpalatable points he makes is that academic are pretty hopeless when it comes to ethics.

He concludes his study as follows: "finally, since the great problems of health care are structural and not the result of poor reasoning, the solutions cannot be created by increasing education, holding ethics seminars or (alas) writing books. In overestimating the good effects of such cognitive solutions, perhaps we academics are well alike. Traditional humanist ethics has not yet been equipped to draw such conclusions as these on its own. For one thing, ethicists are predominantly theologians or philosophers, not social scientists".^13:184

Chambliss goes on, "the facts are these: 1) nurses are not the lowest people in the hospital hierarchy but they are clearly subordinates: often ignored, shown little respect, and generally undervalued. They carry out vital work and are typically not recognized or rewarded for that. Much of their work is of low visibility and of little dramatic potential. In this their situation is typical of that of many women; 2) this is not to say nurses are morally better than doctors or anyone else. They are fundamentally employees in a helping profession. Their self-description as patient advocates is as much ideology as objective description".^13:183-4

The home truths that Chambliss in pointing out contrast sharply with the "care ethics" perspective, where the individual expert nurse is apparently able to achieve her ends despite the structural limitations that confine her practice. If she cannot, she is not an expert.

A second problem is more theoretical and relates to what Jeffrey Minson has described at "the endemic susceptibility of the ethical to be undone by moralism".^14:38 This collapse into moralism – or the "self-righteous parade of virtue" (as Minson describes it) is indeed a clear weakness of the "expert" nurse who needs to assert her knowledge over inferior scientific or organizational rationalities to protect the patient. Importantly, there is a sinister side this moralism – and that is that is privileges one ethical style over all others.

To equate expert practice – in both an ethical and a clinical sense – with one form of ethical comportment renders all other nurses (which is almost everyone) as without ethical capacity or expert status. It fails to recognize the wide repertoire of ethical capacities that most nurses utilize in their daily work with vulnerable and often difficult patients (let alone colleagues!). The professional shaping of all nurse of even modest competence includes a vast array of skills that do not necessarily intersect with the emotivist-humanist capacities privileged by Benner’s care ethics.

In fact it is highly likely that the seven moral sources with which we began this paper may scarcely intersect with this modes repertoire of modes of ethical conduct – but to handle difficult patients, to be kind to people one does not like, to sensitively deal with body breakdown, to joke and pass the time with patients and colleagues, and to moderate the scientific or institutional rationalities to fit the mood and the morning are scarcely out of reach capacities for most nurses. Perhaps too the capacity not to bring the day home with you is more important than the proponents of ‘care ethics’, with its emphasis on over involvement, could ever countenance.

The problem lies with the identification of moral and ethical behaviour in the realm of perfection, as opposed to the highly imperfect world of practice. Moreover we should protest at the ethical lode that such an approach weighs on everyday nurses, who may be neither interested in, nor capable of, highly refined expressive responses to practice situations. (It adds too to the already burdensome sense of failure that many nurses struggle against.) It is this relentless burdening of nurses not only with the responsibilities of the health care system, but with the frailties of the human condition, that this paper critiqued. Indeed, how much ‘work on the self’ do we require of nurses before they can be recognized as expert?

If our starting point in discussing both ethics and expertise lies for once away from perfect principles or exemplary situated revelations, we may be able to bring into focus the more modest, but no less powerful ethical capacities through which nurses habitually enact their practice. Whether they be expert in an ideal or transcendent sense is entirely the wrong the question. Rather it is the ability of nurses to function within an increasingly dysfunctional system that we need to examine and assist.

Recebido em: 15 de agosto de 2006.

Aprovação final: 26 de fevereiro de 2007.

• 1 Sickness and in health: ethics, power, practice, 1. In: Anais 2002 Jul 16-17; Melbourne (Victoria/AU): The University of Melbourne; 2002.
• 2 Nelson S, Gordon S. The complexities of care: nursing reconsidered. Ithaca (NY/USA): Cornell University Pres; 2006.
• 3 Benner P. The roles of embodied emotion and lifeworld in nursing practice. Nursing Philosophy 2000 Jul; 1 (1): 5.
• 4 Dreyfus HL, Dreyfus SE, Benner P. Implications of the phenomenology of expertise for teaching and learning everyday skilful ethical comportment. In: Benner P, Tanner C, Chelsa C, organization. Expertise in nursing practice, caring clinical judgement and ethics. New York (NY/USA): Springer; 1996. p.258-306.
• 5 Rubin J. Impediments to the development of clinical knowledge and ethical judgement in critical care nursing. In: Benner P, Tanner C, Chelsa C, organization. Expertise in nursing practice, caring clinical judgement and ethics. New York (NY/USA): Springer; 1996. p.170-92.
• 6 McIntyre A. After virtue: a study in moral theory. London (England): Duckworth Press; 1981.
• 7 Taylor C. Theories of human meaning: human agency and language, philosophical papers. v. 1. Cambridge (England): Cambridge University Press; 1985.
• 8 Taylor C. A catholic modernity? Oxford (England): Ed. James Heft/Oxford University Press; 1999.
• 9 Taylor C. Philosophy and the human sciences. Cambridge (England): Cambridge University Press; 1986.
• 10 Benner P. A dialogue between virtue ethics and care ethics. Theoretical Med. 1997 Springer; 18 (1/2): 47-61.
• 11 Smith N. Charles Taylor: meaning morals and modernity. London (England): Polity Press; 2002.
• 12 Taylor C. The explanation of behavior. London (England): Routledge/Kegan Paul; 1964.
• 13 Chambliss DF. Beyond caring, hospitals, nurses and the social organization of ethics. Chicago (USA): Chicago University Press; 1996.
• 14 Minson J. Questions of conduct. London (England): Macmillan; 1993.

*

Taylor defines philosophical anthropology as the study of the basic categories in which man and his behaviour is to be described and explained.11-12

Publication Dates

• Publication in this collection
  13 Sept 2007
• Date of issue
  Mar 2007

History

• Received
  15 Aug 2006
• Accepted
  26 Feb 2007