9
Caring and curing revisited: student nurses’ perceptions of nurses’ and physicians’ ethical stances Ron Joudrey BA MA Professor of Sociology and Jim Gough AOCA BA MA PhD Department of Humanities and Social Sciences, Red Deer College, Alberta, Canada Accepted for publication 28 May 1998 JOUDREY JOUDREY R. & GOUGH GOUGH J. (1999) J. (1999) Journal of Advanced Nursing 29(5), 1154–1162 Caring and curing revisited: student nurses’ perceptions of nurses’ and physicians’ ethical stances As a result of a research study involving nursing students, we have discovered some interesting patterns in the way that nursing students perceive physicians’ ethical stances in comparison to their perceptions of their own profession’s ethical stances. Some of the findings of this study confirm what writers in the literature have pointed out regarding how the nursing profession defines and perceives itself with reference to the medical profession. As a result of our findings, it may be useful for nursing programmes to revise and re-think the ethics of their profession vis-a `-vis that of doctors. Keywords: caring, curing, professional, ethos, meta-ethics, practical ethics, social comparison, convenience sample, content analysis, holistic, physicians, nurses INTRODUCTION Nursing programmes are now paying more attention to ethical issues within their curriculum and in doing so they may compare their professional standards with those of the medical profession. The purpose of this paper is: (a) to identify how nursing students conceptually compare the ethical values of their profession to their perception of the ethical values of the medical profession, and (b) to suggest some possible implications for the ethical component of a nursing curriculum. BACKGROUND It is an understatement to say that the field of nursing has been undergoing tremendous change in the last few decades. Discussion of these changes can be found in the nursing literature, especially in the increasing number of professional nursing journals. New work roles for nurses, educational and curriculum innovations, an in- creasing concern with ethics, the relevance of gender, and the new relationship between nursing and physicians are some of the major topics examined in this literature. Textbooks in medical sociology (medical ethics) also increasingly examine some of these same nursing issues, albeit from a somewhat different slant. Sociologists, such as Clarke (1990) and others, analyse some of these changes as part of a more general trend – the striving of nursing to achieve professional status. Although one of the authors has experience teaching nursing students a course in the philosophy of health care, the other has extensive experience teaching a course to these same students in the sociology of medicine. This combined experience, which led to discussions of our mutual concerns for the potentially confused perceptions of nursing students about professional ethics, produced the motivation for this joint research project. The project was conducted independently of any formal connection with Correspondence: Jim Gough, Department of Humanities and Social Sciences, Red Deer College, Box 5005, Red Deer, Alberta T4N 5H5, Canada. Journal of Advanced Nursing, 1999, 29(5), 1154–1162 Philosophical and ethical issues 1154 Ó 1999 Blackwell Science Ltd

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Page 1: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

Caring and curing revisited: student nurses'perceptions of nurses' and physicians'ethical stances

Ron Joudrey BA MA

Professor of Sociology

and Jim Gough AOCA BA MA PhD

Department of Humanities and Social Sciences, Red Deer College,

Alberta, Canada

Accepted for publication 28 May 1998

JOUDREYJOUDREY RR. && GOUGHGOUGH J. (1999)J. (1999) Journal of Advanced Nursing 29(5), 1154±1162

Caring and curing revisited: student nurses' perceptions of nurses'

and physicians' ethical stances

As a result of a research study involving nursing students, we have discovered

some interesting patterns in the way that nursing students perceive physicians'

ethical stances in comparison to their perceptions of their own profession's

ethical stances. Some of the ®ndings of this study con®rm what writers in the

literature have pointed out regarding how the nursing profession de®nes and

perceives itself with reference to the medical profession. As a result of our

®ndings, it may be useful for nursing programmes to revise and re-think the

ethics of their profession vis-aÁ-vis that of doctors.

Keywords: caring, curing, professional, ethos, meta-ethics, practical ethics, social

comparison, convenience sample, content analysis, holistic, physicians, nurses

INTRODUCTION

Nursing programmes are now paying more attention to

ethical issues within their curriculum and in doing so

they may compare their professional standards with those

of the medical profession. The purpose of this paper is: (a)

to identify how nursing students conceptually compare

the ethical values of their profession to their perception of

the ethical values of the medical profession, and (b)

to suggest some possible implications for the ethical

component of a nursing curriculum.

