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Caring Work, Personal Obligation and Collective Responsibility Chris Provis and Sue Stack Nurs Ethics 2004; 11; 5 DOI: 10.1191/0969733004ne662oa The online version of this article can be found at: http://nej.sagepub.com/cgi/content/abstract/11/1/5

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CARING WORK, PERSONAL OBLIGATION AND COLLECTIVE RESPONSIBILITY Chris Provis and Sue Stack Key words: collective responsibility; personal obligation; professional discretion Studies of workers in health care and the care of older people disclose tensions that emerge partly from their conflicting obligations. They incur some obligations from the personal relationships they have with clients, but these can be at odds with organizational demands and resource constraints. One implication is the need for policies to recognize the importance of allowing workers some discretion in decison making. Another implication may be that sometimes care workers can meet their obligations to clients only by taking collective action.

Introduction This article addresses some questions about the obligations that care workers incur in the context of the work they do. Projects we have carried out have drawn our attention to a dimension of moral and ethical responsibility in the work of nurses and other care workers, a dimension that we believe is not always seen clearly, but is sometimes run together with other considerations. In what follows, we attempt to concentrate specifically on this dimension of ethical obligation that is inherent in much caring work, to identify its basis and to suggest how the obligation can be met. Identifying its basis takes us especially to the obligations that care workers have as a result of the individual relationships they have with clients, while suggesting how the obligations can be met takes us to matters of collective responsibility. Many of the points have been made elsewhere, but to our knowledge they have not been set out clearly together. We have come to focus on this sort of question through projects that addressed issues about caring work in several different contexts, including a hospital, different sorts of in-home care, and several residential facilities for the care of elderly people. 1–3 The focus of one project was the use of ‘flexible work practices’ in some care organizations, in particular, for example, the use of casual and part-time work arrangements, as well as the employment of agency staff and multitasking. The focus in another was absenteeism among staff of several residential care Address for correspondence: Chris Provis, School of International Business, University of South Australia, North Terrace, Adelaide, South Australia 5000. E-mail: [email protected] Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

Nursing Ethics 2004 11 (1) © 2004 Arnold

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C Provis and S Stack

establishments for older people, including a comparison with levels elsewhere but also a study of individuals’ reasons for being absent. The projects required interviews with workers who provided a range of different sorts of care, from fully qualified nursing care in various environments to unqualified personal care work in people’s homes and in residential care facilities for elderly people. Among other things, these interviews addressed issues in people’s personal circumstances and in their work lives that affected their response to organizational policies. (Here, we use ‘policy’ in the broad sense of a general prescription that guides action in particular cases.) Issues about personal responsibility were not a deliberate focus of the interviews, but there were a number of occasions when they emerged as a factor that imposed stress on employees where organizational policies or constraints ran counter to what these individuals perceived as the right thing to do. For example, in one case in a hospital, an interviewee did what she believed she ought to do for patients while simultaneously blaming herself for what she described as an ‘extravagant’ use of bath towels. You’re always told how much it costs for linen and that sort of thing . . . I like to put an extra towel over their shoulders to keep them warm while I dry them with the other towel, so that may not be cost conscious.

In another case, in residential elderly persons’ care, an interviewee believed that, owing to time pressures, her inability to spare a resident 10 minutes to help her to start off her knitting was an example of a constraint on resources (here, as in many cases, the resource of staff time) that limited her ability to provide the sort of quality care that was integral to the quality of life of the resident. She explained how spending that time would have provided the resident with an activity for the best part of the afternoon, contributing to that person’s contentment and well-being. Neither case involved high drama or intense emotion. Nevertheless, even though the cases are simple, we find individuals who are at least to some extent confronted by a moral dilemma. They accept that they are bound by the policies, norms and directives of the organization that employs them, but they also sense an obligation to the individuals for whom they are caring that runs counter to the requirements of the organization. These cases are only two examples of tensions experienced by workers. What individuals ought to do in this kind of situation does not seem clear-cut. Our impression was that in general the employees being interviewed were sensitive and compassionate, but some determined to accept organizational directives and resource constraints while others allowed these requirements to be overridden by the obligations they felt to their individual clients.

