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Graded Assertiveness

Graded Assertiveness

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Published by: Lisa on Jul 06, 2013
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Volume 26 Number 1
Mary Chiarella
RN , CM, Dip N.Ed. LLB (Hons) (CNAA), PhD, FRCNAProfessor of Clinical Practice, Development and PolicyResearch, Faculty of Nursing, Midwifery and Health,University of Technology, Sydney, New South Wales,Australia.mary.chiarella@uts.edu.au
Elizabeth McInnes
BA(Hons); Grad Dip App Sci (Nursing); MPH
Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, New South Wales, Australia.Email: elizabeth.mcinnes@uts.edu.au
law, ethics, power, status and image of nursing,retention
This paper explores the legal and ethical frameworksthat inform nursing practice and health care cultures.Using methodologies informed by critical raceand feminist jurisprudence (also called ‘outsiderscholarship’), images of nursing and the positiveand negative effects of these images and their legal,moral and ethical impact on nursing practice, areexplored. This exploration assists in exposing some of the power structures and assumptions which governcontemporary nursing practice and standards of care and which impact on factors such as workforceretention.
Legality, morality and reality ‑ the role of the nurse
in maintaining standards of care
Applies to all settings in which nurses’ practise.
Nurses, other health care professionals and patients
Primary argument
Examples from case law are used to illustrate therelationship between image and power and howthese affect legal and moral frameworks and therealities of the workplace for nurses. This is doneby examining the law, as a form of insider (wherebythe world is described in terms of pre‑existing powerstructures) and outsider story‑telling (whereby stories
and recurrent images of nursing emerge from case lawanalysis. These have implications for: the way in whichnurses respond to critical situations which involve theadoption of a moral stance; nurses’ legal and ethicalstatus, and; the environment in which nurses’ practise.
Each of the images of nurses described in this paperis still present in both recent case law and workplacepractice. These images have deleterious effects, mostparticularly contributing to feelings of powerlessnessin the workplace and affecting nurses’ ability to be‘heard’ when patient safety is at stake. While someimages give the nurse a degree of moral (and clinical)responsibility, there is no promise of power.
an unmet need to feel valued and appreciatedcontribute to nursing workforce attrition. A complexmix of solutions needs to be implemented toachieve improved workplaces, patient outcomesand retention rates. The promotion of a safety andquality agenda; promoting strategies for self care; welldeveloped clinical career paths; implementing clinicalsupervision, and introducing Magnet organisationreform, are among the important solutions foraddressing these issues.
Volume 26 Number 1
This article explores the legal, moral and ethicalframeworks that inform nursing practice, how thesehave shaped and been shaped by images of nursing,and the positive and negative effects of these imagesof nursing. Case law is used to illustrate the pointsraised and suggestions are made to help bridge thegap between legality, morality and workplace realityfor nurses.The legal frameworks that inform nursing practiceinclude the provisions within registration statutes,codes of conduct and other advice through registering authorities; civil requirements in common law andstatute law; industrial requirements and sanctionsand criminal sanctions. Moral and ethical frameworksare enshrined in professional codes of ethics and alsoin normative ways that have developed in responseto historical and sociological developments suchas the ’ethic of obedience’ (Chiarella 1990); the’ministering angel’ ethic (Chiarella 2002) and the’tyranny of niceness’ (Walker 2003). Walker describesthe ’tyranny of niceness’ thus:
The pre‑eminent value inherent in the technique of  sensibility of ‘being nice’ is one that insists that overt
conict must be avoided wherever and whenever possible. This sensibility is sanctied in our culture
in the notion that a good woman does not contradictand a nice woman does what she is told. By extension
then, a good nurse takes what she nds (or is given)
and does not question. A nice nurse therefore mustbe a good nurse
(Walker 2003 p.4).
The behaviour this technique initiates is one of backing off, assuming a passive posture, or silencing oneself. It is a technique of sensibility which shapes(us) in pervasive and powerful ways. The reciprocalbehaviour such a technique of sensibility elicits is onethat is generally tacit; it does not usually ever cometo expression. The combination of value, behaviour and response leads to a form of silent but mutualagreement between the individuals engaged in the
conict situation…it gently insists that no further 
dialogue is needed to resolve the situation
(Walker2003 p.145).The ‘tyranny of niceness’ and the images of the
moral and ethical frameworks that have developedin nursing and most particularly contribute to feelingsof powerlessness in the workplace and affect thenurses’ ability to be heard when patient safety isat stake.
Images and stories of nurses with reference to case
