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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
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
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
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
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
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
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
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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