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Nursing Ethics

http://nej.sagepub.com Visiting Nurses Situated Ethics: beyond care versus justice


Ine Gremmen Nurs Ethics 1999; 6; 515 DOI: 10.1177/096973309900600607 The online version of this article can be found at: http://nej.sagepub.com/cgi/content/abstract/6/6/515

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VISITING NURSES SITUATED ETHICS: BEYOND CARE VERSUS JUSTICE*


Ine Gremmen
Key words: district nursing; ethics of care; ethics of justice; womens studies This article discusses Dutch visiting (district) nurses moral considerations of their daily work. It is based on an empirical study using extensive semistructured interviews. The study is informed by the theoretical debate on the ethics of care and the ethics of justice. It is argued that this debate easily turns into an unfruitful contest between these two perspectives: which one is best? The results suggest that visiting nurses moral considerations of their day-to-day work can be described well in terms of an ethic of care. At the same time, however, concepts and issues central to an ethic of justice are also of crucial importance to their considerations. Nurses ways of managing to combine both perspectives, even in situations of apparent conflict between them, are described. Thus, clues are provided on how the debate on the ethics of care and the ethics of justice may be carried out in a more fruitful way apart from through hierarchically opposing both perspectives.

Introduction
In this article, some results will be presented of an empirical study into the ethics of district nursing in the Netherlands. The study concerns visiting nurses (district nurses) moral considerations about situations that they actually encounter or have encountered in their day-to-day work. This is what will be called their situated ethics. Extensive semistructured interviews were the studys main source of empirical data. The aim was to gain insight into the moral reasoning of visiting nurses, thereby contributing to the theoretical debate about the ethics of justice (focusing on respect for autonomy, and rejecting intrusiveness and paternalism) and the ethics of care (focusing on relational responsibilities and rejecting indifference). One main issue informing the debate on these two perspectives concerns their mutual relationship. Traditionally, they have been considered as hierarchically ordered opposites, the ethics of justice having a higher status than the ethics of care, owing
*A preliminary version of this article was presented at the 10th International Congress on Nursing Research, Utrecht, 1314 July 1998. Address for correspondence: Ine Gremmen, Department of Communication and Social Welfare, Faculty of Social Sciences, Utrecht University, PO Box 80.140, 3508 CT, Utrecht, The Netherlands.

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to its (presumed) universal and impartial character. The genderedness of the perspectives involved (an ethic of justice being considered masculine, and an ethic of care feminine) may be taken to contribute to this hierarchical opposition.1 As a consequence, this hierarchy has been turned upside down by some feminist authors who argue in favour of the merits of care ethics.2 Useful as this strategy may be in certain contexts, it also bears the risk of turning the debate into an unfruitful contest between the two perspectives: which one is best?3 In reply, other feminist authors have, therefore, argued against viewing the ethics of care and the ethics of justice as mutually exclusive opposites.4,5 Some have added that theoretical considerations about their similarities and differences would need to be grounded in empirical research into the daily practices of care.6,7 By engaging in this study of the situated ethics-in-action of home care professionals, I hoped to find more specific clues about how this theoretical debate might be carried out in a constructive and fruitful way. The debate might then, in turn, provide insight and inspiration to nurses and other professional caregivers themselves. In what follows, I shall first explain some of the methodological background of my study. I shall then indicate briefly how visiting nurses daily work is organized in the Netherlands and describe what the nurses I interviewed told about what they identify as important goals and values in their work. In order to illustrate their situated ethics, I shall then describe their moral reasoning about situations where clients choices and preferences were in conflict with the interviewees professional values and goals. In the final part of the article I shall summarize the conclusions that can be drawn from the nurses described moral considerations and consider the implications that these findings may have for the debate on the ethics of justice and the ethics of care that informed my project.

