Professional nursing has emerged from a rich and multi- faceted history which predates the Nightingale era and has its roots in the USA, Canada, Australia and Europe. The influence of ‘vowed’ or religious women has, according to Nelson, been trivialized and even ignored in contempo- rary historical representations of our professional heri- tage.1 Nightingale, however, drew inspiration from those women who did much more than merely set the scene for ‘real’ nursing: she cherished the vocational notion of nursing and feared that professional registration would

erode the public perception of nurses as following a voca- tion or calling.2 This legacy in relation to the notion of nursing as a vocation or a ‘calling’ has been a powerful influence on the development of the profession. The attributes required by the ‘Nightingale’ nurse were articu- lated in the Nightingale Pledge3 and include Godliness, purity, faithfulness, loyalty and a commitment to ‘aid the physician’. Other essential attributes emerging from the early ethics literature were obedience, stoicism, endur- ance, servility, modesty and humility.4–6

According to Fowler, the sense of ‘calling’ lasted into the 1950s in the USA and thereafter began to take a back seat in the drive towards professionalism.7 In Europe, however, the perception of nursing as a vocation lasted beyond this.2 Way’s book Ethics for Nurses is a classic example of the literature portraying nurses as following a code of etiquette rather that ethics.6 This book was

Correspondence: Ann M. Begley, Queen’s University, School of Nursing and Midwifery, 50 Elmwood Avenue, Belfast BT9 6AZ, UK. Email: [email protected]

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doi:10.1111/j.1440-172X.2010.01878.x © 2010 Blackwell Publishing Asia Pty Ltd

reprinted for the last time in 19712 suggesting that this perception of the attributes required by a ‘good’ nurse lasted in the UK until at least the early 1980s.

In this paper, it is suggested that the virtues, or attributes, required by the modern nurse can be catego- rized into three themes, Intellectual and Practical Attributes, Dispositional Attributes and Moral Attributes (Fig. 1a). In addition to this, the thematic professional virtues have been distilled into four core attributes and

presented in a simple framework for good professional conduct (Fig. 1b). The ‘Four As’, Advocacy, Assertive- ness, Accountability and Autonomy, are identified as the linchpins of good conduct. They do not stand alone however, and they depend on the presence of other essen- tial virtues listed in the themes presented. These are grounded in an Aristotelian approach to ethics in which ‘virtue’ arete means excellence of character or intellect. Virtues can therefore be such attributes as friendliness,

Figure 1. (a) Thematic presentation of pro-

fessional attributes/virtues, and (b) simple

framework for professional conduct, the Four

As.

Intellectual/practical Dispositional Moral

Attributes (virtues – excellences)

Theoretical and

(a)

(b)

practical wisdom (Aristotelian)

Competence

Art/skill

Scientific knowledge

Intuition Imagination

Cleverness

Discernment

Judgement

Tolerance

Sensitivity

Courtesy

Approachability

Diligence

Empathy

Kindness

Benevolence

Compassion

Genuineness

Patience

Courage (moral)

Integrity

Justice

Fairness

Honesty

Veracity

Fidelity

Integrity

Trustworthiness

Advocacy

Autonomy

Accountability Assertiveness

Four As

Themes

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wittiness and not necessarily the concepts which we expect to fall under the umbrella of the virtues. It is suggested that in relation to the evolving concept of the ‘good’ nurse, the attributes presented in (Fig. 1b) have become essential hallmarks of good character.

The objectives of the paper are threefold:

• To reflect on the historical notion of the ‘good’ nurse and the associated virtues

• To consider how this understanding of the ‘good’ nurse has changed and how this change is reflected in modern codes of conduct

• To build a thematic table of virtues required by the ‘good nurse’ today and to extrapolate from this table of virtues a framework for good moral practice with four core attributes

Reflecting on the past If we are to fully appreciate the shift in perception in relation to the notion of a ‘good’ nurse there is a need to reflect on how things were, on how professional conduct, ideals and approaches to ethics have evolved over the years. The development of the subject in nursing has made considerable progress particularly in the past 20 years.

Way suggested that ‘matters of moral value fade imperceptibly into matters of etiquette. . . .’6 There is, however, a significant conceptual difference between etiquette, particularly that which is rooted in respect for superiors, and ethics. One of the reasons for nurses’ arrested development as autonomous moral agents has been the blurring of this distinction, and in the past the education of nurses in relation to ethics often focused on how to dress and show respect (etiquette) rather than consider the moral perspectives of practice (ethics). This, however, does not imply that all nurses were weak willed and unable to think for themselves. But in reality, the culture was one which did not encourage or support asser- tiveness or challenges to authority figures.

