Key milestones in the operationalisation of professional nursing ethics in Australia: a brief historical overview.
The history of 'modern' nursing ethics in Western countries can be traced back to the late 19th and early 20th centuries, where its inception and development paralleled the beginning and advancement of the new modern nursing profession credited with having progressed under the influence of the legendary reforms lead by British nurse Florence Nightingale (1820-1910). During this early period, those leading reforms in the thinking, teaching and practice of nursing ethics were clear in their aims, notably, to advance a professional nursing ethics that was secular, scientific and humanitarian in its outlook and, as such, which could be readily distinguished from a professional morality based on traditional religious vows and values, such as those upheld by religious-order nurses at the time (Johnstone 2015a, 2015b).
Ethical codes and statements developed and published for the specific purpose of guiding the conduct expected of a given occupational group have long been recognised as the hallmarks of a 'profession' and the mechanisms by which a profession's ethical values are operationalised. One reason a profession's statements of and commitment to its ethical values stands as a professional hallmark is because, as Churchill (1989, p.30) explains, 'a profession without its own distinctive moral convictions has nothing to profess' and will be left vulnerable to the corrupting influences of whatever forces are most powerful--be they religious, legal, social, political or other in nature. In recognition of this, professional ethics are characteristically comprised of a set of rules which 'govern individuals, which compel them to act in such and such a way, and which impose limits to their inclinations and forbid them to go beyond' (Durkheim 1957, p.7). In short, professional ethics have had--and continue to have--the unique and special task of governing functions which only certain professional people 'can do, actually do, and ought to do' (Durkheim 1957, p.6). In keeping with this stance, the task and purpose of professional nursing ethics is fundamentally concerned with guiding and governing what nurses 'can do, actually do, and ought to do' during the course their everyday professional practice (Johnstone 2015a).
The iterative development of the conceptual and theoretical underpinnings of nursing ethics from the late 19th century up until the present time, and the implications of these developments for the nursing profession across the globe, have already been comprehensively documented and thus there is nothing to be gained by rehearsing this history here (see Johnstone 2015a, 2015b, 2015c). Less well known, however, is the achievement of key milestones in the operationalisation of professional nursing ethics in specific countries over time (e.g., the development of national codes of ethics and position statements; the publication of home grown pedagogical literature on nursing ethics).
An historical perspective on the development and achievement of key milestones in operationalising professional nursing ethics in the United States of America (USA), the United Kingdom (UK), and some Western European countries has been well documented in the academic nursing literature (Fowler 2010; Fowler and Tschudin 2006). Since 2006, the development and achievement of key milestones in operationalising nursing ethics in a small number of other countries, for example, Columbia, Hungary, Israel, Malawi, Spain and Turkey, have also been documented in the academic nursing literature (Davis et al 2006). The achievement of key milestones in operationalising nursing ethics in Australia, however, has not been formally published. It is a key aim of this article to redress this oversight.
In keeping with the above stated aim, the purpose of this article is threefold: to formally document the key milestones achieved in regard to the operationalisation of professional nursing ethics in Australia; to enable developments in Australian nursing ethics to be given a rightful place in global discourses on nursing ethics; and to provide a basis for enabling the identification of opportunities for future scholarship, research and policy initiatives that would contribute to the ongoing advancement of nursing ethics locally and globally.
To this end, in the discussion to follow, attention will be given to providing a brief historical overview of the achievement of key milestone in the development of mechanisms for operationalising nursing ethics in Australia. Brief commentary will also be provided on the possible future of nursing ethics in Australia and the need for a strategic nationally coordinated agenda to advance nursing ethics as a field of inquiry and practice in the Australian cultural context.
EARLY TREATISES ON ETHICS FOR AUSTRALIAN NURSES
The first Australian nursing periodicals the Australasian Nurses Journal (ANJ) (established March 1903, and the official journal of the Sydney-based Australasian Trained Nurses Association (ATNA)) and Una (established April 1903, the official journal of the Victorian Trained Nurses Association (VTNA)) arguably provide the most definitive starting points from which to provide an examination of the nature and early evolution of the mechanism developed for operationalising nursing ethics in Australia (Lemin 1999). As has been previously shown, articles ostensibly published on the subject of 'ethics' in nursing during this period had as their focus 'etiquette' (not ethics) and prescribing behaviours traditionally expected of the proverbial 'good woman', such as submission, obedience, silence, self-sacrifice, and self-restraint--a stance that did not change until well after the second world war (Lemin 1999; Johnstone 1993).
