The purpose of metaphor is to conceptualize one thing in terms of another. Metaphorical concepts shape and reflect our perceptions, actions, and relations to others (Lakoff and Johnson 1). In the field of nursing, many metaphors have emerged which have greatly impacted the practice of nursing.
These metaphors include the “nursing as military” metaphor, which typified nursing during the 19th and most of the 20th centuries, and the “nursing as advocacy” metaphor which became the dominant conception of nursing after the tumultuous social struggles of the 1960's.Most metaphors associated with the nursing profession are referred to as moral metaphors because they involve issues that require ethical reasoning about what possible actions nurses ought to take in various healthcare situations (Milton 318). As such, nursing metaphors have a profound impact on nursing ethics, including stated rules and principles as well as more implicit guidelines to the way nurses think and act. Modern nursing is widely considered to have begun with the work of Florence Nightingale, superintendent of nurses in British military hospitals during the Crimean War in the 1850's.
Nightingale's theories were hugely influential, especially her concerns for sanitation and strict military discipline (BBC History). In Sir Richard Quain's “Dictionary of Medicine” (1894), Nightingale is quoted as saying: “To obey is to understand orders, and to understand orders is really to obey” (Winslow 34). Her dedication to the “nursing as military” metaphor is best summed up in the Nightingale Pledge, a modified version of the Hippocratic Oath, created by nursing school leaders in 1893 in Detroit that professional nurses of the day were sworn to: “With loyalty will I endeavor to aid the physician in his work” (NursingWorld. Org).In the military metaphor, as obedience, loyalty and discipline are the most important qualities a soldier should have, so too nurses. The metaphor was exemplified by a passage in an early book on nursing ethics: “.
.. the love a nurse has for the stern strife of her constant battle with sickness ... the stern joy which warriors feel.
.. should inspirit the valiant heart of the nurse as it does the heart of the brave soldier who bears long night watches, weary marches, dangerous battles, for the love of the conflict and the keen hope of victory” (Winslow 33).Historically, the “nursing as military” metaphor defined the nurse's most important obligations as obedience and loyalty to those of “higher rank. ” With regard to moral/ethical issues, this meant the refusal of nurses to criticize physicians, hospitals or even fellow nurses. The false justification for this unswerving loyalty was that the trust of the patient in the abilities of the doctor/hospital was central to the management of his illness (Milton 318).
Although moral dilemmas existed, ethics in nursing was largely a matter of “doing one's duty.For nurses, acquiescence assured protection from the legal implications of medical malpractice and secure employment (Wurzbach 95). However, an editorial in the January 1910 edition of The American Journal of Nursing openly questioned the ethic of uncritical loyalty saying, “Where does the nurse's loyalty to the doctor end? And is she required to be untruthful or to practice deceit in order to uphold the reputation of the physician at her own expense or that of the patient? ” With this foundation, the training of nurses in obedience, discipline, and loyalty became the norm for the next hundred years.Before the advent of the scrub, even the dress of nurses reflected the military metaphor.
As nurses progressed up the ranks, stripes were added to their caps and insignia pins to their uniforms (Winslow 33). Modern nursing also arose at a time when medicine was appropriating the military metaphor of “medicine as war against disease. ” “Disease is the enemy, which threatens to invade the body and overwhelm its defenses. Medicine combats disease with batteries of tests and arsenals of drugs” (Winslow 33).
However, nursing's military metaphor was not to last forever.Inevitably, the weighty responsibilities of nurses, who literally have patients' lives in their hands, would come into conflict with the irresponsible ethic of uncritical loyalty. A major blow was dealt in 1929 with the Somera case, in which a nurse in Manila was found guilty of manslaughter because she uncritically followed a physician's order. The case changed nursing practice forever, establishing the principle of independent accountability for nurses (Bosek and Savage 35).Then the women's rights and patients' rights movements appeared, part and arcel of the radical social struggles of the 1960's and 70's in the United States which effectively challenged the traditional patriarchal power structures in society.
For nursing, a profession consisting almost entirely of women, important changes were ushered in. It was at this conjuncture that the patient's rights movement turned to nurses in the search for “patient advocates,” giving birth to the new “nursing as advocacy” metaphor (Winslow 36). The advocacy metaphor is essentially a legal one, comparing nurses to attorneys who take fiduciary responsibilities to defend the rights of others (Milton 321).According to this metaphor, nurses are the ideal patient advocates. Nurses have constant, intimate contact with patients and often develop personal-professional relationships with patients that serve as the basis for empathy and concern for the whole patient. Nurses are the educators of patients about their healthcare, so it makes sense that nurses would take a keen interest in patients being properly informed (proper information being something that doctors would routinely keep from patients, such as diagnoses, prognoses, alternative treatments, realistic risk assessments, informed consent and so on) (Winslow 36).
The advocacy metaphor stressed nurses' concern for the well-being of the patient, and nurses began writing about the need to support the patients' goals rather than the goals of doctors and hospitals (Wurzbach 96). Instead of military-style training by hospitals, nursing education programs in the 1960's began to move to the universities, where nurses-to-be were trained in an academic setting based on rational thought about ethics and legal training in patient's rights (Wurzbach 95). Nurses developed their own professional organizations and theoretical journals independently from the traditional sources of authority.During the 1970's, the concept of advocacy was incorporated into nursing codes of ethics. In 1973, the International Council of Nurses dropped all mention of loyal obedience to doctor's orders and replaced it by saying “The nurse's primary responsibility is to those people who require nursing care.
” The 1976 revisions to the American Nursing Association's code made explicit use of the advocacy metaphor: “In the role of client advocate, the nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical or illegal practices by any member of the health care team or the health care system itself... (Winslow 37).
Metaphors are powerful and extremely meaningful indications of the values, virtues, and beliefs that all of us use to define ourselves. For nurses, military and advocacy are the two most influential metaphors that have molded both their own self-perception as well as the views of others. The military metaphor, with its language of loyalty and obedience, and the legal metaphor, with its language of advocacy and rights, will forever serve as opposite models of ideal nursing practice.
