Blackwell Science, LtdOxford, UKNUPNursing Philosophy1466-7681Blackwell Publishing Ltd 200453230241Original articleBeyond CaringDenise S.

Tarlier

Original article

Beyond caring: the moral and ethical bases of responsive

nursepatient relationships
Denise S. Tarlier RN MSN FNP-C PhD(c)
University of British Columbia School of Nursing, Vancouver, Canada

Abstract Although we theorize that nurses make a difference to patient out-

comes and speculate that this happens because nurses care, there is so
far little evidence to support this nebulous claim. Efforts to promote
care as the defining characteristic of nursing, and an ethic of care as
the ethical basis of nursing, have sparked debate within the discipline.
This debate has resulted in a polarization that has effectively stalled
productive discourse on the issues. Moreover, the focus on care has
been at the expense of understanding the true nature of the relationship
between caring and the broader base of ethical knowledge that under-
pins nursing and that must underpin nursing if it is a viable practice
profession. This paper used the framework of philosophical argument
to explore the moral and ethical foundations of nursing from the per-
spective of personal and public morals, and responsive nursepatient
relationships as the reflection of ethical nursing knowledge. The foun-
dation of ethical nursing knowledge is the personal moral sense that
resides within the individual and that nurses hold in common with
others. Personal moral knowledge is transformed into disciplinary
ethical knowledge specific to nursing through disciplinary consensus.
Responsive relationships are conceptualized in the nursing literature as
founded on three essential elements: respect, trust, and mutuality. These
three elements are grounded in ethical nursing knowledge; therefore
responsive nursepatient relationships reflect both personal moral
knowledge and disciplinary ethical knowledge. By facilitating the artic-
ulation of ethical nursing knowledge in practice, responsive relation-
ships connect theory, ethical knowledge, and clinical outcomes.

Keywords: morals, ethics, care, philosophy, responsive relationships,

outcomes.

Correspondence: Denise S. Tarlier, 6335 Chatham Street, West

Vancouver, B.C., Canada V7W 2E1, Tel.: (+1) 604 921 1051; fax:
(+1) 604 921 1051; e-mail: dtarlier@interchange.ubc.ca

