Normative nursing ethics: A literature review and tentative recommendations

Introduction

Ethical controversies abound within nurses’ professional lives—being a nurse entails grappling with difficult and often controversial moral issues that arise at the level of individual practice, as well as organizational and public policy. Ethics, of course, is complex and difficult; indeed, for that reason, practical and professional ethics encompasses an academic discipline, including the disciplines of bioethics and nursing ethics. Scholarship in nursing ethics therefore provides a valuable resource for practicing nurses, by engaging in the methodical, rigorous reasoning necessary to clarify and ultimately resolve difficult ethical issues relevant to the profession. Ideally, the results of scholarship in nursing ethics would influence how nurses engage with patients and play a significant role in policy development. ⁱ

The model of nursing ethics scholarship thus outlined is normative in nature—it is inquiry about what practices and policies are right and wrong, good and bad, and so on. Normative ethical inquiry and analysis is central to the practice of nursing, whether applied to specific situations at the bedside, or institutional and public policies that influence nursing practice. Guiding documents grounded in normative ethical analysis, such as the ANA Code of Ethics ¹ and The International Council of Nursing’s Code of Ethics for Nurses, ² have a fundamental effect on nursing practice. And nursing school curricula are expected to include normative ethical content; for example, the American Association of Colleges of Nurses’ ³ BSN Essentials includes ethics as a primary component. The corollary expectation is that nurses who enter practice have a foundational knowledge of clinical ethics, including prevailing ethical views and laws related to confidentiality, informed consent, truth-telling and deception, the right to refuse treatment, parental autonomy, decisional capacity, and surrogate decision-making.

A broad examination of the nursing ethics literature, however, demonstrates a notable lack of normative inquiry. The volume of empirical ethics research—that is, work that is derived from observation or experiment—on the other hand, has grown significantly, and is far more prevalent than normative scholarship. This is evidenced by a literature review of Nursing Ethics (1994–2017) conducted by the authors, which assessed the number of empirical versus normative articles, and any related trends, over that period. That investigation revealed a steady trend toward more empirical articles and fewer normative papers appearing in the journal, and a large disparity that now exists between the number of articles in those areas—the number of empirical studies currently dwarfs the number of normative articles. Although not definitive, these data provide strong prima facie evidence of the nature of the field of nursing ethics as a whole, due to the fact that Nursing Ethics is the only journal dedicated to that field.

In this article, we describe the results of our review and the problematic implications of the gap between the number of normative and empirical articles in nursing ethics. We then suggest several potential solutions aimed at remedying these problems, and evaluate their costs and benefits. We conclude that there are several steps that can be taken that would strengthen normative inquiry within the nursing academy, and that such measures would be overall beneficial to the profession of nursing, the nursing academy, students of nursing, and patients.

Normative versus empirical investigation

Normative inquiry can be distinguished from empirical research in both content and method.

The domain of the normative can be divided into the deontic, within which actions are classified as required, permissible, impermissible (i.e. wrong), and supererogatory (i.e. above and beyond the call of duty), and the evaluative, within which certain states of affairs, people, motives, or traits of character are classified as good or bad (and better or worse), and virtuous or vicious. ⁴

Strictly speaking, the normative domain includes more than simply the domain of ethics, primarily because deontic features apply outside that domain, for example to law, etiquette, or rationality. The sort of normative inquiry we are interested in discussing here, however, is ethical inquiry, that is, investigation of claims about the ethical or moral permissibility, wrongness, and so on of acts, and the moral goodness and badness of various states of affairs, policies, traits of character, and so on, that are relevant to nursing practice. We therefore use “normative” in its more circumscribed but common sense, to refer to the domain of the moral or ethical per se.

Normative inquiry is a type of philosophical investigation that aims at establishing, rebutting, or otherwise examining the truth or plausibility of normative propositions and the potential justifications for them, where a normative proposition is a claim that falls under the categories described above, for example a claim that some action or practice is morally wrong, or that a certain policy is ethically good or just. Take for example the issue of Medically Assisted Death (MAD). Normative propositions opposed to MAD, for example, would include the following claims: that MAD is morally wrong, that MAD should be illegal, that nurses ought not participate in MAD, that professional nurses’ organizations should adopt official positions opposed to nurse-participation in MAD, that a nurse who participates in MAD is a bad nurse, and so on.