Towards professional ethics Practitioners might reject the notion of the ‘good’ nurse as an outdated concept, but in this paper the word ‘good’ is used within the context of Aristotelian ethics. Anything ‘good’ performs its function well.8,9 Good nurses there- fore perform their functions well and they maintain high standards in all areas of practice and governance. Being good and behaving well depend on the state of character and in order to perform well certain virtues or attributes (alternatively, qualities, character traits or dispositions)

are required. Historically, from the time of Aristotle, many virtues, or attributes have been considered neces- sary for living well in general. Lists of attributes have emerged from various sources, Greek ethics,10

Buddhism,11 Confucian,12 Maori,13 Christian.14,15 Modern secular approaches include Blackburn,16 MacIntyre17 and nurse ethicists.9,18–25 In this paper, relevant attributes arising from these sources have been brought together and arranged in themes, or categories of virtues considered to be necessary for meeting the standards required of a ‘good’ nurse.

The literature on the virtues of nurses in the past reflects an acceptance that nurses should nurture the attributes historically accepted as characteristic of women. Aristotle, for example, suggested that women’s virtues are different from men’s.26 (Neo-Aristotelians reject such views). Also, in more recent times, Rous- seau’s novel Emile reflects the distinction made between male and female virtues. Female traits were considered to be gentleness, tenderness, beneficence, compassion, nurturing, self-sacrifice, intuitiveness, mental passivity and physical and emotional dependence.26,27

Historically, literature relating to nursing ethics indi- cates that the virtues of the nurse included such traits as respect for authority (particularly of medicine), being faithful to duty, being tactful, cultivating a meek and mild disposition, loyalty and cleanliness.4–6 Sympathy, compas- sion, or any emotional involvement with a patient was not encouraged and was portrayed by Way6 as a fault, or weakness of character in the nurse. The reluctance to ‘report’ another nurse or challenge unsafe practice also comes across in the early literature.4–6 Other essential attributes emerging from the early ethics literature were obedience, stoicism, endurance, servility, modesty, humility and loyalty.2–6

Codes and standards: being a good person and being a good nurse

Good nurses do need certain virtues, or attributes, but these are not necessarily lofty, spiritual, or supported by any traditional notion of ‘vocation’ or calling. There has been a shift in the perception of the virtues required by the good nurse and the notion of virtue itself has changed to the extent that it now reflects a classical Greek notion of a virtue as an ‘excellence’ of character or intelligence. This is reflected in Provision 6.1 of the American Nurses Association (ANA) code of ethics:

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Virtues are habits of character that predispose persons to meet their moral obligations, that is, to do what is right.28

As nursing continues to evolve from vocational subservi- ence to a modern profession, so does the perception of what it means to be a ‘good’ nurse.

The practitioner today is expected to question and col- laborate with other professionals rather than obey instruc- tions. Patients are partners in care: we respect their autonomy and are sensitive to their needs when vulner- able and distressed. Most importantly, we are accountable for our actions and we are charged with the responsibility to protect the patient from the mistakes and negligence of others. The nurse today is expected to practice from a sound knowledge base and to be sufficiently confident to challenge questionable practice. This is in stark contrast to the expectations of the nurse in the not too distant past. Modern codes of ethics and standards of conduct reflect a very different understanding of the characteristics expected of the ‘good’ nurse. In relation to these points, modern codes of ethics clearly demonstrate a shift in expectations.

In the UK, for example, the Nursing and Midwifery Council29 expects nurses to make the care of people their first concern, to be personally accountable for their actions and omissions in practice, to challenge unsafe practice, cooperate with colleagues and keep up-to-date. The ANA’s code of ethics28 expects that the nurse is primarily committed to the patient, takes on the role of advocacy, maintains competence and a knowledge base and has a concern for the welfare of colleagues. Simi- larly, the Australian Nursing and Midwifery Council30

highlights these attributes and charges the nurse with upholding certain values and standards. The nurse should: show respect and kindness towards clients, report nursing care that is potentially unethical, illegal, unsafe or incompetent and ensure that decision making is based on contemporary relevant and well-founded knowledge and information.

The International Council of Nurses Code31 reflects the above expectations. Notions of accountability, advocacy assertiveness and autonomy are required if the nurse is to uphold and practice according to the standards expected of them by the international community of nurses. These codes together outline clearly the standards which should be achieved and the desirable professional characteristics. Nurses consider a code of conduct to be an essential com- ponent in protecting the vulnerable and ensuring good

behaviour in practice. Modern codes reflect an expecta- tion that nurses will have the intellectual capacity to prac- tice effectively and to advance the knowledge base of the discipline. There is also evidence of concern in relation to how we respect and value each other: the importance of kindness and rejection of bullying and harassment of colleagues are clearly articulated.