A study analysing the status of the nurse in law, societyand scholarship using methods grounded in criticalrace and feminist jurisprudence, known as formsof outsider scholarship, examined 180 cases from1904 to 2002 (Chiarella 2002). In this study, the lawis described as being about storytelling, with storiescreated by insiders (stock stories), who describe theworld according to their own power structures, andby outsiders, who try to challenge these stories to
‘…the one the institution collectively forms andtells about itself. The story picks and chooses fromamong the available facts to present a picture of 
what happened: an account that justies the world
as it is’
(Delgado 1989 p.2421).
‘... makes sense, is true to what the listeners know about theworld, and hangs together’
(Scheppele 1989 p.2080),outsider stories are those which are told
‘to attack and subvert the very institutional logic of the system’
(Delgado 1989 p.2429) and which provide a meansto expose
‘the perceptual fault lines’
(Scheppele1989 p.2082). Outsider stories can be seen astroublesome, upsetting or interfering and the naturaltendency is to ignore them because the establishedorder already works very well for those in power.Five recurrent images emerged from the caselaw analysis and, it is argued, these providethe backdrop for the ethical and legal practiceframeworks that have developed in nursing. Theseimages are: domestic worker; ministering angel;doctor’s handmaiden; subordinate professional
Volume 26 Number 1
and autonomous professional. These imagesprovide themes as stock and outsider stories and
in which nurses are under control. The associatedimages are the nurse as a domestic worker;doctor’s handmaiden; and subordinate professional.Secondly, as outsider stories (nurses are in control);the nurse as a ministering angel or autonomousprofessional.
Outsider stories and their effects on nurses’ legal,moral and ethical status
For the purposes of this article, outsider stories areused to illustrate the effects of stories on nurses’legal, moral and ethical status. The ministering angelwas the earliest outsider story and is full of ethicalresonance. It was fostered by Florence Nightingale tocounteract the Sarey Gamp image, the image of thedrunken and disreputable nurse described by CharlesDickens, who was a danger both to herself and thehouseholds she visited (Dickens 198). This image of the ministering angel served nurses well in a Victorian’man’s’ world enabling them to maintain proprietyin order to conduct the professional experiment of ’respectable’ women at work, and to some extent itstill serves nurses well in terms of public relations.However there are downsides to this ‘ministering angel’ story which negatively impact on nurses andnursing. These include the fact that nurses tend tobe essentialised as nun‑like creatures; which in turncreates the public view that ’virtue is its own reward’;
creates an environment of permission to suffer andmaintains the notion of a ’cloistered’ profession keptaway from the ’real’ business of the health care world(Barber and Shadbolt 1996).The idea of the nurse as an autonomous professionalbegan with Ethel Bedford Fenwick in 1908, who statedthat:
'the nurse question is the woman question' 
(citedin Dock and Stewart 1938 p.254). The features of this story are that it originally addressed the pursuitof professional equality through a ’sameness’model (MacKinnon 1987 p.33); it sought to breakfree from doctor’s handmaiden and subordinateprofessional images through the pursuit of autonomyin self‑regulation, self‑management and the setting of professional and educational standards (Chiarella2002). This autonomous professional imagehas been the genesis of both the regulatory andindustrial framework in which nurses practise andhas been arguably quite successful in establishing the autonomy of the profession and in the setting of standards.However the main downside of this story is that thismodel has been pursued without redress to the powerimbalances in the way in which health is structured. Ithas not addressed (and may even have perpetuated)the cultural problems, such as institutionalisedpowerlessness, which affect retention (Chiarella
and promote innovation within the profession. Ithas also been focussed predominantly on nursing,rather than health (Chiarella 2007 p.41). Each of the images described here are still present in bothrecent case law and workplace practice to someextent; the examples below demonstrate the effectexerted by these images.
Factors which inuence nurses’ ability to deliverquality patient care
Thirty years of research has consistently found two
is they feel unable to deliver the quality of carethey believe is required and the second is they feelthey are not valued or respected (Chiarella 2002
to deliver quality patient care are: a multidisciplinaryteam approach to patient care delivery (this is wellembedded in the safety and quality agendas); the
patient expectations; a formula to ensure reasonableworkloads (which ought only to be a short‑termsolution) and a work environment which fosters nurseautonomy and control over practice in order to provide
A multidisciplinary team approach and the recognitionof nursing expertise through clinical career pathsare also important. Recently there has been a bodyof international research that suggests that skillmix changes generally require a change of role for

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