230 Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241


In this era of evidence-based practice where an
increasingly critical eye is cast on clinical outcomes
nurse scholars are more than ever compelled to link
theory and philosophy to the wider world of practice.
Despite an enormous amount of theorizing and schol-
arly debate about what nursing is and how nurses
should nurse, there is little evidence that much effort
has been directed towards tying together nursing
practice at the theoretical level and clinical outcomes.
Although we theorize that nurses make a difference
to patient outcomes and speculate that this happens
because nurses care, there is so far little evidence to
support this nebulous claim, which is contested even
within nursing. Moreover, profound problems acc-
ompany the use of care as the defining characteristic
of nursing.
Preliminary evidence suggests that building
responsive relationships with patients may be one
way in which nurses make a difference and influence
clinical outcomes (Diekemper et al., 1999; Tarlier
et al., 2003). Responsive relationships are conceptu-
alized in the nursing literature as founded on three
essential elements: respect, trust, and mutuality. I
claim that these elements are grounded in ethical
nursing knowledge, and that by facilitating the artic-
ulation of ethical nursing knowledge in practice,
responsive relationships connect theory, ethical
knowledge and clinical outcomes.
In this paper I argue that ethical knowledge creates
the possibility of responsive nursepatient relation-
ships, which are key to how nurses influence patient
outcomes. Thus, responsive nursepatient relation-
ships both reflect ethical nursing knowledge, and
provide the link between outcomes and ethical
knowledge in nursing. My arguments rest on two
assumptions: (1) the integration of personal and pub-
lic moral knowledge is the foundation of disciplinary
ethical knowledge required to support and direct
nursing practice; and (2) responsive nursepatient
relationships encompass and provide a framework for
caring behaviours within an ethical nursepatient
relationship, but a concept of caring is in itself insuf-
ficient basis for either nursing practice or responsive
nursepatient relationships. I will first describe and
support each of these assumptions, then present the
core argument of my thesis.
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241
Beyond Caring 231
Ethical knowledge
Once upon a time, nursing ethics seemed relatively
straightforward: nurses had a duty to care for their
patients. The militaristic (de Raeve, 2002) and reli-
gious foundations of nursing (Yeo, 1991), with their
emphasis on duty, along with the prevailing tradi-
tional view of caring as womens work (Liaschenko,
1993; Bowden, 2000), left little reason to question the
ethical basis of caring. For nurses disproportion-
ately female then, as now to care for others was an
unquestioned good. And despite both the momen-
tous social changes of the 20th century and the appli-
cation of formal ethical theory to nursing, caring has
persisted as the ethical concept considered most
central to nursing (Barnum, 1998; Liaschenko; e.g.
Bowden; Lewis, 2003), to the extent that it is difficult
to examine ethical knowledge in nursing without also
examining the role of caring. Because a comprehen-
sive review of the caring literature is beyond the
scope of this paper, the discussion of caring presented
here is necessarily brief and specific to this paper.
An ethic of caring?
The claim that caring is the defining characteristic of
nursing has not gone without challenge (Paley,
2002a). Caring has become a point of controversy
among nurse theorists, and has provoked much criti-
cal debate in the nursing literature on both theoreti-
cal and ethical grounds (Bottorff, 1991). The debate
has resulted in a polarization (Paley, 2002b) that has
effectively stalled productive discourse on the issues.
Seemingly, one must be either pro-care or anticare.
There is high ground and low ground, but no middle
ground.
But does care constitute an ethic in and of itself?
The literature emanating from the care paradigms,
such as those advanced by Benner (Benner &
Wrubel, 1989), Leininger, and Watson (Barnum,
1998), is not explicit on what the source of caring is
(King, cited in Huch, 1995), or what compels nurses
to care, or to care more or in better ways than other
health providers. As many scholars have pointed out,
caring may be carried out unethically; for example,
care that is paternalistic and authoritarian (Yeo, 1991;
232 Denise S. Tarlier
Paley, 2002b) or maternalistic and patronizing
(Holden, 1996; Bowden, 2000).
Yeo (1989) claimed that the rhetoric of science (p.
189) obscured the moral dimension of nursing, and
indeed, the emphasis on care that developed in the
1980s and 1990s may be seen largely as a reaction to
the perceived lack of caring associated with the trend
towards identifying nursing as a science (Bottorff,
1991). It is my view, however, that what constitutes
ethical knowledge in nursing has become equally
obfuscated by the care theorists attempts to promote
caring as not only an ethic in and of itself, but as the
ethic that directs nursing practice, the manifestation
of ethics in nursing, and in fact, as no less than the
essence of nursing. I argue that the focus on caring
(as the ethic of care) has been at the expense of
understanding the precise nature of the relationship
between caring and the broader base of ethical
knowledge that underpins nursing and that must
underpin nursing if it is a viable practice profession.
That is, a fundamental disconnect exists between the-
ory and ethics and this disconnect is reflected in the
contemporary debate within nursing (Yeo, 1989;
Starzomski & Rodney, 1997).
Paley (2002b) has recently taken the care contro-
versy back a step, providing a review of the debate in
philosophical terms. He argues that the care theorists
have placed what they refer to as the ethic of care
derived from a Heideggerian perspective into oppo-
sition with Kantian moral theory (e.g. Benner, 2000,
p. 5), but that this is in fact a false opposition, brought
about by inaccurate or incomplete understanding of
Kants philosophy. Rather than denying the impor-
tance of caring, Paley situates the ethic of care within
a more broadly based understanding of moral theory,
thereby creating space to negotiate the meaning and
significance of care: The Kantian ethic qualifies the
care ethic by locating it within a fuller account of
moral conduct and moral character (Paley, p. 141).
Paleys (2002b) move towards negotiating rather
than negating the meaning of care is a move in the
right direction. While caring as the fundamental eth-
ical basis of nursing is problematic, there is no deny-
ing the concept of caring is sacred to nurses; there is
no other explanation for the pervasiveness of the cul-
ture of care within nursing (Bowden, 2000). Caring
may be a slippery concept that most nurses, whether
clinical practitioners or scholars, are challenged to pin
down, yet it is nevertheless a powerful concept that
resounds among nurses.
Still, caring is only the tip of the iceberg of nursing
ethical knowledge. It is the visible piece that can be
articulated, if only amorphously (Barnum, 1998).
Caring occurs almost incidentally as nurses enact a
larger body of underlying moral philosophy in their
daily practice. An ethic of care is a superficial way of
attempting to describe the complex integration of
personal and public moral knowledge that is the basis
of nursepatient relationships. The focus on caring
ultimately leads to a narrow, myopic understanding
of how nurses relate to patients. I intend to push
Paleys (2002b) contribution further by exploring the
relationships between care and nursing ethics in the
broader context of both a universal moral philosophy
and ethical nursing knowledge. If care appears to get
lost along the way, it is because I am focusing not on
the tip of the iceberg, but on the massive bulk of
ethical knowledge and moral philosophy that sup-
ports the possibility of care.
Personal morals: the foundation of
ethical knowledge
Warnock (1998), whose work provides the basis for
my discussion in this section, presents her discussion
of ethics in terms of personal and public morals. This
view is useful for exploring the two questions that this
section attempts to answer.
1 What is the source of moral behaviour? Which may
also be thought of as how do nurses (as autonomous
individuals) learn moral behaviour?
2 How do nurses understand and share moral behav-
iour at the disciplinary or practice level? Or how
does nurses individual moral behaviour contribute to
normative nursing ethics?
Much of the historical debate concerning the
source of personal morality revolves around the ques-
tion of whether or not altruism can truly exist. Moral
cynics assert that all altruism is no more than a mask
for self-interest, thus it cannot be said to truly exist.
It is beyond the scope of this paper to revisit this
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241