The Nursing and Midwifery Council32 maintains that health-care professionals’ characters must be ‘sufficiently good’ to be capable of safe and effective practice without supervision. This indicates clearly that the focus is shift- ing from a rule-based to a more virtue (or character) based approach to professional conduct. More emphasis is being placed on the character of the agent as a signifi- cant factor in ensuring that we have professionals who will act with integrity. The ANA states that in order to be a good person one requires wisdom, honesty and courage and that in order to be a good nurse compas- sion, patience and skills are needed.28 Florence Nightin- gale believed that to be a good nurse one must first be a good person33 and the good nurse, therefore needs all of these attributes. The good person is more than a rule follower34 and the individual needs to consider what sort of person he or she ought to be rather than simply what he or she ought to do, such as follow rules and principles.35,36

The main issue to be addressed, then, is to identify what it is that constitutes sufficiently good character and what virtues or attributes are essential for good conduct?

The good nurse today: suggested attributes

Referring to the attributes of a good nurse de Raeve21

noted that this was relatively unexplored territory, although there now seems to be a growing interest in the subject. It is also clear that codes of ethics and conduct are more virtue based, focusing more on the characteristics of good practice and the character of the agents than on simple rules and imperatives. In the existing literature on the subject, candidates for consideration as virtues (attributes, character traits in nursing) have been sug- gested by various authors.9,18–25

Themes It is suggested here that the virtues or attributes required so as to exemplify excellence of character can be catego- rized into the following themes:

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• An Intellectual and Practical Theme (with attributes such as Aristotelian theoretical and practical wisdom and the ability to integrate theory with practice)

• A Dispositional Theme (with attributes such as compassion, courtesy, empathy approachability and kindness)

• A Moral Theme (with attributes such as justice, moral courage and veracity). The virtues listed within these themes are inspired by

Aristotle’s account of the virtues or attributes required to live a good life and are congruent with those virtues cited by modern codes of conduct. Some of them might not fit neatly with the modern conception of ‘virtue’ but they are presented here as attributes of character in an Aristotelian conception of virtue—arete, or excellences of character. When we think of virtue as being an ‘excellence of char- acter’ and as something which permeates the whole of life, then it makes sense to include such virtues or attributes as cleverness, courtesy and patience. After all, nurses who are incompetent, or lacking in the ability to deliberate and make wise decisions, can have a very negative impact on the progress of people in their care.9 Similarly, grumpy or rude nurses will not be approachable and it would be impossible to nurture a therapeutic relationship (with the patient) successful mentorship (with the student) or effective inter professional collaboration with such a character.

The ‘good’ nurse requires a synthesis of science and sensitivity. Excellence cannot be achieved without a balance between the Intellectual, Practical, Dispositional and Moral attributes. The intellectual and practical attributes are presented as one theme because it is not possible to be competent without the capacity to acquire theoretical knowledge and apply it appropriately (practi- cal wisdom) to practice.

Although many virtues which reflect a vocational approach to nursing have been rejected by the modern profession, some of the attributes such as courtesy, dili- gence and fidelity which were valued by nurses in the past have been included in these themes. There has been a shift from the servile ‘nun-ish’ virtues often associated with a religious vocation and evident in the ‘Nightingale Pledge’ but some of these virtues continue to be important today and, although ‘sanctimonious’ in nature, it is argued here that they are not incompatible with professional practice. In addition to this, such intellectual attributes as imagina- tion and intuition are essential if the nurse is to be capable of empathy, insight into complex contexts and emotions and ultimately, advocacy.

Learning from the past and preparing for the future

Attributes that were not encouraged in the past (such as having the courage to challenge unsafe practice) are now considered to be professional virtues and conversely, many of the virtues extolled up until the 1950s and into the 1960s and 1970s in the UK are now considered to denote weakness in character. It is clear that certain attributes required by the modern conception of ‘good’ nurse were missing, even actively discouraged. For example, a nurse who questioned the accuracy of a pre- scription, or had the courage to put the patient safety before deference and obedience was likely to be consid- ered a trouble maker, not a ‘good nurse’. On the other hand, today’s good nurse is assertive, having the courage to raise concerns in the interest of patient safety, although failing to do this would be considered unsafe practice.

The ‘good nurse’ was not encouraged to cultivate the following attributes (virtues), and these can be referred to as the ‘Four As’, or Attributes that are essential for caring and good professional conduct (Fig. 1b). These are highlighted in today’s codes of ethics and conduct, and in exercising these virtues professional nurses draw on those virtues listed in the themes presented (Fig. 1a).

Advocacy and the necessary virtues associated with it This was clearly not part of the moral repertoire of the profession in the past. Successful advocacy requires compassion, courage and a commitment to caring for and empowering clients and colleagues. Advocacy is most often associated with the nurse–client relationship, but it is also important in our relationships with colleagues. Nurses have a duty of care towards colleagues and the abuse of power, bullying and harassment are to be chal- lenged robustly.30 Advocacy also requires intuitive skills and a capacity for empathy.