BACKGROUND

It is an understatement to say that the ®eld of nursing has

been undergoing tremendous change in the last few

decades. Discussion of these changes can be found in

the nursing literature, especially in the increasing number

of professional nursing journals. New work roles for

nurses, educational and curriculum innovations, an in-

creasing concern with ethics, the relevance of gender, and

the new relationship between nursing and physicians are

some of the major topics examined in this literature.

Textbooks in medical sociology (medical ethics) also

increasingly examine some of these same nursing issues,

albeit from a somewhat different slant. Sociologists, such

as Clarke (1990) and others, analyse some of these changes

as part of a more general trend ± the striving of nursing to

achieve professional status.

Although one of the authors has experience teaching

nursing students a course in the philosophy of health care,

the other has extensive experience teaching a course to

these same students in the sociology of medicine. This

combined experience, which led to discussions of our

mutual concerns for the potentially confused perceptions

of nursing students about professional ethics, produced the

motivation for this joint research project. The project was

conducted independently of any formal connection with

Correspondence: Jim Gough, Department of Humanities

and Social Sciences, Red Deer College, Box 5005, Red Deer,

Alberta T4N 5H5, Canada.

Journal of Advanced Nursing, 1999, 29(5), 1154±1162 Philosophical and ethical issues

1154 Ó 1999 Blackwell Science Ltd

Page 2: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

the nursing programme. Because we both have taught

service courses to nursing students while having no formal

connection to the nursing programme, we believe this has

provided us with a unique opportunity to investigate the

source of these students' ethical perceptions. The ultimate

goal was pedagogical, so that we could each re-focus our

course content on a better understanding of the beliefs and

attitudes of nursing students regarding their profession.

LITERATURE REVIEW

In 1970, sociologist Eliot Freidson published his seminal

work on the medical profession in which he argues that

nursing cannot be considered a profession in the same

sense as medicine. This occurred largely because nurses do

not have the same amount of (or capacity for) autonomy (in

the sense of control over their work) as do doctors. The

relationship between the two occupations is asymmetrical,

in that `one gives orders to all and takes orders from none,

while the others gives orders to some and takes orders from

others' (Freidson 1970 p. 70). In research conducted by

Isolde Daiski, `Nurses complain that they are viewed as

idealized ``Florence Nightingales'', sel¯essly dedicated,

who do as they are told±not as the real people they are,

breadwinners and professionals who deserve respect. Yet,

they think they should put themselves last. This image is at

least in part accepted and reinforced by nurses themselves'

(Daiski 1996 p. 28). The voluminous attention given by

nurses to achieving recognition as a fully-¯edged profes-

sion since Freidson's work can be partly viewed as a

rebellion against subordinate status vis-aÁ-vis physicians.

Even before Freidson's work, there was some attention

given in the nursing literature to the issue of whether or not

nursing was a profession (Jahoda 1961, Spalding & Notter

1965). The tendency in these earlier inquiries, however,

was to accept the medical profession as a reference group

that nurses (nursing) should try to emulate. For example,

one of the classic works on professional nursing by

Spalding and Notter (which went through seven editions)

uncritically accepts the criteria used to de®ne medicine as a

profession and then asks the question `How well does

nursing measure up to these various criteria?' (Spalding &

Notter 1965 pp. 50±51). In contrast, many of the more recent

writers stress the differences between the two occupations

(Clarke 1990, Kerr & McPhail 1991, Kyle 1995), often

repudiating some of the traits associated with the medical

profession and (among some nursing writers at least) trying

to ®nd some essential characterization that normatively

de®nes an ethos for nursing as a profession separate from

medicine (e.g. Watson 1985).

Professionalization and identity

Nurses have looked to the area of ethics to ®nd their

distinctive identity. For some time now sociologists

studying occupations have regarded ethics, speci®cally

those pertaining to a service occupation, as one of the

major characteristics separating a profession from other

occupations (Goode 1960). In the case of nursing, the

content of their ethics is used to de®ne their ®eld in

relation to medicine. There are at least three different,

common senses of `ethics' captured in this discussion: (a)

ethos, a shared attitude, ideal or ideology; (b) meta-ethics,

values which underpin and form the transition from or to

the ethos, the adjudication and standards used in making

actual ethical decisions: and (c) applied/practical ethics,

where the actual content of ethical problems, issues,

choices and decisions that results in actions occurs. The

hermeneutical relation can operate in either direction

from (a) to (c) or from (c) to (a). Often the development of

professional ethics operates from (c) to (a) as in the case

suggested here, Jean Watson, in her 1979 treatise entitled

Nursing: The Philosophy and Science of Caring, is

essentially given credit for articulating the major ethical

stance of nursing. Hence, meta-ethical and ethos devel-

opments emerge from content considerations of applied or

practical ethics. In Watson's words: `The term carative is

used in contrast to the more common term curative to help

the student differentiate nursing and medicine' (Watson

1985 p. 7).