The earliest mention of the notion 'nursing ethics' can be found in a 1903 report published in the inaugural issue of Una. The report was of a lecture on 'nursing infectious fevers' by Miss Martha D Farquharson, then Matron of the Bendigo Hospital (1902-1913) and previously Lady Superintendent of the Melbourne Hospital (1895-1900), Matron of Melbourne's Alfred Hospital (1890-1895), and who had also been a member of the provincial council of the International Council of Nurses (ICN) in 1900. In this lecture, Miss Farquharson speaks of her 'life pleasure' in instructing nurses, 'not only in the theory and practice of your profession but also in the ethics of nursing and in the etiquette that should exists between you yourselves in hospital and between your medical attendants, and you and your patients in hospital and private nursing' (Farquharson 1903, p.3). While this statement also stands as probably the first in the Australian nursing literature that hints at a recognised distinction between 'ethics' and 'etiquette' and the relationship between the 'theory' and 'practice' of ethics, nothing more is said about these topics in Farquharson's address.
Three years later, the ANJ published its first article on 'Ethics in Nursing'. The article, originally presented as an address to members of the local Branch of the ATNA, was written by Miss Edith Best (1906), Matron of the Children's Hospital, Brisbane. Its contents were in keeping with the conservative conventions of the day apropos extoling the imperatives of the 'moral or the character side of nursing' and the virtues of 'ministering women' qua nurses.
In the decades following the publication of these inaugural articles the theme of 'moral manners' and of the 'moral imperatives' of nurses upholding the virtues of the ideal 'good women' were constantly reiterated (the characteristics of a 'virtuous nurse' commonly reiterated in articles published in the journals are listed in table 1).
It is important to clarify that many of the contributions on the subject of ethics in nursing (e.g., editorials, lectures, commentaries and articles) published respectively in the ANJ and Una during this period stopped short of presenting an authentic Australian perspective or indeed the 'voice' of Australian nurses. There are two reasons for this. First, contributions by Australian nurses were at best limited, with many of the articles published being written by doctors and hospital superintendents (Lemin 1999). Second, many of the early articles appearing in the Australian journals were in fact reprints from their sister journals in other countries including the USA, Canada, the UK and New Zealand (e.g., American Nurses Journal, Pacific Coast Journal,
Canadian Nurse, Trained Nurse and Hospital Review, the Queen's Nurses Magazine, The Trained Nurse, Nursing Mirror and Midwives Journal, and Kai Tiaki) as well as from medical journals (e.g. JAMA, and the British Medical Journal) (Johnstone 2015a, 2015b; Lemin 1999).
In 1953 the Australasian Nurses Journal changed its name to the Australian Nurses Journal thus enabling it to retain its ANJ acronym. In 1976 the ANJ and Una merged to become the Australian Nursing Journal (rebadged in 2013 as the Australian Nursing and Midwifery Journal (ANMJ)), the official journal of the Australian and Nursing Midwifery Federation (formerly the RANF and ANF). In keeping with its longstanding commitment to addressing issues of relevance to the Australian nursing profession, in 2008, just over 100 years after the first article on nursing ethics was published in Una, the journal began publishing its first regular (bi-monthly) column on the subject of 'ethics in nursing'. Since debuting in the February 2008 issue of the ANJ (now the ANMJ), over 50 essays on a wide range of ethical issues relevant to Australian nurses and to the nursing profession as a whole have been published under this segment.
CODES OF ETHICS, POLICIES AND POSITION STATEMENTS
The development and ratification of the International Council of Nurses (ICN) Code of International Nursing Ethics in 1953 marked a significant turning point in the nursing ethics debate in Australia and saw the emergence of a more sophisticated level of thinking on the nature and importance of ethics in nursing. An example of this can be found in the reported comments contained in an address by Miss I S Hall MBE, given to nurses at a graduation ceremony at Sydney Hospital; she is reported to have stated:
"nurses should be encouraged to do some thinking about moral principles [...] Nurses are professional people and among essential qualities of members in a profession is a certain breadth of vision of liberty of thought" (Hall 1959, p.74).