The methodology of normative inquiry is philosophical argumentation. Normative inquiry marshals the tools of logic, critical reasoning, conceptual analysis, and moral theory, and uses various argumentative strategies and methods of reasoning suited to applied ethical inquiry, such as argumentation from analogy, inference to the best explanation, “intuition pumping,” ⁵ and “reflective equilibrium.” ⁶ This is the methodology of philosophy (the academic discipline), applied to ethical questions.

Furthermore, normative nursing ethics is a species of normative inquiry in general (grounded primarily in the field of ethics, understood as a sub-field within the discipline of philosophy), and therefore is an academic specialization, scholarship in which must therefore be practiced (if such work is to be of high-quality) by those with advanced training or background in the relevant field(s). Such training or background would include deep familiarity with the methodologies noted above, as well as a firm grounding in moral theory (e.g. familiarity with the major works, contemporary and historical, that bear on topics in healthcare ethics in general and nursing ethics in particular). Without that theoretical and methodological background, scholars who enter into normative discussions are liable to trod over ground long since covered, miss important arguments and distinctions relevant to the discussion, and fail to marshal the best arguments in support of their positions.

For example, a scholar who wishes to argue against the ethical propriety of MAD on the basis that it involves killing a patient must be familiar, at least to a significant extent, with the large philosophical literature on the distinction between killing and letting die, the related and more general distinction between acts and omissions, and the ethical relevance of those distinctions—especially arguments for the view that such distinctions are not, in fact, morally relevant. ⁷ She must also be familiar with the difference between causing death and causing harm, including the standard view in moral philosophy that killing is not always a harm (and the justification for that view), ⁸ as well as the literature on professional role-based arguments that attempt to support, or argue against, intentionally ending life based on the societal or inherent role of the clinician. ⁹ And this is, in many ways, the tip of the iceberg. Without a substantial grasp of at least many of these concepts and arguments, the relevant discussion of the ethics of MAD will inevitably be incomplete, confused, or both.

And the topic of MAD is not unique in that regard—in order to discuss rigorously most, if not all topics that arise within healthcare ethics, one must have an expert-level grasp of the theoretical issues that bear on those topics. That is, one must be, at least to a sufficient degree, an expert in the field of ethics, per se. Normative scholarship is thus not only important, but importantly distinct from non-normative work, not only in its aim, content, and methodology, but also in terms of what academic background is required to do such scholarship well.

Empirical inquiry, unlike normative investigation, is scientific inquiry in the strictest sense: investigation that begins in observation and through rigorous logical and mathematical methods infers from those observations general conclusions about the way the world is (or probably is), especially conclusions that constitute explanations of why we observe the phenomena we do. Not all non-empirical inquiry is normative (much of philosophical inquiry per se is non-empirical, as are the fields of mathematics and logic), although all normative inquiry is non-empirical (although, normative conclusions will often be based on the results of empirical investigation—more on that below).

An easy, if oversimplified, way of understanding the distinction between normative and empirical inquiry is that the latter aims at discovering what is the case, whereas the former aims at establishing what ought to be the case.

That is not to say that normative inquiry is divorced from empirical inquiry. Facts established empirically (viz. scientifically) will often comprise key premises in normative arguments, especially when the issue is of a practical nature (as one finds in the field of applied ethics in general, and the bioethical fields, including nursing ethics, in particular). For example, the extent to which MAD has been abused in the jurisdictions in which it is legal—a fact that might be investigated empirically (at least once an appropriate definition of “abuse” is determined)—may be a key premise in a normative argument against legalizing MAD. The crucial point is that empirically established facts cannot by themselves settle any ethical questions—for that, a philosophical argument is needed. For instance, even if it were to be established that MAD is routinely abused, in order to support the anti-legalization position an argument must be made that the moral costs of permitting that abuse outweigh, ethically speaking, the moral benefits of legalization (such as respecting patient autonomy or promoting the welfare of patients suffering at end-of-life).

Empirical inquiry, then, can discover facts that are indispensable for making moral arguments about the sort of real-world policies and practices in which bioethicists and clinicians are interested. ¹⁰ But empirical inquiry alone is insufficient for drawing moral conclusions—that is the insight behind Hume’s ¹¹ famous explanation of the “is/ought” gap, and (expressing essentially the same idea) Moore’s ¹² discussion of the “naturalistic fallacy”: one cannot legitimately infer normative conclusions (claims about what ought to be the case) from non-normative premises alone (claims about what is the case). To reach a moral conclusion, you need a moral starting-point–that is, some sort of moral-theoretical premise or moral principle, which is by its nature not empirically discoverable. Considering and evaluating those starting-points is the unique job of normative ethics. Thus, normative inquiry per se, while potentially using empirically known premises in the arguments it marshals (when its investigation is aimed at real-world policies and practices), does not engage in empirical investigation, and vice versa. To suggest otherwise is to miss the important intellectual division of labor, and differences in academic expertise, characteristic of those two distinct modes of inquiry.

