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“NOTICE: this is the author’s version of a work that has been sent for publication in Nursing Philosophy. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may be made to this work since it was submitted for publication.

Lying to ourselves: Rationality, critical reflexivity and the moral order as ‘Structured Agency’.

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Abstract

A report suggests that United States’ Army officers may engage in dishonest

reporting regarding their compliance procedures. Similarly, nurses with espoused

high ethical standards sometimes fail to live up to them, and may do so while

deceiving themselves about such practices. Reasons for lapses are complex.

However, multitudinous managerial demands arising within ‘technical and

instrumental rationality’ may impact on honest decision making. This paper

suggests that compliance processes, which operates within the social structural

context of the technical and instrumental rationality manifest as ‘managerialism’,

contributes to professional ‘dishonesty’ about lapses in care, sometimes through

‘thoughtlessness’. The need to manage risk, measure, account and control in

order to deliver efficiency, effectiveness and economy (technical rationality), thus

has both unintended and dysfunctional consequences. Meeting compliance

requirements may be mediated by factors such as the ‘affect heuristic’ and

‘reflexive deliberations’ as part of the ‘structured agency’ of nurses. It is the

complexity of ‘structured agency’ which may explain why some nurses fail to

respond to such things as sentinel events, a failure to recognise ‘personal

troubles’ as ‘public issues’, a failure which to outsiders who expect rational and

professional responses may seem inconceivable. There is a need to understand

these processes so that nurses can critique the context in which they work and to

move beyond either/or explanations of structure or agency for care failures, and

professional dishonesty.

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Introduction

Wong and Gerras argue that the United States’ Army ought to examine why it is

that US officers’ professional ethos of integrity and honesty is so often breached,

resulting in “lying to ourselves” (Wong and Gerras 2015, p iii). The profession of

nursing may have to address why breaches in care might also involve ‘lying to

ourselves’ about our ability to provide safe, compassionate and kind care. Wong

and Gerras suggest that in the US army, dishonesty is due to the deluge of

managerial demands that require compliance. For many officers, reporting ‘non-

compliance’ is seldom a viable option due to the Army’s requirement for zero

defects. Repeated exposure to these demands results in ‘ethical numbing’ and an

often unstated collusion within many levels of the Army in dishonest reporting.

This may be a result of neutralising unethical action in order to be ‘pro-

organisational’, thus meeting both organisational and personal needs (Umphress

& Bingham, 2011). Their conclusion is that the ‘culture of dishonesty’ firstly

requires acknowledging by the Army; secondly there needs to be restraint in the

propagation of requirements and compliance checks and thirdly that leaders at all

levels must ‘lead truthfully’. Wong and Gerras thus provide managerial reasons

for dishonesty in the US Army (a multitude of compliance procedures aimed at

achieving ‘zero defects’) but there is a need to consider what prevents officers

from exercising their agency to ‘lead truthfully’. The lack of a recognition of the

roots of systemic dishonesty, and the potential for the lack of ownership of

unethical decisions by personnel in health service organisations, might mirror the

US army’s blindspot. In the health service, this lack of recognition may be

facilitated by essentialist, individualist, ‘bad apple’ analyses based on

fundamental attribution errors (Jones & Harris, 1967; Ross, 1977) and a lack of

the development of ‘error wisdom’ based on the ‘person approach’ (e.g. ‘moral

weakness’) to understanding errors (Reason, 2000; Reason, 2004). In this view,

‘moral weakness’ then requires correction by such moral enhancement tools as

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‘values based recruitment’ (Health Education England, 2014) or the UK’s

‘Compassion in Practice’. This is a ‘vision and strategy’ for nurses, midwives and

care staff emphasising 6 core values: Care, Compassion, Competence,

Communication, Courage and Commitment (the ‘6C’s’) (Great Britain Department

of Health 2012). Yet, such tools for ‘moral enhancement’ may not in any case be

necessary preconditions for ethical health care practice (Wasserman, 2014) and

indeed could be misplaced bureaucratic procedures. ‘Why do good people do

bad things?’ (Venditti, 2015) is of course to be explained. This paper seeks to

contextualise nursing care failures in the technical rationality of late modernity

which necessitates ‘thoughtlessness’ (Roberts & Ion, 2014) mediated by factors

such as ‘affect’ and reflexive deliberations. We need to consider why some

nurses fail to recognise their ‘personal troubles’ as public issues’ (Wright Mills,

1959). We thus can move beyond bipolar explanations that seek to either focus

on structural reasons on the one hand or human agency, or ‘essentialist’

explanations on the other.

