Original Manuscript The ambiguity of altruism in nursing: A qualitative study Nursing Ethics 1–10 ª The Author(s) 2017 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733017709336 journals.sagepub.com/home/nej Anna Slettmyr and Anna Schandl Karolinska University Hospital Solna, Sweden Maria Arman Karolinska Institute, Sweden Abstract Background: For a long time, altruism was the basis for caring. Today, when society is more individualized, it is of interest to explore the meaning of altruism in nursing. Methods: In all, 13 nurses from a Swedish acute care setting participated in two focus group interviews performed as Socratic dialogues. Data were analyzed using a phenomenological hermeneutical method. Ethical considerations: Ethical issues were considered throughout the process according to established ethical principles. Informed consent was obtained from all participants, confidentiality regarding the data was guaranteed and quotations anonymized. Findings: Altruism created a sense of ambivalence and ambiguity, described as a rise of sovereign expressions of life caused by “the other’s” need, but also unwillingness to take unconditional responsibility for “the other.” Conclusion: Society’s expectations of altruism and nurses’ perception of their work as a salaried job collide in modern healthcare. Nurses are not willing to fully respond to the ethical demand of the patients. In case of a disaster, when nurses personal safety, life and health may be at risk, there might be reasons to question whether the healthcare organization would be able to fulfill its obligations of providing healthcare to an entire population. Keywords Caring, ethics, individualism, interdependence, Løgstrup, Martinsen, phenomenological hermeneutical, Socratic dialogue Background Altruism is the principle or practice of concern for the welfare of others.1 In nursing and caring science, altruism is related to love, compassion, and responsibility.2 In an ideal altruistic caring relationship, the encounter with fellow human beings is based on a genuine desire to alleviate suffering.3 Nursing as a vocation is historically closely related to altruism.2 Today, vocation as a phenomenon has come to be associated with negative wordings, such as sacrifice, subservience, and obedience, and is in a modern discourse regarded as Corresponding author: Anna Slettmyr, General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital—Solna, 171 76 Stockholm, Sweden. Email: [email protected] 2 Nursing Ethics XX(X) the opposite of professionalism and paid work. Anyhow, Martinsen reminds us that the vocation originally meant a responsibility attached to the patient and to our fellow human beings who suffer.3 Historically, society in the Nordic countries was built on solidarity and equality.4 This structure has gradually changed with time, and today’s healthcare is governed by economic incentives where efficiency, patient flow, and balanced economy play important roles. Social changes, like secularization and an increased individualistic focus, influence all individuals in society which naturally also affects nurses and the entire healthcare system as an organization including attitudes among the staff. In a more individualized society, where autonomy and integrity are highly valued, altruism and compassion may be considered as old fashion expressions of healthcare.5 In altruism, the unselfish act to take care of another lays the unspoken expectation of the nurse as a good and virtuous woman, which implies submission and an unselfish devotion to the care of others,6 in contrast to modern healthcare where nursing is seen as a more technical profession.7 Still, these changes of perception may induce a risk that patients’ vulnerability and dependence are perceived as unnatural and remain unseen.5 The nurses may no longer be willing to stand up for the patients and their families in situations where they may end up in a moral dilemmas regarding their obligation to care for “the other” versus a duty to protect her/himself and family (for example, in a new pandemic influenza). Still, altruism is of great importance for nurses’ motivation and career.8–10 Though important, nurses were less likely to state altruism as a motivator to entering the profession than other non-medical health professions.9 In contrast to this, other studies show that altruism has been undermined over time and is not as highly valued today as it used to be.11,12 Thus, the modern individualistic philosophy of life may contribute to a changed approach to altruism, where such an attitude is not natural or are no longer perceived as important for nurses. This in turn may have the consequence that modern healthcare may face the problem that healthcare personnel are not willing to care for patients, especially if their own personal safety, life, and health may be at risk.13 The phenomenon altruism and the willingness among nurses for self-sacrifice is here a key question and of interest to investigate. The aim of this study was to explore how nurses perceive the meaning of altruism in today’s healthcare. Applying the philosophy of Løgstrup The theoretical framework of this study was grounded in Knud Ejler Løgstrup’s14 philosophy and interdependence, which is the origin for “the ethical demand,” “the sovereign expressions of life,” and the responsibility for “the other.” According to Løgstrup, interdependence is the basic