Nursing practice and research are forms of human activity. Every kind of human activity is based on a set of values, whether consciously or unconsciously. Ethics is the research field with the main interest in values. Research into nursing ethics is concerned, among other things, with the values that lie behind the human activity of nursing, the objective of which is not only to nurse sick patients but also to empower people in their health. There are numerous textbooks on the subject of nursing ethics and, in the research literature, have been many discussions of the ethics of research. Nursing ethics research, however, is not yet a mainstream area within nursing science. My argument is that we should see it as such, and that we need more nursing ethics research.
So what kind of research into ethics do we need in the field of nursing? This question can be considered from the vantage point of how values are defined, on the basis of ontological analysis. Values can be distinguished according to three main types of existence – subjective, objective and natural. Subjective existence implies that values are in a person's mind, hence they cannot be ‘seen’ and essentially are individual. Objective existence implies the presence of values in reality, but they are still not fully perceptible to others. Natural existence, in contrast, implies that values can be perceived by the human senses because they are manifest in observable facts. In the context of nursing practice, therefore, values are not always directly observable. We can only draw inferences about values from what people say or do. However, it is noteworthy that people may exhibit the same values in different ways and there is no specific activity through which any given value is exhibited. Indeed, overly simplistic assumptions about the links between values and behaviour should be avoided.
Research into the value foundations of human behaviour must operate, therefore, at different levels at the same time. We need to build up constructs that explain the nature of values and illuminate what kinds of values are held in nursing and how these values relate to other abstract constructs, and how they translate into human activity. This could be described as the theoretical study of ethics. It also takes in the ethics of research. Nursing ethics research, I contend, needs to be given greater attention in nursing science. True, nursing journals have been publishing discussion papers on nursing ethics for decades, and such writings certainly have a role to play in helping nurses and researchers to address the ethical problems that they face. However, views and opinions do not meet the requirements of rigorous theoretical work.
Empirical research in ethics also needs to expand as a area of nursing science, even in spite of the fact that there is no empirical world of values and despite the uncertainty involved in interpretations made about the values that shape human behaviour. The focus and methods of empirical studies may vary. In an empirical study we might be concerned to study, say, the ethical problems resulting from value conflicts or solutions to those problems in practice. A single solution to an ethical problem rarely exists: in most cases there will be several alternative solutions. Indeed, the first task for the ethics researcher is to identify which research problem is an ethical one.
Empirical research into value systems can be focused on the nurse–client relationship; on the nurse–nurse relationship; or on the relationship between nurses and other professionals. In nursing textbooks, the main accent has been on the ethical issues arising in the nurse-client relationship (whether individual or groups). In this relationship, questions about patients’ rights, autonomy and privacy are particularly prominent. In Europe, the issue of patients’ rights has been receiving ever greater attention in recent years. In 1994 the WHO European Region, for example, published a Declaration on the Promotion of Patients’ Rights (WHO 1994). The extent to which patients are able (or choose) to exercise their rights is one area that deserves to be assessed by nursing research.
Greater emphasis is also now placed on ethical problems that arise in relationships between nurses, mainly from the point of view of collegiality and professional standards and accountability. Pressurised working conditions, job uncertainty and the requirements of continuous professional development have no doubt added to ethical problems among nurses, being driven, for example by envy, power struggles and a lack of respect for the work being done by other nurses or other professionals. This is another field for nursing ethics research that has received very limited attention.
Ethical problems also can be researched in the relationship between nurses and their work organizations or, wider still, the relationship between nurses and society. Nursing values may be at variance with the values of modern healthcare organizations under managerial reform or with the prevailing view in society as to how people themselves believe they should be empowered to enhance health. An example can be drawn from the field of long-term care of older people. With population ageing, this is an area under intense development. Care of older people is often, more or less, the exclusive domain of nurses. It is not insignificant what kinds of values nurses bring with them to this job. Active involvement of nurses in formulating health policies, is one important way in which the nursing profession can influence the values of their society as a whole.
The immense diversity of ethical problems also means that similar diversity is required of the methods in nursing ethics research. This is one of the challenging aspects of this field of research! A nursing ethics researcher also needs the skills to work collaboratively as part of a multidisciplinary team. Many ethical questions in health care are much easier to understand if researched by a team that involves not only nursing scientists but also medical doctors, philosophers, sociologists and lawyers. Multidisciplinary research requires, of course, that the nurse scientist can articulate the nursing angle on the ethical question being researched.
The nursing ethics researcher certainly must be motivated by a genuine personal interest in exploring the complex area of human value systems and requires a sound understanding of ethics as a discipline. Many ethics researchers drift into the field more or less by chance, as a sideline of other research. In nursing, the initial impetus is most likely to come from research that set out to study a ‘clinical problem’ which then re-presents itself as, fundamentally, an ethical issue. This was my own entree to the field when undertaking research into the satisfaction of patients with the information they were being given. After several years of research into questions of quality and patient information, the questions being raised began to take on a distinctly ethical flavour. Why do patients differ in what they want to know? What effects does knowledge have on their beliefs and behaviour? Who ‘owns’ health information and knowledge? Who decides, and on what grounds, about what information is provided for (or withheld from) particular patients? These are no longer clinical questions. They are ethical questions. They are about the values that provide the justification for empowering people (or not) in their health. It is these kinds of questions that drive the ethics researcher.
We need more nursing ethics research. There are encouraging signs that this branch of nursing science is now beginning to develop on a more collaborative scale. In the European context, some funding for health-related ethics research has been provided by the European Commission. One example is a recently-completed, nurse-led research project on patients’ autonomy, privacy and informed consent, which included five European countries (Leino-Kilpi et al. 2000, 2003). More recently, a study of ethical codes in nursing that involves seven European countries has been launched (http://www.ecn.nl).
The current funding and infrastructure for nursing ethics research, however, is still very limited. Nursing ethics research is a field of nursing science that needs to be built up more systematically. The systematic study of value foundations is an essential field of research in any discipline that is primarily concerned with human activity. There surely is no more ‘human’ discipline than the discipline of nursing.