Breaches of care, values and responses - personal troubles and public issues.

To lie is to intentionally mislead, to intentionally make a false statement. If the

perpetrator knows the recipient has knowledge of that intent, because they are

one and the same person, then lying cannot occur without a separation of some

sort. To lie to oneself therefore involves consciously or unconsciously invoking

blindspots and moral machinations to make it work. If the statement is ‘I am

acting morally’ is to be believed to be true, although the evidence around one

would suggest the opposite, then morality itself needs to be redefined in such a

way as to make it true.

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To be clear about discussing breaches of the ‘moral order’ which may threaten

professional values, and nurses’ responses to those breaches, it might be useful

to consider Wright Mills’ outline of identifying ‘personal troubles and public

issues’ (Wright Mills, 1959).

Personal troubles occur within the individual’s immediate experience and

relationships. They relate to the individual self and to those areas of social life of

which the individual is immediately, directly and personally aware. The

description of what the trouble is and what the solutions are, come from the

individual and within the scope of their ‘social milieu’. A trouble is a private

matter; they are values that we feel are threatened. An army officer filing a

report stating ‘zero defects’ when this is not the case knows he is lying, but as a

personal trouble he has to find an individual answer to justify the deception, in

the exercise of his personal agency.

Public issues are matters that go beyond the local environment of the individual

and their inner life. They result as an ‘organisation’ of many such situations into

the structure and institutions of society. An issue is a public matter; issues

threaten values held by the public. When this happens there may be public

debate about what that value is and what really threatens it. The personal issue

of reporting zero defects by army officers when they know this not to be true,

becomes a public issue as this practice becomes widespread within the army.

To paraphrase Wright Mills:

‘When…only one officer is dishonest, that is his personal trouble, and for its relief

we look to the character of the man, his skills and his immediate opportunities.

When…nearly all army officers are dishonestly reporting… that is an issue, and we

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may not hope to find the solution within the range of moral schemata open to

any one individual. The very structure of the moral order has collapsed. Both the

correct statement of the problem and the range of possible solutions require us

to consider the social structural institutions of the army and not merely the

personal situation and character of a scatter of officers’ (Wright Mills, 1959) p9)

(my italics and emphasis).

In this manner Wright Mills points to personal agency operating within social

structure as an insight into developing the ‘quality of mind’ required, i.e. the

sociological imagination, to fully understand social phenomena. Wright Mills then

discusses threats to values in relation to personal troubles and public issues to

describe how this might result in action or otherwise (figure 1).

Figure 1

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Crisis: If we become aware that some aspect of the moral order is being

transgressed but we are constrained by external factors (for example fear or

bullying) that prevent us from acting according to our moral conscience and

ethical codes, we are in crisis. At this point this ‘personal trouble’ of crisis requires

resolution and might lead some to deceive themselves that actually there is no

breach at all or that the breach can be justified using alternative reason (resolving

a cognitive dissonance). But the preferred, and espoused, domain of professional

practice is one in which external factors are overcome and action is undertaken

regardless of personal consequences.

Indifference: In some settings where breaches are occurring, no response is

forthcoming because no one is aware of them. This is our blindspot because we

just don’t recognise a breach for what it is. A culture arises which allows

rationalising of current practice to fit with the established moral order. No one

feels what Wright Mills refers to as a ‘personal trouble’ and thus no ‘public issue’

is raised. This is unconscious ‘lying to ourselves’.

Unease: If breaches are occurring but we have not thought about our values, or

had them articulated clearly, and are unaware of what is really happening, we

may feel unease. In the absence of clearly identifying a breach for what it is we

may again deceive ourselves or misdirect searches for causal issues. Breaches of

care if not clearly understood as such may lead to unease as values are

threatened but we don’t know which ones or why. If we ‘redefine’ values (and

goals) then they no longer become threatened. We may then become indifferent

or even feel well-being because we have told ourselves that values are not under

threat.