prerequisite for human life. Interdependence means a mutual unconditional dependence with the following responsibility for each other as human beings.14 “The ethical demand” arises from a unique situation in the encounter with “the other” and cannot be planned or anticipated. This in turn gives rise to what Løgstrup14 calls “the sovereign expressions of life,” such as trust, hope, and mercy. Kari Martinsen and collegue15,16 has applied the philosophy of Løgstrup to nursing and points to the ethics that is inescapable in encountering human vulnerability as in nursing care. Martinsen describes the nursing profession as a commitment, a will, and a responsibility to prioritize the other’s needs, which can be understood as an altruistic action. She also describes the link between the vocation and Løgstrups thoughts when she says that the vocation is about love of man and to meet him with respect. Vocation can be understood as the “ethical demand” emanating from “the other,” the obligation is thus a claim to take care of the other’s life put in the hands of another human being.2 Løgstrups philosophy of interdependence and responsibility for each other as human beings are based on caring science relevant to the professional assignment to care. Also, the “ethical demand,” “the sovereign expressions of life,” and the compassion and love of neighbors are phenomena understood as the basis for an unselfish action for another, both as fellow human beings and as professionals and nurses.14,15 In this study, the theoretical framework, based on Slettmyr et al. 3 the philosophy of Løgstrup and the theories of Martinsen, was used as the basis for studying the unselfish act for “the other,” that is, altruism. The term “the other” was used to describe the other person in an encounter, from a phenomenological standpoint, inspired by philosophy of Løgstrup14 and Levinas and Nemo.17 Methods Research design The design was a qualitative empirical study where data have been reached in Socratic group dialogues with clinically experienced registered nurses. In Socratic dialogues, the lived experience is reflected upon and discussed from ethical viewpoints; in this study, the concept and phenomenon of altruism were presented as topic and phenomenon for reflective discussion. Participants and research context The study was conducted in a university hospital in Sweden. A purposive sampling was applied and participants with varying experience and demographics were recruited. A total of 13 registered nurses who worked in an acute care setting at the hospital were interviewed, 6 of the nurses had specialist training in intensive care or emergency care, and 7 of the nurses were under specialist training in intensive care. These participants formed two separate focus groups. Demographic data for the participants are presented in Table 1. Table 1. Demographic data of the included registered nurses. Total number (invited) Men, number Women, number Age range (mean years) Number of years as nurse Number of years as specialist nurse (out of years as nurse) Specialist nurse Nurses under specialist training 6 (9) 2 4 25–60 (38) 3–33 1–27 7 (15) 1 6 27–44 (35) 2–8 – Data collection—the Socratic dialogue The focus group interviews18 were conducted in September 2013 and February 2014. The interviews were performed as Socratic dialogues,19–21 which is an interview method that permits a philosophical deepening of the phenomenon by investigating participants’ clinical experiences. For the nurses to have a common starting point, the dialogues started with a joint reflection regarding the question “What is altruism?” Thereafter, the nurses were asked to describe a self-experienced altruistic situation that occurred in their everyday clinical practice. Then, the whole group reflected upon how these examples could be considered to be altruistic actions. These reflections were further discussed to gain a deeper understanding of their experiences. The nurses were also asked to define, in writing, what altruism meant to them in relation to today’s healthcare. The individual definitions were discussed and compared in an attempt to reach a consensus definition. Each dialogue lasted for a little more than 2 h in total, according to the description above. The participants contributed in various extents to the dialogues, some did have a lot of thoughts about altruism, while others contributed less to the joint reflection. The dialogues were recorded to ensure verbatim transcription and were transcribed by the first author (A.S.). 4 Nursing Ethics XX(X) Analysis The analysis included a dialectic movement between the three phases of the phenomenological hermeneutical method: naı̈ve understanding, structural analysis, and comprehensive understanding.22 The text was repeatedly read in its entirety and a naı̈ve understanding was formulated based on the authors’ preconceptions. Thus, two separate naı̈ve understandings were formulated, compared, and discussed until consensus was reached. In the subsequent structural analysis, a more distanced approach to the text was used. The dialogue text was divided into meaning units relevant to the purpose of this study and condensed into everyday language. Among the meaning units, similarities and differences were sought, and through reflection and interpretation, meanings of the phenomenon of altruism emerged. These meanings formed subthemes, which after further analysis