International Journal of Nursing Practice 2010; 16: 525–532

SCHOLARLY PAPER

On being a good nurse: Reflections on the past

and preparing for the future ijn_1878 525..532

Ann M Begley PhD

Lecturer in Ethics, Queen’s University, School of Nursing and Midwifery, Belfast, UK

Accepted for publication August 2010

Begley AM. International Journal of Nursing Practice 2010; 16: 525–532

On being a good nurse: Reflections on the past and preparing for the future

The objectives of this paper include reflecting on the attributes of the ‘good’ nurse in the past, outlining thematically the
essential attributes (virtues) required by the ‘good’ nurse today and presenting an original 4-point framework for ethics
in practice. Although there is no doubt that nurses in the past were highly professional, the culture within which they
practiced tended to stifle the emergence of autonomy, assertiveness, advocacy and accountability.
An original table of contemporary attributes, which is congruent with a neo Aristotelian virtue ethical approach, is
arranged in themes of Intellectual and Practical Attributes, Dispositional Attributes and Moral Attributes. A framework
for professional practice, the ‘Four As’ is then extrapolated from these themes. These four key professional attributes,
autonomy, advocacy, accountability and assertiveness, along with the virtues listed in the themes, exemplify the ‘good’
nurse and are identified as the linchpins of modern professional ethics and good conduct.
Key words: codes, ethics, good character, good nurse, professional ethics, virtues.

INTRODUCTION erode the public perception of nurses as following a voca-

Nursing: a call to service
Professional nursing has emerged from a rich and multi-
faceted history which predates the Nightingale era and has
its roots in the USA, Canada, Australia and Europe. The
influence of ‘vowed’ or religious women has, according to
Nelson, been trivialized and even ignored in contempo-
rary historical representations of our professional heri-
tage.1 Nightingale, however, drew inspiration from those
women who did much more than merely set the scene
for ‘real’ nursing: she cherished the vocational notion of
nursing and feared that professional registration would
Correspondence: Ann M. Begley, Queen’s University, School of Nursing
and Midwifery, 50 Elmwood Avenue, Belfast BT9 6AZ, UK. Email:
a.begley@qub.ac.uk
tion or calling.2 This legacy in relation to the notion of
nursing as a vocation or a ‘calling’ has been a powerful
influence on the development of the profession. The
attributes required by the ‘Nightingale’ nurse were articu-
lated in the Nightingale Pledge3 and include Godliness,
purity, faithfulness, loyalty and a commitment to ‘aid the
physician’. Other essential attributes emerging from the
early ethics literature were obedience, stoicism, endur-
ance, servility, modesty and humility.4–6
According to Fowler, the sense of ‘calling’ lasted into
the 1950s in the USA and thereafter began to take a back
seat in the drive towards professionalism.7 In Europe,
however, the perception of nursing as a vocation lasted
beyond this.2 Way’s book Ethics for Nurses is a classic
example of the literature portraying nurses as following
a code of etiquette rather that ethics.6 This book was

doi:10.1111/j.1440-172X.2010.01878.x © 2010 Blackwell Publishing Asia Pty Ltd

526 AM Begley

(a) Attributes
(virtues - excellences)

Themes

Intellectual/practical Dispositional Moral

Theoretical and Tolerance Courage (moral)
practical wisdom
(Aristotelian) Sensitivity Integrity

Courtesy Justice
Competence
Approachability Fairness
Art/skill
Diligence Honesty
Scientific knowledge
Empathy Veracity
Intuition
Imagination Kindness Fidelity

Cleverness Benevolence Integrity

Discernment Compassion Trustworthiness

Judgement Genuineness

Patience

(b)
Four As
Advocacy

Figure 1. (a) Thematic presentation of pro-

Autonomy
fessional attributes/virtues, and (b) simple
framework for professional conduct, the Four
Accountability Assertiveness
As.

reprinted for the last time in 19712 suggesting that this
perception of the attributes required by a ‘good’ nurse
lasted in the UK until at least the early 1980s.
In this paper, it is suggested that the virtues, or
attributes, required by the modern nurse can be catego-
rized into three themes, Intellectual and Practical
Attributes, Dispositional Attributes and Moral Attributes
(Fig. 1a). In addition to this, the thematic professional
virtues have been distilled into four core attributes and
presented in a simple framework for good professional
conduct (Fig. 1b). The ‘Four As’, Advocacy, Assertive-
ness, Accountability and Autonomy, are identified as
the linchpins of good conduct. They do not stand alone
however, and they depend on the presence of other essen-
tial virtues listed in the themes presented. These are
grounded in an Aristotelian approach to ethics in which
‘virtue’ arete means excellence of character or intellect.
Virtues can therefore be such attributes as friendliness,

