In retrospect, the end of the first decade of the 21st century may well represent a turning point in the history of nursing in the United States. Should this prediction be accurate, 2010 was a landmark year. In that year, the Institute of Medicine (IOM, 2010) submitted a report on the state of nursing entitled, The Future of Nursing: Leading Change, Advancing Health. Simultaneously, Benner, Sutphen, Leonard, and Day (2010) published their treatise on nursing education—the first comprehensive review of nursing education in the 21st century. Both works reached similar conclusions regarding nursing education—sustaining relevance for the nursing profession in modern health care demands fundamental change to nursing curricula, pedagogy, and socialization. The prescience of these documents is already evident in their influence on nursing education. Seemingly overnight, the urgent tone of the book by Benner et al. (2010) and the message of the IOM's (2010) report resonated with nurses across the nation. A clarion call for radical transformation was sounded, and nursing's scientists and educators rushed to answer. However, their earnest haste to enact change created conceptual voids. One of these voids is what Benner et al. (2010) called everyday ethical comportment.
The purpose of this analysis is to clarify the conceptual idea of everyday ethical comportment as it exists today. Accomplishing this task requires identifying the critical attributes of the everyday ethical comportment. This endeavor is meant to sharpen nursing's understanding of the concept using Rodgers' (2000) evolutionary method for concept analysis as a guide. A secondary aim is to establish whether everyday ethical comportment remains important to nursing as a discipline.
Benner et al. (2010) contend that teaching ethics is an area that nursing education traditionally does well. Compared with other professionals such as engineers, architects, and physicians, nurses are socialized to think of people first (Benner et al., 2010), and this contributes to the formation of integrity and person-centered morality. Nevertheless, modern health care ethics is more complex and challenging than ever. Nurses must not only be able to understand ethical concepts, but they must apply them in their daily interactions with patients, other nurses, and other health care team members. In addition, nurses must possess the ability to recognize unethical situations and have the know-how to halt unethical behavior (Benner et al., 2010). Regarding bioethics, as it is understood by most health care professionals, Benner (2005) observed:
Biomedical ethics applied to nursing and medicine has been concerned primarily with 8 interrelated areas: 1) clinical competence, judgement and comportment of practitioners; 2) fair allocation of scarce resources; 3) protection of human subjects; 4) ethical assessment of medical technologies; 5) ensuring patient rights including autonomy and informed consent; 6) beneficent practice; 7) nonmaleficence; and 8) social policy related to healthcare. These bold ethical agendas are still being worked out and will continue to be central to ethics of healthcare.
In fact, Benner, Sutphen, Leonard-Kahn, and Day (2008) observed that nurses are most familiar with biomedical ethics, also known as normative ethical theory or principlism ethics. The classic work of Beauchamp and Childress (2009) exemplifies biomedical ethics and bioethics as a discipline. Biomedical ethics is a methodology where principles such as autonomy, beneficence, nonmaleficence, and justice are applied to ethical dilemmas (Benner, 2005; Beauchamp & Childress, 2009). The biomedical approach is typified by various ethical decision-making models that can be applied to ethical quandaries to aid the user in making ethically sound choices. Biomedical ethics provides a necessary protection against egregious ethical violations while strengthening health care's appreciation of human rights, but it is not without limitations (Benner, 2003, 2005). Although a comprehensive critique of biomedical ethics is beyond the scope of this article, three observations are particularly relevant to conceptualizing everyday ethical comportment. First, biomedical ethics minimizes the importance of relationships in health care ethics. Second, the nature of biomedical ethics encourages health care professionals to perceive ethics as a series of problems with discreet resolutions, and third, principlism ethical theory is the dominant ethical system in health care today (Benner et al., 2008). Finally, the biomedical approach may be culturally biased and predisposed toward marginalization of nondominant viewpoints (Rodgers, 2005). For example, Konishi, Yahiro, Nakajima, and Ono (2009) observed that Japanese culture favors harmony over strategic ethical decision making. Similarly, Benner (2005) noted, “The ethical landscape of healthcare requires a vision of one's basic relatedness to others and notions of a good life in relation to the human condition” (p. 152). In addition, biomedical ethics minimizes advocacy and social justice concerns (Benner et al., 2008) that are important to nursing.