Accountability and the necessary virtues associated with it

Lacking in the literature from the past is the notion that as professionals we are responsible for our actions and the outcomes of these actions. We can not simply obey orders or ignore failures in governance in practice, research and management. In addition to clinical competence and skills the practitioner requires the intellectual virtues of practi- cal and theoretical wisdom, integrity, honesty, trustwor- thiness, veracity and moral courage.

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Assertiveness and the necessary virtues associated with it

All of the above require assertiveness and this in turn depends on moral courage and good interpersonal skills such as those listed in Dispositional Attributes, or virtues. Assertiveness requires, for instance, courtesy and patience, otherwise it becomes another concept— aggression, which is completely counterproductive in pro- fessional relationships.

Autonomy (professional) and the necessary virtues associated with it

This is more often discussed in relation to patient autonomy, but here the emphasis is on the morally autonomous practitioner. The nurse requires discern- ment, judgement and wisdom (practical and theoretical) culminating in the ability to make wise choices. This more than the other attributes represents the shift from an obe- dience model of the past and is presented here in a central and supporting role to the other professional attributes. Being morally autonomous does not mean that the nurse acts alone, or fails to collaborate. The ANA code28 states that:

Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal. In health care, that goal is to address the health needs of the patient and the public. . . . by its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared discussion-making about patient care, and open dialogue among all parties who have an interest and a concern for health outcomes.(Provision 2.3)

Ultimately, however, the decision rests with the indi- vidual nurse and accountability, advocacy and assertiveness depend on the professional being an autonomous agent. The nurse cannot compromise his or her integrity in def- erence to colleagues or other professionals. This is sup- ported by the ANA in relation to acting on questionable practice:

The nurse’s primary commitment is to the health, wellbeing, and safety of the patient across the lifespan and all settings in which health care needs are addressed. As an advocate for the patient, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or

health care system or any action on the part of others that places the rights or best interests of the patient in jeopardy.(Provision 3.5)

The professional nurse has therefore emerged as an autonomous moral agent who engages and collaborates with other health-care professionals and clients: advocacy and assertiveness have replaced the deference, sometimes blind obedience, and misplaced loyalty evident in the past.

CONCLUSION The conception of the good nurse has evolved and there has been a shift from etiquette to ethics, from obe- dience to moral autonomy, assertiveness accountability and advocacy. These attributes (qualities or virtues) are grounded in Aristotle’s approach to ethics9,18,20 and devel- oped through considering those attributes cited in profes- sional codes28–31 and other professional accounts.

Within the context of modern professional nursing one of the most attractive elements of an Aristotelian approach to ethics is the emphasis on practice: ethics is something that we do—we do not learn the theory and then put it away in a file.37 Acquiring excellence of moral character and intellect is, as Carper’s work38 highlighted, about influencing hearts as well as minds, and it requires a dynamic and sensitive approach which goes beyond that which is needed for pure theoretical knowledge. Profes- sional ethics is grounded in every day practice and nur- tured by exemplary practitioners and clinical teachers.

In Aristotle’s conception of ethics, the moral life requires a balance of intellectual and moral excellences, or attributes, and it maps out progression from novice to expert.20,39 The nurse is an autonomous moral practitio- ner who collaborates and is assertive, operates in partner- ship with patients and acts as advocate when they are unable to speak for themselves. The nurse is accountable, takes responsibility and is not subservient. The Nursing and Midwifery Council29 indicates clearly that good char- acter is essential for registered practitioners and for entry to and continuation on pre-registration programmes23 and there is now, in modern codes, more emphasis on articu- lating the qualities required for ‘good character’.

Having reviewed historical and modern accounts of ‘good character’ and the values that they are expected to uphold, it seems that de Raeve’s21 concern that this is relatively unexplored territory is true. High value is placed on the attributes that a nurse might bring to

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nursing by virtue of the persons they are, and identifying the nature of the ‘good nurse’ requires more investiga- tion.40 There will be readers who will suggest that other attributes should be included in the lists cited, or indeed that some of those listed should not be included. There will be others who will challenge the portrayal of the ‘Nightingale nurse’, and there is indeed evidence that Nightingale herself did not promote, for example, the mindless obedience found in later literature.41 There is much room for debate here, and it would be difficult to present a list to satisfy all nurses, particularly when we consider the many different roles within this discipline. The ‘Four As’ Framework, drawn from the thematic table of attributes (Fig. 1a,b) represent an attempt to move closer to identifying the attributes, which, in the context of modern professional practice, exemplify the ‘good’ nurse and indicate the paradigmatic shift in professional ethics from the obedience model to a dynamic profes- sional model of ‘good’ nursing.

ACKNOWLEDGEMENTS My colleagues Daphne Martin and Richard Henry for their helpful comments on earlier versions of this paper.

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