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Wong and Gerras’ officers were aware of both espoused values (deontological

reasoning regarding honesty and integrity) and that breaches were occurring. So

to resolve the dissonance between values and action, they engaged in deception

based on alternative moral justifications (consequentialist reasoning, e.g. the

need to meet wider organisational goals). One may deceive oneself to resolve the

issue or one may redefine the issue so as not to require a resolution. The latter is

still a deception through redefinition. This leads to enquiring how this might

come about.

Structured Agency

This analysis is based on the premise, and to paraphrase, ‘(Nurses) make their

own history but not in the ‘circumstances of their own choosing’ (Cox & Nilsen,

2014). History in this sense is nothing more than the sum of social relationships

which operate within a system of constraints and enablements. Power in social

relationships is thus foregrounded while also acknowledging ‘routine’

(Fleetwood, 2008), ‘habitus’ (Bourdieu, 1977) and ‘structured agency’ (Scambler,

2012a). The critical realist concept of ‘generative mechanisms’ (a process held to

account for an observable phenomenon such as stress, burnout or even health

inequalities) also informs this analysis (Archer et al., 1998). ‘Circumstances not of

their own making’ include technical and instrumental rationality characteristic of

modernity (Feenberg, 2010; Whimster & Lash, 1987) which may lead to ‘moral

blindness’ (Baumann & Donskis, 2013).

An examination of nurses’ behaviours, which include actual blindspots to poor

practice and the lack of response to, for example, ‘sentinel events’ (Darbyshire,

Ralph & Caudle, 2015; Watson, 2009) requires an understanding of their

‘structured agency’ (Archer, 2009; Archer, 2010; Fleetwood, 2008; Scambler,

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2012a) and the ‘generative mechanisms’ that produce them. Scambler argues

that while ‘agency’ has causal power, it is always structured (Scambler, 2012a;

Scambler, 2015). This means understanding structure, the social context in which

nurse work and how this context is felt and reflexively interpreted, and how it

constrains and enables human action (agency). Two psychological factors, among

others such as self-efficacy, may mediate our exercise of agency within social

structure: the ‘affect heuristic’ (Slovic et al., 2007) and our ‘reflexive

deliberations’ (Archer, 2009; Archer, 2010; Fleetwood, 2008). Both may be used

to move us from unease and crisis towards indifference or well-being.

While acknowledging the role of reflexivity in social action, Akram and Hogan

(2015) argue that there ought still to be consideration of the routinisation of

everyday life, the ‘taken for granted’, as a backdrop to reflexivity that operates

within the Bourdesian notion of ‘habitus’ (Akram & Hogan, 2015; Bourdieu,

1977). Akram and Hogan also suggest that people prefer the status quo rather

than the risk of change and uncertainty (Akram & Hogan, 2015). If the ‘habitus’ of

nursing operates within structures outlined below, including ‘thoughtlessness’

(Roberts & Ion, 2015) the causal power of reflexivity for change will be

diminished. We may posit that technical/instrumental rationality operating as

managerial control could be a generative mechanism for such outcomes as

‘thoughtlessness’ and self-deception as it is part of the habitus of clinical practice.

The context for ‘Structured Agency’

The mismatch between a caring discourse (the espoused theory) and actuality

(theory in action) in nursing has been noted for quite some time (Castledine,

1994; Jewkes, Abrahams & Mvo, 1998; Wright, 2006), often in the context of care

for older people (Chan & Chan, 2009; Goodman, 2011; Hillman et al., 2013) and in

the socialisation of student nurses for compassionate practice (Curtis, 2014;

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Curtis, Horton & Smith, 2012; Del Prato, 2013; Thomas, Jinks & Jack, 2015).