were combined in three relational contexts, with an overall main theme. To create a deeper overall understanding of the phenomenon, a comprehensive understanding was formulated from the naı̈ve understanding and the structural analysis, in relation to the research question, preconceptions, and the theoretical framework. To strengthen the credibility and trustworthiness of the interpretations and descriptions, the authors continuously discussed the analysis process. The analysis phase lasted for approximately 1 year, which gave enough time for thoughtfulness and reflections.23 Ethical considerations Ethical issues were considered throughout the process according to established ethical principles.24 To participate in ethical reflections can be both challenging and educational, and the dialogue leader, a nurse herself, was respectfully aware of this. The participants were informed about the voluntary nature of participating, and informed consent was obtained from all of them. Confidentiality regarding the data was guaranteed and the quotations were anonymized. The Regional Ethics Review Board in Stockholm, Sweden approved the study (2013/1702-31). Findings Naı̈ve understanding The meaning of altruism was not something the nurses reflected upon in their everyday clinical work. However, during the dialogues, the topic inspired a diversity of thoughts and feelings and the nurses started to realize that altruism was actually playing a role in their professional life. A totally unselfish act, without any personal gain, was seen as an unrealistic or even utopic act. The most common opinion among the nurses was that altruistic acts were based upon the maxim “treat others as you would like to be treated yourself,” where compassion and empathy were implicit. Altruism also meant making small as well as large sacrifices for the patient. However, less demanding altruistic acts in the caring relationship dominated the self-experienced examples. The meaning of altruism was described in terms of doing “the little extra” for the patient, that is, going further and doing something that was not expected of them in their daily work. It was expressed as “prioritizing ‘the other’s’ needs before your own.” Sometimes, the altruistic actions resulted in positive feedback from patients or their families. Such appreciation was highly valued by the nurses. They also stated that the feeling of “making a difference” for “the other” contributed to a sense of having meaningful work. However, to act altruistically also meant risking criticism from colleagues. Yet, being criticized increased the feeling of sacrifice, which in turn made the altruistic act feel even more altruistic. The nurses implied that they based their altruistic actions on knowledge and professionalism and not on character traits or virtues, such as goodness. They denied that nursing was vocational work, even though they felt that society expected or even demanded altruistic behavior from nurses. Slettmyr et al. 5 Structural analysis The meaning of altruism was related to the person herself/himself, to “the other” in the caring relation, and to the nursing context, which formed the three subthemes of the structural analysis. In each subtheme, the nurses’ perceptions of altruism veered from uncertainty about the meanings of altruism to its meaning for their clinical work. Thus, the main theme was “The ambiguity of altruism.” Quotes were used to illustrate the meanings of the phenomenon of altruism. The ambiguity of altruism: the professional self. The nurses defined altruism as making larger sacrifices, which were considered as being of high value. Yet, they argued that this was not something everyone could achieve. To make immense sacrifices at work, at a personal cost, was perceived as something extreme of remote importance. Altruism within the profession was often perceived as making small sacrifices— sacrifices that did not involve any personal cost for the nurse, but could be of great value to the other person. Altruism was expressed as “treating others the way you want to be treated yourself,” based on the idea of “how would I feel if it was me.” The phenomena “empathy” and “altruism” were perceived to be closely related. Still, the nurses stated that professional knowledge, experience, and compassion were seen as the foundations for altruistic acting. The nurses wanted to be appreciated for the work they conducted but they did not want to be called angels, which were perceived as a disparagement of their professional worth: I am not an angel; I am here to do my job. I am good at it, and I like it as well. Altruism implied a feeling of “making a difference for the other person” and thereby creating a sense of meaningfulness in their work. This motivated them to further altruistic behavior. The nurses were driven by a kind of inner satisfaction, where “doing good” induced a sense of meaningfulness: I do it for myself. There are so many patients in need of care and treatment, and I find it meaningful to take care of them. Why do I do this? Well, I want to have a job which I enjoy, and where I feel that I can make a difference. [ . . . ] But I would not do it for free, I come here because I get paid, and because I like it, and because it is a meaningful job. Only then can I think of altruism. It is, however, not my first thought. I do not wake up in the morning and think; today I will perform altruistic acts. If