Methodological background
This study was set up by using a grounded theory methodological perspective,8,9 from which it is considered to be of first and foremost importance to take seriously what informants who are directly involved with the subject under study (e.g. visiting nurses) have to say.10 Theory development is then realized by constantly going back and forth between the research material (e.g. interview transcripts) and theoretical considerations (e.g. the debate on the ethics of justice and the ethics of care). The projects main part consisted of semistructured interviews with 33 visiting nurses (31 women and two men). The interviewees ages varied between 28 and 57 years (mean approximately 40). Their years of experience as district nurses (years of working in hospital excluded) varied from five to over 25 years (mean about 13). Many interviewees had worked in a hospital setting for at least one year after completing their general nursing training. Several interviewees worked as general (hospital) nurses for more than 10 years before they changed to district nursing, which required an additional two years training. The interviews lasted for between one-and-a-half and three hours each. They have been transcribed as literally as possible. In analysing the transcripts, interview fragments have been grouped according to theme (e.g. clarifying clients needs and wishes or conflicting values). Stories about specific situations con-

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Visiting nurses situated ethics 517 cerning these themes have then been analysed in detail by using social psychological methods of discourse analysis that pay close attention to deliberations and justifications.11 In writing about the results of this study, I have opted for using the term visiting nurses because this shows that the nurses visit the clients in their own homes. This is an aspect of the work that is highly valued by the interviewees, and this, in turn, has quite some impact on their moral considerations, as will become clear from what follows. Furthermore, I chose the term clients as being the most appropriate one for me, as a researcher. Apart from clients the interviewees themselves also use the words patients, persons and people.

Visiting nurses work: a broad view of nursing care


Most visiting nurses in the Netherlands (and all interviewees in the study) work in government-subsidized organizations that, among other things, are specialized in providing nursing care in clients homes. Nurses, nurses aides, and, in an increasing number of organizations, qualified home helps, are the direct care providers. Among them, nurses have the highest level of education and mostly it is the nurses who are formally responsible for the care provided to specific clients. The clients usually belong to one or more of the following groups: elderly people, physically handicapped people, those who are chronically ill (e.g. rheumatism, diabetes mellitus, multiple sclerosis), and those who are terminally ill (e.g. cancer). The interviewees take it to be their professional goal to help clients to regain their self-sufficiency after an illness or an accident, to sustain clients self-sufficiency and quality of life while they are living with an illness or its consequences, and to support terminally ill clients by trying to make the last stages of their lives as bearable as possible. In addition, the clients partners or relatives, and their needs are often included in the interviewees considerations, especially if the partners or relatives are involved as family caregivers. Even though the starting point of the caring process usually consists of clients need for physical care, visiting nurses attention is directed at clients self-sufficiency and well-being in a broad sense, that is, consisting of physical and social, as well as psychological, aspects, which are seen as interrelated. Depending on the circumstances, the interviewees consider that their work entails: Physical care (e.g. washing, wound care); Offering information and advice (e.g. on the use of practical aids or on how the clients living environment may be adapted to his or her health condition); Providing social or emotional support (e.g. when social isolation, anxiety or grief are part of the consequences or the context of a physical illness or handicap); Co-ordinating tasks (e.g. making arrangements for help from different persons and organizations general practitioners, physiotherapists, volunteer organizations etc. to be provided in a co-ordinated way).

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The central value of district nursing: tuning in to clients lives


When the interviewees told of what they consider as central to their working as a visiting nurse, an ever returning issue appeared to be the visiting of clients in their own homes. They stressed the special character of providing care to clients at home. For example:
Its just very special to see these things, as you observe a patient in his own environment, with his partner, his children, his neighbours or his acquaintances being around . . . I still find it amazing how much information you can get about someone just by observing them in their own home. You wouldnt be able to find out about all that in a hospital, by asking questions.

In this context, many interviewees used the term guest to characterize their position in their relationship with clients. At the same time, they appeared to be aware of their being special guests. As the interviewees noted, clients may not feel obliged to clean up, take the curlers out of their hair, or even stop quarrelling with family members, before the nurse arrives. Often, the nurses also enter places in the clients homes where many guests may not be allowed, such as kitchens, bathrooms and bedrooms. They also often encounter clients in circumstances in which they might prefer to hide from other guests, like being undressed or when feeling emotionally vulnerable. As one interviewee said:
Look, youre their guest, you see? You visit clients in their homes, you observe all kinds of things about them. I mean, they have to literally undress for you and thats the way they feel, too, metaphorically speaking, you see? So you enter places that someone else never sees: the bathroom, the bedroom. So, you intrude enormously on their privacy.

