On being a good nurse: Reflections on the past and preparing for the future

S C H O L A R L Y P A P E R

On being a good nurse: Reflections on the pastand preparing for the futureijn_1878 525..532

Ann M Begley PhDLecturer in Ethics, Queen’s University, School of Nursing and Midwifery, Belfast, UK

Accepted for publication August 2010

Begley AM. International Journal of Nursing Practice 2010; 16: 525–532On being a good nurse: Reflections on the past and preparing for the future

The objectives of this paper include reflecting on the attributes of the ‘good’ nurse in the past, outlining thematically theessential attributes (virtues) required by the ‘good’ nurse today and presenting an original 4-point framework for ethicsin practice. Although there is no doubt that nurses in the past were highly professional, the culture within which theypracticed tended to stifle the emergence of autonomy, assertiveness, advocacy and accountability.

An original table of contemporary attributes, which is congruent with a neo Aristotelian virtue ethical approach, isarranged in themes of Intellectual and Practical Attributes, Dispositional Attributes and Moral Attributes. A frameworkfor professional practice, the ‘Four As’ is then extrapolated from these themes. These four key professional attributes,autonomy, advocacy, accountability and assertiveness, along with the virtues listed in the themes, exemplify the ‘good’nurse and are identified as the linchpins of modern professional ethics and good conduct.

Key words: codes, ethics, good character, good nurse, professional ethics, virtues.

INTRODUCTIONNursing: a call to service

Professional nursing has emerged from a rich and multi-faceted history which predates the Nightingale era and hasits roots in the USA, Canada, Australia and Europe. Theinfluence of ‘vowed’ or religious women has, according toNelson, been trivialized and even ignored in contempo-rary historical representations of our professional heri-tage.1 Nightingale, however, drew inspiration from thosewomen who did much more than merely set the scenefor ‘real’ nursing: she cherished the vocational notion ofnursing 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 ofnursing as a vocation or a ‘calling’ has been a powerfulinfluence on the development of the profession. Theattributes required by the ‘Nightingale’ nurse were articu-lated in the Nightingale Pledge3 and include Godliness,purity, faithfulness, loyalty and a commitment to ‘aid thephysician’. Other essential attributes emerging from theearly ethics literature were obedience, stoicism, endur-ance, servility, modesty and humility.4–6

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

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

International Journal of Nursing Practice 2010; 16: 525–532

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

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

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

presented in a simple framework for good professionalconduct (Fig. 1b). The ‘Four As’, Advocacy, Assertive-ness, Accountability and Autonomy, are identified asthe linchpins of good conduct. They do not stand alonehowever, and they depend on the presence of other essen-tial virtues listed in the themes presented. These aregrounded 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

526 AM Begley

© 2010 Blackwell Publishing Asia Pty Ltd

wittiness and not necessarily the concepts which weexpect to fall under the umbrella of the virtues. It issuggested that in relation to the evolving concept of the‘good’ nurse, the attributes presented in (Fig. 1b) havebecome essential hallmarks of good character.

The objectives of the paper are threefold:

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

• To consider how this understanding of the ‘good’ nursehas changed and how this change is reflected in moderncodes of conduct

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

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

Way suggested that ‘matters of moral value fadeimperceptibly into matters of etiquette. . . .’6 There is,however, a significant conceptual difference betweenetiquette, particularly that which is rooted in respectfor superiors, and ethics. One of the reasons for nurses’arrested development as autonomous moral agents hasbeen the blurring of this distinction, and in the past theeducation of nurses in relation to ethics often focused onhow to dress and show respect (etiquette) rather thanconsider the moral perspectives of practice (ethics). This,however, does not imply that all nurses were weak willedand unable to think for themselves. But in reality, theculture was one which did not encourage or support asser-tiveness or challenges to authority figures.

Towards professional ethicsPractitioners might reject the notion of the ‘good’ nurseas 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 highstandards in all areas of practice and governance. Beinggood and behaving well depend on the state of characterand 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 haveemerged from various sources, Greek ethics,10

Buddhism,11 Confucian,12 Maori,13 Christian.14,15 Modernsecular approaches include Blackburn,16 MacIntyre17 andnurse ethicists.9,18–25 In this paper, relevant attributesarising from these sources have been brought together andarranged in themes, or categories of virtues consideredto be necessary for meeting the standards required of a‘good’ nurse.