the nurses found their work to be without substantial meaning, motivation to do “the little extra” for the other person was lost: Sometimes you will find yourself in a position when you do not like what you’re doing; you have lost your motivation and do not want to do this anymore. I did not want to change that diaper but of course I did it anyway . . . The nurses were aware of that lack of motivation in work could affect patients or their relatives negatively. Therefore, they stated that it was important that each individual was responsible for his/her own actions. The ambiguity of altruism: “The other”. The nurses stated that altruism meant to prioritize the needs of the other person before your own and protecting the other persons’ dignity when he or she was unable to do so himself/herself. Altruism was described as doing “the little extra” for the other person, something that was not normally expected or demanded from the nurse. “The little extra” could be anything from combing the patient’s hair or allowing relatives to sleep an extra night at the ward to a more general responsibility for 6 Nursing Ethics XX(X) “the other” in the caring relationship. However, there was disagreement about what was considered to be “the little extra” and what was supposed to be included in the nursing assignments: What does “the little extra” mean? It is my job to do this. My job is to take care of the other person when he/she cannot do it him/herself, to prioritize the other person’s needs. It is not something extra I do . . . When an altruistic act resulted in a positive response from the other person, this was regarded as less altruistic, since altruism was supposed to be a completely unselfish act. In spite of this, when an altruistic act enhanced positive feedback, it was appreciated by the nurses and regarded as something positive: . . . if I get something in return when helping someone else, is it not regarded as an altruistic act? All of a sudden, it is degraded . . . because of my personal gain. Isn’t it a mutual gain? If I feel good doing something and at the same time I can help another person, isn’t that twice as good . . . Acknowledgement of the altruistic act resulted in a sense of satisfaction. The recognition could be immediate, through direct positive feedback, expressed as gratitude. Or it could be delayed, like when patients or their families on a later occasion acknowledged the benefit of the act. Such acknowledgement could also play a role in the following way: Nursing can be quite hard work, and is often badly paid. What motivates you to continue working as a nurse is the positive feedback from the care recipient. The nurses’ attitudes towards altruistic acts were pervaded by ambivalence. They were well aware that altruism was defined as an unselfish act for “the other.” Still, they expressed a feeling of satisfaction when being needed and important for the other person. The altruistic actions were sometimes criticized by colleagues. If the nurses tried to be flexible and do “the little extra” for the other person, they could be reproached by colleagues. Fear of criticism could prevent them standing up for the actions they would like to do for the other person: If there were many relatives visiting the patient at the same time, I sometimes told them, that only one or two at the time could come into the patient’s room. It wasn’t so much for the patient’s safety as it was to prevent me from being criticized by my colleagues. The risk of receiving criticism when doing “the little extra,” enhanced the feeling of sacrifice and made the nurses feel that they had acted for someone else without any personal gain. The criticism became a validation of the altruistic act. In contrast to doing “the little extra,” there was “conditional altruism.” Some of the nurses expressed thoughts about when the other person did not deserve “the little extra.” Being too demanding, or not ill enough, were reasons for being disqualified from receiving altruistic acts. The nurses also wanted patients and their families to show understanding for the stressful working environment at the ward and to consider this in their demand for care: It is frustrating when they (the patients and their families) do not show understanding for our situation, “We just received three acutely ill patients and that is why you have to wait for your turn”, but on the other hand, perhaps we should just consider it from the patients’ perspective . . . Some nurses were annoyed or frustrated about this, while others calmly stated that meeting other people in a vulnerable situation was what being professional was about. Slettmyr et al. 7 The ambiguity of altruism: the society. The possibility for altruism was experienced as being restricted by limited human resources and economic restrains. The nurses described how such economic considerations made their moral obligations collide with the demands of the employer. They gave several examples of situations where they wanted to do “the little extra” for the patients and their families, but the economic aspects of healthcare hindered them: Since someone from the healthcare personnel was ill, we did not have time to mobilize all patients. We were then told by the head nurse to lower our ambitions and reduce the quality of care. Nursing has by tradition been considered as vocational work. The nurses stated that this perception still lingers and