The interviewees reasoned that they should adapt to the clients ways of living in order to minimize the negative consequences of the unavoidably intrusive aspects of their work. This means, among other things, that you automatically keep your distance and rather than rushing in and having things your own way, you try to continue things the way theyre used to and to be supplementary to that, you see? Apart from the aspect of intrusion into clients lives, the interviewees mentioned another reason why they think they should adapt to their life worlds. With the clients being in their own homes, this enables them to have more say in the nursing process than they would have in a hospital setting. At home it is the clients who own the place, as the interviewees put it. As a consequence, it is the nurse who has to adapt and tune in to the clients wishes and habits concerning the activities that the client needs help in fulfilling. For example, the necessity of being washed every day may be taken to be self-evident in a hospital setting and the patient will have to adapt to this rule. In a clients home, however, the washing can be an issue of negotiation between the client and the visiting nurse:
In a hospital, youre sort of picked up and they tell you: Everyone is washed daily, so youre not going to be an exception to that. You dont have a choice. At home, you do have a choice.

In short, owing to the clients staying in their own familiar environment, they (and their family caregivers) may have wishes, habits and preferences that the

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Visiting nurses situated ethics 519 visiting nurses think they both can and should address. Tuning in to clients lives appears to be the value that the interviewees considered to be central to their work. The interviewees expressions about what is most important in their work (e.g. adapt to clients life worlds; tune in to clients wishes, habits and preferences; contribute to their self-sufficiency and well-being; offer them help, advice and support) suggested that an ethic of care is a proper way to describe their intentions and activities. The perspective of tuning in to clients lives expresses context orientated and relational considerations, and suggests an orientation towards commonly (although not necessarily equally) felt or held responsibilities for clients well-being, including self-sufficiency. At the same time, it could be said that the interviewees thought it of the highest importance to respect clients autonomy. For example, they condemned any undue intrusion into clients life worlds. The disapproval of intrusion can be considered to fit well with an ethic of justice. It must be noted, however, that the interviewees disapproved of intrusiveness, using arguments that go beyond a narrow notion of autonomy. They rejected intrusiveness as a form of disrespect for a clients human dignity, and as an obstacle to tuning in to clients lives, rather than just as a form of disrespect relating to the clients right to govern their own lives (autonomy, as the justice perspective would have it). Furthermore, they did not condemn intrusion as being something that should not exist (as, again, a justice perspective might have it). Rather, they conceived it as something that may inevitably be connected to needing and giving care. It should be dealt with properly, rather than ignored. As a consequence, the interviewees moral reasoning about the central value of their work may be described as an ethic of respect for autonomy, provided autonomy is taken to entail not just well-informed, free and rational choices, but also relationships, emotions, habits and preferences. It would also be necessary to broaden respect for autonomy to include contributing to clients autonomy (e.g. their self-sufficiency) because the interviewees considered this as one of the main goals of home nursing care.

Situated ethics: when care and autonomy conflict


From the above it appears that care and respect for autonomy need not be mutually exclusive. Paying respect to clients autonomy can be considered an element of providing good home nursing care. However, care and respect for autonomy do not always go together so easily. Conflicts between them occur especially when clients preferences or decisions go (or at first sight seem to go) against nurses professional (and sometimes personal) values and norms. As to these values and norms, I shall focus on nursing considerations that are linked to the process and content of direct caregiving and care receiving. One interviewee has called these considerations nursing objections to what a client would want. Compared with other types of objections, such as practical or organizational reasons, the interviewees considered nursing objections to be the most legitimate reasons for not wanting to co-operate straight away with a clients decision or wish concerning the nursing process.

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Convincing or even pushing clients while not forcing them


First and foremost, the interviewees appeared to be convinced that, when they have nursing objections to a clients (or a family caregivers) wish, they should try and talk things over in order to come to an agreement, whether immediately or in the future. An example was provided by Barbara (a pseudonym, as are all the names in the interview fragments to be cited below). She told of a client suffering from a leg ulcer:
He doesnt want it to be looked after daily, because he doesnt want to be tied down to such a person [i.e. a stranger] visiting all the time . . . Then the wound gets worse and you consult a medical specialist about it and then you conclude, well, this would have to be looked after daily. And then he doesnt want that. And then, in the end, after a lot of discussion and things and after having waited for quite some time, they do see, well, it has to be, then. And then I got him so far as to allow us to visit daily, except Sundays.

