Cultivating Moral Character and Virtue in Professional Practice

David Carr, David Carr

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351725101
• Edition: 1
• Topic: Education
• Subtopic: Education General

Cultivating Moral Character and Virtue in Professional Practice is a pioneering collection of essays focused on the place of character and virtue in professional practice. Professional practices usually have codes of conduct designed to ensure good conduct; but while such codes may be necessary and useful, they appear far from sufficient, since many recent public scandals in professional life seem to have been attributable to failures of personal moral character. This book argues that there is a pressing need to devote more attention in professional education to the cultivation or development of such moral qualities as integrity, courage, self-control, service and selflessness.

Featuring contributions from distinguished leaders in the application of virtue ethics to professional practice, such as Sarah Banks, Ann Gallagher, Geoffrey Moore, Justin Oakley and Nancy Sherman, the volume looks beyond traditional professions to explore the ethical dimensions of a broad range of important professional practices. Inspired by a successful international and interdisciplinary conference on the topic, the book examines various ways of promoting moral character and virtue in professional life from the general ethical perspective of contemporary neo-Aristotelian virtue theory.

The professional concerns of this work are of global significance and the book will be valuable reading for all working in contemporary professional practices. It will be of particular interest to academics, practitioners and postgraduate students in the fields of education, medicine, nursing, social work, business and commerce and military service.

Part I

Virtue, practical wisdom and moral psychology in professional practice

Chapter 1

Why you cannot regulate for virtuous compassion

Paul Snelling

Introduction

Professional practice within health care undergoes constant development as demographic patterns of health and disease change and the march of medical science brings new treatments to an aging population. In recent years, and particularly in countries operating a socialised system of health care, this development is undertaken within a context of fiscal challenge characterised by large levels of debt and continuing budgetary deficit. In the UK, such challenges have resulted in what some refer to as a crisis in service provision. These challenges have been particularly keen for nursing where a series of scandals of poor care have led to a lessening of confidence in the profession. As part of the response to such episodes, regulators and government have highlighted the need for compassion in care, including its inclusion in a revised professional code of conduct. Nurses are now required to treat people with compassion.

This chapter examines this development in two parts. Initially, a little detail about the events at Mid-Staffordshire NHSFT precedes an analysis of the appearance of compassion in codes and other regulatory and policy documents. In the second part, this appearance in regulatory codes is problematized on four counts. First: that the need for compassion is frequently assumed and seldom challenged; second, that compliance in quasi-legal codes requires understanding of its absence rather than its presence; third, that you cannot require people to have an emotional response; fourth, that enforced behaviour that looks like compassion is not compassionate. Attempting to require individual practitioners to treat people with compassion misunderstands both the nature of compassion and the function of codes. This is not to deny that good health care practice is or should be undertaken by compassionate practitioners, but this is best achieved through education and by providing an environment where compassionate practice can flourish.

Mid Staffordshire NHSFT and the compassion deficit in nurses

When the history of UK nursing in the twenty-first century comes to be written, the events at Mid Staffordshire NHSFT in the years 2005–2009 will be seen as of pivotal importance. Concerns about excess mortality and poor care resulted in a number of reports that failed adequately to answer criticisms or to satisfy local pressure groups. In response, Andy Burnham, the Labour Secretary of State for Health, commissioned Robert Francis QC, to undertake an independent inquiry, and his first report (Francis, 2010) detailed numerous incidences of poor care and recommended that a wider enquiry be undertaken. After the general election of 2010, which returned the Conservative-Liberal Democrat government and a continuing period of austerity, this wider enquiry was given the legal status of public enquiry, reporting in three volumes and almost 1,800 pages in January 2013 (Francis, 2013). Whilst referring to the awful experiences of individual patients at the hands of individual nurses and ward teams, these volumes also detailed wider organisational and cultural issues within the NHS and health care professions.

