If the public bases its estimation of nurses on what they see in television shows, nursing will have a hard time recruiting the best and brightest for the next generation of nurses. Actors largely portray nurses as marginally capable, unskilled, voiceless handmaidens of physicians or husband-hunting physician stalkers, or worse. There is, however, one show that presents an accurate portrayal of nursing: Call the Midwife (BBC One, 2022).
Call the Midwife is set in Poplar, the impoverished East End of London, from 1957 to 1963 (thus far) where 80 to 100 babies are born each month and diseases of poverty are prevalent. It focuses on the work of nurse-midwives in the community. These nurse-midwives live with a small order of Anglican nuns who are, themselves, nurse-midwives. Time marches forward in the series so that the nursing care is set within the historically accurate social and medical context. It is enough to recommend the series based on its portrayal of nurses as educated, highly intelligent, skilled, wise, caring, compassionate, and independent in the practice of that which is authentically nursing. But there is another reason to tune in.
Call the Midwife is an excellent portrayal of nursing ethics. There is a difference between bioethics and nursing ethics, but watching the nursing in this series makes the difference clearer. Fundamentally, bioethics addresses issues in the domain of medicine, customarily problematized, conflictual, or dilemmatic. It tackles interventions that nurses do not, themselves, perform. And, because of the excellent work of Beauchamp and Childress (1979) and the Belmont Report (1979), bioethics has cemented the use of four ethical principles: respect for autonomy, nonmaleficence, beneficence, and distributive justice. These are abstract, decontextualized apriori principles, but not action guidelines. Over the years, ethical principlism has come under thoughtful criticism but remains the prevailing language and conceptual apparatus of hospital ethics committees.
Nursing ethics is not principle, dilemma, or problem-based. Rather, from the inception of modern nursing education, it has been rooted in relationships and in the tradition and narrative of nursing, the character of the nurse-the goods intrinsic to nursing such as dignity, respect, compassion, caring, and in the values and ideals of the profession. Nursing ethics is about relationship, including nurse-to-patient, nurse-to-nurse, nurse-to-self, nurse-to-other health professionals, nurse-to-society, and nurse-to-profession. It is also about the moral formation of the student into the identity of "nurse." Thus, nursing ethics is a positive enterprise and a preventive ethics. Call the Midwife portrays nursing ethics where it emerges-in context and in action.
The characters are "district nurses" (visiting nurses in the United States) who give nursing and midwifery care in homes. The main characters include Sr. Julienne, a nun and nurse-midwife of great skill, kindness, wisdom, faith, and the head of the Poplar Chapterhouse. The nurse-midwives range from newly graduated, qualified (licensed) and inexperienced, to very seasoned, ranging in temperament from sweet and ingenuous to flinty and brusque (but marshmallow inside). Nurse Trixie is fashionable, confident, and supremely competent. Lucille is from sunny Jamaica, resituated in cold, drizzly, classist London. Nurse Camilla "Chummy" is klutzy, unable to ride a bike (essential to get from home to home), inexperienced, and rejected by her upper-crust family for choosing nursing. Nurse Phyllis Crane is a no-nonsense, take-charge nurse. Among these characters (and there are others), one can see many elements of nursing ethics play out in relationships, though, here, we can only briefly address the nurse-to-patient, nurse-to-nurse, and nurse-to-self relationships.
Nurse Lucille visits Clarice, an older woman, to dress a leg ulcer. Clarice is a former teacher: intelligent, articulate, proud, fiercely independent, a hoarder. She is compensating and managing, but not well. On every visit, Lucille is compassionate, interested, and listens with care to Clarice's unfolding story. Clarice had been a suffragette fighting for women's rights and had been imprisoned, beaten, and force-fed. Then, social services intervene and mandate that she be removed to a nursing home. Suddenly, as Lucille is arriving, the police are breaking in to forcibly remove Clarice, and Lucille acts quickly to bar them. She helps Clarice dress in a suit, pins her suffragette "force-fed" medal on her chest, then unlocks the door and escorts her, walking, to the van that will take her to a residential facility. Throughout all the encounters, Lucille preserves Clarice's pride and dignity, listens to her worries, shows her respect, professionally argues with her, is honest, and helps her meet what was to come where others would have used only force. Dignity, respect, compassion, care, skill, wisdom; contextual sensitivity; hearing Clarice's story, seeing and valuing her as a person, as a "woman of substance," helping Clarice to stand when others would have knocked her down, responding with skill and moral good in a fluid situation; and more: these are what nursing seeks (i.e., goods that are intrinsic to nursing, to good nursing, good in a moral sense). In this situation, Nurse Lucille did good, was good, and sought the good. All of it was rooted in and guided by the caring, intimate relationship she had with Clarice, Clarice's story, her changing situation, and a nurse's moral way of being in the world.
Clarice's situation is not a dilemma, not a matter of weighing abstract principles. Instead, it is a positive enterprise of seeking to bring moral good to life in the process of care. It is a process in which Lucille and Clarice had a relational bond that they acted upon and with one another to shape the relationship and its outcomes. Lucille, of course, does not know this out of thin air. It comes in part from the narrative tradition of nursing, with its stories and myths and the community that is nursing, where mentoring, teaching, sharing, guiding, correction, and modeling take place so that nurses participate in a process of ongoing clinical, moral, and identity formation.
A second relationship of nurse-to-nurse is an important part of the series. Trixie drinks too much and Phyllis privately calls her out and pushes her return to Alcoholics Anonymous. Chummy is newly qualified and insecure. Sr. Julienne and Nurse Crane structure success for her-and the nurses even teach Chummy to ride a bicycle. They help each other toward growth, confidence, and expertise and what it means to be a nurse within a community of nursing.
A word is in order about the nurse's relationship to self or duties to self. The nurses encourage, support, and assist one another to care for self. At one point, Sr. Julienne is overwhelmed, so removes her habit, quietly leaves the convent, and takes a respite in the theater to see TheSound of Music. Trixie realizes she has relapsed, so with Sr. Julienne's support takes a leave to address her alcohol dependency. In the many tragic situations the nurses encounter-phocomelia, stillbirth, crib death, abused wives, unfit housing, abandoned children-the nurses grieve, seek comfort, and counsel as needed. And, a "cuppa (tea) and biscuits" follows every dire event.
To incorporate a nursing identity, so that it is inseparable from one's DNA, is not a matter of book-learning or licensure, any more than being a Christian is a matter of owning a Bible. Living into and growing into one's identity as a nurse, or as a Christian, requires basic education (of course), but both also require fellowship, community, a shared narrative, nurture, mentoring, correction, guidance, and caring for one another. It is this process of formation, an ongoing process, that allows us to become and be a nurse, or to be a disciple. It is this formation into identity that allows nurses to say "no, a nurse would never do that," or "yes, I do it because that is what it means to be a morally and clinically good nurse." Nursing is not a set of tasks. Nursing is a skilled, caring, and moral way of being in the world-with patients, other nurses and health professionals, ourselves, nursing, and society.
FOR REFLECTION:
* In what ways do you experience "bringing moral good to life in the process of care"?
* How are you encouraging, supporting, and assisting colleagues to care for themselves?