debate; detailed arguments already exist in the liter-
ature. For example, Warnock (1998) offers a contem-
porary philosophical treatise that examines the
argument that there is no such thing as altruism, and
concludes that altruism both exists and is central to
the concept of personal morality. Warnock achieves
this in part through a deconstruction of the postmod-
ern critique of intrinsic personal morality and the
possibility of altruism. In brief, Warnocks thesis
claims that human rationality and imagination create
the possibility of sympathy, or the ability to sympa-
thize with others condition. Sympathy opens one up
to the realization that because we necessarily coexist
with and are interdependent with others, we have a
responsibility to put aside personal self-interest if it
conflicts with the common good: It is the imaginative
conception of the needs and wishes of others besides
oneself, the sense of them as important, to which we
have given the name of sympathy, which is the source
of ethics (Warnock, p. 88). Altruism is defined as a
willingness to put the interests of others before ones
own for the benefit of the common good.
For each one to take on the needs, wishes, desires of others
and make them into his goal is the beginning of the ethical.
Because of his imagination, and his likeness to other people
(expressed as sympathy), each one is capable of doing this,
but to do it requires an effort of imagination and of sympa-
thy. Altruism does not follow automatically from self-
interest. (Warnock, 1998, p. 87)
In her thesis, Warnock (1998) refers to and relies
to some extent on Kants moral theory of rational
moral law and the categorical imperative. However,
Warnock identifies limitations with Kants work,
claiming that reason alone is insufficient to explain
the source of ethics because it is fallacious to think
that reason can be separated from all other human
faculties and propensities (p. 82); e.g. sympathy. In
contrast, Paley (2002b) provides an interpretation of
Kants moral theory that refutes this traditional ren-
dering. Paley claims that, in fact, Kants philosophy
embraces the concepts of both sympathy and interde-
pendence, drawing on references from Kants original
work to illustrate the relationship Kant acknowl-
edged between ones own ends and the ends of others
in applying the categorical imperative. Moreover,
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241
Beyond Caring 233
Paley argues that autonomy in the Kantian sense does
not exclude consideration of others, which has been
one of the main objections of the care theorists to
Kantian ethics and a focal point of the polarization of
views on caring in the nursing literature.
While Kants philosophy has obviously become
something of a football among moral philosophers, it
equally obviously holds continued importance for
moral philosophy in the western tradition. Relevant
to this paper is that as both Warnock (1998) and Paley
(2002b) have shown, it is possible to define moral
behaviour as being simultaneously both intrinsic to
individuals and interdependent with others. Defining
the source of personal moral behaviour in this way
creates space for a concept of care while offering
some explicit underpinning through which care may
be more clearly articulated. Thus it becomes possible
to see the polarization that has stymied progress in
nursing ethics as ideologically driven (Paley, 2002a)
rather than due to genuinely incompatible beliefs
about the nature of the moral basis of nursing.
Warnocks (1998) views on altruism and the inter-
dependence of humans imply an ontological orienta-
tion that has parallels in Buddhist philosophy.
Buddhist philosophy is based on an ontology of
dependent origination, and compassion as a funda-
mental human way of being. Dependent origination
is a complex concept; it is beyond the scope of this
paper to engage in an explanation of all its complex-
ities. At a superficial level, the essence of dependent
origination is that individual well-being depends on
an awareness that all things are interrelated and inter-
dependent (Gyatso, 1999). This view exhibits patent
similarities to Warnocks claim that the basis of sym-
pathy and altruism is human perception of the condi-
tion of human interconnectedness. Gyatso goes on to
say,
. . . Self-interest and others interests are closely interrelated
. . . Due to the fundamental interconnectedness which lies
at the heart of reality, your interest is also my interest . . .
[as] our interests are inextricably linked, we are compelled
to accept ethics as the indispensable interface between my
desire to be happy and yours (p. 48).
Similarly to Warnocks (1998) discussion of sym-
pathy and altruism, Buddhist philosophy describes
234 Denise S. Tarlier
the concepts of empathy and compassion.1 Like War-
nock, Gyatso (1999) asserts that it is the combination
of human reason and imagination that create the
possibility of compassion. Likewise, Gyatso also
associates compassion (or sympathy) with ethical (or
moral) behaviour: The more we develop compas-
sion, the more genuinely ethical our conduct will be
(p. 78).
Discovering such parallels between Warnocks
(1998) work, which is based on an examination of
western moral philosophy, and an established non-
western philosophical tradition such as Buddhism,
supports the possibility of universal humanistic val-
ues (Meleis & Im, 1999, p. 96), thereby further sup-
porting the thesis that personal morality may and
does exist intrinsically within individuals. That is,
despite being situated differently in the world, moral
philosophers on both sides of the globe and through-
out the ages have come to a similar conclusion: indi-
viduals do develop the innate will and capacity to
behave altruistically towards others, thus providing a
basis for moral behaviour at a personal level. The
speculation that fundamental moral principles may
be universally recognized suggests a pan-ontological
understanding of moral behaviour.2
Through this reasoning, it becomes possible to jus-
tify the thesis that nurses interactions with patients
may be directed at the most fundamental level by the
same intrinsic sense of morality, or knowing what
