The present paper is devoted to the investigation of the advanced nursing practice (ANP) leadership from the perspective of the ethic of care (EC). The paper includes a discussion of EC, which is structured to demonstrate its difference from the ethic of justice (EJ). This comparison allows pinpointing the features that make EC more applicable to ANP leadership and provides the ground for the discussion of the interconnections of ANP leadership and EC perspectives. The paper argues that EC is more applicable to healthcare settings due to it being more extensive than EJ and views EC as an appropriate tool for ethical decision-making, which can be used and promoted by advanced practice nurses (APN) and their leaders.
To describe ANP leadership dynamics, it is necessary to define the practice situation extensively. APNs are a specific and rather numerous group of health care providers who have “expanded clinical and decision-making skills, professionalism, and work experiences,” which is why they require the leadership and management of peer providers (Metzger & Rivers, 2014, p. 337). Metzger and Rivers (2014) and Scully (2015) suggest that ANP leaders are APNs, who are familiar with the specifics of ANP work, and who use their leadership skills to supervise APNs, typically also carrying out certain managerial activities, even though they do not have to hold a position of authority. Their primary aim is the improvement of care, and it is correlated with motivating and empowering the nurses and forwarding change on various levels (Metzger & Rivers, 2014; Scully, 2015). Moreover, ANP leadership presupposes leading by example and setting the standards of care for the nurses and other healthcare specialists (Metzger & Rivers, 2014). ANP leaders are likely to be found and act in hospitals and similar healthcare institutions, but they are also expected to act outside of these settings, especially when performing their change agents’ activities on municipal, state, national, or global levels (Olson & Stokes, 2016; Scully, 2015).
Scully (2015) affirms that the modern-type nursing leadership began to emerge in the 1990s, even though it also existed earlier in a less extensive form (p. 2). However, even though nursing leadership appears to have a long history, ANP leaders seem to be lacking in numbers nowadays (Lachman, 2012). Moreover, Lachman (2012) suggests that they also lack frameworks and tools that can guide them through their responsibilities. The present paper discusses one of the tools that can be employed by ANP leaders to inform their decisions: EC.
Ethics of Care versus Ethic of Justice
EC can be better defined in comparison with EJ. EJ is related to the case when an ethical issue or dilemma is resolved impartially, justly, and with a consideration of equality and human rights (Lachman, 2012; Skoe, 2014). In other words, it appears to be a valid approach to nursing, especially in the light of Provision 3 of the American Nurses Association (ANA) Code of Ethics (Olson & Stokes, 2016, p. 10). Indeed, EJ requires taking into account the ethical obligations that a caregiver (a nurse) has towards the person who is cared for (a patient) and making decisions based on the rights of the latter. EJ should have the outcomes of just and legally appropriate decisions, and it is also regarded as a relatively simple tool for decision-making (Skoe, 2014). However, this approach does not take into account an important element of nursing: the emotional aspect of caring for a patient.
EC is directly related to the definition of caring, which is multidimensional and includes the feeling of empathy as well as the action promoted by this feeling (Lachman, 2012). EC is focused on a “caring relationship,” which presupposes a supportive, meaningful, trusting, and professional relationship between the carer and the one who is cared for (Lachman, 2012; Skoe, 2014). EC’s focus on the relationship and respect is in line with the ANA Code, especially with the first provision that explicitly requires practicing “with compassion and respect for the inherent dignity” of every patient (Olson & Stokes, 2016, p. 10). EC requires recognizing the individuality of a person and ensuring a respectful attitude that should protect their dignity (Lachman, 2012), which seems to make EJ and EC similar. However, EJ lacks the focus on the relationship or the intent to achieve this relationship exhibited by nurses.
Another distinction that can be used to set apart EJ and EC is that EJ focuses on the obligations of the caregiver, but EC draws on their responsibility (Lachman, 2012; Skoe, 2014). Thus, it is apparent that EC does not rule out justice or competence. Instead, it incorporates both of them while also introducing the dimension of relationship into the decision-making process (Lachman, 2012, p. 113). As a result, the outcomes of EC use in healthcare would be expected to include those of EJ while offering additional ones. In particular, it would be reasonable to expect a more trusting relationship between the nurse and the patient and more weighted and customized decisions that take into account specific circumstances and individual patients.
Lachman (2012) illustrates EC by discussing a case of a nurse who advocated for an increase in the level of analgesia for a diabetes patient with a below-the-knee amputation. The increase corresponded to the wish of the patient. The decision required resolving an ethical dilemma: the empowerment of the patient and the protection of their right to self-determination, which is required by Provision 1 of the ANA Code, may conflict with Provision 3, that is, the protection of the health of the patient (Olson & Stokes, 2016). The process of decision-making is not discussed by Lachman (2012) in detail. However, it can be assumed that since the nurse has managed to convince the physician to change the order, the patient was well-informed, and the risks that the physician was hesitant about were deemed relatively insignificant as compared to the needs and wishes of the patient.