Although Watson does not explicitly use the term

`ethics' when discussing caring, she does talk about how

a major dimension of nursing involves the `formation of a

humanistic-alternative value system' (Watson 1985 p. 10).

Other writers since Watson (Leininger 1984, Fry 1989,

Kerr & MacPhail 1991, McAlpine 1996) have explicitly

regarded caring as the ethical ideal (ethos) for nurses and

have sought to re®ne and expand upon the concept.

Recent writers such as Kyle (1995) and Warelow (1996)

have begun to take a more critical approach to the ethical

ideal of nursing.

As Allmark (1995 p. 379) pointed out, nursing's concern

with ethics is not new but in the last 20 years there has

been a resurgence of attention to ethics, particularly in the

nursing curriculum. Others, such as Fry (1989) and

McAlpine (1996), also pinpointed the last two decades

as the period heralding the return to more research and

interest in nursing ethics. Given nursing's drive towards

professionalization, it is hardly surprising that nursing

schools have been emphasizing the teaching of ethics to

nursing students. Sociologists and others studying profes-

sional socialization have long pointed out that this process

involves teaching not only the skills needed but also the

`proper' values and attitudes (translate ethos ethics)

(Moore 1969, Cohen 1981). As Du Toit (1995 p. 165)

states: `The novice enters the school with a set of values,

which may change during the socialization process to

re¯ect the values the profession holds in high esteem'.

The importance of ethical values is further underscored

by Quinn and Smith (1987 p. 3) who argued that this

Philosophical and ethical issues Ethical stances

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162 1155

Page 3: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

dimension may be critical for in¯uencing `the esteem in

which members of a profession are held by the public'.

Indeed, as Michael Bayles pointed out, this is a general

problem since public `criticism has become widespread

and is directed at almost all professions' and `recent

criticism re¯ects the development of consumerism', trans-

lated as `a new emphasis on consumer rights' (Bayles 1981

p. 4). Medical sociologists have been studying profession-

al socialization for some time now, although earlier

studies focused on socialization of medical students

(Merton et al. 1957, Becker et al. 1961). Since this early

research, there has been more emphasis on the profes-

sional socialization of student nurses (Psathas 1968,

Simpson 1979, Cohen 1981, Du Toit 1995). It is our

conjecture that when an occupation seeks to acquire a

professional identity its members will partly do so by

comparing themselves to more established professions.

Just as individuals use what social psychologists call

`social comparison' (Festinger 1954) to construct a sense of

individual identity, it is likely that this social comparison

will be used in a more collective sense by occupational

groups such as nurses. As Goethals and Darly (1987) have

pointed out, it is more likely that the social comparison

process will be used the more similar the persons are to

those doing the comparison. Despite historical differences

in status and level of education, there are enough simi-

larities between nurses and doctors to warrant nurses

using doctors as a reference point for their sense of

professional identity. This should not be surprising since

nurses work side-by-side with doctors on a daily basis in

hospital and other clinical settings. One comparison point

might be the area of ethical values (construed broadly as

including ethos, meta-ethics and applied ethics). It is to

this subject that we now turn.

THE STUDY: METHODOLOGY

In this study, we set out to investigate how student nurses

construct ethical values pertaining to their professional

®eld. We were interested in how these students learn or

acquire ethical values, what they perceive nursing ethics

to mean, and whether they view the teaching of ethics in

their programme as effective. As part of this larger study,

we also examined the question of how nursing students'

perceptions of their own professional ethical values

compare to their perceptions of the ethical values of

physicians. The latter is the primary focus of this paper,

although later on in this paper we refer to another

question to illuminate how nursing students construct

ethical values.

The setting for this research was a community college in

central Alberta, Canada. In the early 1970s, this college

began to offer a 2 year diploma in nursing and recently

celebrated their 25th year of this programme. Moving

nursing training from hospitals to colleges and universi-

ties was part of a general trend throughout North America.