constitutes good and right behaviour towards another
human being, that ideally directs all human interac-
1
Compassion is translated using the Tibetan word nying je,
however, Gyatso takes pains to describe the more all-inclusive
meaning of nying je: it connotes love, affection, kindness, gen-
tleness, generosity of spirit and warm-heartedness. It is also used
as a term of both sympathy and endearment. On the other hand,
it does not imply pity as the word compassion may. There and justification (p. 344). Personal morality necessar-
is no sense of condescension. On the contrary, nying je denotes
a feeling of connection with others, reflecting its origins in empa-
thy (1999, p. 77).
2
This statement holds important implications for much of the
debate within nursing which attempts to distinguish (and fre-
quently dichotomize) among theory and ethics on the bases of
ontology and epistemology.
tions. In this sense, it becomes difficult to extract any
special or unique meaning of caring between nurses
and patients. All people ought to care for one another
in some sense, so what if anything makes the
relationships nurses form with patients any more
particular or unique than other relationships? Public
morals offer a way to conceptualize how personal
morals may be shared and enacted within a disciplin-
ary understanding.
Public morals: the social manifestation of
personal morality
Public morals are differentiated from personal morals
in that they are shared morals, or moral values that
are defined at the societal level as rights (e.g. human
rights). Public morals may also be protected at the
societal level, as rights enshrined as laws (e.g. prop-
erty rights). Enshrining socially shared morals as
rights and laws effectively pushes public morality into
the legal arena. That is, when an individual or group
is denied their rights they have recourse to justice.
The concept of justice implies promises and expecta-
tions, and thus represents the interface between duty
at the level of personal morality and duty in a profes-
sional, disciplinary or legal sense. Warnock (1998)
states, Justice sits uneasily among the other virtues.
It may be the property of institutions as well as of
individuals. It is essentially a civil, not a personal
virtue. Justice is an aspect of public morality . . . (p.
73).
Another aspect of the shared nature of public
moral knowledge is that it may be shared in the form
of ethical theory. Sarvimki (1995) describes ethical
theory as being organized into concepts and propo-
sitions that are formulated into judgements, rules,
principles, and theories. These serve as instruments
for moral reasoning, that is, for moral deliberation
ily presupposes public morality, that is, rights are
derived from pre-existing morality (Sarvimki; Yeo,
1991). Ethical knowledge identified as specific and
particular to a certain profession or discipline may be
considered an aspect of public morality; thus what
we refer to as nursing ethics may be considered a
particular form of public morality.
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Nursing ethics, as a form of public morality, delin-
eates the duties, or obligations nurses have that arise
out of and belong to their professional role (War-
nock, 1998; p. 72). However, following the reasoning
presented above, nursing ethics must originate in per-
sonal morals, that is, from nurses intrinsic individual
sense of morality. Thus, while based in the concept of
personal morals, nursing ethics represent the duties
and obligations nurses have collectively (as a disci-
pline) promised to patients. These promises made
may be thought of both in terms of patients rights
and patients legal rights. Yeo (1991; p. 8) substanti-
ates this claim when he describes the contractual
model and the clients advocate models as the two
models of ethical roles most favoured in the nursing
ethics literature. The contractual model is described
in terms of negotiated moral parameters and mutual
expectations in a nurseclient relationship, that is, the
process of clarifying what rights the patient may
expect. The advocacy model is described in terms of
nurses ethical duty to advocate for patients rights to
be informed and involved in their care decisions.
These two models essentially provide the frame-
work for the various nursing codes of ethics. For
example, the American Nurses Association Code of
Ethics for Nurses (2001), the Canadian Nurses
Association Code of Ethics (2002), and the Interna-
tional Council of Nurses (ICN) Code of Ethics for
Nurses (2000) are each based on the ethical princi-
pals commonly espoused in the ethics literature:
respect, beneficence, nonmaleficence, veracity, fidel-
ity, and justice (Yeo, 1991, p. 239). However, it is
apparent that public morals, while founded on a
shared understanding of what has been accepted as
good or right behaviour towards others (to the
extent that such particular behaviours have been
formally enshrined as codes of behaviour or laws),
represent no more than a set of rules. As such,
there is little to indicate the intrinsic moral sense
that motivates an individual to respect and follow
the rules (Sarvimki, 1995). In a profession such as
nursing, which has developed its own specific public
morality (in the form of codes of nursing ethics, for
example), and which is also subject to legal regula-
tion, what is it that motivates individual nurses to
follow a disciplinary code of ethics?
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241
Beyond Caring 235
Integrating personal and public morals: integrity
in nursing
Yeo (1991) used the word integrity to describe what
I argue may be characterized as the integration of
personal and public morals. He claimed integrity is
unique and the most fundamental of the values that
direct nursing practice, and citing Mitchell (1982),
asserted that whereas [the] other values have to do
with what is owed to clients, integrity directs atten-
tion to the moral agency of the health professional
(p. 185). Davis (1995) similarly referred to the need
to integrate personal moral knowledge with princi-
ple-based ethics. Sarvimki (1995) explained moral