Compassion fatigue (Coatzee & Klopper, 2010; Kelly, Runge & Spencer, 2015;

Kitwood, 1997), Malignant Social Psychology (Kitwood, 1997), burnout

(Gustavsson, Hallsten & Rudman, 2010; Kanai-Pak et al., 2008; O'Mahoney, 2011),

bullying (Hoel, Giga & Davidson, 2007; Hutchinson & Jackson, 2013; Hutchinson &

Jackson, 2015; Hutchinson et al., 2006; Jackson et al., 2011) and anxiety/threat

(Kouchaki & Desai, 2014) all may characterise some clinical settings and lead to

unethical behaviour, preventing nurses from exercising compassionate agency.

Ethical breakdowns are not uncommon in organisations and may occur due to

fear, isolation and misunderstanding (Curtin, 1996), the ‘neutralising’ of moral

concerns (Bersoff, 1999; Umphress & Bingham, 2011), the consideration of

outcomes (ends justifies means) or conflicts of interest which result in silence due

to fear of negative outcomes (Bazerman & Tenbrunsel, 2011). Some of these

factors involve self-delusion, some are about rational responses to external

threats. All are results of structured agency. The context may blind nurses to the

‘generative mechanisms’ (Archer et al., 1998) that underpin their actions and

responses.

In these contexts even when nurses are aware of poor practice, they may fear

professional discipline via a focus on their personal accountability for prioritizing

patient care which disregards the systemic, unpredictable and hazardous

circumstances of practice (Beardwood et al., 1999; Beardwood & Kainer, 2015),

circumstances in which workplace relationships may not be safe to blow the

whistle (Jackson et al., 2010).

The ‘affect heuristic’, which suggests emotion is important in guiding judgments

and decisions, acts as a mental short cut to aid quick decision making. Fox argues

that “alongside reasoned choices and decisions, what humans feel has a part to

play in producing the world” (Fox, 2015 p2). Conscious reasoning, including

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conscious moral reasoning, is in this view mediated by heuristics. The rational

actor (‘homo economicus’) who is consciously weighing up cost/benefits and

analysing ethical and moral positions is therefore more myth than reality.

Rational action as the primary driver for action and decisions is challenged by

Haidt’s Moral Foundations Theory, arguing that our moral intuitions come first,

strategic reasoning comes second. In other words, our intuitions commit us to

judgments and then we engage in post hoc rationalisations to justify those first

judgments (Haidt, 2012). Standing’s revised cognitive continuum suggests

(Standing 2008), decision making operates in complex clinical situations which

lead to very different reasoning processes (intuitive to analytical) and thus

decisions. Rational actor theory may tend to be an essentialist, person based

rather than system based analysis (Reason, 2000), overlooking cognitive

processes such as ‘attribution error’ (Jones & Harris, 1967) and social ‘generative

mechanisms’ which are not always visible or understood. To be clear, conscious

individual rationality may not be a primary driver for judgments and actions. It

operates in a social context involving individual ‘affect’ and heuristics and the

social rationality of modernity. This leads to a suggestion that the social

relationships characterised by forms of social rationality (Goodman, 2014) may

indeed be an overlooked generative mechanism, in the same manner that

Scambler argues that the renewed class/command dynamic of financial

capitalism is a generative mechanism for health equalities (Scambler, 2012b).

Rationality and Reflexivity.

Max Weber argued modern society is characterised by rationality (Weber, 1992

orig 1905). This includes the management of risk (Beck, 1992; Giddens, 1999).

Weber’s theory of ‘rationalisation’ suggests that modern societies become

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increasingly rational and bureaucratic whereby social life becomes more and

more prone to scientific analysis, measurement, bureaucratic control and the

application of ‘instrumental rationality’ to social problems and issues. Paul Du

Gay however, draws a conceptual difference between Weber’s classic forms of

bureaucracy necessary for smooth and equitable functioning, and that of

‘managerialism’ (Du Gay, 2010) which, he argues, can be anti-bureaucratic and

functions within an ‘Audit Society’ (Power, 1999). Auditing, argues Power, results

from political pressures and demands for accountability and control. The way in

which audits produce ‘assurance’ and ‘accountability’ are open to question but

also have unintended and dysfunctional consequences. This theme emerges in

critiques of managerial practices which see audit as a new form of coercive and

authoritarian governmentality requiring political reflexivity as a response

(Richardson, 2000; Shore & Wright, 1999).

