Strengthening Nurses' Moral Agency
Critical Care Nurse, Vol 20, No. 3, October 2000
Carolyn Hayes, RN, PhD
In The 7 Habits of Highly Effective People Year-in-a-Box Calendar(1),
Steven Covey offered the following reflection for March 17, 2000: Synergy is everywhere
in nature. If you plant two plants close together, the roots commingle and improve
the quality of the soil so that both plants will grow better than if they were separated.
If you put two pieces of wood together, they will hold much more than the total
of the weight held by each separately. The whole is greater than the sum of its
parts. One plus one equals three or more.
Covey's sentiment of strength gained from uniting separate
roots resonates with AACN Certification Corporation's conceptualization that
when synergy exists between patients' characteristics and nurses' competencies,
the outcomes are mutually enhancing.(2) The synergy creates something greater than
the sum of its parts. The strength is not merely the result of an additive process.
It is more than just the combination of two.
Specifically addressed here is the suggestion from the Synergy
Model that the nurses' competency of advocacy and moral agency practiced within
a synergistic relationship would strengthen not only patients' outcomes but
also nurses' moral agency. Within the Synergy Model, the competency of advocacy
and moral agency is defined as working on another's behalf and representing
the concerns of the patient, the patient's family, and the community.(2) In
the realities of clinical ethics today, nurses face rapid reorganizations, changing
technology, resource challenges in collaborative practice, and cultural diversity.
Nurses' sense of their own moral agency can be challenged on a near-daily basis.
Chambliss, author of Beyond Caring: Hospitals, Nurses and
the Social Organization of Ethics,3 completed an extensive study of the moral agency
of nurses by shadowing clinical nurses at 3 different hospitals in various geographic
locations in the United States. This book details individual and collective acts
that illustrate the moral agency of nurses. It describes some of the challenges
to the nurses' sense of their own moral agency. In the conclusion of the book,
Chambliss(3 - pp186-187) states, "The mundane must be respected. . . . People
don't live only in bright visible moments of decision; they live and die, and
work in the ordinary everyday world." Overall, Chambliss's observations
support the ethical dilemmas and acts of moral courage that nurses experience in
their everyday work, but the observations also highlight the invisible nature of
the nurses' moral agency and the struggles that nurses have even to recognize
moral agency in themselves.
Shannon(4) examined the roots of interdisciplinary conflict,
specific to end-of-life decisions, that may arise from differences in socialization
and training of nurses, physicians, and social workers. That study, whose participants
were from each of those 3 disciplines, explored some of the stereotypes that influence
interdisciplinary communication. Nurses stereotyped physicians and social workers
in different ways and claimed moral superiority among the 3 disciplines on the basis
of the nature and amount of time nurses spend with patients.
Although the nurses claimed superiority, the physicians in
the study revealed that they perceived nurses to have little moral or legal accountability.
Social workers in the study reported that they perceived both nurses and physicians
as too focused on the technical aspects of critical care. Nurse-patient synergy
is the strongest argument against these negative perceptions, both self-perceptions
as reported by Chambliss and perceptions of other healthcare professional colleagues
as reported by Shannon.
Nurses cannot fulfill their moral contracts with patients
and patients' families if the nurses are not advocating "from" the patient
or family, as would result from a synergistic relationship. Common language is that
nurses advocate "for" the patient and/or the patient's family. If a
nurse's intent is to advocate for a course of action that he or she believes
is in a patient's best interest, then the nurse is advocating "for"
the patient. If, on the other hand, the intent is to represent what the patient
wants but is unable to articulate for himself or herself, then the nurse is advocating
"from" the patient. The synergistic relationship strengthens the nurse's
ability to advocate "from" the patient. An argument can be made that if
nurses advocate "for" patients outside of a synergistic relationship rather
than "from" patients within a synergistic relationship, then the nurses'
moral agency along with the patients' outcomes are at risk of being diminished.
The nurses' moral agency is strengthened within the Synergy Model because patients'
needs ought to be the source and purpose of all nurses' acts of advocacy for
The significance of providing nursing care from a synergistic
perspective is presented in the discipline's various contracts with society.
For example, The American Nurses Association's Nursing Social Policy Statement(5
- p3) of 1995 states that nurses view the "human experience as contextually
and culturally defined." The social policy statement also states that nurses
believe humans manifest as an "essential unity of mind/body/spirit."(5 - p3)
Because it is rarely possible to look at one aspect of the
Synergy Model in isolation, it must be recognized that advocacy and moral agency
also contains a component of response to diversity. The American Nurses Association's
Position Statement on Cultural Diversity in Nursing Practice(6 - p1) states the
following: Ethnocentric approaches to nursing practice are ineffective in meeting
health and nursing needs of diverse cultural groups of clients. Knowledge about
cultures and their impact on interactions with health care is essential for nurses.
