Strengthening Nurses' Moral Agency

Critical Care Nurse, Vol 20, No. 3, October 2000

Carolyn Hayes, RN, PhD

In The 7 Habits of Highly Effective People Year-in-a-Box Calendar(1), Steven Covey offered the following reflection for March 17, 2000: Synergy is everywhere in nature. If you plant two plants close together, the roots commingle and improve the quality of the soil so that both plants will grow better than if they were separated. If you put two pieces of wood together, they will hold much more than the total of the weight held by each separately. The whole is greater than the sum of its parts. One plus one equals three or more.

Covey's sentiment of strength gained from uniting separate roots resonates with AACN Certification Corporation's conceptualization that when synergy exists between patients' characteristics and nurses' competencies, the outcomes are mutually enhancing.(2) The synergy creates something greater than the sum of its parts. The strength is not merely the result of an additive process. It is more than just the combination of two.

Specifically addressed here is the suggestion from the Synergy Model that the nurses' competency of advocacy and moral agency practiced within a synergistic relationship would strengthen not only patients' outcomes but also nurses' moral agency. Within the Synergy Model, the competency of advocacy and moral agency is defined as working on another's behalf and representing the concerns of the patient, the patient's family, and the community.(2) In the realities of clinical ethics today, nurses face rapid reorganizations, changing technology, resource challenges in collaborative practice, and cultural diversity. Nurses' sense of their own moral agency can be challenged on a near-daily basis.

Chambliss, author of Beyond Caring: Hospitals, Nurses and the Social Organization of Ethics,3 completed an extensive study of the moral agency of nurses by shadowing clinical nurses at 3 different hospitals in various geographic locations in the United States. This book details individual and collective acts that illustrate the moral agency of nurses. It describes some of the challenges to the nurses' sense of their own moral agency. In the conclusion of the book, Chambliss(3 - pp186-187) states, "The mundane must be respected. . . . People don't live only in bright visible moments of decision; they live and die, and work in the ordinary everyday world." Overall, Chambliss's observations support the ethical dilemmas and acts of moral courage that nurses experience in their everyday work, but the observations also highlight the invisible nature of the nurses' moral agency and the struggles that nurses have even to recognize moral agency in themselves.

Shannon(4) examined the roots of interdisciplinary conflict, specific to end-of-life decisions, that may arise from differences in socialization and training of nurses, physicians, and social workers. That study, whose participants were from each of those 3 disciplines, explored some of the stereotypes that influence interdisciplinary communication. Nurses stereotyped physicians and social workers in different ways and claimed moral superiority among the 3 disciplines on the basis of the nature and amount of time nurses spend with patients.

Although the nurses claimed superiority, the physicians in the study revealed that they perceived nurses to have little moral or legal accountability. Social workers in the study reported that they perceived both nurses and physicians as too focused on the technical aspects of critical care. Nurse-patient synergy is the strongest argument against these negative perceptions, both self-perceptions as reported by Chambliss and perceptions of other healthcare professional colleagues as reported by Shannon.
Nurses cannot fulfill their moral contracts with patients and patients' families if the nurses are not advocating "from" the patient or family, as would result from a synergistic relationship. Common language is that nurses advocate "for" the patient and/or the patient's family. If a nurse's intent is to advocate for a course of action that he or she believes is in a patient's best interest, then the nurse is advocating "for" the patient. If, on the other hand, the intent is to represent what the patient wants but is unable to articulate for himself or herself, then the nurse is advocating "from" the patient. The synergistic relationship strengthens the nurse's ability to advocate "from" the patient. An argument can be made that if nurses advocate "for" patients outside of a synergistic relationship rather than "from" patients within a synergistic relationship, then the nurses' moral agency along with the patients' outcomes are at risk of being diminished. The nurses' moral agency is strengthened within the Synergy Model because patients' needs ought to be the source and purpose of all nurses' acts of advocacy for patients.

The significance of providing nursing care from a synergistic perspective is presented in the discipline's various contracts with society. For example, The American Nurses Association's Nursing Social Policy Statement(5 - p3) of 1995 states that nurses view the "human experience as contextually and culturally defined." The social policy statement also states that nurses believe humans manifest as an "essential unity of mind/body/spirit."(5 - p3)

Because it is rarely possible to look at one aspect of the Synergy Model in isolation, it must be recognized that advocacy and moral agency also contains a component of response to diversity. The American Nurses Association's Position Statement on Cultural Diversity in Nursing Practice(6 - p1) states the following: Ethnocentric approaches to nursing practice are ineffective in meeting health and nursing needs of diverse cultural groups of clients. Knowledge about cultures and their impact on interactions with health care is essential for nurses.