The prevailing reality of ethics in health care, therefore, does not align with the vision of everyday ethical comportment that Day and Benner (2002) described as “a prereflective, socially embedded practical knowledge that is rational, even though it is not based on rational calculation (ie, based on formal criteria)” (p. 77). The discrepancy between how most health care professionals perceive ethics and the concept of everyday ethical comportment is exemplified by Jurchak and Pennington (2009), who reported a successful intervention for fostering “ethical comportment” in new intensive care unit (ICU) nurses. The new ICU nurses were asked to identify a clinical problem encountered during their ICU orientations and write a narrative describing how they solved their moral quandary. Although ethical reflection is vital to the formation of ethical comportment (Benner et al., 2010), a dilemma-based understanding of ethical behavior is not representative of the fully developed concept (Benner, 2005). Liaschenko, Oguz, and Brunnquell (2006) called this the “tragic case” (p. 672) approach to ethical decision making, and it encourages viewing ethics as isolated worst case scenarios with relatively simple solutions. Although Jurchak's and Pennington's (2009) attempt at supporting ethical practice is laudable and probably useful, it likely represents a fundamental misunderstanding of everyday ethical comportment. Conversely, a compelling example of promoting the formation of ethical comportment in nursing education are pedagogies that encourage the becoming of an ethical nurse through the embodiment of experiences (McAllister, Levett-Jones, Petrini, & Lasater, 2016). For example, Benner (1991) noted that nurses express ethical comportment through skills, knowledge, actions, and the nurse's intent. In other words, everyday ethical comportment is embodied by the nurse. In addition, everyday ethical comportment is indivisible from practice (Benner, 2005). Benner (2005) asserted that becoming a good nurse requires connecting clinical and ethical reasoning, developing moral imagination, moral agency, and acute skills of ethical perception so that the nurse may respond with skill and know-how in every professional interaction.
In summary, Benner et al. (2010) argued that formation of ethical comportment should be a priority for nursing education. Moreover, Benner et al. (2008) claimed that understanding rules for ethical conduct and the application of ethical principles is insufficient for navigating modern health interactions on an everyday basis. These authors suggested that nurses must develop an embodied notion of good derived from praxis. However, a review of the literature reveals a confusing jumble of characteristics and definitions for everyday ethical comportment. The current descriptions of everyday ethical comportment lack clarity. A nurse would be hard-pressed to recognize ethical comportment when it occurs in practice, and it is challenging to teach what cannot be conceptualized in a meaningful way. Therefore, the remainder of this analysis focuses on providing clarity for the concept of everyday ethical comportment.
Rodgers' (2000) evolutionary approach to concept analysis best aligns with current philosophical thought on the nature of science and the development of scientific thought in nursing (Rodgers, 2005), and it is the method used for this concept analysis. For Rodgers (2000), the overarching purpose of concept analysis is to identify the attributes of the concept. In pursuit of identifying the concept's critical attributes, antecedents, and consequences, Rodgers (2000) identified a six-step process for analyzing concepts. These steps are: (a) identify concept of interest and surrogate terms, (b) select a setting and sample, (c) collect data about the concept, (d) analyze data, (e) identify essential(s), and (f) identify consequences (Rodgers, 2000). The following analysis uses Rodgers' (2000) six-step process as a format for relating a detailed plan for conceptually analyzing everyday ethical comportment. However, it should be noted that the process is inherently iterative and fluid. Although presented separately, the steps may overlap or coincide (Rodgers, 2000). For example, it is difficult to identify surrogate terms for everyday ethical comportment without first collecting data about the concept. Consequently, steps two and three preceded identifying surrogate terms for everyday ethical comportment and coincided with identifying a need for analyzing the concept. In addition, Rodgers (2000) stressed that data collection must be rigorous with every effort taken to reduce bias. This admonishment demands systematic data collection. Therefore, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2017) guidelines were used to conduct a systematic review of the literature.
