Nursing is a profession with a moral dimension. In other words, nursing practice can be considered as a moral practice. While this starting point seems generally accepted, at the same time there are different opinions on how morality is or should be shaped in the nursing profession. There is consensus where moral action takes place: in the primary process and in relationships with patients. Nurses themselves agreed to this statement in a 1995 survey on moral problems in nursing and care. They primarily experience moral problems in the primary process, namely if patients are neglected. In the 15 years that have passed since the survey, there has been much debate about the moral aspects of nursing and the possibilities for moral professionalization, both in professional literature and in scientific publications. This study provides a further contribution to the debate. In addition, we aim to provide nursing professionals with explicit recommendations for further development of the moral dimension of their practice.
The primary research questions are:
How can we describe the moral professional practices of nurses? What central concepts can we identify and how do these concepts relate to each other?
These questions lead to two interdependent secondary research questions: What assistance can be offered to nurses relating to the moral dimension of their professional practice?
What assistance can be offered to nurses in handling moral problems in patient care?
To answer these questions, two separate qualitative research methods have been used, namely literature study and case study. The paediatric department of a major hospital has been asked to present patient cases that the staff members considered to be morally complex. Three cases are included in this research; they will be presented in detail in chapters 3, 4 and 5. The files of these patients have been studied and the health carers involved in direct care of these patients have been interviewed. Based on findings from both file study and interviewing, each case has been reconstructed in ‘thick description’ before anonymization. All case descriptions were subsequently presented to closely involved staff members to ensure justice was done to their moral experiences. Paediatric case histories were chosen, because paediatric carers have to show commitment and responsibility towards their patients. Paediatric nurses are obliged to evaluate care processes to make sure the process is progressing in a way that benefits the child. The term ‘best interests’ is often used to emphasize the child’s interests. However, it is not easy to determine what ‘the ‘best interests’ of a child in need of care are. Various criteria are said to be of importance, such as quality of life, physical, emotional and social welfare and the right to an open future. Therefore, in caring for and treating children, attempts will be made to determine a child’s ‘best interests’ in consultation with parents, carers and the child itself. Parents play an important role in these consultations, especially if the child is too young to express an opinion on these matters. The parents are the child’s representatives. The position of nurses in this matter is complex. It can be difficult to achieve care goals that suit both the child’s and its parents’ interests, for example when nurses’ choice of care based on professional expertise does not match parental expectations. Examples of these difficulties are described in this study.
Chapter 2
Over the past decades and following developments in medical ethics, there has been growing interest in nursing ethics. In medical ethics, the debate has been dominated by major ethical themes such as organ transplantation, abortion and euthanasia. One could describe these themes as themes of crises and tragedies. Nurses have tried to find their own way to handle these major themes within their professional practice. At first, they strived to do so by acquiring reasoning skills for handling ethical dilemmas. Being able to reason is seen as a precondition that enables nurses to participate in discussions and shared decision making on moral issues regarding patient care. Furthermore, nurses have followed a second strategy in which they explicitly distinguish themselves from physicians in order to get their own voices heard. Several conceptual pairs are used to emphasize the differences between nurses and physicians, including care vs. cure and patient vs. illness.

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