Instrumental rationality is a mode of thought and action that identifies problems

and works directly towards their solution, often focusing on the most efficient

and cost effective methods of achieving certain ends. It may not stop to ask what

those ends should be, or what effect efficiency and cost effectiveness has on

human relationships. It is this instrumental rationality (zweckrational) that might

have unintended consequences for social practices (dishonest reporting of zero

defects, overlooking sub-optimal care).

Using the insights of Hannah Arendt, (Roberts & Ion, 2014) suggest that late

modernity is increasingly characterised by technical rationality: rule following in

order to deliver efficiency, effectiveness and economic ends, and to manage risk

inherent in modern practices. This becomes a defining ‘habitus’ in itself.

Following rules can become more important than the purpose for which rules are

developed. In addition, technical rationality necessitates ‘thoughtlessness’, as

critical reflexive thinking is almost a luxury in these complex technical

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environments. It was the ‘thoughtlessness’ of nazi bureaucrats such as Eichmann,

rather than some inherent demonic nature, that allowed the ‘final solution’ to

proceed. Eichmann also argued that following orders was not sufficient

justification for action. Indeed he ignored orders at one point in order to uphold

the higher moral law of the state as he saw it. Eichmann, in upholding the moral

law of the state was unable to think beyond this justification, even though earlier

in the process (deportation as solution before the ‘final solution’) he was aware

and felt that the consequences of action were ‘questionable’ (Arendt, 1963).

Arendt discussed the involvement of Jewish Leaders, without whom she argued

the ‘final solution’ would have been much more difficult to action. Denmark

refused to cooperate and far fewer Danish jews faced the fate of the German

Jews. Thoughtlessness and the redefining of moral action allowed jewish leaders

to assist in the bureaucratic control required. This was, at the time of publication,

hugely controversial.

Arendt’s ‘banality of evil’ was ‘thoughtlessness’ operating in a social system that

was antithetical to thinking and critiquing ‘that which comes to pass’ (Arendt,

1963). Arendt argued that the moral concepts of ‘individual responsibility’,

‘personal integrity’ and ‘personal intent’ are not sufficient concepts for

understanding why people let bad things happen. For Arendt, this ‘essentialist’

approach (the ‘unequivocal voice of conscience’) avoided the key philosophical

challenge arising from Eichmann’s trial. The holocaust was not a conspiracy of evil

men, it was essentially a bureaucratic phenomenon (a generative mechanism?).

In this view, ‘Individual responsibility’ deflects us from understanding how

individual moral awareness can be warped by society wide moral change, and

secondly it deflects us from thinking that this warping is only possible because of

the superficiality of most people’s moral character i.e. their inability to think.

Society can ‘invert’ its moral lexicon so that words like duty, honesty, care and

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conscience reverse their meaning. Within a social context that warps morality

these terms mean other things allowing us to believe we are acting morally when

in fact we may be ‘lying to ourselves’.

The holocaust is not to be equated with clinical practice, and it is a huge leap

from Eichmann’s trial to a hospital ward. However, Arendt’s argument indicates

that moral conscience exists within a social context (a ‘habitus’) and thus the

exercise of that conscience can be warped to fit a new moral context. This may

happen especially if the exercise of that conscience occurs in changing moral

circumstances in which to challenge it requires ‘hard thinking’ and critical

reflexivity. To engage in critical reflexive thinking may require a ‘breach’ in the

‘new normal’ moral order of things to stimulate it. The breach itself may not

however be a sufficient condition. Akram and Hogan (2015) suggest that any

threats to personal and social identity, which may arise from becoming aware of,

for example, breaches arising from poor care issues, can be emotionally highly

charged and that we do our best to assert membership of a specific social group

rather than face negative sanctions or marginalisation. In this context we may be

less likely to engage in critical reflexivity. Habitus (the routine taken for granted

intersubjective lifeworld) involves embodied experience that is not readily open

to change as we operate in a pre-reflexive and pre conscious manner especially in

the absence of a ‘breach’ or a discontinuity of a social practice.