We concur with Clarke (1990) that this shift in training

location was part of nursing's attempt to enhance its

professional status. In 1990, the nursing programme at this

college began a 4 year collaborative baccalaureate degree

with the University of Alberta. Presently, students have

the option of taking a 3-year diploma or a 4-year degree in

nursing. The ®rst 2 years of the programme are similar for

all students. After that they must choose between the two

streams. At the time of the study, there were a total of

approximately 200 students over the 4 years of the

programme.

As a result of a pilot study using interviews with some

of the students in the above mentioned programme, we

became sensitized to issues and questions deserving

exploration. Due to time constraints as well as the

possibility of getting a larger sample, we decided to use

a questionnaire format. These questionnaires were

distributed in classroom situations over a 2-year period.

One of the writers teaches three sociology classes a year to

nursing students during the seconds year of their pro-

gramme. This allowed for the opportunity to collect our

data using what might be called a convenience sample.

Besides the convenience factor, it later occurred to us that

concentrating on second-year students was a good idea in

that they had all undergone similar learning experiences

to those of the third-year and fourth-year students, who

were split between the diploma and degree tracks. All but

four of our sample were female. We stressed the fact that

participation in the study was voluntary and in no way

connected to the student's performance in any course. Of

the 110 questionnaires distributed we ended up with 73

usable ones (a response rate of 66%). The questionnaires

consisted of 10 questions (Figure 1). The non-random

nature of the sample did not concern us since we were not

hypothesis testing but rather generating qualitative data of

an exploratory nature (Strauss & Corbin 1990). Our

analysis is based on the elaboration provided by respon-

dents to explain their choice of a response to the ques-

tions. Prior to the classroom administration of the

questionnaires, respondents were verbally encouraged

to elaborate on their responses and given suf®cient time

to do so. The ®ndings discussed here are in response to

question 10: Do you perceive any differences between the

ethical positions of nurses and doctors? What constituted

a `difference' and how to de®ne a `position' were delib-

erately left open-ended for the respondents to interpret for

themselves, as well as whether there was , in fact, any

difference at all, in an attempt to make this question as

non-directive as possible.

FINDINGS AND ANALYSIS

We analysed the data using content analysis. Responses

were compared and coded in an effort to ®nd common

R. Joudrey and J. Gough

1156 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162

Page 4: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

themes. The resulting categories outlined below were used

to capture these common themes. We wanted our catego-

ries to emerge from the data and thus re¯ect the respon-

dents' meanings rather than imposing categories on the

data (Blumer 1969). Hence, whenever possible, our

naming of categories used language of the survey partic-

ipants. In addition, we illustrated our categories by

quoting directly from our respondents. Since it is their

viewpoint we were concerned with, we felt that their

discourse should be faithfully represented (Stryker 1980).

In this section, we merely present our ®ndings using the

categories generated from our analysis. We leave the

discussion of these ®ndings to the following section of the

paper.

Of the 73 respondents, 59 (81%) stated that they

perceived clear differences between the ethical positions

of nurses and physicians. While eight respondents merely

answered `yes' to the above question, the majority (51

respondents) went on to elaborate on the nature of these

varying ethical stances. These responses were detailed

enough to allow us to do a qualitative analysis.

The caring ethic versus the curing ethic

The following quote from one of the respondents suc-

cinctly captures our major ®nding: `Nurses care and

doctors cure' (#10). In fact, 15 students used the terms

`caring' and `curing' to distinguish between their percep-

tions of nurses' ethical values and their perceptions of

physicians' ethical values. They also went on to elaborate

on their interpretation of the meaning of these terms.

Later, as a means of testing the trustworthiness of these

categories, we used the technique of member checking

with members of the responding group. According to

Lincoln and Guba (1985 p. 314):

The member check¼ is the most crucial technique for establish-

ing credibility. If the investigator is to be able to purport that his

or her reconstructions are recognizable to audience members as

adequate representations of their own (and multiple) realities, it is

essential that they be given the opportunity to react to them.

In this case, member checking consisted of open dis-

cussion of the study results and our interpretations with

30 of the survey respondents; this checking con®rmed that

our interpretations adequately represented their percep-

tions. While 44 respondents did not explicitly use the

`caring±curing' terminology, their descriptions of ethical

differences were so similar to those using these terms that

we felt justi®ed in using caring and curing as our two

major categories. For these (51) students, at least, nursing

ethics was clearly viewed as synonymous with caring. A

close comparison of responses yielded further dimensions

of the caring and curing categories. Table 1 illustrates

these dimensions.