Lachman (2012) suggests that this case is an example of EC, and this suggestion can be proved. Indeed, the process of decision-making involved treating the patient as a person, who has the right and should be empowered to make decisions concerning his treatment and who very often reports being in pain. This decision-making process appears to have included EJ (that is, the understanding of the rights of the patient), which could be rather ineffective in resolving the dilemma on its own since the nurse also had an obligation of ensuring the patient’s safety and protecting their health. However, the decision-making was also extended to include the feeling of caring for the person (trusting their self-assessment of the intensity of pain), which prompted the action of providing care (Lachman, 2014, p. 113). Thus, as Lachman (2014) suggests, EC can be regarded as a decision-making tool or problem-solving method, which makes it particularly useful in leadership practice.
The APN Leader Practice and the Ethic of Care Perspective
As it was discussed above, EC incorporates EJ, but it also expands and extends it, which makes EC more applicable to APN leadership and its settings (Skoe, 2014, p. 97). For example, as pointed out by Lachman (2012), EC is compatible with nursing partially because nursing and caring are closely interrelated. Apart from that, Melia (1994) points out that patient-centered approaches are natural for nursing, and if compared to EJ, EC shifts the focus of care from patients’ rights to patients as persons. Moreover, ANP leadership is also characterized by its attention to patient-oriented decision-making (Scully, 2015). Therefore, the EC’s focus on the patient and caring for the patient is compatible with ANP leaders’ perspective.
As pointed out by Lachman (2014), EC is also more likely to bring positive results since EC relationships presuppose a better ability to define patients’ needs and offer more opportunities for receiving feedback on the care due to the developed trust. Indeed, from a purely practical point of view, EC is geared towards the development of the relationship between nurses and patients, which is beneficial for the quality of care and the quality of the lives of the patients. Since the ultimate aim of ANP leaders is the achievement of person-centered high-quality care (Scully, 2015), EC appears to be an appropriate choice for them. In this respect, EC, which requires continuous development of the relationship, can be regarded as a mode of operation rather than just a decision-making tool, and it is a mode of operation that is compatible with ANP leadership.
There are some drawbacks to EC. According to Skoe (2014), EC-informed decisions are more difficult to make than EJ-informed ones since the introduction of the interrelationships into the process makes it more complex (p. 95). In the provided example of dosage increase (Lachman, 2012), it can be suggested that the difficulty consists of taking exceptional responsibility for the well-being of the patient regardless of the decision. In the case of EJ, the nurse would be able to distance themselves from the relationship with the patient, but in EC, they have to take it into account, which should be more psychologically and emotionally difficult. However, nursing leaders typically possess certain qualities that can facilitate the process, including being positive, visionary, flexible, and competent (Scully, 2015). Therefore, ANP leaders would be expected to be capable of applying and empowering others to apply a more complicated framework.
Indeed, nursing leaders are capable of motivating and empowering people around them, which is why ANP leaders would be expected to promote EC in their settings and empower others to use it. Here, it should be pointed out that that ANP leaders do not have to take the position of authority (Scully, 2015), which implies that any APN can become engaged in the process of promoting EC, in particular, through leading by example. However, more structured means of promoting the idea also appear to be relevant. In general, the perspectives of ANP leadership and EC seem to be compatible both concerning the theory and practice of nursing, which should prompt the leaders to promote the latter.
While both EJ and EC seem to apply to healthcare and are in line with the ANA Code of Ethics, the latter is more comprehensive and corresponds to the Code to a greater extent. Indeed, EC includes the EJ perspective (that is, the respect towards human rights, caregivers’ obligations, and justice), but it also incorporates a wider perspective on nursing dilemmas. In particular, it extends the obligation of nurses to their responsibility to care, which is supposed to involve the feeling of caring for and the action of providing care and requires taking into account the personality and specifics of the circumstances of every patient. The major tool that EC uses is that of building trusting and reciprocal relationships between nurses and patients, which is likely to complicate the process of decision-making and is also expected to improve the quality of care. Indeed, a more trusting relationship presupposes more accurate diagnoses of patients’ needs and more extensive feedback on care, which is an apparent advantage of the approach.
From the point of view of ANPL, EC is a nursing-specific decision-making tool that can have positive outcomes for the quality of care, which is why it is extremely helpful. EC is also in line with the focus of ANP leadership on patient-centered care, which is why it could be viewed as a highly compatible tool that should be relatively easy to adopt. Concerning the methods of adoption, leading by example can be offered as well as more organized efforts, including educational ones. To sum up, the perspectives of EC and ANPL intersect, and ANPs can and should adopt and employ the tool to inform their decisions.
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