society expects altruistic acts from healthcare personnel. However, the nurses did not want to acknowledge their profession as a vocation, but stated that it was a salaried job like any other. Altruism is considered to be closely related to nursing. But why is it so? We have a nursing education, we do the job that is assigned to us, and we get salary for this. It doesn’t have to be an altruistic act. However, the character of the work assignment might contribute to this misinterpretation, as argued by the same nurse: We do take care of critically ill patients and their families in a strained situation, which may be an explanation for why nursing is associated with altruism. Comprehensive understanding Altruism conveyed a sense of ambiguity and ambivalence among the nurses. On one hand, encountering “the other’s” need caused an increase in sovereign expressions of life, such as spontaneous mercifulness and trust which called for offering care. On the other hand, social and organizational structures require nurses to have a more task-oriented and technical attitude towards the other person. A deeper motivation for engagement in “the other” was expressed, but the expectations of altruistic acts within nursing collided with the nurses’ perceptions of their own profession as a salaried job. Interdependence and natural responsibility for “the other” were explicit in the nursing role and in the encounter as human beings, yet linked to ambivalence. A willingness to engage in the caring relationship and stand up for “the other” was enounced. In the caring encounters, the needs of “the other” were prioritized, which made room for “sovereign expressions of life,” and most nurses had experienced receptivity to the “ethical demand.” Such actions created a feeling of meaningfulness and contributed to an ambition to perform further altruistic acts. However, so-called “conditional altruism” was also at state and was expressed as an unwillingness to engage in “the other” if the altruistic act did not result in a sense of reciprocity. In such situations, “constrained expressions of life,” like mistrust, was present. Critical comments from colleagues prevented the nurses from engaging in and taking responsibility for “the other.” This resulted in a contradictory uncertainty about the impact of altruism in today’s nursing and healthcare. Discussion The ambiguity of altruism was illustrated in the nurses’ narratives from daily practice where they described its subtle influence in their work, patient and family encounters, as well as in relation to the society and economic values. The nurses described the rise of “sovereign expressions of life” caused by “the other’s” need which to some extent were restricted by a narrow frame, set by social, organizational, and financial structures in healthcare. This resulted in a more task-oriented attitude towards nursing, something the nurses seemed unaware of, but that pervaded the caring encounter. 8 Nursing Ethics XX(X) Interdependence, according to Løgstrup, is a great power, and whenever “the other’s” situation is not received in mutual trust, it is devastating. This means that we are all in the hands of other human beings and therefore also vulnerable in such situations.14 According to Martinsen,15 a caring relationship is characterized by vulnerability, where patients and their families are dependent upon the nurse. The expectation of trust, which is present in all interpersonal encounters in healthcare, makes the patient vulnerable and gives power to the caregivers. Vulnerability is required for showing compassion for “the other’s” suffering. In the nursing context, it is important for the patients and their families that the nurses can relate to their own vulnerability as well as “the other’s” and use this to offer caring acts.15 To be able to achieve this, trust in other human beings and compassion on the basis of unconditional interdependence are required as a part of the nurses’ professionalism. In the more individualized and self-centered society, such trust and compassion may not be present.2 In the absence of interdependence in healthcare, the others’ needs may risk to be neglected. In this study, the nurses sometimes showed willingness to take unconditional and spontaneous responsibility for “the other,” thereby enabling a caring relationship. In a previous study, it was shown that there was willingness for altruism among nurses, but also an ambivalence towards the helping motive, especially regarding the unselfish focus on “the other.”25 In the dialogues, there was an ambiguity towards the concept of altruism, where some nurses were willing to take unconditional responsibility for “the other” in most situations and others were not. Some nurses did not fully respond to “the ethical demand” of the patients and their families, which might have contributed to uncaring encounters, and therefore lead to unnecessary suffering for “the other.”5 The individualistic attitudes in today’s society influence healthcare and nurses’ behaviors when caring for patients. In previous research, the evidence for altruism’s importance in modern healthcare is contradictory which may indicate that ambivalence in nurses’ attitudes towards the phenomenon exists.8–12 Today, the spontaneous acting for “the other” in the nursing context does not seem to be without consideration. This is what Løgstrup calls “constrained expressions of