The stated imperative to avoid ethnocentric approaches to
nursing practice strengthens the importance of moral agency for nurses themselves.
To avoid ethnocentric approaches, nurses must know themselves compared with the
patient. An approach that is not ethnocentric reinforces the nurse as a moral agent
in interaction with the patient. The Synergy Model not only accommodates this level
of advocacy, it describes nursing practice as based on knowledge generated from
both the nurse and the patient in a synergistic relationship that would not accommodate
ethnocentric goals of care.
The Synergy Model describes "creating safe passage"
as a product of excellence in nursing practice.(2) Curley(2 - p67) states, "In
fact, excellent nursing care is often invisible, and from a perspective of preventing
untoward effects and complications, it should be." When a nurse is advocating
from a perspective of culturally competent care, it should be difficult to hear
the nurse's voice in the presentation. Culturally competent care has the voice
of the patient, not the personal beliefs of the practitioner. This articulation
advocates from the patient.
In addition to supporting full nurse-patient interaction and
cultural competence, the Synergy Model highlights the essential component of trust
in excellent nursing practice. The Wall Street Journal and NBC recently conducted
a joint national survey of Americans on healthcare issues and reported that nurses
ranked at the top in public trust.(7) In Curley's presentation of the Synergy
Model, "trust" is described as a product of the nurse's clinical competency
and moral agency.(2) As trust builds, so too does the moral agency of the nurse
caring for the patient and the patient's family. Trust facilitates clinical
activities necessary in increasingly short periods of interaction time. Trust is
an essential element for collaborative practice as well.
A case study (below) illustrates this strengthening of moral
agency within the Synergy Model. The Synergy Model frames the nursing plan of care
in a comprehensive way. The model interweaves ethical analyses, culturally competent
considerations, and holistic approaches to care from nursing's social contracts
described earlier with the patient's fundamental needs as the source of the
nurse's actions. In the case study, a direct challenge would be putting the
husband in an uncomfortable, undesired position.
In addition, because the husband most likely will not reinforce
the nurse's representation of the patient's wishes, a direct confrontation
may put the nurse's moral agency at risk of being judged in a manner similar
to that described by Shannon,(4 - p15) who found that physicians stereotype nurses
as "ethical dilettantes flitting from one situation to the next with little
moral or legal accountability." Without reinforcement from the husband, the
nurse may appear to fit that stereotype. If the nurse's approach is to perceive
advocating for a less aggressive treatment plan (advocating "for" the patient)
separate from the patient and family as they wish to be represented (advocating
"from" the patient), then the nurse will risk that the patient's voice
is not heard at all. That approach weakens the trust between the nurse and the patient
and the patient's family, collaboration, the patient's outcomes, and the
nurse's moral agency.
Cultural competence within the Synergy Model challenges the
nurse to explore substituted judgment and less aggressive treatment goals while
respecting the desired deference to authority and maintaining the trust between
the nurse, the patient, and the patient's family. The nurse most likely does
not share that cultural imperative, but here is a case in which best practice may
be invisible because an ethnocentric approach by the nurse (eg, direct approach
to sharing of information) may exclude the husband as a full partner with the healthcare
team. It is the patient's need, not the nurse's goals, that guide the nursing
plan of care and approach to practice.
The nurse can facilitate meaningful conversations that elicit
substituted judgment statements from the husband, for the patient, in the presence
of the attending physician. If the nurse is able to remain unwedded to a particular
outcome that represents his or her views without the added dimension of the needs
of the patient and the patient's family, as the Synergy Model describes nursing
practice as doing, then the nurse may maximize culturally sensitive outcomes and
advocacy for patients. The nurse's moral agency is strengthened by this approach
because it fulfills all contracts and because it is derived from a synergistic rather
than an individualistic stance.
It is still ethically justifiable to pursue aggressive treatment,
but is it as justifiable as respecting the patient's wishes? The cultural dimension
that prohibits the husband from stating those wishes does not exempt the nurse from
advocating for autonomy. The Synergy Model challenges the nurse to maintain trust,
advocate from the patient, and respect the cultural desire for nonconfrontation.