The tension between situational and individual factors in influencing behaviour is well known and can be seen in the events at Mid-Staffordshire and elsewhere. There is no doubt that some nurses showed ‘callous indifference’ towards patients, but a number of situational factors which significantly contributed to events were also identified, including poor leadership, prioritising financial targets and staff shortages. In an already much cited paper Paley (2014) drew upon the social psychology literature to suggest that there was no deficit in the compassion of nurses, and that lapses in care, which more often took the form of omissions than deliberately cruel acts, could largely be explained by general busy-ness. Well-known psychology experiments were cited in support. In one, an obviously visible man in a gorilla costume strolls across a basketball court unseen by many participants concentrating instead on counting passes (Simons & Chabris, 1999). In another, seminarian students late to deliver a lecture fail to spot a man in need of assistance as they rush past (Darley & Batson, 1973). By inference, nurses ‘run-ragged’ by ever-increasing demands and staff shortages simply failed to see the distress of the patients.

For a lengthy paper published in a normally rather esoteric academic journal, Paley provoked a number of responses (for example, Rolfe & Gardner, 2014). As well as robustly critiquing Paley’s application of the psychology experiments, the responses largely accepted that there had been erosion in standards in bedside nursing care. Individual nurses just aren’t as compassionate as they used to be. Explanations in terms of personal moral failure (The ‘Bad Apple’ – Traynor et al. 2014) find some favour with a public influenced by press coverage which tends to portray nursing as a ‘troubled’ profession (Girvin et al. 2016), reinforced by some scepticism about the value of graduate preparation and professional status (Gillett, 2012). Politicians have also been quick to point the finger at the profession of nursing and individual nurses. For example, the Prime Minister, David Cameron, was reported as saying that ‘there is a real problem with nursing in our hospitals’ which has been hidden to avoid rows and because people are so respectful of the work that nurses do (Kirkup & Holehouse, 2012a, 2012b). He was speaking at the launch of an initiative requiring nurses to perform ‘rounds’ on all patients every hour whether they need it or not; a clear example of response which sees episodes of bad care principally in terms of underperforming individuals who just need to be told what to do (Snelling, 2013).

Taken together, the reports received a number of responses, including from the regulator, the Nursing and Midwifery Council [NMC](NMC 2013), who proposed, inter alia, to undertake a comprehensive review of their professional code – recognising that there is a ‘need to raise awareness of, and ensure compliance with, the Code…’ (NMC 2013, p. 21). In fact, Robert Francis saw no need to change the Code, and had praised an earlier version. A version of the NMC Code written in 2002 was in force at the start of the period investigated (January 2005–March 2009), and a newer version was implemented from 2008. It is worthwhile to quote the relevant paragraph in full:

The NMC’s fitness to practise role is based on a Code which, like the GMC’s Good Medical Practice, has the merit of clarity and simplicity. Criticisms have been suggested of the 2002 version of the NMC’s Code for not making clear the priority that has to be given to patients. That criticism is unfounded. Not only is the requirement plain on a reading of the whole of The Code, it was also the product of a time when it was probably presumed that no nurse would ever think anything else was the priority. Unhappily, experiences such as that of Mid Staffordshire show that this presumption can no longer be made.

(Francis, 2013 p. 1040)

Nursing organisations and their codes

Broadly speaking, there are three different functions performed by organisations operating in the environment of professional health care (International Council of Nurses, 2015). First, the promotion of professional practice, which involves writing guidelines and other promotional and educational material, organising conferences and lobbying government. Second, regulation protects the public by enforcing minimum standards, including maintenance of a register of individuals permitted to practice. Entry to the register is controlled by validation of educational courses, and individual nurses whose practice is deficient can be removed from the register through fitness to practice procedures. Third, the socioeconomic welfare of nurses requires negotiating pay and conditions of work. Although there is some overlap between these functions, there is also clearly some tension: for example, nurses accused of malpractice by the regulator are often represented by their union. Organisations tend to undertake one of these roles, but in some cases fulfil more than one. In the UK, the professional body is the Royal College of Nursing (RCN) and the NMC is the regulator. The RCN also fulfils the role of trades union. Tension between these roles may have contributed to the events at Mid-Staffordshire, particularly in relation to lack of support for staff, but the RCN rejected Francis’ recommendation that the roles be separated (RCN 2013). It is important to keep these different organisational remits in mind when assessing the function of codes in professional practice, since the nature and form of a code depends upon which organisation wrote it and for what purpose.