Seeking agreement entails, in the interviewees opinion, that they should first acknowledge the clients view of the matter. They should explain the consequences of the course of action preferred by the client, as well as the reasons for the nurse to prefer a different course of action. All this should be aimed at reaching an agreement, even if only a preliminary one, or at finding a compromise where both client (or family caregiver) and nurse give in a little. Putting these considerations into practice requires that nurses should have information and knowledge available and be able to present them in an adequate way. They must be able to offer suggestions or make proposals (e.g. that the client or the family caregivers give it a try the nursing way) without putting the client under (too much) pressure. They should show patience (e.g. in suggesting to clients that they might like to think things over), and keep in touch with the client about the matter without undue pressure. They would have to try to win the clients confidence in order to ensure opportunities for him or her to voice objections, fears or worries, and they would have to listen and give information or support when the client wanted to discuss matters again. Last, but not least, they should think over the content and the weight of their own objections, as will be illustrated below. Many situations of conflict between what clients want and what nurses think is preferable may be settled to both the clients and the nurses satisfaction through discussion and negotiation. However, in certain situations, the seriousness of ones nursing objections seems to be strong enough to justify that, as a nurse, one explicitly resorts to ones professional authority. (This is not to imply that resorting to professional authority is absent in other situations. It can also be engaged in in a less explicit way.) The following is an example provided by Hannah, who told about a situation in general terms, but had actually confronted it in her work:
Sometimes it happens that family caregivers just leave someone lying in his own dirt. And often that is because of their fear and concern, or something: If you turn him, it hurts so much and . . . Well, it does hurt. And then you talk about alleviating the pain and what more can be done about that, together with the doctor. But I just think that you cant leave someone lying in his own dirt. I just consider that . . . And then I think: this is what I am a nurse for . . . This just is why they asked a nurse to come and help

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Visiting nurses situated ethics 521


out. Just to push such things through, I guess. So, sometimes I say: You may leave the room for a moment if you want to or, rather, if the family caregivers can manage: You could stand on that side close to his face and talk to him. And then Ill do all of the unpleasant work for the patient. Yes, but . . . Well, I think sometimes you really have to push things through and if they really dont want it, well, then thats the end of it.

In any case, clients should not be pushed too far or forced. Hannah, in the example just cited, explicitly stated that if they really dont want it, well, then thats the end of it. Many other interviewees would agree. They used the very same expression. According to the interviewees, situations for the legitimate use of force concern only forced admission into a nursing home in the case of clients who suffer from dementia and whose condition has deteriorated to such a degree that staying at home can be considered to imply serious risks for either the clients themselves or their environment. (Serious risk is the legally sanctioned reason for resorting to measures of force. Even then, several interviewees were greatly troubled by having to opt for forced admission into a nursing home, because they considered it a moral problem to go against a clients wish to stay at home. The interviewees stressed that the decision to resort to measures of force should never be taken by one nurse alone.) Dialogue and, in certain situations, explicitly resorting to professional authority, enable nurses to find out whether the clients (as well as the nurse) really want what they appeared to want in the beginning. What, then, if a client holds on to his or her wish, while the nurse still has serious professional objections but using force is not an option? The interviewees reasoned that then, thats the end of it. However, their stories and their moral reasoning did not stop here.

Not withdrawing from clients while disagreeing with them


The interviewees intimated that, when nurses have no more possibilities left to negotiate with clients, and when using force is not an option, as is usually the case, they cannot have things the nursing way when the client persists. Put slightly differently, if it appears that the clients really want what they wanted to begin with, then the interviewees concluded that they should acquiesce, even though they do not agree. They should just try to deliver the care that is accepted. The following example was provided by Kim. She visited a client in order to help her to prepare for going to a day therapy centre three times a week. The client resisted being washed. Even while the client may not have been able to understand the consequences of her wish, Kim was not willing to undermine the clients autonomy, taking autonomy to be the clients self.
I visit a lady who I cant get to accept help with washing herself. She ehm . . . [laughs] really smells, and she looks dirty, too. Yes, but you cant get her to have herself washed. Never. No. (I: Whats the situation?) Well, she has dementia . . . She can tell you in detail how she washes herself. But she doesnt do it. No. Then thats the end of it. Yes. Then its finished. In such situations people would get really angry if you said something about it and youd have all kinds of arguments about it and a real unpleasant situation; in fact, that would only make them upset, and then wed be even worse off. Its no use. And . . . yes, then you have

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to stop trying. Yes . . . The only thing you could do is to give her a medicine in order for her not to have the strength of will any longer. And I dont think that is acceptable at all. So, it is the way it is . . . If she can function this way, even though it may not be at a high level, then thats still something of her own. To change someones character or something, by medication . . . If she would behave in an aggressive way or would do dangerous things, then it would be a different matter. But otherwise I dont think you should resort to giving forced injections just because that would make it easier for us to wash her. Then I would say no. No, I ehm . . . have something against that. No, then her self . . . then she herself is more important. When it comes to that. As long as she is having a good time. And she wont be clean, then, if only she is content for the rest. At that point, she is more important than hygiene is. Yes, too bad if I dont succeed, then.