Setting, Sample, and Data Collection
In accordance with Rodgers' (2000) method, a systematic literature review was conducted on October 5, 2017. The Cumulative Index to Nursing and Allied Health Literature (CINAHL®) and PubMed® databases were used. The search terms everyday ethical comportment and ethical comportment were used. The search was limited to English language studies. Because everyday ethical comportment is a newer concept and literature on the subject is limited, no disciplinary restrictions were employed. In addition, because knowledge of this phenomenon developed primarily within a dialectic, it is essential to capture the genesis of ethical discourse on the subject (Rodgers, 2005). Further, opinions, letters to the editor, and other nonexperimental articles may have merit in concept analysis (Rodgers, 2000). For all these reasons, data were collected without temporal restrictions. Furthermore, during the appraisal process, the articles were appraised for relevancy, clarity, and whether assertions were supported by evidence, but they were not leveled in hierarchal fashion; the search yielded 28 results. A purposeful review of commonly cited bibliographical references from selected ethical works of Benner and a focused search of the terms using the Google™ Scholar search engine resulted in 11 additional items identified as seminal or substantive contributors to current thinking on the concept. These 11 articles and texts were added to the results. The records were checked for duplicates using the online citation manager RefWorks©; seven duplicates were found. A total of 32 articles were identified for preliminary screening. Abstracts were reviewed for relevancy, clarity, and scientific foundation. Twelve articles were found to be noncontributory to the concept of everyday ethical comportment; these 12 articles were excluded from analysis. No articles were excluded for lack of clarity or scientific foundation.
At this point, 20 full articles or texts were retrieved. Each article or relevant section of text was read and evaluated for significance to the concept of everyday ethical comportment. The systematic review process is depicted in Figure 1, and the included articles and texts are listed in the Table. Next, each article or relevant text was reread and selected quotes were identified. These quotes were coded as related to either attributes, antecedents, or consequences. Furthermore, several related topics were identified. These topics are disclosed and briefly explored to better distinguish everyday ethical comportment. Finally, themes were identified between the quotes by reviewing a journal kept during the review and coding process. The findings are presented in the following sections.
Flowchart depicting the systematic literature review conducted in this concept analysis.
Articles and Texts Included From Review
Surrogate Terms and Related Concepts
An exhaustive literature search did not reveal any terms that mean the same thing or should inspire a mental image or intuitive notion that is equivalent to everyday ethical comportment. There are several related terms including ethics of care, practice-based ethics, and professional comportment. Edwards (2009) observed that Benner, a scholar of note regarding everyday ethical comportment, is influenced by the ethics of care. In addition, the concept of practice-based ethics is frequently alluded to in the literature (Benner, 1991, 2005; Benner et al., 2008). Furthermore, Clickner and Shirey (2013) provided a concept analysis of professional comportment, and Clark (2017) along with Day and Benner (2002) underscored the relatedness of etiquette and civility to ethical comportment. These concepts are undeniably related to everyday ethical comportment. In the cases of the ethics of care and practice-based ethics, the related concepts may provide the epistemological bases for everyday ethical comportment (Benner, 1994). Therefore, related concepts are worthy of consideration. However, these related concepts are only akin to everyday ethical comportment and not a substitute term for it. For example, if an investigator identified an instance of practice-based ethics, that instance is not necessarily an example of everyday ethical comportment.
Antecedents are events, instances, behaviors, or occurrences that must precede the concept (Rodgers, 2000). Antecedents are analogous to the circumstances involved in physiologic reactions. Figure 2 provides a comprehensive list of antecedents for everyday ethical comportment. In everyday ethical comportment, a client–nurse relationship must be established for the concept to occur. Further, a state of mutual respect must exist within the relationship (Benner et al., 2008). Openness is another antecedent to everyday ethical comportment. Benner (1991) noted that openness to new experiences suggests the ability to learn and adapt to unexpected human encounters. Openness in client–nurse interactions implies an internal moral dialogue and the acceptance of the patient as a person with inherent dignity, rather than merely the object of nursing care (Benner, 1991). Once the nurse meets the patient as another human, the nurse may be more present for the encounter. Presence is an additional antecedent to everyday ethical comportment, but presence is more than a physical state of being. Presence requires active consideration, engagement with the “other,” and caring (Benner et al., 2008). When nurses are genuinely present for client–nurse relationships that are mutually respectful, their openness allows them to appreciate the client's innate dignity and meet the client as a person.
Visual representation of conceptualized everyday ethical comportment.