In order to understand the meaning of these two ethical

stances, we now examine the sub-categories associated

Instructions: Please take some time to complete all the

questions on this survey, which is designed to guage

the perceptions of nursing students to ethics and

ethical issues. All responses will be kept in strictest

con®dence. Do not identify yourself on this survey.

Participation in this study is completely voluntary.

This survey is conducted as part of a Special Project

conducted by Ron Joudrey, sociology and Jim Gough,

Philosophy, and has no connection to the nursing

programme at Red Deer college.

1. Please indicate the year of your current enrollment

in the nursing programme at Red Deer College. Year

[ ]

2. Brie¯y indicate your understanding of the term

`nursing ethics'.

3. Identify what you take to be 2 or 3 signi®cant

ethical issues in nursing.

4. Do you feel the importance of ethics in nursing is [ ]

less important, [ ] more important, [ ] about the

same, in current nursing practice as in the past? If

you believe that the importance of ethics in nursing

has changed, what, in your opinion, accounts for

this change?

5. How does your nursing program at Red Deer

College address the teaching of ethical issues in

nursing?

6. Is the approach to teaching ethics you are most

familiar with one which you would characterize as

[ ] directive (where a particular ethical stance or

approach is advanced) or [ ] non-directive (where

no particular ethical positions are advanced)?

7. What is your opinion of the effectiveness of the

nursing ethics component of your nursing pro-

gram?

8. What do you believe is the primary source of your

particular ethical values?

9. Do you perceive any signi®cant ethical con¯icts

between your ethical values and those of your

nursing instructors and/or others in clinical settings?

10. Do you perceive any differences between the

ethical positions of nurses and doctors?

Table 1 Student nurses' perceptions of the caring and curing

ethic

Curing ethic Caring ethic

(Physicians) (Nurses)

Medically speci®c Holistic

Non-advocate Patient advocate

Figure 1 Questionnaire.

Philosophical and ethical issues Ethical stances

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162 1157

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with each position. While we consider these dimensions

separately, in some cases respondents viewed them as

overlapping. For example, one respondent said: ``Drs. deal

with disease and disorder, nurses with how disease affects

patients socially, emotionally, physically and spiritually.''

(#6)

Medical speci®city versus holistic approach

For many of the respondents, the curing ethic of physi-

cians was associated with a narrow focus on the technical,

medical aspects of patients whereas the caring ethic of

nurses was related to a much broader interest in patients

as human beings (viz. much more than just a patient with

a medical condition). Consider the following as illustra-

tive of this contrast:

Many Physicians do not see people holistically where more

nurses than doctors do. Physicians often see the disease/ailment/

condition, not the person behind the disease. (#23)

Nurses are so involved with the client and really get to know them

and their families. They [nurses] seem to be more concerned for

the client and do not focus just on the current illness. They deal

wholistically [sic]. (#44)

A few students mentioned that because nurses spend

more time with patients they get to know them as people

with feelings, thoughts and social relationships rather

than just diseased bodies. The tone of some of the

responses further indicated that nurses' holistic emphasis

was regarded as a virtue. For example:

I perceived that many nurses approach pts. in a humanistic

approach whereas doctors many times group the pt. into their

illness stereotypes. (#56)

I don't think some doctors take into account the whole picture.

(#14)

Patient advocate versus non-advocacy

The second perceived contrast between caring and curing

had to do with patients' needs and wishes being central

(advocacy) versus treatment (curing) being motivated by

other goals. Again, several respondents mentioned clear

contrasts between the two occupational groups. Patient

advocacy was associated with the caring ethic. The

following articulate the perceived contrasts between phy-

sicians and nurses:

`Doctors follow the medical model and base their diagnosis and

treatment on curing the patient. Nurses on the other hand follow a

caring model and base their case on protecting the rights of the

client and improving the quality of life and health, without

jeopardizing the patient's autonomy and rights. (#44)

Nurses help to support person with whatever decision they make

where doctors at all cost want to preserve life. (#19)

Nurses want to do what is best for the patient even if it goes

against their own thoughts and feelings. Doctors try to cure people

instead of actually being an advocate for their client. (#37)

We also found in some cases a perception that the goal

of nursing is altruistic whereas physicians were painted as

more motivated by either self-interest or advancing med-

ical science. Consider these respondent statements:

¼ doctors like to try out their new research on patients¼ when

this is not really what the patient wants or needs. (#26)

¼ Sometimes you see or hear about the nurses doing for the pts

behalf and drs doing for their own behalf. That is frustrating and

rude. (#6)

Yes, drs are money grubbers and some won't help if pts can't pay.