The stated imperative to avoid ethnocentric approaches to nursing practice strengthens the importance of moral agency for nurses themselves. To avoid ethnocentric approaches, nurses must know themselves compared with the patient. An approach that is not ethnocentric reinforces the nurse as a moral agent in interaction with the patient. The Synergy Model not only accommodates this level of advocacy, it describes nursing practice as based on knowledge generated from both the nurse and the patient in a synergistic relationship that would not accommodate ethnocentric goals of care.

The Synergy Model describes "creating safe passage" as a product of excellence in nursing practice.(2) Curley(2 - p67) states, "In fact, excellent nursing care is often invisible, and from a perspective of preventing untoward effects and complications, it should be." When a nurse is advocating from a perspective of culturally competent care, it should be difficult to hear the nurse's voice in the presentation. Culturally competent care has the voice of the patient, not the personal beliefs of the practitioner. This articulation advocates from the patient.

In addition to supporting full nurse-patient interaction and cultural competence, the Synergy Model highlights the essential component of trust in excellent nursing practice. The Wall Street Journal and NBC recently conducted a joint national survey of Americans on healthcare issues and reported that nurses ranked at the top in public trust.(7) In Curley's presentation of the Synergy Model, "trust" is described as a product of the nurse's clinical competency and moral agency.(2) As trust builds, so too does the moral agency of the nurse caring for the patient and the patient's family. Trust facilitates clinical activities necessary in increasingly short periods of interaction time. Trust is an essential element for collaborative practice as well.

A case study (below) illustrates this strengthening of moral agency within the Synergy Model. The Synergy Model frames the nursing plan of care in a comprehensive way. The model interweaves ethical analyses, culturally competent considerations, and holistic approaches to care from nursing's social contracts described earlier with the patient's fundamental needs as the source of the nurse's actions. In the case study, a direct challenge would be putting the husband in an uncomfortable, undesired position.

In addition, because the husband most likely will not reinforce the nurse's representation of the patient's wishes, a direct confrontation may put the nurse's moral agency at risk of being judged in a manner similar to that described by Shannon,(4 - p15) who found that physicians stereotype nurses as "ethical dilettantes flitting from one situation to the next with little moral or legal accountability." Without reinforcement from the husband, the nurse may appear to fit that stereotype. If the nurse's approach is to perceive advocating for a less aggressive treatment plan (advocating "for" the patient) separate from the patient and family as they wish to be represented (advocating "from" the patient), then the nurse will risk that the patient's voice is not heard at all. That approach weakens the trust between the nurse and the patient and the patient's family, collaboration, the patient's outcomes, and the nurse's moral agency.

Cultural competence within the Synergy Model challenges the nurse to explore substituted judgment and less aggressive treatment goals while respecting the desired deference to authority and maintaining the trust between the nurse, the patient, and the patient's family. The nurse most likely does not share that cultural imperative, but here is a case in which best practice may be invisible because an ethnocentric approach by the nurse (eg, direct approach to sharing of information) may exclude the husband as a full partner with the healthcare team. It is the patient's need, not the nurse's goals, that guide the nursing plan of care and approach to practice.

The nurse can facilitate meaningful conversations that elicit substituted judgment statements from the husband, for the patient, in the presence of the attending physician. If the nurse is able to remain unwedded to a particular outcome that represents his or her views without the added dimension of the needs of the patient and the patient's family, as the Synergy Model describes nursing practice as doing, then the nurse may maximize culturally sensitive outcomes and advocacy for patients. The nurse's moral agency is strengthened by this approach because it fulfills all contracts and because it is derived from a synergistic rather than an individualistic stance.

It is still ethically justifiable to pursue aggressive treatment, but is it as justifiable as respecting the patient's wishes? The cultural dimension that prohibits the husband from stating those wishes does not exempt the nurse from advocating for autonomy. The Synergy Model challenges the nurse to maintain trust, advocate from the patient, and respect the cultural desire for nonconfrontation. Only through the strength of two, patient and nurse, can this patient's wishes and the nurse's moral agency be maximized.

