Running head: RELATIONSHIP BASED CARE: A QUESTION OF GENDER
Relationship Based Care: A Question of Gender Neutrality
Teresa D. Welch
University of Alabama
BEF 641 Studies in the Social Foundations of Education
AEL 681 Ethics and Education
Becky Atkinson & Stephen Tomlinson
July 25, 2013
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RELATIONSHIP BASED CARE: A QUESTION OF GENDER
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Relationship Based Care: A Question of Gender Neutrality
In the past decade we as healthcare providers have found ourselves in an ever
increasing dynamic and chaotic world of change. Complex economic and political policies have
collided and forced healthcare organizations to re-evaluate their core principles of patient care
processes to meet those demands. Improved patient outcomes and the patient’s perception of the
healthcare experience will be two key determinates of organizational success in the future. As a
result intensive self-reflection and a radical shift in the nurse-patient relationship is inevitable.
(Koloroutis, 2004) The philosophy and practice of nursing care has been indoctrinated by the
biomedical model of medicine. Patients are treated with a paternalistic attitude that focuses on
the scientific and technological approach to interventions that are predicated upon a disciplined
rationality with little to no regard for the essence of the person (Waldow, 2009). Survival in the
healthcare market of today will require that providers respond with a transformative attitude.
Evidence suggests that relationship based care (RBC) will improve clinical patient outcomes and
overall patient satisfaction with hospital care (Koloroutis, 2004). RBC is both a philosophy of
care and an operational framework that brings the patient and family back the center and focus of
care. Healthcare is provided through authentic therapeutic relationships organized around the
needs and the priorities of the patient and their families. As more healthcare organizations move
to this patient care model more nurses will be forced to re-evaluate their daily practice of task
oriented, fragmented care to engage the patient and family with a more authentic presence in the
‘caring moment’(Koloroutis, 2004). Who will be better suited to successfully engage the patient
with authentic presence? Is it our moral obligation to ‘care’ rather than to provide competent
care? The purpose of this paper is twofold: first examine the place of caring in moral judgment
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and action and, secondly, offer a discussion on the relevance of caring with nursing as a female
dominated profession.
Caring in Moral Judgment and Action
Dianne Ustaal is a registered nurse who eloquently summed up the heart of nursing in
this quote: “Nursing is a moral art…It involves the design and fostering of a healing atmosphere
that rests upon the creation of a therapeutic relationship and the application of scientific
knowledge and skill“ (Koloroutis, 2004, p. 117). The difference between a good nurse and great
nurse lies within the heart and the essence of the person. Today’s nurses are highly skilled
trained professions who are called upon every day to incorporate accurate clinical assessment
skills, decisive critical thinking and judgment skills in a dynamic, oftentimes emotionally
charged situation to effectively manage patients with complex medical conditions. Positive
patient outcomes are directly impacted by the expertise and care of the nurse. It will require
more from the nurse than excellence in techne or excellence in cognition to set themselves apart
as extraordinary; moving from good to great. It will require that we give of ourselves as one
human being engaging with another who is in a vulnerable state. We must move beyond the
action of nursing care to the essence of ‘caring’ to define the great nurse. The purposeful
engagement of one human being to another demonstrating a caring attitude is indeed a moral act
worthy of recognition and dignity elevating the art of nursing to a much higher degree. The
performance of a required action, while certainly better than nothing, is not enough to meet the
needs of the patient and family and leaves the interaction lacking (Lachman, 2012).
Caring is both an intrinsic and an extrinsic moral concept. Caring is that intrinsic
consciousness and judgment that compels us into a moral action aiming to alleviate the needs of
another person: to help, to comfort, and to support. Caring is also that extrinsic moral concept
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that is interdependent with others with whom we interact (Tarlier, 2004). Nursing then provides
goal-directed and specific care to help someone who is more vulnerable and experiencing
emotional and/ or physical distress and need (Waldow, 2009). With purpose and intent, the
nurse will seek to engage the patient and family in an authentic therapeutic relationship to
promote the best possible outcomes for the patient.
