Legality, morality and reality ‑ the role of the nurse in maintaining standards of care

Abstract

Objective: This paper explores the legal and ethical frameworks that inform nursing practice and health care cultures. Using methodologies informed by critical race and feminist jurisprudence (also called ‘outsider scholarship’), images of nursing and the positive and negative effects of these images and their legal, moral and ethical impact on nursing practice, are explored. This exploration assists in exposing some of the power structures and assumptions which govern contemporary nursing practice and standards of care and which impact on factors such as workforce retention. Legality, morality and reality ‑ the role of the nurse in maintaining standards of care.

Setting: Applies to all settings in which nurses’ practise.

Subjects: Nurses, other health care professionals and patients.

Primary argument: Examples from case law are used to illustrate the relationship between image and power and how these affect legal and moral frameworks and the realities of the workplace for nurses. This is done by examining the law, as a form of insider (whereby the world is described in terms of pre‑existing power structures) and outsider story‑telling (whereby stories are challenged to reflect experiences). Five dominant and recurrent images of nursing emerge from case law analysis. These have implications for: the way in which nurses respond to critical situations which involve the adoption of a moral stance; nurses’ legal and ethical status, and; the environment in which nurses’ practise.

Conclusion: Each of the images of nurses described in this paper is still present in both recent case law and workplace practice. These images have deleterious effects, most particularly contributing to feelings of powerlessness in the workplace and affecting nurses’ ability to be ‘heard’ when patient safety is at stake. While some images give the nurse a degree of moral (and clinical) responsibility, there is no promise of power. Both the inability to influence patient care and an unmet need to feel valued and appreciated contribute to nursing workforce attrition. A complex mix of solutions needs to be implemented to achieve improved workplaces, patient outcomes and retention rates. The promotion of a safety and quality agenda; promoting strategies for self care; well developed clinical career paths; implementing clinical supervision, and introducing Magnet organisation reform, are among the important solutions for addressing these issues.