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This research paper traces the historical development of nursing ethics from the age of Nightingale to the present globalized age and provides an overview of ethical issues and future perspectives on nursing. The nursing profession commenced with sacred work values, and for a long time, a nurse’s primary role was to be a physician’s loyal helpers. However, from the 1970s onward, mainly inﬂuenced by the thoughts of the times in the USA, it enhanced its professional autonomy, and nurses came to play a role of patients’ advocates in order to protect patient’s interests and rights based on nursing advocacy. With the opening of the age of globalization, this also affected the nursing profession. Speciﬁcally, it is now facing the issue of the migration of the nursing workforce from poor countries to wealthier countries, which has led to serious problems, including unfairness and gap expansion in health care. It is also facing the issue of how to develop cross-cultural nursing in the world where different cultures intermix. This research paper presents a possible global basis for nursing ethics so as to promote ethical nursing under such an unprecedented circumstance.
The development of nursing ethics has paralleled the development of nursing as a profession (Fry 1995). This research paper ﬁrst provides an overview of the development of nursing ethics in the history of nursing. The values and ethics of nursing constitute the basis for nursing. Therefore, it focuses on how the values and ethics of nursing changed according to the evolving trends of the times, as well as changes in the role of nursing and its signiﬁcance. It also provides overviews of the main ethical theories of nursing and codes of ethics of major nursing associations. Changes in the metaphors used to understand nursing and the development of nursing ethical education and nursing research are also brieﬂy covered. Then, the paper examines the relationship between globalization and the nursing profession, focusing on nurse migration from poor countries to wealthy countries, and the impact of the nurse migration on health care and societies. Also, the paper examines nursing care in the globalized and multicultural settings from the viewpoint of cross-cultural or transcultural nursing. Finally, the paper concludes by examining how ethical nursing can be provided in a world plagued with various problems with an emphasis on a global basis for nursing ethics.
History And Development Of Nursing Ethics
Nursing is an expression of the natural human feeling and desire to go and help the injured or the sick. So, it can be said that nursing began with the history of human beings. On the other hand, nursing can easily be linked with the religious and spiritual ends and as such brought about many activities of mercy and love. In the nineteenth century, Florence Nightingale took the ﬁrst step toward an independent profession; however, the basic idea underlying nursing practice was the sense of sacred work derived from God’s calling, for which women with high character were desirable. And, despite the innovative ideas for making nursing an independent profession proposed by Nightingale, the core value of nursing was dedication to the spiritual ideals of Christianity. Christianity required women who were nurses-to-be to be well educated, polite, and virtuous. These requirements were evolved into nursing ethics later, but, in those days, there was no clear distinction between nursing morals and the nursing ethos of the physician’s little helper.
Through the two world wars, the role of nurses gradually changed. However, in the USA, which was a leading nation in nursing, changes in awareness and the nursing profession role did not take place until the period from the 1960s to the 1970s during which the human rights movement (civil, women’s lib, etc.) heightened. Meanwhile, remarkable advancements were achieved in medical sciences which forced the medical world to face new challenges, such as brain death criteria that caused challenges, and resulted in the birth of a new study, “bioethics.” In the modern society, facing the new challenges, and with a growing awareness of people’s rights, a “let’s protect our lives ourselves” sentiment arose among patients. In line with this, the Helsinki Declaration was adopted by the World Medical Association (WMA) based on the lessons and reﬂections from the Nazi crimes in World War II, which led to a new decision-making process known as informed consent. The basis for this decision-making was the concept of autonomy, which later became the prime principle of medical ethics and bioethics in the USA and Western nations. Hereupon, the way of decision-making shifted away from the paternalistic model to the patient-centered model.
Such a new wave in the medical world also made a difference in nurses’ awareness of nursing, which led nursing to develop and expand its professional role and to formulate a deeper understanding of the nature of care. These changes coupled with the improvement of nursing education, the mainstream of which had been shifting to college education, also provided backdrop for this development.