Only through the strength of two, patient and nurse, can this patient's wishes
and the nurse's moral agency be maximized.
The current realities of healthcare include culturally diverse
populations of patients, high acuity, diminishing resources, and multiple technological
and social changes. These changes demand that nurses serve as advocates for patients
more frequently than in recent decades and simultaneously demands a more diverse
and sophisticated level of advocacy. Advocacy and moral agency is weak at best without
skilled assessment of cues from the patient in an interaction based in trust and
cultural competence. At its worst, advocacy without a synergistic relationship can
misrepresent patients and their families, diminish collaborative efforts, and harm
patients; cultural cues get missed and the nurse advocates from a false premise.
The nurses' competency of advocacy and moral agency enacted within the Synergy
Model strengthens the nurses' moral agency because patients' needs are the
source of nurses' acts of advocacy for patients, ethnocentricity is avoided,
and trust in the relationship is enhanced. (9)
An 84-year-old woman is admitted to a critical care unit after
a cerebrovascular accident. She is intubated and so cannot communicate verbally
with the healthcare providers. It is difficult to assess her understanding because
it is impossible for her to communicate a decision beyond yes or no answers given
by blinking once or blinking twice. Therefore, the healthcare team is collaborating
with her husband to make treatment decisions.
During the first 2 days of hospitalization, the nurse comes
to "know" the following by being present while the husband and wife interact
and by having conversations with the patient's husband, son, and sister.
- The patient and her husband are from Italy. They have been
in the United States for 50 years, but still consider Italy their home.
- The patient's brother died of a cerebrovascular accident
3 years ago under similar circumstances.
- Because of her experience with her brother, the patient
has expressed fear in recent months that she would also die of a cerebrovascular
- The patient made statements that she would not want aggressive
treatment if she did have a stroke.
- The husband fears that his wife is on a long course of suffering
with no hope of a good outcome.
- The family holds onto their belief that at least eventually
she will "return to God's loving arms," and that event is something
they know she is looking forward to after all the suffering is over.
- The couple and the other family members believe in deference
to authority, specifically the physician. It would be unthinkable to them to challenge
the physician's recommendations.
From collaboration with the members of the healthcare team,
the nurse knows the following:
- The attending physician believes that the patient has a
50/50 chance of meaningful recovery if all available treatments are pursued.
- The current goals of care established, with the husband's
input, focus on an aggressive treatment plan.
- The attending physician is aware of the family's deference
to authority and is willing "to take charge."
The nurse personally supports the aggressive treatment plan
because she believes the potential benefits (meaningful recovery) justify the burdens
(eg, intubation, intravenous devices, and discomfort). The plan is ethically justifiable
from this perspective. However, the nurse realizes from multiple family conversations
(substituted judgment statements) that the patient's autonomous wishes stated
before this admission would be for less aggressive, more comfort-promoting goals
of care. Death is less of a fear for the patient and her family than is the prolongation
of suffering even if she may recover. Therefore, the nurse can see an ethical justification
for these different goals of care.
Two, or more, justifiable courses of action exist, but adding
complexity to the discussions are the patient's and the husband's deference
to authority. The patient's previously expressed wishes for less aggressive
treatment are not being represented. The nurse is the only member of the healthcare
team who is aware of the fears and substituted judgment statements. How can the
nurse advocate "from" the patient without violating the need to be deferent?
To override that approach can be viewed as an additional harm or burden. Should
the nurse accept the current goals of care because doing so is ethically justifiable,
in fact preferable to the nurse, and the husband will not argue against it? Or should
the nurse advocate from the perspective of the reported autonomous wishes of the
patient? Which choice is most respectful of the patient? Does it matter if the Synergy
Model is the framework for the nursing care?
1. Covey SR. The
7 Habits of Highly Effective People Year-in-a-Box Calendar . Indianapolis,
Ind: Cullman Ventures Inc; 1999.
2. Curley MAQ. Patient-nurse synergy: optimizing patients'
outcomes. Am J Crit Care. 1998;7:64-72.
3. Chambliss D. Beyond Caring: Hospitals, Nurses, and the Social
Organization of Ethics. Chicago, Ill: University of Chicago Press; 1997.
4. Shannon SE. The roots of interdisciplinary conflict around
ethical issues. Crit Care Nurs Clin North Am.
5. American Nurses Association. Social Policy Statement. Washington,
DC: American Nurses Association; 1995.
6. American Nurses Association. Position Statement on Cultural
Diversity in Nursing Practice. Washington, DC: American Nurses Association; 1997.