The literature on the virtues of nurses in the pastreflects an acceptance that nurses should nurturethe attributes historically accepted as characteristic ofwomen. Aristotle, for example, suggested that women’svirtues are different from men’s.26 (Neo-Aristoteliansreject such views). Also, in more recent times, Rous-seau’s novel Emile reflects the distinction made betweenmale and female virtues. Female traits were consideredto be gentleness, tenderness, beneficence, compassion,nurturing, self-sacrifice, intuitiveness, mental passivityand physical and emotional dependence.26,27

Historically, literature relating to nursing ethics indi-cates that the virtues of the nurse included such traitsas respect for authority (particularly of medicine), beingfaithful to duty, being tactful, cultivating a meek and milddisposition, loyalty and cleanliness.4–6 Sympathy, compas-sion, or any emotional involvement with a patient wasnot encouraged and was portrayed by Way6 as a fault, orweakness of character in the nurse. The reluctance to‘report’ another nurse or challenge unsafe practice alsocomes across in the early literature.4–6 Other essentialattributes emerging from the early ethics literaturewere obedience, stoicism, endurance, servility, modesty,humility and loyalty.2–6

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

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

On being a good nurse 527


Virtues are habits of character that predispose persons to meettheir 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 ofwhat 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 theirautonomy and are sensitive to their needs when vulner-able and distressed. Most importantly, we are accountablefor our actions and we are charged with the responsibilityto protect the patient from the mistakes and negligenceof others. The nurse today is expected to practice from asound knowledge base and to be sufficiently confident tochallenge questionable practice. This is in stark contrastto the expectations of the nurse in the not too distantpast. Modern codes of ethics and standards of conductreflect a very different understanding of the characteristicsexpected of the ‘good’ nurse. In relation to these points,modern codes of ethics clearly demonstrate a shift inexpectations.

In the UK, for example, the Nursing and MidwiferyCouncil29 expects nurses to make the care of peopletheir first concern, to be personally accountable for theiractions and omissions in practice, to challenge unsafepractice, cooperate with colleagues and keep up-to-date.The ANA’s code of ethics28 expects that the nurse isprimarily committed to the patient, takes on the role ofadvocacy, maintains competence and a knowledge baseand has a concern for the welfare of colleagues. Simi-larly, the Australian Nursing and Midwifery Council30

highlights these attributes and charges the nurse withupholding certain values and standards. The nurseshould: show respect and kindness towards clients,report nursing care that is potentially unethical, illegal,unsafe or incompetent and ensure that decision makingis based on contemporary relevant and well-foundedknowledge and information.

The International Council of Nurses Code31 reflects theabove expectations. Notions of accountability, advocacyassertiveness and autonomy are required if the nurse is touphold and practice according to the standards expectedof them by the international community of nurses. Thesecodes together outline clearly the standards which shouldbe 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 thediscipline. There is also evidence of concern in relation tohow we respect and value each other: the importance ofkindness and rejection of bullying and harassment ofcolleagues are clearly articulated.

The Nursing and Midwifery Council32 maintains thathealth-care professionals’ characters must be ‘sufficientlygood’ to be capable of safe and effective practice withoutsupervision. 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 emphasisis being placed on the character of the agent as a signifi-cant factor in ensuring that we have professionals whowill act with integrity. The ANA states that in order tobe a good person one requires wisdom, honesty andcourage 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 agood person33 and the good nurse, therefore needs all ofthese attributes. The good person is more than a rulefollower34 and the individual needs to consider what sortof person he or she ought to be rather than simply what heor she ought to do, such as follow rules and principles.35,36

The main issue to be addressed, then, is to identifywhat it is that constitutes sufficiently good characterand what virtues or attributes are essential for goodconduct?

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 thesubject. It is also clear that codes of ethics and conduct aremore virtue based, focusing more on the characteristicsof good practice and the character of the agents than onsimple rules and imperatives. In the existing literatureon the subject, candidates for consideration as virtues(attributes, character traits in nursing) have been sug-gested by various authors.9,18–25

ThemesIt is suggested here that the virtues or attributes requiredso as to exemplify excellence of character can be catego-rized into the following themes:

528 AM Begley


• An Intellectual and Practical Theme (with attributessuch as Aristotelian theoretical and practical wisdomand the ability to integrate theory with practice)

• A Dispositional Theme (with attributes such ascompassion, courtesy, empathy approachability andkindness)

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

Aristotle’s account of the virtues or attributes required tolive a good life and are congruent with those virtues citedby modern codes of conduct. Some of them might not fitneatly with the modern conception of ‘virtue’ but they arepresented here as attributes of character in an Aristotelianconception 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 ascleverness, courtesy and patience. After all, nurses who areincompetent, or lacking in the ability to deliberate andmake wise decisions, can have a very negative impact on theprogress of people in their care.9 Similarly, grumpy or rudenurses will not be approachable and it would be impossibleto nurture a therapeutic relationship (with the patient)successful mentorship (with the student) or effective interprofessional collaboration with such a character.