In the1970s, some American nursing researchers began to emphasize a concept called “nursing advocacy,” which is a view that nurses have an ethical responsibility as advocates of patients’ rights and interests. Some tried to argue that advocacy is the foundation for the philosophy of nursing. For example, some argued that “Advocacy is based upon our common humanity, our common needs, and our common human rights” (Tschudin 2002). Some nursing ethicists interpreted advocacy as “the ethical principle that underwrites what nurses do to protect the human dignity, privacy, choice, and well-being of the patient” (Fry 1995).
The concept of advocacy is not a new concept because nurses have always put patients’ wellbeing ﬁrst in their practice since the ancient times. Then, what is the difference between the advocacy concept emphasized at that time and the traditional one? They are not different in nature at all. However, the modern conception of advocacy places more emphasis on protection of patients’ rights and interests in difﬁcult situations. For instance, imagine a case where a physician orders a clinical test which does not serve a patient’s direct interest. Traditionally, a nurse reluctantly followed such physician’s orders even if she/he thought it was an odd order. However, modern advocacy requires nurses to stand on the patient’s side, not the physician’s side, and protect patient’s interests and rights. In this case, the nurse can ask the physician a question. In fact, she/he must do it.
Accordingly, the primary professional responsibility of nurses became to care receivers. In this context, the role of the nursing profession recognized by nurses themselves was changed from a physician’s loyal helper to an independent practitioner. With this change in their role awareness, nurses began to regard themselves as healthcare professionals to be engaged not only in caregiving to the sick but also in disease prevention and health promotion and, eventually, expanded their awareness as healthcare professionals related to various issues, including social injustice and unfairness.
These changes in nurses’ awareness of the nursing profession are clearly reﬂected in the Code of Ethics of the American Nurses Association (ANA) and the Code of Ethics for Nurses of the International Council of Nurses (ICN). Since its adoption in 1950, the ANA Code of Ethics has been revised many times, and the newest edition clearly describes the object of nurses’ ethical responsibility and nurses’ role as advocates. And, since its adoption in 1953, the ICN Code has also been revised many times. It also clearly describes that a care receiver is the prime object of ethical responsibility of nurses, and a wide range of nurses’ ethical conducts are based on the concept of advocacy. Later, these codes of ethics inﬂuenced the code of ethics of each nation’s nurse association.
In this trend, the way of decision-making concerned with nursing care also changed. Up to that time, nurses had decided everything about care for patients and implemented it like a mother in the spirit of paternalism or “maternalism.” Then, after patient’s autonomy began to be emphasized mainly in American society, some began to argue that the nurses’ role as advocates was to respect patient’s autonomy on decision-making and support them so that they could make better decisions for their well-being. This sort of relationship can be realized as a partnership between nurses and patients, which is called the “contracted clinician model” of the patient-nurse relationship introduced by Smith (Smith 1981). This is not a relationship where patients decide their care plans unilaterally and request that nurses implement them, but it requires agreement between the patient and the nurse. Only after nurses’ agreement is gained, a care service contract is concluded between a caregiver and a care receiver. Another model gives more authority to patients for decision-making. In this “technician model” introduced by Smith, patients unilaterally decide care programs, and nurses should accept them without evaluating them and implement them with their best nursing skills. In this model, nurses’ ethical responsibility is in exact implementation of the care plans decided by patients. Some nurse ethicist uses the metaphor of “nurse as guest.” In this case, the host is not a nurse but a care receiver, and a nurse is the guest invited by the host to provide the host with the best care. The nurse has to provide the best care for the quality of life of the host, a care receiver, complying with the requests from the host, who is the expert of his/her own life. Nurse’s ethical responsibility lies in providing the best care for the host (Milton 2006).
The changes in the models of relationships in nursing overviewed here clearly show the changing process from “physician’s obedient helper” and “surrogate mothers of patients” to “advocates of patients” who support their decision-making and protect their interests and rights.
In the 1970s, nursing ethics was ofﬁcially introduced in the nursing education curriculum, but it was not until the 1980s that satisfactory textbooks of nursing ethics were published. In 1979, the famous book Principles of Biomedical Ethics written by Beauchamp and Childress was published. Inﬂuenced by this book, nursing researchers, for themselves, also began their researches on nursing ethical principles and the ethical basis for caring. Details will be described later.