(#17)

Drs are in the market to make money and advance science. Nurses

are in the market to make the best of the money we have and to

advance the health and well-being of our clients. (#23)

Finally, as the above quotes indicate, just as in the

holistic-speci®c contrast we found that some of the

respondents approached the ethical differences with a

sense of moral superiority. They perceived their ethical

stances as superior to those of the physicians. In a few

cases, they perceived doctors as either being unethical or

unaware of ethical issues. Consider these responses:

Very few nurses have been observed to be unethical compared to

doctors. (#3)

Doctors are usually too busy to really think about what is ethical

or not. Nurses are much more aware. (#68)

Not all of our survey respondents mentioned or per-

ceived ethical differences between the two occupations

(14/19% of respondents). We were not able to make much

of these `negative cases' since they usually either left the

answer blank or merely answered `no' to the question.

Two people replied that they did not have enough

experience yet to make any distinction.

DISCUSSION

In this section we suggest possible interpretations for

some of the information gained from the survey.

First of all, most respondents in our survey made clear

distinctions between the ethical positions of nurses and

doctors. This raises the question of how they developed

these perceptions. The most obvious answer would be

professional socialization. In this particular training pro-

gramme, as with others elsewhere, brochures, course

outlines and programme descriptions are replete with

references to `caring', `patient advocacy' and the `holistic

approach', terms found abundantly throughout the nurs-

ing literature. Some of this literature (such as Watson's

book) is a reading requirement in courses at this particular

R. Joudrey and J. Gough

1158 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162

Page 6: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

institution. Conversations with instructors at this college

also revealed that the caring ethic is a dominant theme in

their curriculum. It is probably not surprising therefore

that since these students are continuously exposed to this

discourse, they do buy into it and use it as a reference

point for developing a sense of professional identity.

In our study, the respondents' descriptions used were

synonymous with those of nursing writers, educators and

researchers. Despite the uncertainties expressed about the

effectiveness of ethics teaching (Allmark 1995, McAlpine

1996) our study strongly suggests that student nurses

incorporate some of this ethics teaching into their world-

view. `Talking the talk', however, is not the same as

`walking the walk'. Because nurses use the dominant

rhetoric associated with this ®eld does not necessarily

mean that they internalize these ideas and use them in

actual clinical situations. It may be, as Gaut (1983)

suggested, that terms like `caring' have merely become

slogans that are used as resources to gain (recognition for)

professionalization. Discussions about this issue with

regard to medicine suggest that claims of an altruistic

ethic may be as much (empty) rhetoric as fact (Hafferty &

Light 1995). Further research may be needed to determine

whether or not this might be the case in nursing. What is

clear, however, from our research is that student nurses do

use the language of ethics to construct their difference

(and identity) from doctors. As pointed out recently by

May and Fleming (1997) there is a need for more research

in this area.

What happens in nursing school is but one in¯uence on

ethical values. In another part of our survey we explicitly

questioned these same students about their sources of

ethical values. Question 8 asked: What do you believe are

the primary sources of your particular ethical values? The

vast majority listed family as the major source, followed

by religion, peers, and nursing school (instructors) in that

order. This presents somewhat of an anomaly since the

ethical values espoused by these students were identical

to those promoted by the profession. However, given that

most of our respondents were female it could be that the

altruistic caring ethic stressed in nursing is reinforced by

traditional gender socialization wherein women have

been socialized to care for others (Noddings 1984, for

example, in a controversial view discusses caring as a

feminine ethic). There may be enough of a perceived ®t

between family ethical socialization and nursing training

that these students merely graft the elaborated ethical

language offered by nursing onto an ethic they have

already accepted earlier in life. For example, Noddings

made her connection between caring for other and family

values over public morality as a male-dominated approach

to ethics. It might also be that females who have these

strongly held altruistic values are more likely to select

themselves into nursing. If this is the case, they may see

their nursing training as offering nothing new with regard

to ethics and therefore do not give credit to this source. We

offer this as a hypothetical conjecture requiring more

research.

It is not surprising that religion was ranked second to

family as in¯uencing ethical values. There has been a long

standing association between religion and nursing going

back to when some of the earlier nurses were motivated by

notions of Christian charity (Freidson 1970, Clarke 1990),

and when nursing schools were located in church-af®li-

ated and supported hospitals.