The authentic therapeutic relationship is characterized by openness, respect, empathic
understanding and cooperation while striving for a mutual nurse-patient common goal. Nursing
literature consistently provides three essential elements to the authentic therapeutic relationship:
respect, trust and mutuality. These elements are grounded in ethical nursing knowledge, and as
nurses incorporate them into clinical practice, through the engagement of the therapeutic
relationship, they have the power to connect theory, ethical knowledge, and clinical outcomes at
the bedside (Tarlier, 2004, p. 231). Simply saying that nurses ethically provide care is a meager
attempt to describe the actual complexity of integrating personal and public moral knowledge as
the foundation of the nurse-patient relationship. “Caring occurs almost incidentally as nurses
enact a larger body of underlying moral philosophy in their daily practice” (Tarlier, 2004, p.
232).
In order to explain the intrinsic consciousness, that which motivates our actions, we
should consider the universal moral principles that relate to basic human rights by examining the
principles of justice as offered by Kant, Locke, Mill and Nozick. Collectively they all speak to
universal basic human rights. We have an intrinsic duty to respect the dignity and the rights of
the individual as human beings. Human beings have unalienable rights (Locke) that cannot be
forsaken or taken away. Through pure practical reason (Kant) we have the capacity to recognize
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the universal principle of morality and the freedom to choose to act autonomously (Sandel,
2009).
Building upon the intrinsic moral principles of human rights motivating our judgments
and actions, we need to also consider the extrinsic influences that impact and motivate our
actions. To understand the inter-connectedness of relationships found within communities we
need to examine the philosophies and writings of Alasdair MacIntyre and Aristotle; men who
both spoke to the importance of past experiences and life’s history and how those ‘histories’
have impacted our interactions and relationships moving forward. “The narrative, or teleological
aspect of moral reflection is bound up with membership and belonging.” (Sandel, 2009). The
ethics and morality of care then follows these basic principles and is derived from the idea that
care is basic to human existence weaving people into a network of inter-related relationships and
experiences. “When a person chooses to become a nurse he or she has made a moral
commitment to care for all patients. The decision to care is not to taken lightly, as the Code of
Ethics for Nurses clearly states that: “The nurse respects the worth, dignity and rights of all
human beings irrespective of the nature of the health problem.” (ANA, 2001, p. 7) (Lachman,
2012, p. 113)
Carol Gilligan (1982) was the first ethicist to “discuss ethics of care from the contextual
perspective of the situation rather than the impartial deliberation of the ethical issue itself”
(Little, 1996). The ethics of care seeks to explore and maintain the integrity of the relationship
by contextualizing the issue and promoting the well-being of the care-giver and care-receiver in a
network of social relations; implying that there is moral significance in the fundamental elements
of relationships and dependencies in human life. Ethics of care then builds on the motivation to
care for those who are dependent and vulnerable (Sander-Staudt, 2011).
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Following a Kantian theoretical approach, the moral worth of an act depends upon its
intention; its motive. If the motive is derived autonomously out of a categorical imperative, then
the act is an imperative of morality (Sandel, 2009). The moral weight of the individual as a
human being, the encounters and the relationships that we have within the community can be
further illustrated in the writings of Kant and Rawls. Consider Rawls’ categories of obligations;
natural duties, voluntary obligations, and obligations of solidarity. Moral obligations can arise in
one of two ways: as natural duties that we owe to human beings and voluntary obligations that
we incur through consent. Natural duties are universal; implicitly owed to one another as rational
beings. They don’t require an action of consent as they arise from autonomous will (Kant) or
from a hypothetical social contract (Rawls). Unlike natural duties, voluntary obligations are
specific and arise from consent. Obligations of solidarity, or membership, that can’t be explained
in contractual terms. (Sandel, 2009). The basic principle of the caring ethic is reflected within
the obligation of solidarity. Obligations of solidarity are situationally specific, and not universal;
involving the moral responsibilities that we owe to those with whom we share a history; “Their
moral weight derives instead from the situated aspect of moral reflection; from recognition that
my life’s story is implicated in the stories of others” (Sandel, 2009, p. 225). For Kant there is
value in human beings as an end unto themselves and moral principle based upon Kantian ethics
places high regard on human dignity and human rights. (Sandel, 2009). Kant also speaks to a
relationship between one’s own ends and the ends of others in applying the categorical
imperatives or unconditional moral law. “Autonomy in the Kantian sense does not exclude
consideration of others. Moral autonomy is the categorical imperative, or the internal will an
individual exerts to decide to act in a moral manner and follow through with his decision: It is
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both a necessary and a sufficient condition for compliance with the moral law; through the
exercise of pure practical reason” (Sandel, 2009, p. 123).