The final three antecedents to everyday ethical comportment are notions of good, moral agency, and courage. Benner (1991) contended:
Through experience within a socially based practice, stories and concrete firsthand experiences build narratives and memories of salient clinical situations so that one moves from the status of a novice to that of a skillful practitioner. This process of membership and participation creates a socially embedded knowledge of the good in the practice.
Therefore, comprehending the ethical good is linked to clinical practice and experience. Notions of good are found in the narrative accounts of experienced nurses. These narrative descriptions of real-life practice suggest a situated understanding of ethical reasoning (Benner, 1994; Benner, Tanner, & Chesla, 2009). Socially embedded notions of good permeate every aspect of the client–nurse relationship. However, understanding what is good or ethical does not ensure the manifestation of everyday ethical comportment. Nurses must have a sense of moral agency or the feeling that one's actions can influence ethical situations (Benner, 2005). Finally, nurses must have the courage to call out poor practices, advocate for patient's rights and inherent dignity, and defend nursing as a profession—even in the face of power or personal and professional repercussions.
Embodiment. As previously discussed, biomedical ethics is an important safeguard against violations of patients' rights or addressing heretofore unnoticed ethical problems (Benner, 2005). However, principle-based ethical decision-making models frame ethics as a system for problem-solving (Benner, 1991, 2005). Benner (1991) observed, “It is in disembodied and conceptual distance that normative ethics fails to grasp essential embodied human distinctions of worth, such as honor, courage, and dignity” (p. 4). Understanding human distinction requires direct exposure to patients' lived and expressed reactions to specific ethical situations (Benner, 1991). Webster's New Dictionary defines embodiment as “to form into a body; to incorporate; to give concrete expression to; to represent” (Landoll Inc., 1997, p. 130). The embodiment of everyday ethical comportment, therefore, is the fusion of lived experience with physical presence and action (Benner, 1991). Normative ethics, or the biomedical ethical model, may allow clinicians to view problems with distance and objectivity, thus facilitating an ethical choice. However, normative ethics circumvents the experiential ethical narrative indicative of clinical experience (Benner, 2003, 2005; Benner et al., 2010). Everyday ethical comportment is identified by its inexorable link to clinical practice and an experiential understanding of the good in every patient encounter; everyday ethical comportment is not guided by tragic case scenarios (Benner, 2005). Further, Day and Benner (2002) noted that everyday ethical comportment is lived and embodied in practice. Consequently, accurately understanding ethical situations requires physioemotional contact with clients within a therapeutic client–nurse relationship (Benner, 1991). Thus, everyday ethical comportment demands a nurse who embodies clinical and ethical reasoning manifested through the sum of the nurse's thoughts, intents, and actions no matter how small (Clickner & Shirey, 2013).
Skilled Relational Know-How. Everyday ethical comportment occurs within relationships. These relationships may extend beyond the traditional client–nurse dyad to include the nurse's interactions with families, communities, or other members of the health care team. Skilled relational know-how is the purposeful and respectful ways, developed through experience and exhibited in practice, that nurses relate to others in supporting their interests (Benner, 1991). In nursing, relational skills are learned through discourse based on personal narratives of right and wrong, as well as what is good in different contexts (Benner, 1991; Benner et al., 2008). Benner (2005) observed that ethical comportment is bound to clinical comportment because forming helpful and therapeutically effective relationships requires knowledgeable and practical ethical and clinical reasoning skills. As nurses move from novice to expert, their relational know-how becomes more refined and their ability to recognize and impact ethical outcomes increases (Benner, 1982). For example, McAllister et al. (2016) described using cinema to foster relational know-how in nursing students. A film can be transformative for students by helping them explore the authentic emotions within themselves that are portrayed on screen. This process aids students in learning to recognize and empathize with those emotions in others. Cinema also enhances the development of moral imagination and helps students identify strategies to help patients (McAllister et al., 2016; Noone, 2009). The more experienced and competent nurse builds on this foundation. For example, Jurchak and Pennington (2009) encouraged reflection on actual encounters that vexed new ICU nurses. During this stage of development, nurses may rely on rules, laws, or policies to direct their ethical interactions with clients (Benner, 2005; Day & Benner, 2002). Finally, experienced nurses develop and transmit to others a rich narrative history of ethical encounters that nurses apply to client–nurse relationships and other ethical situations (Benner, 1991; Benner et al. 1996). Nurses at this stage expertly apply a practice-based understanding of the good in addressing patients' everyday needs (Benner, 1991). Critically, it is important to realize that skilled relational know-how manifests differently depending on the nurse's progression from novice to expert (Benner, 1982).