Likewise, peers obviously play an important role as

agents of socialization. This in¯uence is likely to be

particularly pronounced in programmes such as nursing

where students spend most of their school time in classes

with one another. In our location, in-class group work is a

major feature throughout the curriculum. Students

continually work in small groups discussing nursing

issues and doing joint projects. In this kind of situation,

we would expect that peers would in¯uence and reinforce

each others' ethical values, producing what symbolic

interactionists refer to as a sense of shared meaning

(Blumer 1969). As Moore (1969) pointed out, the learning

of technical language is important in forming occupational

identity as well. Hence many of our survey respondents

used similar terminology. Our informal communications

with students and instructors indicated that ethical values

are often discussed in a group context both in and out of

the classroom.

We now need to address the respondents' comparative

perceptions of physicians' and nurses' ethical positions.

Simply stated, the dominant perception was that nursing

operated from a caring ethic involving holism and patient

advocacy, whereas medicine was more curing oriented

with a narrow focus on the patient's medical condition (a

function of a male-dominated profession-science/

quaniti®cation, etc., as indicated in the works of Noddings

1984 and Gilligan 1982) and acting out of self-interest as

motivated by the goal of advancing medical science. Again

it is understandable that student nurses do use the

caringÐcuring lexicon to distinguish the two ®elds since

it is abundant in the literature (see, for example, Watson

1985, Kurtz & Wang 1991, Kyle 1995). However, in the

literature the ethical distinction is usually discussed in a

non-evaluative way. One ethical stance is not usually

touted as superior to the other. We have no evidence,

either, that nursing instructors at our college openly

denigrate the ethical stance of physicians. However, some

recent writers have suggested that instructors in various

areas of medicine `either consciously or otherwise, may

pass on the prejudices that were passed down to them by

their own clinical instructors and developed from their

own clinical experiences' (Frankel et al. 1996 p. 57). A

common thread in our ®ndings was, as some of the above

quotes demonstrate, that many of our respondents not

only contrasted their perceptions of the ethics of doctors

Philosophical and ethical issues Ethical stances

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162 1159

Page 7: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

and nurses but went on to disparage the ethical position of

physicians while holding nursing up as the exemplar of

what ethics should be. Part of the reason for their

glori®cation of the nursing ethic may be due to idealism

since many of these students were still less than half way

through their degree programme. It is possible that had we

questioned them latter we might have found less of an

idealistic outlook, as other researchers have found with

nursing, medical and dental students (Becker & Geer 1961,

Psathas 1968, Morris & Sherlock 1971).

We suggest also that these negative perceptions about

physicians may be an attempt to counteract traditional

medical hegemony for, as May and Fleming (1997)

pointed out, discourse is related to (perceived) power

relationships. Since nurses have been in a subservient

position vis-aÁ-vis doctors for a long time, viewing them-

selves as ethically superior may be an attempt on the part

of nurses to compensate for their long standing lower

status, power and prestige. Since they have not been seen

to be the equals of physicians in other respects, an

attitude of ethical superiority may help bolster their

collective self-esteem. There are at least three sections of

the Code of Ethics of the Canadian Medical Association

(1996) which seem designed to curb entrepreneurial and/

or self-interested tendencies. Section 28 states `In deter-

mining professional fees to patients, consider both the

nature of the service provided and the ability of the

patient to pay, and be prepared to discuss the fee with the

patient', and Section 40 states `Avoid promoting, as a

member of the medical profession, any service (except

your own) or product for personal gain', while Section 41

states `Do not keep secret from colleagues the diagnostic

or therapeutic agents and procedures you employ'. None

of these prohibitions or guideliness appear in the Cana-

dian Registered Nurses Association (1996) Code of Ethics

and it may be that the necessity of including these

sections in the CMA Code indicates something about the

negative perceptions of some physicians, perceptions not

generally held about nurses and so not included in their

code. To a certain extent, a code of ethics can be

understood as a self-re¯ective document critically re¯ect-

ing on some criticism of members of the profession by the

profession itself and by others, criticism taken seriously

enough to provide the need for explicit documented

guidelines and prohibitions.