From 1953 until the mid-1970s, the ICN Code (the latest revision of which was undertaken in 2012) emerged as a dominant focus of attention in journal articles published on nursing ethics during this period. The issues considered ranged from how to teach the Code, to how to ensure it was seen as an 'integral part of nursing practice' and not merely a printed document (ANJ 1953, pp.251-253; see also Hughes-Ford 1976; Aydelotte 1973; Lancaster 1962; Swaby 1960; Hall 1959; Haines 1957).
Despite recognising the importance of having a professional code of ethics for nurses, the Australian nursing profession was relatively slow compared to its counterparts in other countries in adopting its own national code of ethics, which did not occur until 1993. Countries that were among the first to adopt their own national codes of ethics included Liberia (1949), the USA (1950), Poland (1973), Canada (1980), the UK (1982), Ireland (1983), Norway (1983), and New Zealand (1987) (Sawyer 1989). One explanation for this is that, like the nursing profession in other countries, the Australian nursing profession had primarily relied on the ICN Code for nurses for guiding the ethical practice of nursing (Sawyer 1989). This was so even though the ICN had encouraged its ICN member states in 1977 to devise their own national codes for administration within their own respective cultural and jurisdictional boundaries (Esterhuizen 1996).
The impetus for change in Australia eventually came from two key sources: the findings and recommendations of a working party established by the Royal College of Nursing, Australia (RCNA) in 1990 (now the Australian College of Nursing); and the independent evaluation in 1990 of a list of competencies expected of the beginning registered nurse, which had been developed and endorsed by the then Australian Nurse Registering Authorities Conference (ANRAC) (Grealish 2012).
NURSING ETHICS WORKING PARTY (NEWP)
A significant although little-known initiative undertaken during the early 1990s was the establishment by the RCNA of a Nursing Ethics Working Party (NEWP) to consider the College's role in relation to nursing ethics. Operating under the acronym NEWP, the working party began to address its Terms of Reference (presented in table 2) in 1990 and presented its final report and recommendations to the RCNA Council in May 1991 (RCNA 1991). Among the recommendations made by the NEWP was that an Australian Code of Ethics be developed and that the ethics education needs of nurses be formally reviewed and addressed as a matter of priority. In making these recommendations, NEWP noted that a key obstacle to improving the ethical competencies of nurses was a 'paucity of literature and research' formally addressing key issues of concern (RCNA 1991, p.21). Issues of particular concern identified by NEWP are summarised in table 3.
Coinciding with the work of the RCNA, in 1990, an independent evaluation of the list of competencies expected of the beginning registered nurse endorsed by ANRAC indicated 'many of the practising nurses had difficulty in assessing the ethical aspects of the competencies' due in large to their 'inability to identify ethical issues in the workplace' (Kelly and Woodruff 1995, pp.93-94). These findings, together with a recommendation made by NEWP that nurses needed education and guidance on ethical decision-making in practice, convinced ANRAC a code of ethics for Australian nurses was needed (Kelly and Woodruff 1995, p.94). To this end, in 1991, ANRAC commissioned the distribution of a discussion paper on a code of ethics for Australian nurses that would complement the competency standards (Kelly and Woodruff 1995). In 1993, following a prolonged period of consultation with nurses and nursing organisations around Australia (including state and federal professional associations, industrial and regulating authorities), the final version of the Code of ethics for Australian nurses was adopted and disseminated under the auspices of the then Australian Nursing Council Inc. (ANCI), the Royal College of Nursing, Australia (RCNA), and the Australian Nursing Federation (ANF) (Australian Nursing and Midwifery Council 2002). The 1993 Code was reviewed in 2002 and again in 2008. Significantly, in response to the changing social, cultural and political environments that nurses were working in, the 2008 review resulted in a radical revision and rewriting of the Code (Nursing and Midwifery Board of Australia (NMBA 2008). The Code is, once again, under review.