In those days when “nursing ethics” was started in the curriculum in real earnest, the following topics were discussed in the lectures: “balancing harms and beneﬁts in patient care,” “protecting patients’ autonomy,” “distributing nursing care resources,” etc. These are often discussed still today. The overall goal of nursing ethical education in those days was to produce nurses who could make good ethical decisions and fulﬁll their ethical accountability (Fry 1995). This has been handed over until today.
As nursing ethics education widely spread, research on nursing ethics became active. As the age of globalization dawned, international collaborative research has been conducted more frequently. Growth of the Internet has partially contributed to realizing this, since in the late 1990s when the world entered into the age of globalization. The term “globalization” ﬁrst appeared in a dictionary in 1961 and had been used mainly by economists as early as 1981. In the late 1990s, it became widely known (Davis and Tschudin 2008). What caused the phenomenon known as globalization? Possible causes might be changes in geopolitics, the opening of borders, praise of free market economy by the demise of the Soviet Union, and spread of the Internet by advancement in information technology (Hirschfeld 2008). Here, details are not discussed. The nursing profession was also swallowed by the surge of globalization, and a new development took place.
New Ethical Issues And A Perspective Of The Nursing Profession In The Age Of Globalization
Nancy Crigger describes globalization as follows: “Globalization is deﬁned as a process by which the world is interdependently organized and understood. This deﬁnition implies that the process is discursive and holistic, and will in turn affect people economically, psychologically, spiritually, politically and culturally. With globalization, the borders of nations become porous and encounters among people become inevitable. Exchanges and changes occur among people, nations and ideas” (Crigger 2008, p. 19). Using the well-known Adam Smith metaphor, she argues that globalization has formed the world society by its powerful and dynamic “hidden hand,” including exchanges of ideas and values. She introduces two models of globalization, referring to works by W. Schweiker and S. B. Twiss, “from above” and “from below.” The former is political and economic globalization, which often creates injustice through the complex tangled webs of business, politics, and economies among nations and enterprises. In other words, it has produced victims by causing exploitations, spreading poverty, and damaging the environment. The latter is social globalization supported by grassroots activities, primarily by NGOs, human rights advocacy groups, religious organizations, ecological groups, and scholars groups, including nursing. Crigger argues these are activities to improve social quality, heighten social awareness, and call for better health and wellbeing for all the people.
It is obvious that nursing has been hit by the wave of globalization similarly to others. “Globalization impacts nursing at all levels and in all places” (Davis and Tschudin 2008). Therefore, it is imperative to see nursing after the late 1990s in its relationship with globalization in order to have perspective on the future of the nursing profession.
Globalization’s Impacts On Nursing: Focusing On The Issue Of Nurse Migration
The most striking impact on the nursing profession caused by globalization is the international migration of the nursing workforce. A worldwide nursing shortage serves as a backdrop for this issue. Originally, developing countries had suffered a nurse shortage. Due to their poor education systems, the number of qualiﬁed nurses produced each year was limited, and although new graduates were willing to work, there were not enough workplaces to accept them due to the defective medical systems or money shortage to ofﬁcially hire them. As a result, in those countries, there are many qualiﬁed nurses without employment, while health care is in high demand. In remote areas, imbalance between demand and supply of health care has become more severe due to the geographically uneven distribution of medical facilities in those countries. Among them, sub-Saharan African countries are in the most serious situation due to their nurse shortages (Hirschfeld 2008).
Besides, developed countries are also facing the serious nurse shortage problem caused by the population increase, especially the increase in the elderly population, and the growing demand for healthcare service. In addition, due to the low birthrate, the population of young nurses-to-be is decreasing. To make matters worse, young people, who are used to an abundant lifestyle in those countries, tend not to want to be healthcare workers. In Japan as well, nurse shortage has been a serious problem. In addition to the nursing profession’s low social status, bad working conditions, and other issues besides, Japan has had this problem since its vocational school-based nursing education system has kept young people seeking higher education away from the nursing profession. As in Japan, people’s educational background has been all-important; the more intelligent young people have tended to go to colleges or universities rather than to vocational schools. However, as the number of nursing colleges or universities has increased, the nursing education system has improved (Sawada 1997).