integration in a somewhat different but not incompat-
ible way:
The morally integrated person displays integrated moral
knowledge: (1) a persons acts reflect self as a moral being
(2) a person can understand and analyze his or her own
action and character (3) the principles that a person knows
theoretically and expresses verbally are also manifested in
action in concrete situations (p. 349).
Gadow (1999) first deconstructed nurses ethical
knowledge into three layers: ethical immediacy, uni-
versalism, and engagement (the first two layers are
roughly analogous to personal and public morals),
then discussed these in terms of premodern, modern,
and postmodern ethics. As I attempted to show in my
earlier discussion, however, there is some substantia-
tion for my claim that fundamental morals are pan-
ontological, and indeed, Gadow concluded that the
three ethical layers were interdependent and that
their integration is in fact prerequisite to an ethically
vital practice (p. 66).
Four essential elements comprise moral integrity:
moral autonomy, fidelity to promise, steadfastness,
and wholeness (Yeo, 1991). Moral autonomy is the
categorical imperative, or the internal will an individ-
ual exerts to decide to act in a moral manner and
follow through with this decision. Paley (2002b) char-
acterized autonomy as both a necessary and a
sufficient condition for compliance with the moral
law, through the exercise of pure practical reason (p.
135). Fidelity to promise refers to an individuals will
to make and keep promises, or to allow others to have
236 Denise S. Tarlier
expectations of one and to meet those expectations.
Steadfastness is the ability to stand by ones moral
beliefs and actions in the face of difference or discord;
it refers to what in times past was meant by moral
fibre. Being steadfast may involve taking personal
risks to remain true to ones morals: Steadfastness
has to do with standing fast and speaking up for what
is right (Yeo, p. 186). Wholeness refers to the neces-
sary integration of personal and public morals, or the
need to be consistent in all the dimensions of ones
life.3
Beneficence and caring are closely related concepts
(Yeo, 1991). Yeo pointed out the platitudinous (p.
27) nature of much of the literature in nursing ethics,
stating that although beneficence, as a duty owed to
patients by nurses, is accepted as a good at a superfi-
cial level, nurses have failed to explore the concept at
a deeper level of understanding. That is, there is little
understanding of the source of caring or the motiva-
tion to act with beneficence. Thus, I assert, we have
lost sight of the fundamental underpinnings of ethical
knowledge in nursing and its foundation in integrated
personal and public moral knowledge; instead
emphasizing ethical knowledge as a legal and rights-
based ethics, while overlooking its connection with
personal moral behaviour at the level of the individ-
ual nurse (Davis, 1995).
One effect of this disconnection between personal
and public morals in nursing has been the creeping
tendency within nursing to overlook the use of caring
as a pseudonym to represent the complexities of per-
sonal moral knowledge that underpin nursing prac-
tice. The imprecision of meaning that is inherent in
the way the word caring has been used in nursing has
enabled the word to be hijacked by certain factions
within nursing. This usurpation has ultimately led to
the polarization pointed out by Paley (2002b) and the
ensuing debate over the role of caring as the primary
3
I do not want to discount the notion that oppressive structures
in society and health care may influence the enactment of moral
integrity; however, this paper focuses on the possibility that
moral and ethical knowledge is reflected in responsive nurse
patient relationships. Acknowledging this possibility would open
up another perspective from which to evaluate the influence of
oppressive structures on nursing practice.
ethic directing nursepatient interactions. But bec-
ause caring is not as the foregoing discussion has
hopefully established the summation of ethical
nursing knowledge, it becomes possible to examine
nursepatient relationships as a reflection of some-
thing more than merely caring, and to thereby
develop insights into the possibilities of understand-
ing that are created when ethical knowledge is exam-
ined in the more precise language of personal and
public morals.
Responsive relationships
Although the term responsive relationship exists in
the nursing literature, it has not been widely used and
thus far remains somewhat lacking in its conceptual
development. This paper will hopefully contribute to
that conceptual development by situating responsive
relationships as a concept within a philosophical
framework, thereby connecting the concept to extant
nursing theory, ethics and practice.
I am using the term responsive to describe nurse
patient relationships that are conceptualized as
encompassing three essential elements: respect, trust,
and mutuality. This conceptualization is based on, and
I believe is essentially consistent with, the way
SmithBattle et al. (1997) conceptualized responsive
nursepatient relationships. These authors defined
responsive relationships in terms of nurses respon-
sive use of self (p. 79) to build relationships with
patients that exemplified respect, trust, and mutuality.
Reciprocity is also used in the nursing literature
to express the concept of mutuality. I have deliber-
ately chosen to avoid using the word reciprocity
because in the nursing literature, it is also sometimes
used to denote a type of relational reciprocity that is
in some sense transformative, for both nurse and
patient. I am not using the concept of reciprocity or
mutuality in this transformative sense.
In one sense, responsive relationships may be
thought of as analogous to caring relationships, how-
ever, it would be more accurate to say that responsive
relationships may encompass and provide a frame-
work for caring behaviours and actions within an eth-
ical nursepatient relationship. The articulation of
respect, trust and mutuality as the underpinnings of
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241