It should be noted that although Australia was relatively slow to develop its own national code of ethics, Australian nurses were not bereft of guidance on ethical issues. What may not be widely known is prior to the publication of the 1993 Code of ethics for Australian Nurses, Australian nursing organisations had nonetheless been active in adopting a suite of policies and positions statements on issues that their members faced and which were perceived as not being covered by the ICN Code of ethics (Sawyer 1989). A list of the policies and position statements 'active' prior to the adoption of the Australian code is presented in table 4. Although some of these position statements have since been rendered obsolete and are no longer available, most have been and remain the subject of regular review, updating and reaffirmation (see, for example, the ANMF suite of policies and position statements available via its homepage at http://anmf.org.au/pages/ anmf-policies). In several instances, commensurate with the ongoing emergence of issues relevant to the profession and practice of nursing, entirely new policies and position statements have been adopted--some examples of which are presented in table 5.
NURSING ETHICS PEDAGOGY AND PRAXIS
Nursing ethics pedagogy and the teaching of ethics to nurses were topics rarely mentioned in the early journals. The first article on the subject titled 'Teaching ethics to probationer', published in Una in 1917, was a reprint from the US journal The Trained Nurse (The Trained Nurse 1917). Aside from an article by a French nurse in the aftermath of the second world war, in which a plea was made for nurses to be given 'a strong moral education' (Clamageran 1948), the topic of nursing ethics education received little coverage until the 1980s when 'references to the need for courses and the teaching of ethics' became more frequent (Lemin 1999, p.65).
The rise in interest in nursing ethics pedagogy in the journals during the mid-to-late 1980s is unsurprising given that the period in question coincided with the transfer of Australian nurse education from the hospital to the higher education sector (i.e., colleges of advanced education and universities). The transfer, which occurred circa 1985-1993, was enabled following the passage of legislation in August 1984 and the provision of funding from the Australian Commonwealth Government (Mason 2013). It was during this period that unprecedented attention was given to the subject of professional nursing ethics in the curricular of both undergraduate and post-graduate nursing programs and demand for 'locally grown' (as opposed to USA and UK authored) texts and references began to grow. This period also saw the first national distance education course on 'Ethics and nursing' for registered nurses being offered. Administered by the Distance Education Division of the then RCNA (which became the Australian College of Nursing in 2012 following the merger between its two predecessors, the RCNA and the NSW College of Nursing), the course was offered between 1990 and 1992 (RCNA 1992, 1990). After this period the course was discontinued due to decreasing demand as nurses took up opportunities to study ethics via the new tertiary nurse education programs which had been established following the transfer of nursing education to the higher education sector.
Another significant milestone achieved during this period was the publication of the first comprehensive text book on nursing ethics written from an Australian perspective and published by an Australian-based imprint of Harcourt Brace Jovanovich Group (Australia). The work Bioethics: a nursing perspective, first published in 1989, instantly became a bestselling nursing title and today is regarded internationally as a classic in the field (Johnstone 1989). Revised editions of the work were published respectively in 1994, 1999, 2005, and 2009. A 6th revised edition of the work was published in 2016 (Johnstone 2016), marking its 27th year of being in print. Other Australian books on nursing ethics published over the past two decades include Hawley's (1997) Ethics workbook for nurses (one print run only and now out of print), and Atkins, de Lacey and Britton's Ethics and law for Australian nurses (first published in 2011 and published as a second revised edition in 2014) (Atkins et al 2014).
NURSING ETHICS LEADERSHIP
The achievement of key milestones in operationalising nursing ethics in Australia during the 1980s and 1990s would not have been possible had it not been for the progressive initiatives lead by Australia's lead national nursing organisations, in particular the RANF/ANF (now the ANMF) and the new schools of nursing that were established following the transfer of nursing education from the hospital to the higher education sector. Notwithstanding the findings and recommendations of commissioned reports on nursing (e.g., the much touted Marles (1988) report The study of professional issues in nursing, and the Monash University, Centre for Human Bioethics (1988) report The ethical, legal and social dilemmas in nursing), it was primarily due to the efforts of Australia's peak nursing organisations and schools of nursing which, during the 1990s, saw an unprecedented number of workshops, seminars and conferences being organised specifically on the subject of ethical issues in Australian nursing (e.g., RANF 1987; ANF 1989; School of Nursing, Phillip Institute of Technology 1988, 1989, 1991). This period also saw the establishment in 1996 of the RCNA inaugural Nursing Ethics Society open to members of the RCNA (now the Australian College of Nursing). As nurse academics from around Australia pursued higher degrees and completed minor and major theses on nursing ethics-related topics, nursing ethics research and scholarship began to increase.