The ‘good’ nurse requires a synthesis of science andsensitivity. Excellence cannot be achieved without abalance between the Intellectual, Practical, Dispositionaland Moral attributes. The intellectual and practicalattributes are presented as one theme because it is notpossible to be competent without the capacity to acquiretheoretical knowledge and apply it appropriately (practi-cal wisdom) to practice.

Although many virtues which reflect a vocationalapproach to nursing have been rejected by the modernprofession, some of the attributes such as courtesy, dili-gence and fidelity which were valued by nurses in the pasthave been included in these themes. There has been a shiftfrom the servile ‘nun-ish’ virtues often associated with areligious vocation and evident in the ‘Nightingale Pledge’but some of these virtues continue to be important todayand, although ‘sanctimonious’ in nature, it is argued herethat 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 capableof empathy, insight into complex contexts and emotionsand ultimately, advocacy.

Learning from the past and preparingfor the future

Attributes that were not encouraged in the past (suchas having the courage to challenge unsafe practice) arenow considered to be professional virtues and conversely,many of the virtues extolled up until the 1950s and intothe 1960s and 1970s in the UK are now considered todenote weakness in character. It is clear that certainattributes required by the modern conception of ‘good’nurse were missing, even actively discouraged. Forexample, a nurse who questioned the accuracy of a pre-scription, or had the courage to put the patient safetybefore deference and obedience was likely to be consid-ered a trouble maker, not a ‘good nurse’. On the otherhand, today’s good nurse is assertive, having the courageto raise concerns in the interest of patient safety, althoughfailing to do this would be considered unsafe practice.

The ‘good nurse’ was not encouraged to cultivate thefollowing attributes (virtues), and these can be referredto as the ‘Four As’, or Attributes that are essential forcaring and good professional conduct (Fig. 1b). These arehighlighted in today’s codes of ethics and conduct, and inexercising these virtues professional nurses draw on thosevirtues listed in the themes presented (Fig. 1a).

Advocacy and the necessary virtues associated with itThis was clearly not part of the moral repertoire ofthe profession in the past. Successful advocacy requirescompassion, courage and a commitment to caring for andempowering clients and colleagues. Advocacy is mostoften associated with the nurse–client relationship, but itis also important in our relationships with colleagues.Nurses have a duty of care towards colleagues and theabuse of power, bullying and harassment are to be chal-lenged robustly.30 Advocacy also requires intuitive skillsand a capacity for empathy.

Accountability and the necessary virtues associatedwith it

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



Assertiveness and the necessary virtues associatedwith it

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

Autonomy (professional) and the necessary virtuesassociated with it

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

Collaboration is not just cooperation, but it is the concertedeffort of individuals and groups to attain a shared goal. Inhealth care, that goal is to address the health needs of thepatient and the public. . . . by its very nature, collaborationrequires mutual trust, recognition, and respect among thehealth care team, shared discussion-making about patientcare, and open dialogue among all parties who have aninterest and a concern for health outcomes.(Provision 2.3)

Ultimately, however, the decision rests with the indi-vidual nurse and accountability, advocacy and assertivenessdepend 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 questionablepractice:

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

health care system or any action on the part of othersthat places the rights or best interests of the patient injeopardy.(Provision 3.5)

The professional nurse has therefore emerged as anautonomous moral agent who engages and collaborateswith other health-care professionals and clients: advocacyand assertiveness have replaced the deference, sometimesblind obedience, and misplaced loyalty evident in the past.

CONCLUSIONThe conception of the good nurse has evolved andthere has been a shift from etiquette to ethics, from obe-dience to moral autonomy, assertiveness accountabilityand advocacy. These attributes (qualities or virtues) aregrounded 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 oneof the most attractive elements of an Aristotelian approachto ethics is the emphasis on practice: ethics is somethingthat we do—we do not learn the theory and then put itaway in a file.37 Acquiring excellence of moral characterand intellect is, as Carper’s work38 highlighted, aboutinfluencing hearts as well as minds, and it requires adynamic and sensitive approach which goes beyond thatwhich 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 liferequires a balance of intellectual and moral excellences,or attributes, and it maps out progression from novice toexpert.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 areunable to speak for themselves. The nurse is accountable,takes responsibility and is not subservient. The Nursingand Midwifery Council29 indicates clearly that good char-acter is essential for registered practitioners and for entryto and continuation on pre-registration programmes23 andthere 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 expectedto uphold, it seems that de Raeve’s21 concern that thisis relatively unexplored territory is true. High valueis placed on the attributes that a nurse might bring to

530 AM Begley


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

ACKNOWLEDGEMENTSMy colleagues Daphne Martin and Richard Henry for theirhelpful comments on earlier versions of this paper.

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On being a good nurse: Reflections on the past and preparing for the future