Arendt suggested that thinking is hard and the lack of thinking leads to moral

catastrophe. Is it a step too far to suggest that many nurses are wont not to

engage in critical reflexive thinking either for extrinsic reasons (fear, anxiety,

bullying) or for intrinsic reasons - the lack of recognition that managerial

rationality can distort nursing priorities (Hillman et al., 2013; Lees, Meyer &

Rafferty, 2013)? Menzies Lyth described a situation back in the late 1950’s

whereby many nursing students did not complete their training. Those that left

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were supposedly the most mature and thoughtful. With chilling echoes of

Arendt’s descriptions, it was those who liked to follow simple orders who were

the ones who stayed (Menzies Lyth, 1960). To address the reality of patient care,

various defences were erected to avoid emotional and psychological involvement

with patients. More recent literature describes the often very difficult student

experience (Chachula, Myrick & Yonge, 2015; Goodare, 2015; Maben, Latter &

Clark, 2006; Thomas, Jinks & Jack, 2015) . Maben et al (2007) revealed that within

2 years in practice newly qualified nurses could be categorised as sustained

idealists, compromised idealists, or crushed idealists. The majority experienced

frustration and some level of ‘burnout’ as a consequence of their ideals and

values being thwarted (Maben, Latter & MacLeod Clark, 2007).

Rudge (2015) outlines an exploration of the interaction of managerial style,

regulation processes and constraints on nursing practice. Rudge suggests that

nurses lack the ability to raise their collective voice…(and) need to understand

and act on their own discomfort (Reiger & Lane, 2013) with the contemporary

managerial ethos in health care. Shore and Wright’s (1992) notion of ‘political

reflexivity’ is thus under used by nurses. ‘Compliance’ which operates within the

context of managerialism underpinned by technical and instrumental rationality,

is part of the neoliberalist agenda for public services (Crouch, 2011; Hall, 2011),

fuelled by suspicion of both clinical leadership (Edmonstone, 2009) and trust in

professional values and autonomy within public sector organisations (Gilbert,

2005).

Compliance can mean either a state of being or a process towards accordance

with guidelines, regulations, risk management, specifications, protocols,

procedures or legislation. It also involves the auditing and recording of activities

to measure the state of being in the exercise of one’s accountability to various

stakeholders. Other meanings of the word include ‘conformity’ ‘yielding’ and

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‘acquiescence’ to another’s will. A deconstruction of meaning might also point to

‘subservience’ to others from a position of weakness, involving submission and

obedience, adaptation and flexibility (Anderson 1994).

Ingram (2009), following earlier work by Evangelista (1999), attempts a concept

analysis of compliance in nursing contexts and argues a clear definition should be

explored while also acknowledging that it means different things in different

disciplines and contexts. However, Ingram identifies the defining attributes as

‘ability to follow a prescribed plan, yielding to the request of others, obedience,

adaptability and flexibility. This subservient aspect of compliance fits in with a

managerial, and neoliberal, discourse that emphasises professional accountability

to external power. This can become the habitus of nursing care in some clinical

settings.

Instrumental and technical rationality involving compliance, managerialism,

neoliberalism and risk shape ‘subjectivities’, i.e. the ways that individuals behave,

conduct lives, make sense of the world. This gets represented in writing and

‘cultural products’ that reproduce certain subjectivities. These subjectivities then

become part of the lifeworld (Habermas, 1987) of nursing. For more detailed

discussion see (Davies, 2003; Davies & Petersen, 2005) and for Higher Education,

(Grant, 2014) who draws upon Foucaldian post structural theory and the concept

of ‘governmentality’ to describe the creation of nursing subjectivity.

Archer’s reflexive deliberations.

Arendt suggested there can be unthinking acceptance of a warped moral order

resulting in a perceived lack of need for critical reflexivity. The moral order of

technical rationality requires a degree of thoughtlessness in order to exist. In the

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case of what Wright Mills called a ‘personal trouble’ the nurse becomes aware

that something is not right (a ‘breach’) but may not be sure why. Sentinel events

for some nurses may not be recognised as such if they are part of the warped

moral order of the habitus. The personal trouble might however call forth

reflexivity but as suggested above it may not bring forth action. Just as Eichmann

deferred to the moral order of the state, we might unthinkingly defer to the

moral order of technical and instrumental rationality.