A strong sense of occupational cohesiveness may also

explain the negative portrayal of physicians. Sociologists

have known for some time that one of the consequences of

a group developing a strong sense of `we' feeling is the

tendency to create an ethnocentric attitude towards `out'

groups. In this case, the physicians are perceived as the

`they'. The tendency for nurses to view physicians in a

negative light has been noted by others (Henneman 1995,

Sweet & Norman 1995). It would, perhaps, be interesting

to do some follow-up comparative research on student

physicians' perceptions of nurses' ethical values, since

some researchers have found that physicians have more

favourable attitudes towards nurses' ethical stances.

Would student doctors view nursing ethics in a positive

light? Frankel et al. (1996) attributed these negative prej-

udices about other professions to the professional social-

ization experience, namely the sequestered nature of an

occupational group's separate training. These authors also

discussed how these negative opinions of other groups

can hinder effective teamwork in a clinical setting. A

practical implication of all this is that perhaps nursing

instructors when dealing with ethics should address this

negativity and seek to correct what in some cases may be

negative misperceptions.

So far we have been discussing in¯uences on ethics at

the micro level. We need to mention the possibility that

some of these students' images of medicine might be

in¯uenced by the larger social context. In recent years

there has been a lot of discussion of what Hafferty and

Light (1995) call medicine's `fall from professional grace'

(see also, Freidson 1970, Clarke 1990, Shorter 1991). The

loss of a service ethic manifested partly through several

doctors' strikes in Canada may have helped contribute to a

decline in public prestige for the medical profession. The

feminist challenge to a traditionally male-dominated pro-

fession (Clarke 1990), as well as their training experience,

has probably played a role in this negative perception of

physicians as well. Note again that the student respon-

dents to our study were overwhelmingly female. These

broader public challenges to medical dominance undoubt-

edly may have contributed to some of our respondents'

apparent denigration of doctor's ethics. We would expect

some of these perceptions to be modi®ed as students get

more clinical experience working with doctors. Whether

the attitudes will change in a more positive or negative

fashion, however, is an empirical question.

LIMITATIONS OF THE STUDY

This exploratory study was carried out in only one setting

and therefore the ®ndings cannot be generalized beyond

this setting. Further research could test these ®ndings

more rigorously in other locales using larger samples.

While our questionnaire technique generated some very

useful data, future researchers might consider the inter-

view method as a means of probing for more elaborate

responses.

Another limitation is that the study was of a cross-

sectional nature. It would be worth exploring whether the

perceptions of student nurses change over time as a result

of more training and experience. In this regard a longitu-

dinal study following the same subjects over a period of

time would be most useful.

R. Joudrey and J. Gough

1160 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1154±1162

Page 8: Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances

CONCLUSION

Our exploratory study found that some student nurses

perceive substantial differences between the ethical

position of nurses and physicians holding the caring

ethics of nurses as an ideal, while disparaging the curing

ethic of doctors. One way an occupational group seeking

professional status achieves a sense of collective identity

is by comparing themselves to other groups and stressing

what favourable characteristics they possess that the other

group lacks. Many of our ®ndings are supportive of other

research in this area. We believe that studying student

nurses' ethical perceptions is a useful venture in that

during training some of the foundations for ethical think-

ing are developed that will guide and determine their

practice later in their careers. Approaches like ours might

help clarify how different sub-groups in nursing actually

make sense of ethical values held in high esteem in their

profession.

Finally, if team work and an emphasis on inter-

disciplinarity mark a new emphasis in the medical

professions, some work may need to be done in the

training of nursing students to mitigate against negative

perception of their medical colleagues along with the

increased interest in professionalization of their occupa-

tion. It may be that the other medical profession has a

more pronounced history as a profession, which places

nursing always in the position of de®ning itself, as Simone

de Bouvoir argues (De Bouvoir 1952) in relation to women,

as the negation of the other. This kind of comparison

always leaves women in a secondary position vis-aÁ-vis the

One, or in this case, the de®ning medical profession. In

this sense, a social comparison strategy for identifying the

nursing profession may not be the best approach.

Acknowledgements

We express our appreciation to the nursing students who

participated in our study as well as the co-operation

shown us by the Nursing Department, Red Deer College.

We also appreciate the helpful comments made on an

earlier draft of this paper by the two referees for this

journal and by our colleagues Dr Paul Nonnekes, Sociol-

ogy, Dr William Stuebing, Sociology and Dr James Scott,

English, Red Deer College. Our research was funded by a

Special Projects Grant approved by the College-Wide

Faculty Board Professional Development Committee, Red

Deer College.

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