Policies and personal obligations In general terms, we could characterize this sort of conflict as one between commitment to individual other people on one hand and commitment to an organization or institution on the other. Defined in these terms, this sort of conflict can be found in a number of places. One example is organizational ‘whistleblowing’, where individuals draw public attention to ethical concerns about the Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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policies or practices of the organizations in which they work. Glazer and Glazer note that often such individuals are caught between their loyalties to the organization and their beliefs about what is ethical. 4 However, the sort of case we are considering is removed from whistleblowing cases by the fact that there is nothing clearly and demonstrably unethical about the organizational policies and practices that conflict with the commitments that employees feel toward individual clients. Someone could suggest that, in the cases we have described, a nurse or care worker is caught between an ethical obligation to comply with organizational policies and an emotional commitment to an individual client, where the ethical obligation ought to be given priority over the emotional tug just because ethics ought to be given priority over personal inclination. However, it is not clear that the obligations individuals feel towards one another must always be grounded in emotion. It is possible that the grounding of obligation in an interpersonal relationship is as much a matter of cognition and volition as of emotion: a matter of mutual recognition of one another as human beings. Although such mutual recognition can often generate an emotional response, it may be distinct from that response. It is beyond the scope of this article to analyse the nature of such mutual recognition in detail, but there is a long tradition that discusses such encounters, rooted to a significant extent in Hegel’s Phänomenologie des Geistes,5 and there is recent work on ‘mutuality’ in a number of contexts that tends to emphasize participants’ expectations more than their emotions.6 The idea recalls to some extent the point made by Pellegrino that obligations of health practitioners are rooted to a significant extent in the ‘encounter’ with an individual patient. 7 The relationship involved in such an encounter goes beyond a straightforward means–ends relationship, even when the end is to some extent the good of the patient, just as actions born of friendship cannot be analysed simply as means to ends.8 Over the last 20 years, philosophers have paid a good deal of attention to the point that relationships like friendship that have particular other individuals as their object can generate obligations. 9 This is not quite the same as the sorts of view that have been developed by some writers about nursing and other caring professions to the effect that members of such professions have duties that include some degree of empathy or deep emotional concern for clients.10,11 The view that loyalties to other individuals may generate specific obligations to these others is not quite the same as a view that one ought to have some special sort of emotional attitude towards them. An example is the nurse who used an extra towel to keep patients warm when drying them after a shower. Although it is arguable that what is shown here is a particular emotional response to the individual patient, we suggest that a more adequate and complete way to conceptualize the situation will refer to the judgement the nurse is making about her obligations. It may seem likely that her judgement is born of compassion and sympathy, but the essence of the situation seems to be the decision she makes about what she ought to do. In one view, indeed, it is precisely this that is questionable. Ewin suggests that loyalty can be problematic just because to a significant extent it seems to require ‘a setting aside of good judgment’ (p. 415). 12 In the context of nursing, this kind of issue has been discussed in terms of ‘partiality’.13,14 However, the idea of partiality conjures up an idea of one patient being treated better than another for reasons that have nothing to do with his or her condition or situation. This is not our suggestion. It is typical, Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


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in caring work, to establish personal relationships with clients. This is not problematic when we remember that personal relationships come in a variety of types and degrees. They may not all involve affection or any other particular sort of emotion. The ‘encounter’ involved in ‘personal’ relationships seems to be distinguished rather by some degree of reciprocity and recognizing one another as persons who are recognizing one another. Thus, for example, Woodward has noted that ‘caring may be considered in terms of Buber ’s I–Thou relationship’ (pp. 391–92).14 There can be caring work that does not involve such personal relationships, where the person being cared for is comatose, for example. However, where there is the sort of personal relationship that involves reciprocity and mutual recognition, then it is plausible to suggest that it generates some degree of obligation on the participants in the same general sort of way that friendship generates obligations. To some extent personal relationships have important derivative effects on people’s health. We know about the significance that social relationships have for health and well-being in various contexts.15,16 This is one reason why care workers’ relationships with clients are important and are a source of obligation. However, personal relationships that care workers enter into with clients generate obligations not only because of their good effects but also as a matter of integrity and keeping faith with the other party to the relationship. This does not generate any specific implications about the obligations that are engendered by such relationships. The content of such obligations will vary, depending on the circumstances, and a personal relationship with another person does not generate an obligation to heed their interests above all else. Clearly, in some cases, heeding a commitment to an individual over wider policy considerations could be the wrong thing to do. An individual’s request for some treatment may need to be overridden when resources are in limited supply and other clients’ needs are greater. At the same time, however, in some circumstances the ethical thing to do may be to place one’s commitment to an individual client above organizational policy: if a resource policy prescribes a limit on the use of towels, the nurse may decide that the obligation to a patient is more important. Thus, Gastmans, for example, notes potential tensions between a ‘business-like culture’ and nurses’ ‘directed concern with the patient’ (p. 221). 10 Reay notes that ‘Many ethicists have argued the need to make health resource allocation decisions at a policy level and not at the bedside’ (p. 244). 17 However, that may not take sufficient account of the real personal obligations that nurses and other care workers can have to their individual patients. There seem to be some cases where obligations to individual clients may outweigh the obligations created by institutional or organizational policy. We suggest that a key implication has to do with the formulation of good policies.