Putting to one side issues such as a social threats and our prereflexive

dispositions, Archer outlined four ideal types of ‘modes of reflexivity’ which might

explain why some nurses act and others do not (Archer, 2009; Archer, 2010) in

the face of managerial demands and contexts.

The autonomous reflexive has an ‘inner dialogue’ that is self-referential and thus

action is based on the individual’s wants, needs, interpretations and desires. The

support, opinions, actions of peers or significant others are not required. It may

be theorised that nurses who have this as a dominant mode of reflexivity may be

the ones to challenge the warped moral order, especially if they can also engage

in critical political, social and moral reflexivity which allows them to feel personal

troubles in the first place. Their personal trouble is such that ‘something must be

done’ regardless of social consequences. Autonomous reflexivity is no guarantor

of action in a warped moral order because its dialogue is about the individual not

about morality per se. An autonomous reflexive requires seeing the moral order

as being in need of change before acting.

Communicative reflexives act after considering what others might want, think or

do. Their inner dialogue asks ‘what would they do?’ before action. Nurses with

this mode of reflexivity may be less willing or able to feel a personal trouble

because no one else seems to, and/or be less willing to act because of the social

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consequences. It might be that communicative reflexives also lack the ability to

think outside the social order (warped as it might be) before acting for social

change.

Meta Reflexives ‘think about thinking’; their inner dialogues question whether

action is achievable, they consider and critique why they think they way they do.

They thus wonder about their own moral thinking and feelings. This mode may

lead to action not because others may or may not do so but because they have

thought about their own morality and action. These perhaps are Arendt’s

‘thinkers’.

Archer’s final mode is that of the fractured reflexive whose disorientation and

distress renders them incapable of clarity of thought or action.

However, reflexivity may not operate at all as it requires a cognitive load which

many of us cannot undertake on a daily basis. Indeed this is why technical and

instrumental rationality comes to the fore due to the requirements of clinical

practice which requires these forms of decision making. There is no way of

knowing if this typology actually fits nurses, the empirical work has not been

done, but we may hypothesise that communicative reflexives who work in a

moral order shaped by technical rationality and managerial demands might be

less likely to want to stand out and be counted unless everyone else will do so.

Conclusion

It is the case that there exists opportunities for dishonesty, self-deception and

ambiguity in moral reasoning across both private and public sector organisations.

This exists in organisations and professions that profess high ethical standards

both to themselves and to the public. It is tempting to point to lapses as arising

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within the individuals themselves, based on ‘essentialist’ notions of individual

responsibility and professional accountability. It will be the case that there are

individuals for whom this is an appropriate response. For recruiting staff for

responsible positions involving trust and integrity, it is the case that high ethical

standards and the correct values should be part of the individual’s moral

character. Yet, evidence exists that the social systems within which people work

impact upon their ethical decision making. Lapses from ethical decisions are at

times conscious reasoning under duress. At other times it may be due to

cognitive processes operating at the unconscious, pre reflexive, level involving

affect and heuristic reasoning. This may also operate in social systems that have

warped the moral order so that what is unethical becomes ‘normal’, part of the

routine everyday practice. It is suggested that social rationality (e.g.

managerialism or technical/instrumental rationality) is the backdrop, the habitus,

in which personal agency is exercised. It may also be the case that the individual’s

mode of reflexive deliberations mediate structure and agency and explains why

some act and others do not. The complexity of structured agency requires critical

analysis of social structures in which agency operates and for the individual the

need for critical, political, social and reflexivity is crucial. Wong and Gerras point

out that the US army needs to acknowledge systemic dishonesty and reduce

managerial demands. To be able to ‘lead truthfully’ staff need to be able to

develop and use critical reflexivity (Archer’s meta reflexives), understand the

moral context, and critique the organisational and social milieu, so that personal

troubles may be seen as public issues. Leaders of organisations need to examine

both the social system as well as the moral character. Without it, we will continue

to experience ‘ethical ambiguity’ (lies) in professional practice decision making.

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