Trends in Nursing Ethics and nursing ethics

Nursing Ethics began publication in 1994. We reviewed all the articles in Nursing Ethics published from 1994 through 2017. Given the scope of the review, there was no search strategy and the only inclusion criterion was the availability of an abstract. A total of 1199 articles were reviewed and categorized.

All articles with abstracts were individually reviewed and categorized initially by the first author, a bioethicist with expertise in normative inquiry. All abstracts for all articles were read and if categorization was clear from the abstract alone the article was not read. If there was doubt with regard to categorization after reading the abstract, the article was either skimmed (if sufficient for categorization) or read in its entirety, in order to glean its main focus. Results were reviewed and confirmed by the second author, a nurse with expertise in empirical inquiry. Each article was categorized in one of three ways: (1) essentially normative, (2) essentially empirical, or (3) hybrid (both empirical and normative to significant extents) or miscellaneous (not reasonably categorizable within (1) or (2)). Review articles were categorized as follows: reviews with all empirical articles were labeled as empirical, and reviews of all normative articles were labeled hybrid. ⁱⁱ Data were entered into an Excel spreadsheet and frequencies were computed for each category and the sample as a whole.

The results of the review are provided in Figure 1 below, which shows the total number of articles in each category for each year.

OPEN IN VIEWER

Figure 1.

Results of the literature review; horizontal axis displays years, vertical axis represents numbers of articles, which are displayed and color-coded by category.

These results illustrate a stark lack of normative inquiry, in terms of both total numbers of articles as well as percentage of total articles. Furthermore, the trend over time reflects an increasing emphasis on empirical inquiry and a comparative loss of focus on normative scholarship in Nursing Ethics. And because Nursing Ethics is the only journal dedicated to the field of nursing ethics, this change plausibly represents a shift in the focus of the field itself. Importantly, the data demonstrate not only a comparative divergence between normative and empirical scholarship in nursing ethics, but also an overall drop in the number of normative papers.

Problems with a lack of normative scholarship

These findings suggest that the field of nursing ethics as a whole has taken a profound and steady empirical turn over the past decades—one that threatens to relegate crucial normative scholarship to subsidiary or even fringe status. The comparative lack of normative scholarship in nursing ethics may be indicative of the makeup of the nursing academy as a whole and the sort of academic work that is valued therein. In particular, nursing scholars are by and large nurse-scientists—the humanistic and thus the normative dimensions of nursing scholarship are therefore a small and, we would argue, undervalued dimension of the nursing academy.

Notably, a recent review of bioethics literature per se demonstrated a shift toward empirical research across the field; however, this trend was attributed, in large part, to articles in Nursing Ethics. ¹³ The shift at issue can be, and has been, plausibly explained by several additional factors, most notably a dissatisfaction with the abstract nature of normative ethics, the integration of ethicists into the clinical setting, and the relatively new but exceedingly influential focus on evidence-based practice. ¹⁴ It has also been suggested that the inclusion of more healthcare professionals on research teams, including nurses, might result in the use of more empirical methodologies, given the training and experience of those involved. ¹³ In addition, it is plausible that as nursing professors have needed to compete for increasingly scarce academic resources, empirical research has become even more of a priority, since such research is usually required for securing large external grants. Relatedly, it is possible that the faculty shortage in nursing, and the increased teaching loads that result from it, have compelled some professors who are interested in nursing ethics generally (including normative inquiry) to focus instead on empirical work in nursing ethics, due to the greater likelihood of securing grants that might alleviate their teaching loads.

To be sure, addressing the exact nature of the cause of the trend in question is both interesting and important, and requires further research. However, our focus is primarily on identifying the trend itself, and proposing some solutions in response to its problematic implications. And while uncovering precisely the trend’s causes may, in some cases, be important for fully incorporating relevant solutions, we believe that many methods of promoting normative inquiry are largely independent of the exact ways in which historical, cultural, and institutional factors have interacted to produce the current gap between normative and empirical work in nursing ethics. We therefore focus on understanding some of the main problems with that gap, and on how the nursing academy, and the profession of nursing as a whole, might fruitfully address them.