THE FUTURE OF AUSTRALIAN NURSING ETHICS
Australian nursing ethics has an uncertain future. Reasons for this are both complex and multifacted and include, but are not limited to: the lack of a strategic nationally cordinated agenda for progressing nursing ethics in Australia, the legacy of historical deficits in nursing ethics pedagogy and praxis (comprehensively considered in Johnstone 2015b), and the lack of a critical mass of nursing scholars with formal education and grounding in the theoretical foundations of moral philosophy and a substantive track record of peer reviewed publications on nursing ethics. While it is acknowledged that many nurses have a strong interest in and 'passion' for nursing ethics, this is not the same as--and should not be mistaken for--expertise in the discpline, as has sometimes been the case.
Arguably one of the most pressing issues facing the Australian nursing profession at this time is how best to address the deficits in nursing ethics pedagogy and praxis. Although the Australian Nursing and Midwifery Accreditation Council (ANMAC) Registerd Nurse Accreditation Standards requires teaching and learning approaches that promote 'ethical practice and leadership skills expected of registered nurses' (ANMAC 2012, Standard 2.4i) and program content that 'supports the development and application of knowledge and skills in legal and ethical issues in health care and research' (ANMAC 2012, Standard 4.4d), a cursory search of Australia's 37 university programs offering undergraduate and postgraduate nursing courses reveals significant disparities in the approaches taken to meet these standards. For example, where as some university programs have discrete subjects/units addressing 'ethical issues in health care', others have none with content being 'sprinkled' through the curriculum (in one case, anecdotally reported to be as little as four hours over the entire three year Bachelor of Nursing program). Still others have units that combine the content of law and ethics, which risks limiting the depth of inquiry that is otherwise warranted for these distinct subject areas. There is also variation in the level of offerings in a course, ranging from ethics being situated as a core subject to being offered as an elective only; offered in undergraduate, but not postgraduate courses, and vice versa; and a taking a 'generic' approach (i.e., for health care professionals generally) as opposed to a nursing-specific approach (i.e., for nurses only) to the content being taught.
Unfortunately it is beyond the scope of this present article to explore this issue in the depth that is warranted, suffice to say that unless the issue of nursing ethics pedagogy and praxis is comprehensively addressed at a national level, the moral competency of Australian nurses will stand in doubt (see also Johnstone 2015d). More worryingly, it will leave Australian nurses vulnerable to being ill-prepared for the major ethical challenges that lay ahead, such as those posed by antimicrobial resistance (Johnstone, in press), climate change, peak oil, pandemic-influenza, and the potentially catastrophic health inequalities associated with these things (Johnstone 2016). Ultimately, the professional ethics of Australian nurses--and what they 'can do, actually do, and ought to do'--will rest on whether and what response Australia's national nursing organisations responsible for setting the agreed ethical standards of the profession will give to this issue.
Nursing ethics in Australia, as in other countries, stands as an 'enduring and intimate concern of the profession' (Fowler 2010, p.31). Despite the operationalisation of Australian nursing ethics having a slow start, an Australian perspective on nursing ethics has gained a noticeable presence in the international arena with Australian nursing scholars making a significant contribution to the field. A notable example of this can be found in the Sage major reference work titled Nursing ethics (three volumes) curated by Johnstone (2015a, 2015b, 2015c). This work, which spans 127 years and encompasses more than 1,000 pages of pioneering articles on nursing ethics, has the distinction of being the first of its kind in the world (ANMJ 2015).
The Australian nursing profession is committed to achieving the ever expanding moral goals of the profession and practice of nursing. There is, however, room for improvement in regard to the development and practice of nursing ethics in Australia. To this end, the advancement of nursing ethics in Australia warrants being situated as a strategic priority--in education, research, scholarship and practice. Meanwhile, it would be both timely and instructive for a robust program of collaborative, comparative international and interdisciplinary nursing ethics scholarship, research and critique to be progressed. This would help to ensure that the nursing profession in Australia is appropriately positioned to not only meet the moral challenges that it will face in the future, but also contribute to global discourses on how best to meet these challenges.