responsive relationships similarly suggests that
responsive relationships are conceptualized in more
concrete terms than the notion of presencing
described by Benner & Wrubel (1989, p. 13).
While their work relies heavily on that of Benner
(e.g. Benner & Wrubel, 1989), SmithBattle et al.
(1997) did not specifically address the ethical under-
pinnings of responsive relationships, other than to
claim that nurses learn a relational ethic (p. 76).
However, as I have attempted to illustrate in this
paper, it may be claimed that personal morals are
inherently relational, in the sense that they depend
on an individuals acknowledgement of human inter-
dependence and interconnectedness. It follows there-
fore that responsive relationships between nurses and
patients (i.e. professional relationships) are based on
nurses personal and public moral knowledge; that is,
their integrated ethical knowledge. At the most fun-
damental level, this ethical knowledge is reflected by
the three essential elements that make up the concept
of responsive relationships: respect, trust, and mutu-
ality. In the following section I offer an examination
of each of these subconcepts from the perspective of
ethical nursing knowledge.
Respect
Respect for self as well as others is arguably the most
fundamental moral value, in that other basic values
depend at least to some extent on an individuals
regard or respect for human interconnectedness. For
example, honesty, generosity, and selflessness are
basic moral values that are relevant to any relation
between one person and others (Warnock, 1998, p.
123). Gadow (1999) identified equal respect for self
and others as the essence of ethical universalism.
In a study of respect in nursepatient interactions,
Browne (1995) concluded that respect is an essential
concept for nursing and . . . the qualities of respect
reflect ethical concerns (pp. 106107). This finding
was consistent with Brownes review of the philosoph-
ical basis of respect as an ethical principle, wherein
she noted that respect is the central moral attitude
from which all other moral principles are explained
(p. 96). The five characteristics of respect that
emerged as findings in Brownes study reveal the rela-
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241
Beyond Caring 237
tional ethical basis of respect: (1) treating others as
inherently worthy and equal; (2) acceptance of others;
(3) willingness to listen to others; (4) genuine attempts
to understand another and the others situation; and
(5) sincerity. However, these characteristics are
plainly not exclusive to nursepatient relationships.
Because these characteristics reflect personal moral
knowledge it may be said they are also characteristic
of any respectful relationship between individuals.
Thus, at a fundamental level, responsive nurse
patient relationships reflect personal moral knowl-
edge. In what way then does a respectful relationship
between nurse and patient also reflect integrated
moral knowledge and disciplinary ethical knowledge?
Respect is patently a shared moral value among
nurses at the disciplinary level, as evidenced by its
inclusion in formal codes of ethics at all levels of
nursing organization, that is, national, international,
and provincial (Yeo, 1991). Indeed, I would claim that
respect takes priority in nursing ethical codes, and
may thereby be considered the founding principle of
formalized nursing ethics. Thus, while the source of
respect lies within individuals personal moral knowl-
edge, its shared nature (or public morality) at the
disciplinary level implies that rights are associated
with respect within nursepatient relationships. That
is, nurses at the collective level promise respect, and
patients have a right to expect respect.
Trust
Trust, while founded on personal morals, is also
related in a fundamental way to professional qualifi-
cations, skills, and competence. These aspects of trust,
which are specific to the manifestation of trust within
a professional relationship, reveal the role of trust as
a critical link between personal and public morals, or
personal morals and disciplinary ethics. Thus trust
may be considered instrumental to the disciplinary
integration of personal and public morals.
De Raeve (2002) suggested that trust may be
reduced, at its most basic level, to the level of per-
sonal morality. While the development of trust in a
nursepatient relationship is manifestly a multidi-
mensional process, it may depend on a patients
ability to predict an individual nurses likely moral
238 Denise S. Tarlier
responses (de Raeve, p. 159), based on an evaluation
of the nurses moral character. I would argue that at
the level of personal morals, trust is based at least in
part on the five characteristics of respect identified by
Browne (1995). For example, acceptance of others,
sincerity, and genuineness are prerequisite to the
development of trust. Thus, the nurses personal
moral character becomes an important issue to estab-
lishing trust.
De Raeve also asserted that nurses are morally
obliged to make an effort to establish trust with
patients, even in situations where the nurse might
happen to dislike a particular patient, or feel the
patient was undeserving (e.g. as might occur if a nurse
were required to care for a convicted criminal). The
notion of nurses being under a moral obligation to
foster trust in their relationships with patients moves
trust from personal morality to disciplinary morality,
in that nurses make a disciplinary promise to patients
to be trustworthy. The promise to be trustworthy is
reflected in disciplinary ethical knowledge as fidelity
to promise (Yeo, 1991), and is enshrined in nursing
codes of ethics in standards that address issues such
as maintaining patient confidentiality and providing
competent nursing care (e.g. ICN, 2000).
The provision of competent care by nurses exem-
plifies the link between integrated ethical nursing
knowledge at the theoretical level and the tangible
realities of nursing practice (Holmes & Warelow,
2000; de Raeve, 2002). Explicitly, competent care
does not refer to how caring the nurse is in an emo-