The ostensible decrease in normative scholarship in recent years has implications for practice and research. One relatively obvious reason why the decrease is problematic is that normative scholarship is beneficial and directly applicable to the practicing nurse. Sustained scholarly inquiry into the moral foundations of nursing and the ethics of specific nursing policies and practices contributes to ethical nursing practice. A more robust and engaged literature on the normative dimensions of nursing practice stands to engage more nurses, both inside and outside of academe, in the debates and conversations that promote a deeper and fuller understanding of ethical nursing. Insofar as normative scholarship is lacking, or is crowded out by empirical inquiry, those benefits are lost.

We may reasonably infer that the relative lack of normative scholarship in nursing ethics is due, at least in large measure, to a corresponding lack of scholars of normative nursing ethics, at least compared with those who work on empirical issues related to nursing ethics (unless we are to presume, implausibly, that those working on normative scholarship have a far lower publication-rate than those working on empirical nursing ethics). This should not be a surprise, given that nursing PhD programs do not, in general, train scholars in normative ethics, or in any humanistic discipline for that matter. Such programs train empirical researchers–that is, nurse-scientists. PhD-trained nurses who wish to work in normative nursing ethics are therefore left either to learn the relevant fields on their own (a dubious prospect for producing high-quality scholarship), or to acquire additional and significant formal training beyond their PhD, such as a master’s degree in bioethics (an onerous and often undesirable task for newly minted researchers).

The result is that nurse-scholars interested in ethics will tend to take the empirical route, rather than the normative one. This has significant negative consequences not only due to an absence of beneficial normative scholarship, but also because normative scholars must be central to nursing education related to normative nursing ethics. Ideally, we would argue, this means having those scholars teach full courses in nursing ethics and function as full-time faculty within schools of nursing. At a minimum, we must work to ensure that normative inquiry is prominent within nursing education, and normative scholars can provide a credible foundation for teaching students the relevant concepts and skills. If nurse-scholars interested in ethics are pushed, by disciplinary norms and inertia, toward empirical ethics, or more generally if there is a large comparative numerical gap between nurse-ethicists who are empirical researchers and those who are normative specialists, the risk is that there will be too few normative specialists to teach a sufficiently robust curriculum in normative nursing ethics.

Thus, there are strong research-based and teaching-based reasons for having more scholars of (i.e. trained specialists in) normative nursing ethics. A final reason is that scholars of normative nursing ethics contribute to interdisciplinarity, because the normative dimension of nursing practice requires engagement with humanists, not just scientists. Interdisciplinarity is especially enhanced if those who work on problems in normative nursing ethics are not nurses. Inviting non-nurse bioethicists or philosophers to contribute to the core debates in normative nursing ethics will also enhance the field, by incorporating novel perspectives and methodologies. The result would likely be more well-rounded teachers and higher quality scholarship.

Addressing the problems: supply and demand for normative nursing ethics

If we accept that these findings represent a trend indicative of the status of inquiry in the field of nursing ethics, and that there are compelling reasons to approach it as problematic, solutions are needed. In this section, we outline several ways this might be accomplished. The broad theme is that normative nursing ethics ought to be a mainstream area of specialization within the nursing academy.

If we are to effectively increase the “demand” for normative inquiry, we must explicate the value of normative ethics for nurses at all levels. This means being able to articulate how scholarly work in this area informs practice, and we need to include the language of normative ethics in nursing curricula. Conversations about evidence-based practice, which on their surface seem to embrace empirical evidence while rejecting normative inquiry, must incorporate a normative perspective. The “evidence,” narrowly construed as that which comes from scientific research, cannot by itself settle how nurses ought to care for patients; and insofar as a focus on evidence-based practice obscures that fact, ¹⁵ a conscious effort to include normative thinking within discussions of “the evidence” is needed. More generally, as nurses—both in the academy and in practice—become more comfortable with normative language, theories, arguments, and their application to real problems and issues in nursing, there will likely be a corresponding increase in the demand for normative scholarship, as well as broader participation in the relevant debates. To that end, for example, practicing nurses can be encouraged to join ethics committees, and ethics rounds might include normative presentations on nursing-focused topics by specialists in normative ethics.

Attention must be paid to ensuring that there is an increase in the volume of the appropriate content, and as such, the nursing academy should take steps to increase the number of specialists in normative nursing ethics within its ranks. In particular, normative ethics should be an area in which a nurse-scholar might write a dissertation. That means that a nurse-scholar should be allowed to be a nurse-humanist, and (correspondingly) not required to be a nurse-scientist. That is not to say that PhD-trained nurses should be unfamiliar with nursing science—what it does mean is that a purely normative dissertation should be permitted. That is what is required in order acquire a research specialization in the field of normative ethics via formal academic training. Indeed, such projects should not only be permitted, but should be supported by nursing PhD programs.