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Megan-Jane Johnstone PhD, BA, RN, FACN, Professor of Nursing School of Nursing and Midwifery Deakin University 221 Burwood Highway, Burwood, Victoria, Australia email@example.com
Table 1: Characteristics of the 'virtuous nurse'. * Characteristics of the 'virtuous nurse' absolute loyalty gentleness prudence (to doctors/ hospitals) absolute obedience good fellowship quietness (to doctors/ (with fellow hospitals) nurses) abstinence (from good manners refinement drugs, alcohol and sex) altruism good temper respectful (of authority) bravery good will secrecy charity grace self-command chastity healthfulness self-control cheerfulness helpfulness self-reliance cleanliness honesty self-respect (morally and physically) common sense honour self-restraint compliance hopefulness self-sacrifice (with authority) conscientiousness ideal womanliness silence (particularly 'controlled tongues') compassion kindness (in spirit of service word, deed to humanity and manner) courtesy love (of patients) strength (of body, mind, character) culture loyalty (to submission (education) doctors/hospital) discretion ministering sympathy discipline nobility of tact character empathy obedience trustworthiness endurance patience unselfishness (physical and mental) fidelity perseverance versatility forbearance pleasing and willingness attractive (to serve, to manner(s) obey, to oblige) gentle demeanour pitiful womanliness * Source: Johnstone (1993). Reprinted with permission. Table 2: RCNA Nursing Ethics Working Party (NEWP) Terms of Reference To make recommendations to Council regarding: * mechanisms through which the collective experience of nursing can be gathered, recorded and shared * mechanisms through which policy decisions can be monitored and reviewed for their implications for nurses and nursing practice * structures through which individuals, groups or the profession as a whole can consult on ethical issues * ways in which the professional stance of nurses on ethical issues can be enunciated and communicated to the public * ways to improve nurses' knowledge in ethical issues and skill in ethical discussion and decision making (RCNA 1991). Table 3: Key issues identified by the RCNA Nursing Ethics Working Party 1991 * The nurse's ability to act as an effective ethical negotiator, mediator, and decision-maker * The ethical and legal content of nursing curricula across Australia * The adequacy and appropriateness of courses (both nursing and non-nursing) designed to improve nurses' ethical and/or legal knowledge and decision making skills * The awareness of nurses reading the ethical and legal dimensions and implications of nursing practice (RCNA 1991). Table 4: Examples of ANMF nursing organisations' policies and position statements adopted or endorsed pre-1993 Australian Code of ethics * * Biomedical research involving human subjects (1984) * Children's rights (1986) * Detainees and prisoners (1986) * Disabled persons (1986) * Dying - Assuring quality of care for those who are dying (1986) * Family planning (1986) * Female circumcision (1983) * Health care and quality of life (1986) * Health hazards (1986) * HIV/AIDS and the nursing profession (1987) * Human rights (1983) * International nursing migration (1986) * Nuclear disarmament (1983) * Nuclear war (1986) * Nursing care of the elderly (1984) * Nursing research (1986) * Patient rights (1984) * Policy making and planning (role of the nurse in)(1983) * Refugees and displaced persons (1984) * Safe-guarding the human environment (1986) * Source: ANF (1989) Index to policy and position statements 25 March, 1988. In Ethics: Nursing perspectives, Volume 2 (pp.84-86). North Fitzroy, VIC: ANF. Table 5: Policy and position statements endorsed by ANMF since 1994 * Policies * Conscientious objection (E: 1994; R&R: 1996, 2004, 2007, 2011) * Privacy (E: 2014) * Whistleblowing (E: 2004; R&R: 2007, 2011, 2014) Position statements * Child abuse and neglect (E: 2007; R&R: 2010, 2013) * Climate change (E: 2011) * Organ and tissue donation for transplantation (E: 1994; R&R: 1996, 2005, 2008, 2011) * Voluntary euthanasia/assisted suicide (E: 2007; R&R 2009, 2012) * E- Endorsed * R&R - Reviewed and Re-endorsed
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