Personal obligations and resource policy If genuine ethical obligations could conflict with detailed policy prescription, one way out is for ethically sound policies to leave appropriate scope for decisions by care workers that allow them to take account of the needs and situation of their individual clients. In doing so, policies would have to provide both discretion and time; without time, discretion would be to no avail. Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.



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To say that care workers must be afforded discretion to make appropriate care decisions about individual clients is not to suggest that they can disregard organizational policy, or that they ought to give the needs of their clients priority over all other demands. It is rather to note a particular limitation to the ‘managerialist’ or ‘audit culture’ approaches to accountability and control of care workers that have been noted by many writers. It is to recognize that organizational policies can only ever be formulated reasonably in terms that incorporate some elements of vagueness, or open texture, that can properly be given precise interpretation only in the specific circumstances of individual clients. There are, we believe, two distinct grounds for this approach. One is the fact that care work involves sustained close attention to clients’ condition and needs. Davies refers to the ‘minute and detailed observation that takes place in the sustainedly close relationship’ (p. 22).18 There is a simple sense in which care work may often be ‘holistic’: the sense in which it involves attention not just to a defined set of factors such as blood pressure, temperature, pulse and the like, but to any relevant factors about the client’s situation or condition that may have implications for their future well-being. To the extent that this is a requirement of caring work, it involves some alertness to factors that have not been exhaustively predetermined, just as understanding and monitoring the condition of an environmental ecosystem may involve attending to all the factors and interrelationships that impact on the wellbeing of the system and its elements. Because caring work may involve such sustained close attention to individual clients, it is likely that care workers will be in a better position to make decisions about client needs than is possible in a general policy-making context that necessarily abstracts from general cases. For example, they may be better able to determine priorities and ways of attending to those priorities. A care worker with a disabled client being cared for at home may arrange directly for someone to repair a piece of equipment for the disabled person as a matter of urgency when policy requires them to go through a liaison person in the health department. In this respect, however, the situation is no different from many others where general policies have to be formulated in terms that allow trained individuals to make decisions about how to apply the policies in practice. Hunt has noted that ‘The exercise of “judgement” or “discretion” is often taken as a mark of the true professional’ (p. 521). 19 Soldiers, priests, managers and numerous other types of professionals are guided by general policies that may constitute a ‘guideline’ or ‘rule of thumb’ rather than an absolute prescription. For the arrangement to work effectively, the general policy must be formulated in a way that allows discretion but still provides a guideline, and the individuals charged with implementing the policy must be trained and willing to act according to the spirit of the general policy. What makes caring work distinctive is not the need to formulate policies that allow a degree of discretion and the need to train professional care workers in ways that lead them to use that discretion appropriately. What is distinctive is rather another ground for the approach that requires general policy to have some degree of open texture built into it. If the previous ground is associated with the fact that care work involves sustained close attention to clients’ condition and situation, this other ground is that care work quite properly involves some degree of personal relationship with clients that establishes obligations of the same general type as are Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