Caring. A tendency toward caring is essential for nursing practice (Edwards, 2009). However, caring, as a critical attribute of everyday ethical comportment, must not be conflated with an ethic of care. Edwards (2009) noted that the ethics of care, like those described by Gilligan, Tronto, and Gastmans, focuses on the emotional and contextual dimensions of the ethical situation. It well may be that the ethics of care underpins the philosophical foundations of everyday ethical comportment (as does practice-based ethics), but an in-depth epistemological analysis of everyday ethical comportment does little to clarify the concept (Benner, 1994; Edwards, 2009). Such an epistemological analysis is also beyond the scope of this article. For conceptualizing everyday ethical comportment, caring as a critical attribute refers not to a philosophical ethic of care, nor does caring refer to the caring a neighbor might provide by watering plants for a vacationing friend (Edwards, 2009). Rather, the attribute of caring references knowing the patient and valuing their innate dignity and personhood as one might their own. Caring, in this sense, also describes the nurse's ability to experience emotion, history, and context alongside the patient and form ethical choices in conjunction with, not apart from, the client (Benner, 1991; Benner et al. 2009).
Salience. Benner et al. (2010) described salience as knowing what is and is not important in situations based on clinical reasoning. As previously noted, clinical and ethical comportment are linked (Benner, 2005). Benner (2005) noted, “ethical and clinical reasoning cannot be separated because the vision of what is good, bad, or harmful dictates sound clinical judgments” (p. 153). Likewise, developing an ethical sense of what is good is essential, and this is accomplished through situated learning, practical experience, and socially embedded notions of good (Benner, 2005; Benner et al., 2010). For nurses, ethical reasoning occurs authentically and in action. In other words, abstract ethical deliberation is unrealistic in most daily real-world nursing interactions (Alexander, 2002; Benner, 2005); nonetheless, ethics remains an integral part of these interactions. Again, this emphasizes the ubiquity of ethics in client–nurse relationships and that dilemma-based ethical decisions are atypical occurrences (Benner, 2005). Benner (2005) described complex ethical deliberation as taking a picture for later examination when real-life is a film—constantly evolving. Developing a sense of ethical salience requires transitional reasoning. Transitional reasoning is the ability to respond to changes and adjust care appropriately while still identifying and prioritizing the most critical issues (Benner, 2005). Experienced nurses recognize salient ethical situations by drawing on previously developed ethical narratives and applying learned notions of good to actual situations.
Rodgers (2000) noted that consequences result from the concept. The concept analysis of everyday ethical comportment identified four main consequences: excellence in nursing practice, improved patient outcomes, protection of the vulnerable, and moral imagination. Benner (2005) emphasized six aspects of everyday ethical comportment essential to becoming an excellent nurse or provider. These aspects are “1) linking clinical and ethical reasoning; 2) thinking in action and reasoning in transition; 3) perceptual acuity and the skill of involvement; 4) skilled know-how; 5) response-based practice; and 6) agency” (Benner, 2005, p. 153). These qualities demonstrate excellence in nursing practice. Improved patient outcomes result from the qualities exemplifying excellence in nursing practice (Silber et al., 2016). Furthermore, patient advocacy is foundational to contemporary nursing practice (Alexander, 2002; American Nurses Association, 2015; Benner, 2005; Wocial, 2010). Indeed, nurses are mandated to create ethically supportive environments in whatever capacity they practice nursing (American Nurses Association, 2015; Clark, 2017; Lachman, Swanson, & Winland-Brown, 2015). Everyday ethical comportment results in protection for the most vulnerable members of society because skilled everyday ethical comportment requires knowledge of what is morally good in clinical practice (Benner, 1991, 2005; Wocial, 2010). Knowing what is morally good allows nurses to create rules, policies, and safeguards that protect vulnerable populations (Day & Benner, 2002). Also, everyday ethical comportment fosters a sense of moral agency and courage in nurses (Benner, 2005; Benner et al., 2009). Courage facilitates action to enhance or restore what is morally good, thus protecting patients (Benner, 2005). In this way, a cyclical feedback mechanism exists between the consequences of everyday ethical comportment and the concept's antecedents whereby the consequence of everyday ethical comportment creates an environment conducive to the concept's manifestation. Finally, everyday ethical comportment both requires and nurtures a sense of moral imagination (Wocial, 2010). Wocial (2010) observed, “Moral imagination is the ability to ponder and wonder about the inherent rightness or wrongness of decisions, choices, and behaviors. It is the act of considering the possibilities of things one cannot see or hold” (p. 93). Developing moral imagination helps nurses fulfill their professional obligations as described in nursing's code of ethics while navigating the moral complexities of daily nursing practice by encouraging character development, moral sensitivity, and professional maturation (American Nurses Association, 2015; Lachman et al., 2015; Wocial, 2010).