Regardless of whether they are developed or developing countries, nurse shortage has become a worldwide phenomenon. The situation where the sustainability of public health care is being jeopardized has become a serious problem for the health maintenance of people. Under such circumstances, the idea of recruitment of nurses from developing countries was proposed to make up for the nurse shortages in the developed countries. As it was carried out frequently, the international nurse migration began to cause serious ethical problems.
With the power of money, developed countries have been recruiting nurses from developing countries, especially from Africa, Southeast Asia, and South America. According to the statistics as of 2002, the rate of unﬁlled post for registered nurse in Ghana was 57 %, and the vacancy rate for nurses in Malawi was 52 %. Speciﬁcally, Malawi is a country with one of the highest shortages of nurses, and according to the WHO’s nurse availability data in 2006, the stock per 1,000 population is 0.59. WHO recommends the minimum standard of nurses is 1.71 per 1,000 population. In Ghana, it is 0.92 (Twining 2010). Also South Africa is suffering the brain drain of nurses due to recruitment by developed nations, and now South Africa is recruiting nurses from other African nations to make up for its nurse shortage. In Peru, 15 % of the nursing workforce migrated primarily to Spain, Italy, and the USA between 2002 and 2006 (Hirschfeld 2008). In Southeast Asia, the Philippines has been the main supplier of nurses. Historically, the economy of the Philippines has been supported partially by overseas migrant workers, and with a view of nurse supply to foreign countries, higher numbers of nurses have been educated than its domestic demand. However, Bertram argues, referring to the article by J. Buchan and J. Sochalski, that recently the situation seems to be changing as the continued migration has left a shortage of nurses to provide care in the Philippines (Bertram 2008).
Nurse recruitment by developed countries has caused various problems in developing countries. Before looking at these problems, beneﬁts brought by nursing workforce migration are brieﬂy described below. First of all, from a standpoint of accepting countries, nurse migration contributes to easing those countries’ nursing shortages to some extent. Particularly, for countries like the USA where patients have different cultural backgrounds and languages, suitable nurses are more likely to be assigned to patients. And, migrated nurses can gain better salaries and improve their quality of life. In some countries, such as Saudi Arabia, Asian or African nurses are paid less than European and American nurses, but still their salaries are higher than those paid in their countries. With their salaries, nurses can support the livelihoods of their families left behind. Moreover, working in developed countries gives them opportunities to learn more, which leads to their career progressions. For countries whose economies are supported by its citizens working overseas, money sent by nurses working overseas enriches the nations’ ﬁnances. In this way, it can be said that nurse migration does not necessarily lead to bad results.
Nevertheless, many of the problems caused by nurse migration are very serious. Above all, health care in those countries from which nurses migrated has fallen into a desperate situation. With few exceptions, those countries originally suffered serious nurse shortages, and nurse migration has depleted their nursing workforces, which not only makes it impossible to satisfy their citizen’s health needs but also has seriously affected patients’ safety. Furthermore, as physicians also have migrated from those countries for better salaries and lives, the healthcare situation in those countries is critically serious. In families of migrated nurses, who are left behind in their countries, children lose a mother who takes care of them, and, in many cases, elderly people who need care are also left behind, which makes things much worse. Even in the case when nurses work in their own countries, many nurses from countryside’s move to big cities to ﬁnd jobs, seeking better working conditions. So, the difﬁcult situation of the children and elderly people left behind is similar to that of the migrated nurses’ families (Hirschfeld 2008). This is particularly true in sub-Saharan African countries with a high HIV/AIDS burden, especially where elderly women take care of their dying adult children and the orphans without any social sustainable means (Hirschfeld 2008). While those countries originally had suffered a serious nurse shortage, the drain of nurses worsened the situation extremely.