tional sense, but rather to the nurses proficient enact-
ment of knowledge and skills in the course of
implementing physical, hands-on therapeutic inter-
ventions. For example, a nurse who is changing a
dressing on a burn patient may exemplify a caring
manner, but lacking proficiency in the procedure, is
unlikely to achieve a good clinical outcome. Trust in
responsive nursepatient relationships is thus predi-
cated on the patients belief that the nurse will assist
him or her in achieving a good outcome, and not
merely that the nurse will care for the patient in an
emotional sense.
Individual nurses also garner trust with patients
through their associations with both nursing, as a pro-
fessional organization, and health care institutions, as
public institutions in which patients place their
confidence (de Raeve, 2002). Nursing is a definable
profession wherein membership is regulated and is
dependent on qualifications and demonstrable com-
petency. The public places trust in certain individuals
based on their societal role being perceived as having
a duty to be trustworthy (Warnock, 1998).
De Raeve (2002) describes the idea of trust
through association as being necessarily a partial
kind of trust because the nurse may be a complete
stranger (pp. 157158). Thus there seems to be a
dynamic, two-way aspect to trust, in that patients
trust nurses in part because of nurses identifiable
disciplinary affiliation, and in part because a particu-
lar nurse earns the trust of a particular patient by
demonstrating a trustworthy personal moral charac-
ter. This dynamic, two-way quality of trust is the basis
of mutuality in nursepatient relationships.
Mutuality
Mutuality implies that responsive relationships are
conceptualized as a negotiated process between nurse
and patient. Responsive relationships are a process in
the sense that relationships develop, or are con-
structed. There is a temporal aspect to relationship
building. However, I would contend that relationship
building is not necessarily a lengthy process; nurses
may become skilled at building responsive relation-
ships quickly, for example, in the context of the emer-
gency or operating rooms.
Responsive relationships are negotiated in the
sense that each party participates in the process. The
nurse and patient mutually discover the clients
needs, concerns, and strengths (SmithBattle et al.,
1997, p. 79). Responsive relationships encompass col-
laboration and the notion of partnerships between
nurses and patients, thereby reflecting shared knowl-
edge and power within the relationship (SmithBattle
et al.). This process therefore both is dependent on
and reflects personal morals, in that the nurse must
necessarily demonstrate respect for patients, and
patients in turn, necessarily hold the nurse in some
respect. Similarly, nurse and patient must trust one
another. Thus the process of negotiating a responsive
relationship is predicated on mutual respect and trust.
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The process of negotiation creates the possibility
for variation to exist in relationships between differ-
ent individuals. That is, the nurse tailors responsive
relationships to meet the needs, expectations and
receptivity of a particular patient (SmithBattle et al.,
1997, p. 78). While the relationship is grounded in
personal morals, it is expressed within the context of
disciplinary ethical knowledge. However, the rela-
tionship itself shapes the rights and duties proper to
it (de Raeve, 2002, p. 155). Thus, the role-relation-
ship, or professional boundaries between nurse and
patient may vary not only from relationship to rela-
tionship but also at different times within the same
relationship. This notion that ethical knowledge
shapes relationships that are dynamic and responsive
rather than codifiable (Bowden, 2000, p. 39) is
reflected, for example, in the most recent version of
the Canadian Nurses Association Code of Ethics
(2002).
Responsive relationships as a
reflection of ethical nursing
knowledge
In this final section I will present the core argument
of my thesis, that is, responsive nursepatient rela-
tionships reflect ethical nursing knowledge. The
reflection of ethical nursing knowledge through
responsive relationships is an iterative process, in that
such relationships are both grounded in and reflect
moral and ethical knowledge. While I present this
argument from the perspective of two aspects of
responsive relationships that reflect ethical nursing
knowledge, I acknowledge that other important
aspects of nursepatient relationships exist and these
also reflect ethical knowledge. The two aspects I focus
on here are (1) directing appropriate engagement
between nurse and patient; and (2) directing the pol-
itics of nursepatient relationships.
Appropriate engagement within the nurse
patient relationship
There are two related but subtly different facets of
appropriate engagement within nursepatient rela-
tionships that are relevant to this discussion of man-
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241
Beyond Caring 239
ifested ethical knowledge. The first of these facets has
to do with negotiating intersubjectivity. By this, I
mean that the nurse engages with a patient from the
perspective of her own standpoint as a person and as
a professional, while simultaneously acknowledging
and engaging from the standpoint of the patient
(Kemmis & McTaggart, 2000). Acknowledging and
engaging from the patients standpoint may be under-
stood as a reflection of personal morals, that is, as the
nurse sympathizing or empathizing with the other
(Warnock, 1998), or equivalently, having compassion
for the other (Gyatso, 1999). It may also be under-
stood as a reflection of the five characteristics of
respect identified by Browne (1995). Thus appropri-
ate engagement also reflects public or disciplinary
ethics in terms of the patients right to expect respect,
support for self-determination in health care deci-
sion-making, and to be valued in spite of difference.
The second facet of appropriate engagement has to
do with negotiating intersecting paradigms. That is, in