life.” In contrast to “the sovereign expressions of life” such as trust and mercy, “constrained expressions of life” revolve around oneself in a self-absorbed or self-protecting way and encompass, for instance, mistrust, jealousy, and egocentrism.14 In our study, “the constrained expressions of life” were expressed as “conditional altruism” where the nurses expected that the patients and their families should take the nurses’ interests and needs into account when demanding care. When the focus was no longer primarily on “the other,” the altruistic element became secondary or absent, also in professional care. This may reflect the changes of modern society, where individualism may lead to a desired contact in relations, where positive feedback gained from the patient encounters may play an important role in self-realization.25 In such scenario, the nurses own well-being becomes as important as the concern for “the other” as a patient. Anyhow, the caring relationship is asymmetric and the focus should, as Northaug and Nortvedt26 say, be on “the other” and not on the caregiver. Professional nursing should not be blind to working conditions or to healthcare workers’ interests, but these considerations should not be the primary focus in the caring situation.26 Altruism is closely related to nursing as a vocation. Even in today’s healthcare, the nursing profession is best understood as a vocational occupation, where vocation is described as a personal and moral disposition to “the other” in the nursing context.2,27 In our study, as in another previous study, the nurses distanced themselves from this statement.28 At the same time, they expressed a motivation for the profession, closely connected with their own identity, values, and behaviors. This might be interpreted as lasting deep traces of vocational or altruistic motivation, although they hesitated to use such words.28 Here, dissociate from something contemporaneous expressed as an important part of the profession, which becomes a contradiction or an expression of the ambiguity to the phenomenon itself. With some astonishment, we noted that the nurses did not reflect upon their professional responsibility for “the other” in a broader context or out from society perspective, such as being exposed to contagious diseases when caring for infected patients or being at risk for developing illnesses because of working conditions.29–31 Slettmyr et al. 9 Instead, the dialogues were focused on small sacrifices in daily work. Furthermore, the nurses did not express any thoughts about what demands society would make in case of disasters, such as a new pandemic influenza, natural disasters, or conflicts and war. Many nurses in Sweden have never been confronted with such situations in clinical practice and that may be the reason for not reflecting upon this in the dialogues. Questions like how much self-sacrifice can reasonably and justifiably be expected of nurses in such situations were left unanswered. The availability of healthcare workers will be essential in order to provide an effective response to, for example, an influenza pandemic. Policies should be formulated so they contribute to a climate in which healthcare workers feel a personal moral responsibility to care for patients despite an increased risk to their health.32 Therefore, future studies to investigate nurses’ attitudes towards altruism when their personal comfort, safety, life, and health may be at risk are warranted. The result of this study should be seen in light of its strengths and limitations. The study is empirical but mainly included nurses from intensive care units, which may limit the transferability to other contexts. All authors had preconceptions that influenced the interpretations of the text, experiences from both clinical nursing and theoretical perspectives. However, the preconceptions have been controlled by thorough data analysis and discussion among authors and by being open to a new perspective. Conclusion In today’s clinical praxis, the society’s expectations of altruism collide with nurses’ perceptions of their profession. The nurses have to balance the paradigm of nursing as a vocation, where altruism has a natural place, with the perception that the profession is a salary work like any other. Hence, we have found an uncertainty about and an ambiguity towards altruism among nurses. This confusion is seen on a surface level, yet signs of a deeper motivation to altruism still remain. The ambivalence may lead to the fact that nurses do not always respond to “the ethical demand” of patients and to the expectations of society. Today, many nurses also intend to leave the profession after only a couple of years, turning their back to the vulnerable patient, which is a problem for healthcare organizations.33 In the utter case of a disaster, when nurses personal safety, life and health may be at risk, there might be reasons to question whether the healthcare organization would be able to fulfill its obligations of mobilizing nurses and providing healthcare to an entire population. Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References 1. 2. 3. 4. Scott N and Seglow J. Altruism. Maidenhead; New York: Open University Press, 2007, p. 153. Martinsen K. Øyet og kallet [The eye and the vocation]. Bergen: Fagbokforlaget, 2000, p. 173. Eriksson K. Caring science in a new key. 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