The current realities of healthcare include culturally diverse populations of patients, high acuity, diminishing resources, and multiple technological and social changes. These changes demand that nurses serve as advocates for patients more frequently than in recent decades and simultaneously demands a more diverse and sophisticated level of advocacy. Advocacy and moral agency is weak at best without skilled assessment of cues from the patient in an interaction based in trust and cultural competence. At its worst, advocacy without a synergistic relationship can misrepresent patients and their families, diminish collaborative efforts, and harm patients; cultural cues get missed and the nurse advocates from a false premise. The nurses' competency of advocacy and moral agency enacted within the Synergy Model strengthens the nurses' moral agency because patients' needs are the source of nurses' acts of advocacy for patients, ethnocentricity is avoided, and trust in the relationship is enhanced. (9)

Case Study

An 84-year-old woman is admitted to a critical care unit after a cerebrovascular accident. She is intubated and so cannot communicate verbally with the healthcare providers. It is difficult to assess her understanding because it is impossible for her to communicate a decision beyond yes or no answers given by blinking once or blinking twice. Therefore, the healthcare team is collaborating with her husband to make treatment decisions.

During the first 2 days of hospitalization, the nurse comes to "know" the following by being present while the husband and wife interact and by having conversations with the patient's husband, son, and sister.
  • The patient and her husband are from Italy. They have been in the United States for 50 years, but still consider Italy their home.
  • The patient's brother died of a cerebrovascular accident 3 years ago under similar circumstances.
  • Because of her experience with her brother, the patient has expressed fear in recent months that she would also die of a cerebrovascular accident.
  • The patient made statements that she would not want aggressive treatment if she did have a stroke.
  • The husband fears that his wife is on a long course of suffering with no hope of a good outcome.
  • The family holds onto their belief that at least eventually she will "return to God's loving arms," and that event is something they know she is looking forward to after all the suffering is over.
  • The couple and the other family members believe in deference to authority, specifically the physician. It would be unthinkable to them to challenge the physician's recommendations.
From collaboration with the members of the healthcare team, the nurse knows the following:
  • The attending physician believes that the patient has a 50/50 chance of meaningful recovery if all available treatments are pursued.
  • The current goals of care established, with the husband's input, focus on an aggressive treatment plan.
  • The attending physician is aware of the family's deference to authority and is willing "to take charge."
The nurse personally supports the aggressive treatment plan because she believes the potential benefits (meaningful recovery) justify the burdens (eg, intubation, intravenous devices, and discomfort). The plan is ethically justifiable from this perspective. However, the nurse realizes from multiple family conversations (substituted judgment statements) that the patient's autonomous wishes stated before this admission would be for less aggressive, more comfort-promoting goals of care. Death is less of a fear for the patient and her family than is the prolongation of suffering even if she may recover. Therefore, the nurse can see an ethical justification for these different goals of care.

Two, or more, justifiable courses of action exist, but adding complexity to the discussions are the patient's and the husband's deference to authority. The patient's previously expressed wishes for less aggressive treatment are not being represented. The nurse is the only member of the healthcare team who is aware of the fears and substituted judgment statements. How can the nurse advocate "from" the patient without violating the need to be deferent? To override that approach can be viewed as an additional harm or burden. Should the nurse accept the current goals of care because doing so is ethically justifiable, in fact preferable to the nurse, and the husband will not argue against it? Or should the nurse advocate from the perspective of the reported autonomous wishes of the patient? Which choice is most respectful of the patient? Does it matter if the Synergy Model is the framework for the nursing care?


1. Covey SR. The 7 Habits of Highly Effective People Year-in-a-Box Calendar . Indianapolis, Ind: Cullman Ventures Inc; 1999.
3. Chambliss D. Beyond Caring: Hospitals, Nurses, and the Social Organization of Ethics. Chicago, Ill: University of Chicago Press; 1997.
4. Shannon SE. The roots of interdisciplinary conflict around ethical issues. Crit Care Nurs Clin North Am. 1997;9:13-28.
5. American Nurses Association. Social Policy Statement. Washington, DC: American Nurses Association; 1995.
6. American Nurses Association. Position Statement on Cultural Diversity in Nursing Practice. Washington, DC: American Nurses Association; 1997.
7. In the News . . . Health Care Industry Facts, 1998. Wall Street Journal / NBC Poll on Health Care. Available at: Accessed August 10, 2000.
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