Globalization allows wealthy countries to economically exploit poor countries, widens the richpoor gap, and is ever widening the chasm between the have and have-nots (Austin 2008). And, it is said that the burden of poverty ﬁrst comes to women. When families cannot live on their incomes, it is almost always women that go abroad to ﬁnd jobs. That is because, in developed countries, a variety of jobs ranging from healthcare workers to live-in maids and jobs at brothels await poor women (Davis and Tschudin 2008). Globalization and gender issues are intricately intertwined with each other. These are challenges which must be considered seriously, and it must be kept in mind that poor female migrant healthcare workers are an integral part of health care in the healthcare systems of some wealthy countries (Hirschfeld 2008).
As just described, the nursing workforce migration from poor countries to wealthy countries has caused various problems, such as expansion of the rich-poor gap and unfairness. Is it morally acceptable to recruit nurses from developing countries in such a reckless manner? Some argue, referring to the A. H. Aiken’s article, that it is not acceptable, and, in the ﬁrst place, wealthy countries have to address the nurse shortage by making effort for achieving self-sufﬁciency in their health workforces. Regarding the reckless recruitment, recruitment agencies seem to play active roles in the global healthcare market (Hirschfeld 2008). With this information, international society began making guidelines for nursing recruitment. The UK issued international recruitment guidelines in 1999 and 2001, and the USA did in 2005, which prohibited nurse recruitment from countries experiencing nurse shortages unless there is an explicit government to-government agreement to promote recruitment. However, the main focus of each guideline varies depending on countries. The ICN issued the position statement of Ethical Nurse Recruitment in 2001, placing focus on the right of individual nurses to migrate wherever they choose (Bertram 2008). This makes us face an ethical dilemma: when a country suffers a nurse shortage, is it ethically acceptable that nurses seek work outside the country? In light of the ethical principles, this is a conﬂict between the ethical principle, “autonomy” for nurses and their “freedom of choice,” to migrate and another ethical principle of “distributive justice” or fair distribution of nursing care for a nation’s common good. ICN claims that, basically, a nurses’ fundamental right of freedom of choice to migrate must not be infringed. Though, in this case, nurses need to take deliberate actions. They are asked to make an ethically correct decision through serious consideration by examining their nursing competence and their own situations.
Nurses And Patients In Cultural Diversity: Transcultural Nursing
In the age of nursing globalization where nurses are internationally migrating, it adds another aspect to their workplaces: various cultures are brought to healthcare settings. According to the statistics in the USA, which has accepted a great number of nurses from overseas, 11 % of the US registered nurse workforce were “foreign born,” and, of these, 70 % immigrated from developing countries (Hirschfeld 2008). Such a circumstance may give rise to cultural friction between migrated nurses and patients or care receivers, but in the USA, many patients are also of culturally diverse backgrounds. It is said that there are roughly two cultural groups in the world. One group is an individualist culture which refers to mainly North American and Western European cultures. The other group is a collectivist culture which refers to Asian, African, and South American cultures. These are chieﬂy cultures of the developing countries and account for about 70 % of the cultures in the world (Davis 1999). As nurse migrations are mostly moves from the developing countries to the developed countries, it is quite understandable that people may have concerns about cultural frictions between nurses from collectivist cultures and people from individualist cultures. There is an exception. Japan, which has a collectivist culture, has accepted nurses from Southeast Asia due to its nurse shortage. Getting back to the issue of cultural friction, it is friction between a culture that claims individual rights, such as autonomy, and a culture of shared decision-making with one’s family or group. As already mentioned, the decision-making based on autonomy was born in American culture. As American nursing values and ethics have been disseminated to nursing societies all over the world (Davis 1999), even nurses in the collectivist culture group have some knowledge about them. However, their native cultures are so deeply rooted in the migrant nurses that it is not easy for those nurses to get rid of their cultures even after they migrate to the European and American cultural region.
Respecting the collectivist cultural traits of nurses mentioned above, what should we do to provide suitable care for patients who increase cultural diversity in the surge of globalization? Based on the awareness of such a problem, a concept of transcultural, or cross-cultural nursing, was born. Transcultural nursing refers to nursing practice and research focusing on cultural differences and similarities and is aimed at providing patients with culturally ﬁtting care. Therefore, to provide care which ﬁts the cultures of the care receivers is important, and the ability to achieve this is called cultural competence. To acquire this competence, nurses are required to sharpen their sensitivities to care receivers’ value systems as well as receiving a series of training for fostering such cultural sensitivities (Donnelly 2000). Care supported by those who have this competence is culturally competent care. However, there is a different view over the concept of cultural competence that questions: Is it possible to understand different cultures so easily? One’s self-conﬁdence that he or she understands other cultures very well may sometimes lead to problems. Some researcher argues that it is important to know that a sufﬁcient enough understanding of different cultures is difﬁcult for us (Davis 2007).