Codes, generally, are either aspirational or prescriptive (Snelling, 2016). Aspirational ethics codes tend to be written by professional bodies outlining good practice and using descriptive or normative language. Prescriptive codes tend to be codes of conduct, written by regulators outlining minimum standards of practice and using directive language: each clause of the NMC Code starts with ‘you must…’. Conduct-codes are quasi-legal in the sense that they are used in fitness to practice proceedings as the benchmark below which conduct is not only blameworthy, but liable to sanction. A good deal of grey separates the black and the white poles of this dichotomy: for example, in the US (American Nurses’ Association, 2015) and Canada (Canadian Nurses Association, 2008), codes written by national professional bodies are referred to in hearings by regulators in some states and provinces. In the UK, separation between professional body and regulator is clear and The Code is clearly prescriptive. The difference between these two different sorts of codes and their expectations or requirements is of considerable importance, but there is ambiguity in the NMC Code (Snelling, 2017). The paper that presented The Code for approval to the governing Council stated that the ‘…Code is not an ‘aspirational’ document but a clear statement of the professional standards everyone should be able to expect from a nurse or midwife.’ (NMC 2014, p. 3), and yet The Code requires that nurses must: ‘Act as a role model of professional behaviour for students and newly qualified nurses to aspire to’ (NMC 2015, clause 20.8).

The distinction in level between ‘just acceptable’ and ‘good’, as related to the issue of compassion is seen elsewhere: Pellegrino and Thomasma’s influential book The Virtues in Medical Practice includes, in the chapter on compassion, the following:

Compassion is an essential virtue of medical practice. A good physician does not just apply cognitive data from the medical literature to the particular patient […]. Rather, the good physician cosuffers with the patient.

(Pellegrino & Thomasma, 1993, p. 79)

Compassion is considered both an essential medical virtue as well as one shown by the good doctor. The quotation is embedded in an account that identifies and explains the key medical virtues, which are not concerned with minimal standards of behaviour, but rather encourage doctors and nurses to become actually virtuous. But that is a different thing altogether than requiring virtue, something that the use of compassion in conduct codes attempts to do.

Regulation for compassion – professional codes

The version of the Code which impressed Robert Francis was published in 2002. In fact the word ‘compassion’ cannot be found within it. It states that:

You have a duty of care to your patients and clients, who are entitled to receive safe and competent care (clause 1.4).

[…],You are personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients (clause 2.2).

(NMC 2002)

The 2008 version, developed before the failures in care became nationally prominent, introduces the notion of kindness:

You must treat people kindly and considerately (clause 3).

(NMC 2008)

This was the version in operation at the time of the publication of both Francis reports. The latest version confirms that nurses must be kind, but now the word ‘compassion’ is added on four occasions, including at the start:

You must treat people with kindness, respect and compassion (clause 1.1).

(NMC 2015)

This clause applies to all cases, but there is also reference to the special needs of people as they approach the end of life:

You must recognise and respond compassionately to the needs of those who are in the last few days and hours of life (clause 3.2).

(NMC 2015)

There has clearly been a shift towards including compassion in the UK code for nursing – requiring it of nurses and midwives – that is not required for other professional groups. There is no mention of kindness or compassion in the UK medical regulator’s code, though it is seen in other countries’ medical codes. UK doctors ‘must be polite and considerate’, and ‘must treat patients as individuals and respect their dignity and privacy’ (General Medical Council, 2013, clauses 46 and 47). Fifteen other professional groups in the UK are regulated by the Health and Care Professions Council (HCPC), whose code requires that registrants must ‘treat service users and carers as individuals, respecting their privacy and dignity’ (Health and Care Professions Council, 2016, clause 1.1). The differences in approach to codified compassion may be a result of the perceived widespread lowering in standards of practice seen in Mid-Staffs and elsewhere as a problem particular to nursing, but it also reflects the claims that nursing makes about the nature of its relationship with patients that other professional groups do not. Doctors treat patients, while nurses care for them – and there is a literature on love in nursing (Arman & Rehnsfeldt, 2006) rarely seen in literature of other professional groups. The word ‘compassion’ can be found in most nursing codes around the world, though generally (with some exceptions) more visible in ethics codes than regulatory conduct codes (Snelling, 2016). The Hong Kong conduct code does not mention compassion, and in France, the latest country to introduce a conduct code, nurses are instead required to be conscientious and attentive: ‘Ses soins sont consciencieux, attentifs…’. (Ordre National des Infirmiers, 2016, Art. R. 4312–10).

These codes apply to regulated health care professionals, who share the feature of being required...