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established by personal relationships such as friendship. To some extent, this point is identified in Sabatino’s comment that, according to many nurses, the health care system ‘may not be allowing caregivers the necessary time to respond with the sensitivity of care’ (p. 375), 11 but sensitivity of care need not be interpreted to refer only to an emotional attitude. What is at issue to a significant extent are the obligations that care workers have to clients and the requirement that they be able to fulfil those obligations. These seem to be the sort of things implicit in saying that, in dealing with a client, we recognize the other as a person like ourselves, with concerns and interests that have some intrinsic weight. Workers require both a degree of discretion and sufficient time to exercise it conscientiously. Here, it may be argued that it is not part of a professional care worker’s role to establish such personal relationships with clients. Indeed, it may be said that a good deal of professionals’ training addresses both the need and the possibility to relate to clients in a detached way in order to allow good decisions about care, without distortion or bias. The response to that objection has already been given. Personal relationships come in a wide variety of degrees and types. It is absolutely true that professionals may err by establishing too close a relationship, because that may distort judgement and create an inappropriate sense of obligation on both sides. The fact that it is possible to establish relationships that are inappropriate does not imply that all personal relationships are inappropriate; some degree of personal relationship is inevitable for the sort of effective caring work that depends on sensitivity to the details of clients’ condition and situation. In that case, however, it does seem to follow that the general policies guiding care workers must afford them some discretion over how to act with clients if they are to meet the obligations that are inherent in the personal relationships they legitimately establish. Here we are not speaking of intimate friendships, or of deep, long-standing affection, but of the sort of relationship that a care worker may have with an elderly nursing home resident that would make it reasonable for the worker to feel some obligation to start the client’s knitting for her. It is a characteristic not only of care work but also of some other sorts of work that the very performance of the work involves people in establishing relationships with others, but, to the extent that it does, it must be accepted as a requirement of the conditions of work that those performing it have scope to meet the obligations they incur.20 One implication is that individual workers need to be afforded appropriate decison-making discretion, and often an equally important implication is the need for resource allocations that allow care workers sufficient time to exercise that discretion appropriately. If there is some degree of latitude in organizational policy (i.e. a vagueness or open texture in what is required and possible, so as to allow care workers some discretion in what they can do) then that may take us some way towards overcoming the sort of moral dilemmas that nurses and other care workers sometimes identify in their work. Seventy per cent of respondent care workers in a study by van der Arend and Remmers-van den Hurk experienced moral problems in cases where ‘institutional rules obstructed “measured care” ’ (p. 477). 21 Problems arise not only from general policies but also from limitations on time that leave care workers no scope to deal with the personal obligations they inevitably, and properly, establish Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.



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with individual clients. As we have emphasized, such obligations will be limited in their scope, but they are real and important for the individuals involved, and, if the general policy environment or prescriptive rules allow no scope to comply with them, that it creates a moral dilemma. There is good general evidence that the ambiguity of conflicting obligations and pressures of workload and time are likely to result in staff ‘burnout’,22 potentially leading to high levels of absenteeism or staff turnover. It could be argued that there are occasions when individual care workers and others will benefit from a prescriptive rule. Sometimes, it could be said, everyone will benefit if the care worker is able to say, ‘I’m not allowed to’, and does not have to say, ‘I don’t think it would be appropriate.’ That is to say there will be occasions when the care worker’s relationship with the client will benefit from some restriction or limitation being a matter of outside constraint, rather than the individual care worker’s decision. If there are situations where that is a real issue, the appropriate strategy to deal with it is probably suitable training rather than a general environment of prescriptive rules. Care workers who have some discretion over how to act can still distance themselves from decisions by reference to resource constraints or general policy, even if that policy is not formally prescriptive in fine detail: ‘I’m afraid there isn’t enough time for that today’ points to external constraints (and to other possibilities for different days), rather than emphasizing the care worker’s own decision.

Individual obligation and collective responsibility Paradoxically, stronger obligations on care workers may arise from less closely prescriptive rules and policies, which put some onus on them to reconcile general constraints with the obligations they have to individual clients. Closely prescriptive policies invalidate themselves by their disregard for genuine moral concerns, but policies that leave staff some discretion pass on to them the responsibilities for care and attention to details of clients’ needs. The difficulties that then arise for care workers are not directly from those obligations but from the need to make decisions about how to implement general policies. Then we rely primarily on care workers’ training to enable them to make good decisions about how to meet the obligations they have to clients, and the situation is no different from any other of the many kinds of circumstances in which we all have to make such judgements. However, somewhat different considerations come into play when the level of resources provided falls short of what staff need in order to meet their obligations to clients. The issue that then has to be confronted is the extent to which care workers may share in some collective responsibility for shortfalls in resources of time in particular. What ethical responsibilities do health care staff have then? On one hand, it may well be that many care workers deplore the inadequate resources that the community sometimes allocates for the care of sick and aged people. At the same time, it is care workers who are most directly in a position to recognize the shortfall. In the personal contact they have with clients, they most fully appreciate the concerns and needs of those clients. Whereas outsiders may assume that all is well, care workers may see more clearly what problems there are. The personal relationships they properly form with clients can be a source of obligation Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