Ethical and philosophical theories give us the unifying foundation with which to build
our practice. Jean Watson’s Human Caring theory is a well-known theory within nursing that
embodies the caring ethic and provides the model and framework needed to transform nursing
care from the biomedical influence of medicine into a patient-centered relationship based model
of care. The three major elements of Watson’s theory are the caring principles (caritas factors),
the transpersonal caring relationship, and the caring moment. The foundation of Watson’s
Human Caring Theory is derived from the development and maintenance of a “helping-trusting,
authentic caring relationship and being present to and supportive of, the expression of positive
and negative feelings as a connection with a deeper spirit of self and the one being cared for
develops” (Lachman, 2012, p.112). The nurse must be self-aware and recognize any judgments
or prejudices that could interfere with open honest communication to effectively build a trusting,
caring relationship with the patient. Watson also recognized the importance of recognizing and
acknowledging the uniqueness of the individual patient and the nurse’s ability to preserve the
patient’s dignity. “The transpersonal caring relationship, described the nurses caring
consciousness and the moral commitment to make an intentional connection with the patient.
The caring moment is the space and time where the patient and nurse come together in a manner
for caring to occur” (Lachman, 2012, p.112).
Historically within the disciplines of philosophy, anthropology, and psychology there has
been a tendency to regard reason and emotion as two separate and conflicting functions.
Emotion has typically been devalued and regarded as irrelevant or disruptive to moral efforts and
debate oftentimes at the expense of reason. These disparities have their origins embedded within
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the propagandized gender bias of sociocultural practice and custom. I would argue that being
moral frequently involves feeling appropriate emotions, including anger, indignation, and
especially caring (Little, 1996) and these emotions are not unique to gender. The experience and
expression of emotion is a healthy exercise for holistic care and well-being for all individuals.
Feminist theorists argue that these presuppositions may not survive their gendered origins as
inequalities and disparities are questioned and examined through inquiry and research.
Possession of appropriate emotion arguably forms an indispensable component of a wise
person's rationality and reason (Little 1995). Passions and inclinations can mislead us and distort
our perceptions, but, they can also motivate and guide them. (Little, 1996).
Gender; Does it matter?
The successful building of a caring therapeutic nurse- patient relationship is not a
mutually exclusive gender trait to either males or females. Admittedly, ‘caring’ is typically
associated with feminine traits and gender, but that association should not confer truth nor imply
that ‘caring’ is an exclusive trait to one or the other. Male nurses do demonstrate caring
behaviors and can therefore engage in a rewarding nurse-patient therapeutic relationship
providing ‘care’ to a sick and vulnerable patient population as effectively as female nurses do.
“Gender is a social-specific phenomenon whereby certain expectations, roles and behaviors are
ascribed to a person merely because they were born either biologically male or biologically
female. The gender code has therefore prescribed a range of pervasive unwritten rules as to
‘how we should be’ simply because of our biological sex. Gender therefore prescribes behavioral
differences founded in social culture” (Loughrey, 2008, p. 1328).