The crucial point in not forcing clients to have it the nursing way appears to be that it must be clear that they really want what they indicated they wanted in the beginning. What, then, about the nursing objections to these wishes? The dilemma implied for the nurses can be explored somewhat further by using another fragment of the interview with Barbara. Earlier on she told about a client who did not want to have a leg ulcer attended to every day. She concluded her story by saying:
Yes, you do respect it when people do not want that. But that doesnt imply that you leave it at that or that you let go of it altogether. I think, you still are . . . thats what I think your task is, or your obligation is . . . you are still responsible for keeping an eye on the situation and for bringing up the subject again to see whether you can motivate people, anyway. If they dont want it, then they dont want it. But thats what youre obliged to do, as a professional, as well, thats what youre a nurse for. In that sense, youre not free of obligations. But in the end, clients have the last word, thats what I think. If they dont want it any more, well, then they dont want it any more. But you always have to be able to bring it up again and . . . And if they do see the sense of it at a certain point in time, then you always have to be open for change. So, you shouldnt say, If you dont want it, Ill withdraw. Thats not how it should be, as I see it. Even though you disagree so strongly.

Respecting the clients decision not to have the wound looked after on Sundays seemed to be in conflict with another element of Barbaras professional responsibilities, namely providing good nursing care. Solving the dilemma by giving priority to either element did not seem to be an option. As soon as one element tended to tip the scales, Barbara continued her account by objecting to this tendency, introducing the objection by using the word but. In other words, when respect for clients autonomy and providing good nursing care are in apparent conflict, what is needed is still to find a way of combining them, rather than to opt for either one. How can this be achieved? As Barbaras story shows, one important point seems to be that the nurse, in going along with the clients wish, goes on to keep a constant eye on how the situation develops. A second requirement appears to be that nurses continue the process of defining their responsibilities towards clients. Take, for example, a story provided by Helen. She visited a young client who suffers from incurable cancer. The client and his family had resorted to an extensive alternative therapy, which Helen thinks a waste of time and energy. She observed that the clients condition was worsening rapidly and the general

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Visiting nurses situated ethics 523 practitioner agreed with her that he may die within a week. Helen discussed her view of the situation with the client and his family, but they stuck to having it their way. She continued:
And then you start defining your own task: what is my task, here? And I think: it is quite important that people are aware of the fact that they can spend their time doing different things, that they might do something else. You have to offer them a choice. I cant force them and say, Youd better stop this [alternative therapy] business, it is nonsense, it takes too much time and this mans condition is getting worse and worse. Thats not what I should say. But I think I should tell them: You might rather try and occupy yourself with his having to part, because, well . . . its rather insecure whether this therapy is going to work out, and, well . . . he . . . as I see it, he is just getting worse and worse. I had quite a conversation with them like that. And then they . . . they kept it up . . . Yes, I do explain my view of the situation. I mean . . . But I leave the decision to them. Often, things get clear, then. Then the family members or the patient make themselves clear to you, like: Well, Helen, I can see what you think of it, but I find that nonsense. . . . You have to respect that. And then you shouldnt keep bringing it up. Then I think you would have to go along with the patient.

Helen argued that she should explain her view of the situation. As the client and his wife hold on to their decision, Helen went on to argue that she should clearly determine her responsibilities. It appeared that, in her eyes, the possibility of sharing responsibility for the caring process had diminished owing to the difference of opinions. As a consequence, Helen seemed partly to divide (rather than share) the responsibilities to be taken. She proceeded by reflecting on and differentiating between her own norms and the clients. All this seemed to be aimed at continuing the caring process while at the same time showing respect for the clients decisions. Going along with a clients wish can be especially difficult when his or her health condition or general well-being could benefit a lot in the eyes of the nurse if the client would accept more of the care and advice offered. As a consequence, a third requirement in trying to combine respect for clients autonomy and providing good nursing care when these are in apparent conflict may be that nurses should deal properly with their own feelings about the situation. This is illustrated in a story by Sylvie, about a client who had a wound on his foot:
He just lets it rot away, while something could be done about it quite easily. But he just doesnt want it. Well, I find that hard to take, indeed. And its difficult to get that out of your mind. Then I really feel, well, something can be done about it and why ever dont they do anything? And then youre inclined to take over that responsibility, but each time I really have to think hard: no, the responsibility is with these persons themselves. You just have to explain to them time and again what that responsibility entails, what it implies if they dont do anything about it. And I think that requires a certain rationality and distance. But often its . . . I find that difficult, I really do. I find myself feeling angry about such things, or sad or whatever.