Rodgers (2000) encouraged investigators to use exemplars of the concept under study from the literature rather than constructing one for illustration purposes. The purpose of the authentic case is to illustrate and explain the concept in real life (Rodgers, 2000). Benner (1991) explored the role of narrative in developing skilled ethical comportment. In recounting a narrative supplied by Baird, a pediatric RN, Benner (1991) provided an exemplar for everyday ethical comportment. Nurse Baird was caring for Sammy, a 6-year-old Amish boy with severe cerebral edema. Sammy was transferred to the medical–surgical floor in preparation for transfer to an extended care facility. Sammy was ventilator-dependent, and his prognosis was poor. Sammy's family was told that the hope was that he would someday be able to consume foods orally but that he could not make significant neurologic recovery because of the extent of his injury. At the beginning of the weekend, nurse Baird began tube feeding in accordance with the agreed-on plan of care. However, the nurse was worried that Sammy would pull out the irritating tube. Over the weekend, nurse Baird noticed how Sammy's mother stayed by his side, attended to him, and prevented him from pulling out his feeding tube. On Sunday, Sammy's mother notified Baird that she was leaving for church and that Sammy's sister would stay with him. The family expressed their belief that healing was possible through their faith. Later, nurse Baird was called to the room by Sammy's sister. Baird found the feeding tube lying beside Sammy. Baird began talking to Sammy as she interacted with him by cleaning him and changing his linens. Baird asserted, “as I spoke, I looked at him and I felt for the first time since I'd been caring for him that he was looking at me—not the vacant, wild-eyed look I'd grown accustomed to, but an understanding, ‘with-it’ gaze I had not seen before” (Benner, 1991, p. 5). Knowing how traumatic replacing the feeding tube had been previously, nurse Baird looked at Sammy and decided to execute a standing order for oral fluids. However, Baird was concerned because she and her colleagues all agreed how dangerous it would be to give Sammy liquids orally. Nurse Baird feared that he might aspirate. Nevertheless, Baird gave Sammy 60 mL of water, which he consumed ravenously and without aspiration. Subsequently, Sammy began to speak in his native Pennsylvania Dutch language. From that point, Sammy made a rapid recovery. Readers interested in the original unabridged version of this narrative are referred to Benner (1991).
In this exemplar, nurse Baird has concerns over causing harm to Sammy by giving him oral liquids. However, nurse Baird was directly involved in Sammy's care and was able to distinguish the new way Sammy made eye contact with her (embodiment). Baird knew her patient and cared about him at a personal level. In addition, Baird had established a relationship with Sammy and his family (skilled relational know-how and caring). Further, Baird possessed the ability to choose attempting orally administered liquids rather than reinserting the feeding tube because nurse Baird recognized that the situation had evolved (salience). Finally, nurse Baird's sense of moral imagination was fostered because although she did not believe that Sammy could be healed by his family's faith, Baird allowed for the possibility of healing because nurse Baird recognized that possibility was accepted by Sammy's family. It is interesting to note that a decision made using principlism ethical decision-making models would likely weigh the principle of nonmaleficence against beneficence. In this case, the risk of harm may well have outweighed the good that would come from providing liquids by mouth—if the ethical component of the interaction was recognized at all (Benner, 1991, 2003).