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for care workers, but they are not the only source. They also have obligations because of their detailed knowledge and understanding of clients’ needs and of the shortfall they may see between those needs and the resources provided to meet them. However, care workers may often find themselves in situations where they are unable to take any individual action that fully satisfies the obligation they feel. In our studies, some interviewees simply had insufficient time to meet all their obligations. If care workers are in that situation is there any way for them to resolve their moral dilemma? Here, we suggest, the situation needs to be accounted for on the basis that we have a responsibility to do whatever we can to meet our obligations. In the present context this may mean that, if we cannot meet our obligations as individuals, we have a responsibility to meet them collectively. An extreme analogy may still be inappropriate , yet serves to bring out the issue. Members of the public in Nazi Germany may truthfully have been able to disclaim knowledge of what was happening in concentration camps. Camp guards could not; they knew all too well. We may then want to say that they bear far more responsibility for what was done than members of the general public. It may well seem outrageous to draw such an analogy with workers in care institutions who know more than the general public about the shortcomings of ‘managed care’ and other similar arrangements. It seems reasonable to believe that often care workers at least try to do what they can to ameliorate difficulties caused by shortages of funding and resources. They certainly do work that is, among other things, demanding, difficult and requires great skills of sensitivity and discernment. On the other hand, members of the general public may be content to turn a blind eye to the resource constraints, happily accepting the lower taxes that funding limitations allow. Undoubtedly, that is true. The analogy with Nazi Germany is very limited, but it does serve to identify the significance of clear knowledge about the problems in care institutions. If we are correct in thinking that the personal relationships that care workers have with clients do put them in a special position of knowing most clearly the implications of resource constraints, then there is a real question about the extent to which that creates some special responsibility for them. This point may not be unique to care workers. For example, bank staff may have a special responsibility if they have particularly clear knowledge about the impact of bank policies on poorer and more disadvantaged clients, and university staff may have a special responsibility if they have specific knowledge about the impact of funding limitations on students. It may be that what is partly at issue is the general extent to which we can properly disavow responsibility for the policies implemented by the organizations of which we are members. In an age of managerialism, where individuals are constantly under pressure to conform to organizational policies, it may be that there is a general ethical issue about the extent to which individuals ought to accept responsibility for raising questions about policies whose effects they can see with special clarity. Perhaps for many of us the most salient difference between us and the people of Nazi Germany is the fact that we live in a more democratic regime, where there are opportunities for us to have some influence on political decisions. In particular, for us, there is some opportunity to influence decisions about our community’s priorities and allocation of resources. We can do so not only through voting at elections Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.



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but also by, for example, lobbying, writing letters to newspapers and participating in meetings. For care workers, however, the extent to which they can take account of these opportunities depends on a number of factors. One is the nature of their employment. There is some general evidence that employees who express dissent or involve themselves in controversy can suffer disadvantage at work as a result.23,24 Managerialist policies in organizational administration can go with intolerance of dissent. At the same time, some workers are better able than others to articulate their concerns. The skills to be expected of lower-level care workers may include degrees of interpersonal awareness and sensitivity and a number of others, but not necessarily the ability to articulate concerns and issues in a clear way in a public forum. Even professionally qualified nursing staff can have that expected of them only to a limited extent as part of their professional role. What can be presumed, however, is that care workers at all levels can reasonably be expected to contribute to the development of policy positions by their professional and union organizations. 25 Individual care workers have individual obligations to clients, just as all people have to one another. It goes beyond such individual obligations to cope with limited resources or with questionable priorities and policy directions. However, it seems reasonable to suggest that there are collective obligations to address such issues where they are matters of concern, and that individuals have obligations to participate in collective action aimed at addressing them to an extent that depends partly at least on their training, skills and experience. (In this context, ‘collective action’ is a generic term that may refer to a wide range of things including collective public statements, overt lobbying and other possibilities.) This general suggestion is consistent with the idea that collective action may sometimes emerge from people’s shared values more than from common interests.26

Summary In summary, then, if our argument is correct, care workers have two especially notable sorts of obligations that emerge from the work they do. One is the sort of constant specific obligations they have to individual clients as a result of the personal relationships they quite properly form with them, which are part of effective care work. Meeting such individual obligations requires them to have discretion and resources, including, among others, resources of time. Our studies showed that all too often care workers are not afforded the resources they need to meet individual obligations, which may be a shortcoming of either policy direction or community resource allocation. Although they cannot as individuals be expected to overcome these resource shortfalls, it may be that care workers do have a collective responsibility to do what is possible to remedy them, and that they have individual obligations to assist in meeting that collective responsibility to an extent that depends on their skills, training and experience.

Acknowledgements The authors gratefully acknowledge comments and suggestions from David Cox, Evdokia Kalaitzidis, participants in discussion at the 2003 Conference of the Downloaded from http://nej.sagepub.com at PENNSYLVANIA STATE UNIV on April 12, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.


Association of Industrial Relations Academics of Australia and New Zealand, and from referees for this journal. Chris Provis, University of South Australia, Adelaide, Australia. Sue Stack, Flinders University of South Australia, Adelaide, Australia.

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