Apart from the necessity of reflecting on ones professional norms and how these may differ from the clients norms, Sylvies considerations illustrate the additional necessity for reflective thinking on ones feelings about the situation. The nurse, rather than the client, is responsible for dealing with these feelings. As a consequence, a fourth condition to be met by visiting nurses who are trying to combine the values of providing good nursing care and respecting clients

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autonomy may be that they can share (both their considerations and) their feelings about the situation with supportive team members. As Sylvie went on to explain:
Its awful being confronted with a rotting foot every day; youre not going to keep that up. So, together [with colleagues] you try to . . . Some have one idea and some have another and its just nice to put these ideas together. And thats nice when youre different. Some may be a bit emotional, some may be a bit rational and, well, I think that works out nicely. At least, thats what I find, its quite important to have a good team. Because, at the clients home, you work by yourself, you see? Thats why such conversations are quite important.

It must be noted that reflecting on ones own norms and feelings in order not to project them on to the clients situation does not amount to distancing oneself from the client to the extent that the relationship is disconnected. On the contrary, it may be argued that the process of self-reflection and making differences is engaged in in order to continue the caring relationship. This is illustrated by the last example from my study given here. It is a story told by Alice.
One time we had a man who suffered from cancer of the [body part] . . . He allowed us in to help him with washing now and again, but he didnt want to be washed daily. And then you have that discussion [among colleagues], you know: well, he never used to wash himself every day, so why should he change to doing so now, you know, just because there are these home care people visiting him. And this man used to lie on his couch and . . . He did have a hospital bed in his room, but he didnt want to lie in it. And then to respect that, even that he didnt use the bed to sleep in and just stayed on the couch. Just like his having the television on 24 hours a day. That was his choice, and even when his situation got worse and worse, you know [medical detail], he still opted for staying by himself. And then I asked him, I said: Gee, dont you feel lonely? No, I dont, theres the TV, theres always someone talking. You know? That was fine with him, he did have his company. And he died by himself, too. That was what he opted for. But to just let that happen, you know, to leave someone like him being so ill, to leave him by himself in that house. Thats a difficult thing to do. But he . . . that was what he opted for. It was fine with him the way it was. Otherwise, we might have been able, you know, to make an arrangement with a volunteers organization to pay him visits, you know? But he just didnt want it. So, one day, we found him, dead. You see, thats what may happen, then. But . . . yes, it really was his choice. And then I think: thats what you should try and show respect for, actually. And then Im glad that it came out. That I managed to continue it his way.

Alices story shows, among other things, that leaving clients uncared for is a difficult thing to do, even if they opt for that and apparently want to be taken care of by being left to their own devices. It may be said that Alice nevertheless succeeded in going along with the clients preferences, while at the same time continuing to provide good nursing care, and that she did so by staying attentive to the clients situation, by continually negotiating her responsibilities towards the client, by differentiating between her professional norms and the clients decisions, and by reflecting on her own feelings about the situation. Not ignoring any of these aspects may have enabled her to go along with the clients wishes, while at the same time continuing the caregiving in a way she herself could feel glad about afterwards. In conclusion, not forcing clients appeared to be the most important norm to