constructing responsive relationships with patients,
the nurse creates a common space in which to engage
with the patient despite possibly differing world views
(e.g. culturally disparate world views). The basis for
creating space lies in the pan-ontological or universal
nature of personal morals, and by extrapolation, the
enshrinement of personal morals as nursing ethics.
That is, there appears to be a consensus on fundamen-
tal relational values (as demonstrated earlier in this
paper) that transcends ontological or epistemological
differences. Thus the ability of a nurse to build a
responsive relationship with a patient despite differ-
ent world views held by each reflects the moral and
ethical knowledge that is the foundation of such
relationships.
The politics of power in nursepatient
relationships
Three points are key to the concept of power politics
within nursepatient relationships: (1) issues related
to balancing paternalism/maternalism with advocacy;
(2) issues related to mediating the nurses personal
and professional mandates; and (3) managing issues
of power in nursepatient relationships. These points
are related in that each may be considered an aspect
240 Denise S. Tarlier
of the power differentials that potentially exist in
nursepatient relationships.
A responsive nursepatient relationship implies
collaboration and negotiation and sharing of knowl-
edge and power. Thus by definition, responsive
relationships are conceptually incompatible with the
abuse or misuse of power. However, I speculate that
power issues may pose the most serious challenges to
the enactment of ethical nursing knowledge in prac-
tice, both because power corrupts, and because
there is a tendency for nurses to either ignore or
remain oblivious to issues of power in their relation-
ships with patients.
The issue of power within nursepatient relation-
ships is poorly understood and has seldom been
addressed in the literature, largely because there is an
inherent tendency among nurses to shy away from
using language that explicates power, or to admit to
issues of power in their relationships with patients. I
believe the corruptive influence of power operates at
an unarticulated, subtle and largely subconscious
level among nurses, but it operates nevertheless.
However, a full discussion of ethical knowledge
related to power issues in nursing is a topic for
another paper.
It is important, both to this argument and to the
ethical management of power issues in nursepatient
relationships in practice, to keep sight of personal
relational morality as the source of responsive rela-
tionships. That is, the concepts of interconnectedness
with and compassion for others, and altruism, or put-
ting the best interest of the other before ones own
best interest, provide a moral basis for negotiating
and managing power issues. Moreover, it is important
to recall that moral effort is required to enact altruism
(Warnock, 1998), thus power issues do not manage
themselves but require an effort of critical reflection
and deliberation on the part of the nurse.
The concepts that guide nurses behaviour in rela-
tion to power issues in nursepatient relationships are
implicitly reflected at the level of disciplinary ethical
knowledge. However, there tends to be little explicit
acknowledgement of power issues at this level, for
example, the ICN Code of Ethics (2000) does not
refer to issues of power per se. This failure to articu-
late power issues, or even a common understanding
of the meaning of power within professional relation-
ships, at the level of disciplinary ethics contributes to
what I contend is the invisibility of nurses ethical
management of power issues. Relational power issues
represent a significant interface of nursing philoso-
phy, ethics and practice, yet as a discipline, nurses
have largely failed to acknowledge and explore this
interface and its relevance for practice.
What happened to caring?
Disciplinary ethics represents a particularized form of
public morals. That is, ethical nursing knowledge
determines and directs the interface of nursing with
the public in terms of rights, justices and laws. Public
morals can be enshrined in a disciplinary code of
ethical behaviour. But public morals are presupposed
by personal morals, or the universal, intrinsic moral
sense that in an ideal world, would exemplify every
human interaction. Thus the foundation of ethical
nursing knowledge is the personal moral sense that
resides within the individual and that nurses hold in
common with others. Personal moral knowledge is
transformed into disciplinary ethical knowledge
specific to nursing through disciplinary consensus.
Responsive nursepatient relationships reflect both
personal moral knowledge and disciplinary ethical
knowledge. Thus responsive relationships manifest
ethical nursing knowledge in practice.
Did caring get lost along the way? My hope is that
by articulating the moral and ethical bases of nursing,
I have shown that responsive relationships reflect
much more than simply caring. By polarizing schol-
arly nursing debate (Paley, 2002b) and focusing atten-
tion on the superficial tip of the iceberg, the rhetoric
of care has effectively stalled disciplinary discourse
on the question of how do nurses make a difference
in practice and effect positive clinical outcomes? It is
time for nurses to get beyond this ideological debate
over what has in essence become an intellectually
sloppy approach to characterizing the complex body
of knowledge that underpins nurses work.
Situating care within a broader framework of per-
sonal and public morals suggests that caring is an
imprecise and insufficient term to capture what
nurses do and how they do it. I submit that building
Blackwell Publishing Ltd 2004 Nursing Philosophy, 5, pp. 230241

responsive relationships with patients allows nurses
to fuse philosophy, theory and ethics into practice.
Articulating this fusion through the more precise lan-
guage of moral philosophy creates exciting new pos-
sibilities for linking practice with clinical outcomes.
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