However, should nurses respect and accept all cultural customs of care receivers? For instance, if a mother who migrated from Equatorial Africa attempts to practice female genital mutilation (FGM), which is an African tradition, on her young daughter, how should nurses handle this case? Not only does FGM have substantial medical risks as a matter of developing complications for those girls who undertake the procedure, but also it encourages gender discrimination. So, this is an unethical act. Care with respect for one’s culture is necessary, but unethical acts must not be allowed. Then, a global standard on nursing ethics is needed. This issue is considered in next section.
Cultural issues of migrant nurses are also relevant. For example, at a hospital with few Muslims, a Muslim nurse asked for permission to wear a niqab (a veil over her face, leaving only eyes visible). The hospital decided to give her temporary permission in order to see patients’ reactions. The result was that in particular, children, elderly people, and confused patients were frightened by the invisibility of the nurse’s face. The hospital concluded that wearing a niqab would not lead to good care and forbade the nurse to wear it. In this case, producing a good result for patients was judged to have more importance than respecting nurses’ autonomy. In another case, a Muslim nurse asked for permission to wear a hijab which covers only her hair. It was approved because a hijab does not hinder contact with patients as much as a niqab (Rowson 2008). As seen in these cases, nurses’ cultural issues must be considered in line with nursing goals, and, if it becomes an obstacle to achievement of the goal, some argue that the nurse’s autonomy has to be limited. On the other hand, patients’ cultural customs must be respected unless they are unethical.
Global Basis Of Nursing Ethics
As mentioned above, in the age of globalization, different cultures make a culturally complex world, and various ethical issues have arisen, including gap expansion and unfairness in health care. In such an age, is it possible to establish a common basis for nursing ethics beyond the differences among countries and cultures? Richard Rowson stated at the international conference on Globalization of Nursing in the UK in 2006: “In the globalized nursing world and increasingly complex cultural situation, it is not easy to establish core values on nursing ethics.” Even so, if a common basis for nursing ethics cannot be established, nurses may fall into ethical relativism and allow themselves to do anything, in a way, by positioning each individual’s conscience under the traditions and social customs. In such a situation, it might be impossible to provide proper nursing. Then, Rowson set nursing goals in the age of globalization as follows: “to promote the health of, and to care for, all people, regardless of their cultural afﬁliation, race, sexual orientation, level of disability, and so on” (Rowson 2008). In order to ethically achieve these goals, he proposed four basic elements of a global basis for nursing ethics. Those are fairly, autonomy, integrity, and results. With initial letters of each element, he termed them FAIR. Each means: nurses treat people fairly, respect people’s autonomy, act with integrity, and seek the most beneﬁcial results (Rowson 2008). He argues that FAIR ﬁts with most people’s personal values. It may be from the inﬂuence of American ethics that autonomy is included in the four elements, because such an ethical concept is largely a Western, speciﬁcally American, idea. In terms of autonomy, today there are criticisms against the trend that places too much emphasis on autonomy. Autonomy is surely important, but it is not an absolute principle. And, in these days, more patients tend to make decisions by consulting with important others like families or friends more frequently rather than alone (Tschudin 2002). In the Principles of Biomedical Ethics (2012) written by Beauchamp and Childress, the supremacy of autonomy has been toned down. The four principles proposed by them, autonomy, non-maleﬁcence, beneﬁcence, and justice, are well-known principles which have long been weighed in nursing ethics and are still applied to it (Beauchamp and Childress 2012). However, some argue that the principles of medical ethics do not necessarily ﬁt nursing well, because the relationship between nurses and patients, and between doctors and patients, rests on different basis. The former is one of more intimate and more long-term care (Tschudin 2002). Then, nursing researchers have started studies on ethical principles that could be a basis for global nursing ethics like those established by Rowson, and, moreover, other researchers notice ethical elements as a basis for care. The following are samples based on the introduction by Tschudin (2002).