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Visiting nurses situated ethics 525 stick to for the interviewees when clients keep refusing the help offered and the nurse has professional objections to the clients refusal. When the opportunities for discussion or negotiation with the client are exhausted, the interviewees reasoned that they must go along with what the client really wants. Thus, it seems that the (ethic of justice) principle of respect for clients autonomy finally proves to be the decisive element in the interviewees moral considerations. However, considerations central to an ethic of care prove to be equally important. In a way, an ethic of care and responsibility, again, seems quite adequate as a means of description. While an ethic of justice perspective would hold that clients right to autonomy should be respected for its own sake, the interviewees reasoned in favour of going along with clients decisions, arguing that forcing them would undermine their well-being and, what is more, their own selves. As the examples given above show, selves encompass more than the ability to make free and well-informed autonomous decisions. Autonomy should be considered in the broad sense of what clients really want, whether or not this may be a rational choice. Furthermore, the interviewees considerations of their responsibilities are not replaced by and do not end at the point of respecting clients autonomy. The caregiving (and the care receiving) as well as the associated moral reasoning, continue and that is how the interviewees seemed to think it should be. They considered it their moral obligation to continue providing care that is accepted, which implies, among other things, keeping a constant eye on how the clients situation develops and continuing the process of defining ones responsibilities towards him or her. In order to combine in a satisfactory way (a way that they can feel glad about afterwards) the requirements of going along with the clients wish and going on to provide care, the interviewees indicated that, with the help of colleagues, they must differentiate between the clients and their own (professional and/or personal) values and norms, and reflect on their feelings about the situation, because these should not be projected on to the client. This may be considered a way of reasoning that fits well with an ethic of cares focus on diversity rather than universality, even while, at the same time, it provides a safety net against intrusion and paternalism, which are rejected from an ethic of justice perspective.

Conclusions
The results of this study suggest that an ethic of care and responsibility adequately describes the situated ethics of district nursing. An ethic of care fits in with both the content and the terms of the interviewees considerations, which concern, among other things, context orientated and relational considerations, responsibilities, and differences that may exist between specific nurses and specific clients norms and feelings. However, if the concept of respect for (clients) autonomy, which is central to an ethic of justice, is taken to encompass contributing to clients self-sufficiency and supporting clients expressions of their needs, wishes and preferences, as well as what clients really want, rather than just rational well-informed decisions, then an ethic of justice can also be considered as central to the interviewees considerations. Indifference to clients needs (condemned from an ethics of care perspective) and paternalism and undue intrusion into a

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526 I Gremmen clients life world (rejected from an ethics of justice perspective) are also condemned by the interviewees on the basis of this broad conception of clients autonomy. However, even if reconsidered, autonomy may not be thought of as the only theoretical concept that is useful when taking home nursing care into account. It would need to be embedded in an ethical theory (of care) that offers much more, namely concepts such as attentiveness, openness, communication, trust and responsibility. This is because, as I hope to have shown, there is much more to home nursing care than respect for autonomy, even if considered in its broadest sense. Home nursing care also entails processes such as: establishing and sustaining contact and a trusting relationship with clients; interpreting their needs, preferences and wishes; communicating about these needs, preferences and wishes; negotiating what are both clients and nurses responsibilities; and, last but not least, critical self-reflection by nurses, both individually and within their teams. These conclusions can be considered as arguments in favour of the merits of an ethic of care. In the context of the traditionally assumed (and gendered) hierarchy between the ethics of care and the ethics of justice, they may be thought of as arguments that undermine this hierarchical order by turning it upside down. However, the results reported here may be taken to imply an argument in favour of undermining the hierarchical opposition between the ethics of care and the ethics of justice in a way that is even more fundamental. The situated ethics of district nursing suggests, first, that respect for autonomy can be, and often is, an unproblematic element of providing good nursing care, rather than the opposite. Secondly, even when autonomy (i.e. clients choices and preferences) and care (i.e. nurses professional responsibilities) are apparently in serious conflict, both concepts are of crucial importance to visiting nurses moral considerations. Finding a proper (even if only temporary) way of taking both obligations into account seems to be what is needed, rather than preferring one to the other. In the same vein, the theoretical debate on the ethics of justice and the ethics of care may not be solved by opting for one of the two perspectives. Rather, it would be necessary to think of ways of taking into account both perspectives at the same time, however difficult this may be on occasion. The situated ethics-in-action of the visiting nurses in this study may entail a reminder that the similarities and differences between justice, autonomy, care and responsibility would have to be theorized contextually, that is, without trying to find the one final answer. This, especially, may contribute to undermining these values gendered hierarchical order.

Note
The research project described in this article was a follow-up study to a PhD project on the situated ethics of home helps.12 Both studies were undertaken at the Womens Studies Department of the Faculty of Social Sciences at Utrecht University, The Netherlands.

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Visiting nurses situated ethics 527

Acknowledgements
Special thanks go to Michael Crijns, Myra Keizer and Selma Sevenhuijsen for their helpful comments on an earlier version of this article.

References
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