Traditional moral theory has vastly underplayed the importance of the "emotional work"
of life negating the relevance of nurturing, offering sympathy, or felt concern for another. This
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emotion/ reason debate is one that has transcended the passage of time and continues to emerge
with remarkable consistency (Little, 1996). A core theme within the feminist theory has
maintained the assumptions that gender differences, as previously mentioned, have historically
devalued women and polarized specific personality traits based upon some arbitrary
sociocultural ideal. The man's central role has consistently been associated with and placed
within the public sphere: economics, politics, religion, culture. While the woman's central role
has consistently been associated with and placed within the private sphere; the domestic realm of
care taking for the most intimate, natural, and personal aspects of human beings.
“One of the most distinguishing roles the male nurse occupies is his gender role; after all
the quintessential difference between female nurse and male nurse is indeed male” (Loughrey,
2008, p. 1327). It is important to acknowledge that men and women are different; not that one is
subordinate to the other, but different. It is morally defensible to accept that reasonable
pleuralisms may exist in how we view the morality of care, but in doing so, it doesn’t change the
morality of the issue at hand (Sandel, 2009). Our interactions and resulting actions are
dependent upon our ‘histories’; that history will certainly encompass, gender, race, and economic
influences as we determine our responses and reactions. Gilligan (1982) found that both men
and women articulated the ‘voice of care’ at different times and in different ways. She
characterized the difference as one of ‘theme, however, rather than of gender’. Men and women
often think the same thing, but speak different languages to express their thoughts and feelings.
It is important to recognize and challenge bias in moral theory and correct the tendency to take
the male perspective as the prototype for humanity in moral reasoning (Loughrey, 2008).
Research on the concept of care in the male nurse’s professional experience has
demonstrated the male nurse’s ability to transcend the biomedical healthcare model and
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successfully engage in the authentic therapeutic nurse-patient relationship. Gilligan (2001)
concluded in her research that men’s articulation of the caring process ‘transcended the
biomedical model’ and involved a relationship with the patient and patient’s family (Loughrey,
2008). Likewise a phenomenological research study from Paterson et al (1995) explored the
process by which male nursing students learned to care and concluded that caring is a
transformational experience that develops over time based on personal and professional
experiences of caring and being cared for (Keogh & Gleeson, 2006, p. 1172). Both of these
studies appear to support the idea that the ability to provide care transcends gender. “Individual
actions in the context of social practices can illuminate differences between individuals, male or
female, and provide guidance for private and public issues that bring clarity and an egalitarian
view to society” (Jaggar, 1991). Despite the influence of gender bias men do become nurses
who successfully adopt profoundly caring roles in healthcare (Loughrey, 2008) and at the same
time, there are women who fail to do so. Gender is not the deciding factor.
In Summary, care is both an intrinsic (self) and extrinsic (community) moral concept.
Moral philosophy is a compass, providing the foundation and understanding to ‘legislate our own
piori’ (Sandel, 2009) guiding our judgments and resultant actions. The morality of care is then
exemplified as moral judgment in ethical action. If moral philosophy provides the foundation
from which to understand universal moral principles, then a model of care based upon an
authentic patient-centered relationship provides the clinical framework with which to engage
patients and families with the authentic caring relationship demonstrating the morality of care.
Social roles and expectations for men and women have been in cultivated through
generations of repetition and a social ambivalence to universally establish social norms. These
gender roles and expectations have no basis in biological predisposition or prescription and
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represent a social phenomenon worthy of introspection and query. Males defying established
social norms are working in a female dominate profession and successfully engaging patients
and families to establish caring authentic relationships. They care for their patients transcending
the biomedical allegiance to elevate nursing care to a place of personhood with dignity. Gilligan
(1982) in her research discussed key observations that she coined ‘a different voice’. She
alluded to the differing viewpoints of men and women on the morality of caring and the
differences with which we communicate and express ourselves. There may be ‘different voices’
singing with different ranges, but it’s the same song; only in harmony.
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