This is, perhaps, an expansive view of nursing scholarship, and entails an extension of what it means to be a nurse-researcher. It means that the nursing academy is not simply a home for scientists and empirical researchers, but for the broad swatch of researchers and scholars of nursing practice. That includes those whose work focuses in the humanities. We think it hardly needs defense that humanistic nursing research (especially of the normative kind) is a vital part of nursing scholarship and is important for practice, and thus should have a core role within the nursing academy.

It might be thought that permitting purely normative dissertations in nursing PhD programs is unnecessary to achieve the aim of increasing the number of specialists in normative nursing ethics; and in that case, providing the relevant resources to support such programs (especially hiring additional faculty who specialize in normative ethics) might be unnecessarily burdensome on schools of nursing. In particular, it might be suggested that MSN-prepared nurses should pursue a PhD in bioethics or philosophy and write their dissertations on a topic in normative nursing ethics. There are several problems with such a proposal. First, if the goal is to increase normative nursing ethicists within schools of nursing, such a proposal remains wanting—it is currently an advantage to have a PhD in nursing, if the goal is to be hired as a nursing faculty member. And the goal should be to have more nursing faculty with the relevant specialization, not just more scholars of normative nursing ethics wherever they happen to be housed, in particular because of the teaching-related benefits of additional scholars in normative ethics within nursing schools. In addition, a nursing faculty with ethicists is a more enriched academic community than one composed simply of nurse-scientists. The ethical and more generally humanistic aspect of nursing-scholarship can provide a beneficial perspective and source of ideas for all sorts of scholarship, including empirical inquiry.

Furthermore, not offering the normative option limits those who would specialize in normative nursing ethics, in at least two ways. First, some students might desire a PhD in nursing with a focus in normative nursing ethics, without a degree in bioethics or philosophy. Indeed, the nursing curriculum is decidedly distinct from that of a program in bioethics or philosophy, and the latter might be unattractive to those who are nevertheless committed to a scholarly career focused on normative nursing ethics. Second, many PhD students are not committed to a particular area of specialization when they enter the program, and may discover their interest in normative ethics during their studies. Having a normative option may be attractive to such students who wouldn’t have enrolled in a bioethics or philosophy PhD program nor would transfer into one at that point, but wish to be scholars of normative nursing ethics.

In order to support dissertations in normative nursing ethics, nursing schools should hire more ethicists. This includes hiring bioethicists and philosophers with research and teaching interests in normative nursing ethics, whether or not they are nurses. Interdisciplinary hires enrich departments and schools by providing varying perspectives and methods of inquiry. Schools of nursing should not shy away from hiring non-nurse bioethicists and philosophers as tenure-track faculty members. Correspondingly, schools of nursing should require stand-alone normative nursing ethics courses for all students, taught by experts in the field. This has not only the obvious benefits for students, but, more apropos to the issue here, encourages and promotes the normative dimensions of nursing scholarship, solidifying it in the minds of young nurses as a core dimension of the nursing academy.

Conclusion

According to our review of literature from Nursing Ethics, from its inception in 1994 through 2017, there is currently a substantial gap between the number of normative articles and empirical articles that appear in the journal. It is especially telling that over the 6 most recent years of the literature review (2012–2017) there are approximately 5.3 times as many empirical articles (305) than normative articles (58). This reflects an overall trend toward less normative work, and a large increase in empirical work, over the history of the journal. Insofar as Nursing Ethics is a reliable proxy for the field of nursing ethics as a whole (and as the sole journal dedicated to the field, we submit that it likely is), these data reflect the status of nursing ethics per se.

Normative and empirical scholarship in ethics are complimentary and necessary components of improving patient care. Empirical studies illuminate the sorts of concerns and ethical problems that need to be addressed normatively, and provide the factual basis for resolving those problems through ethical analysis. Thus, neither form of inquiry is, by itself, sufficient for improving practice: normative inquiry without empirical evidence is irrelevant, and empirical inquiry without normative analysis is incomplete. To that end, we have suggested some concrete ways in which we might remedy the relative dearth of normative scholarship in nursing ethics, and some complimentary steps related to practicing nurses that might set the stage for a broader understanding, acceptance, and specialization in the field normative nursing ethics.