Simone Roach has established 5Cs for caring: compassion, competence, conﬁdence, conscience, and commitment. Compassion is a gut-wrenching feeling we feel at others’ agonies. This is what is experienced rather than what is learned in theory and is the basic attitude of caregivers. Competence is a professional coping ability and one’s state of acquired knowledge, judging capability, skills, energy, experiences, and motivation. Conﬁdence is the quality of fostering trusting relationships. Without that the essence of caring is lost. Conscience can be deﬁned as a state of moral awareness, and it urges people to take moral actions. Commitment is necessary for conﬁrming other 4Cs. This is a sort of devotion, because professional care is a form of love which entails a personal commitment (Tschudin 2002).
Rita Manning proposes ﬁve elements of care ethics: moral attention, sympathetic understanding, relationship awareness, accommodation, and response. Moral attention requires caregivers to take time for giving holistic care. Sympathetic understanding is close in meaning to what Carl Rogers called “unconditional positive regard.” Relationship awareness is described in three levels: the relationship with colleagues, the relationship of need and ability, and the relationship of professional and client. Accommodation is to think about all the people involved and listen to them. Response is to ﬁnd out others’ wish through close communication and to act according to it (Tschudin 2002).
The abovementioned ethical standards proposed by nursing researchers were introduced as a basis for global ethics. The ICN Code of Ethics for Nurses can also be a common ethical standard in the age of globalization. In particular, the four responsibilities described in the “Preamble” – “to promote health, to prevent illness, to restore health, and to alleviate suffering” – can be standards easy to understand.
Many studies on the basis for nursing ethics that are suitable for the age of globalization are being conducted today. This is because it is of immeasurable importance for nurses to have common ethical standards in order to deepen their common understanding about the important issues. Not only absolute ethical principles but also broad ethical concepts were introduced in this article. In the age of globalization when diverse cultures, people, languages, and religions coexist, ethical expressions which allow ﬂexible interpretations may be more suitable than rigidly deﬁned ones.
However reﬁned ethical standards we have, it is human beings that use them. That is the reason why caregivers are required to have a certain quality. On this point, A. Sen identiﬁes ten human capabilities as central human capabilities: life; bodily health; bodily integrity; senses, imagination, and thought; emotions; practical reason; afﬁliation; other species (animals, plants, and the world of nature); play; and control over one’s environment. These are the benchmark on which to base the development of a global nursing ethic and have a direct link to our central nursing responsibilities (Hirschfeld 2008).
Some stress that ultimately everything depends on the level of trust in the relationships that nurses can establish with care receivers. Verena Tschudin (2002) considers that all ethical reasoning approaches start from here. She argues that, not acting rigidly based upon ethical principles, nurses need to think about care receivers’ needs from various aspects, including their emotional aspects, through communications with them, and conduct heart-based ethical decision-making and nursing. I and Thou (Ich und Du) by Marin Buber is a good model for the relationship of this kind. It might be too high an ideal to realize, but it is vital as a direction to pursue. Nurses who are caregivers are required to meet care receivers without any bias and relate to them with empathy. This is the basis for relations suitable for the era of globalization. Care starts with “we.”
In this research paper , the history of nursing ethics, starting from the Nightingale age to the age of globalization, was traced. Since the wave of globalization hit the nursing world, particularly with the global nurse shortage in the background, various ethical issues have emerged. Furthermore, healthcare settings have become increasingly multicultural. In the midst of such an age, what ethical principles that can be used as a common ethical basis for realizing ethical nursing were explored. Today, it is no longer possible to grasp our life-threatening issues within our domestic framework. Nurses are expected to be more aware of social justice and their global responsibility and play active roles. For achieving these, ﬁrst of all, it is necessary for nurses to start from their own workplaces. Constantly thinking how they should live their lives as human beings and how they can fulﬁll their responsibilities for others, nurses should cultivate their capabilities for the future good. The arena for nurses’ activities is expanding.
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