© 2010 Blackwell Publishing Asia Pty Ltd

On being a good nurse
wittiness and not necessarily the concepts which we
expect to fall under the umbrella of the virtues. It is
suggested that in relation to the evolving concept of the
‘good’ nurse, the attributes presented in (Fig. 1b) have
become essential hallmarks of good character.
The objectives of the paper are threefold:
• To reflect on the historical notion of the ‘good’ nurse
and the associated virtues
• To consider how this understanding of the ‘good’ nurse
has changed and how this change is reflected in modern
codes of conduct
• To build a thematic table of virtues required by the
‘good nurse’ today and to extrapolate from this table of
virtues a framework for good moral practice with four
core attributes
Reflecting on the past
If we are to fully appreciate the shift in perception in
relation to the notion of a ‘good’ nurse there is a need to
reflect on how things were, on how professional conduct,
ideals and approaches to ethics have evolved over the
years. The development of the subject in nursing has made
considerable progress particularly in the past 20 years.
Way suggested that ‘matters of moral value fade
imperceptibly into matters of etiquette. . . .’6 There is,
however, a significant conceptual difference between
etiquette, particularly that which is rooted in respect
for superiors, and ethics. One of the reasons for nurses’
arrested development as autonomous moral agents has
been the blurring of this distinction, and in the past the
education of nurses in relation to ethics often focused on
how to dress and show respect (etiquette) rather than
consider the moral perspectives of practice (ethics). This,
however, does not imply that all nurses were weak willed
and unable to think for themselves. But in reality, the
culture was one which did not encourage or support asser-
tiveness or challenges to authority figures.
Towards professional ethics
Practitioners might reject the notion of the ‘good’ nurse
as an outdated concept, but in this paper the word ‘good’
is used within the context of Aristotelian ethics. Anything
‘good’ performs its function well.8,9 Good nurses there-
fore perform their functions well and they maintain high
standards in all areas of practice and governance. Being
good and behaving well depend on the state of character
and in order to perform well certain virtues or attributes
(alternatively, qualities, character traits or dispositions)
527
are required. Historically, from the time of Aristotle,
many virtues, or attributes have been considered neces-
sary for living well in general. Lists of attributes have
emerged from various sources, Greek ethics,10
Buddhism,11 Confucian,12 Maori,13 Christian.14,15 Modern
secular approaches include Blackburn,16 MacIntyre17 and
nurse ethicists.9,18–25 In this paper, relevant attributes
arising from these sources have been brought together and
arranged in themes, or categories of virtues considered
to be necessary for meeting the standards required of a
‘good’ nurse.
The literature on the virtues of nurses in the past
reflects an acceptance that nurses should nurture
the attributes historically accepted as characteristic of
women. Aristotle, for example, suggested that women’s
virtues are different from men’s.26 (Neo-Aristotelians
reject such views). Also, in more recent times, Rous-
seau’s novel Emile reflects the distinction made between
male and female virtues. Female traits were considered
to be gentleness, tenderness, beneficence, compassion,
nurturing, self-sacrifice, intuitiveness, mental passivity
and physical and emotional dependence.26,27
Historically, literature relating to nursing ethics indi-
cates that the virtues of the nurse included such traits
as respect for authority (particularly of medicine), being
faithful to duty, being tactful, cultivating a meek and mild
disposition, loyalty and cleanliness.4–6 Sympathy, compas-
sion, or any emotional involvement with a patient was
not encouraged and was portrayed by Way6 as a fault, or
weakness of character in the nurse. The reluctance to
‘report’ another nurse or challenge unsafe practice also
comes across in the early literature.4–6 Other essential
attributes emerging from the early ethics literature
were obedience, stoicism, endurance, servility, modesty,
humility and loyalty.2–6
Codes and standards: being a good
person and being a good nurse
Good nurses do need certain virtues, or attributes, but
these are not necessarily lofty, spiritual, or supported by
any traditional notion of ‘vocation’ or calling. There has
been a shift in the perception of the virtues required by the
good nurse and the notion of virtue itself has changed to
the extent that it now reflects a classical Greek notion
of a virtue as an ‘excellence’ of character or intelligence.
This is reflected in Provision 6.1 of the American Nurses
Association (ANA) code of ethics:
© 2010 Blackwell Publishing Asia Pty Ltd
528
Virtues are habits of character that predispose persons to meet
their moral obligations, that is, to do what is right.28
As nursing continues to evolve from vocational subservi-
ence to a modern profession, so does the perception of
what it means to be a ‘good’ nurse.
The practitioner today is expected to question and col-
laborate with other professionals rather than obey instruc-
tions. Patients are partners in care: we respect their
autonomy and are sensitive to their needs when vulner-
able and distressed. Most importantly, we are accountable
for our actions and we are charged with the responsibility
to protect the patient from the mistakes and negligence
of others. The nurse today is expected to practice from a
sound knowledge base and to be sufficiently confident to
challenge questionable practice. This is in stark contrast
to the expectations of the nurse in the not too distant
past. Modern codes of ethics and standards of conduct
reflect a very different understanding of the characteristics
expected of the ‘good’ nurse. In relation to these points,
modern codes of ethics clearly demonstrate a shift in
expectations.
In the UK, for example, the Nursing and Midwifery
Council29 expects nurses to make the care of people
their first concern, to be personally accountable for their
actions and omissions in practice, to challenge unsafe
practice, cooperate with colleagues and keep up-to-date.
The ANA’s code of ethics28 expects that the nurse is
primarily committed to the patient, takes on the role of
advocacy, maintains competence and a knowledge base
and has a concern for the welfare of colleagues. Simi-
larly, the Australian Nursing and Midwifery Council30
highlights these attributes and charges the nurse with
upholding certain values and standards. The nurse
should: show respect and kindness towards clients,
report nursing care that is potentially unethical, illegal,
unsafe or incompetent and ensure that decision making
is based on contemporary relevant and well-founded
knowledge and information.
The International Council of Nurses Code31 reflects the
above expectations. Notions of accountability, advocacy
assertiveness and autonomy are required if the nurse is to
uphold and practice according to the standards expected
of them by the international community of nurses. These
codes together outline clearly the standards which should
be achieved and the desirable professional characteristics.
Nurses consider a code of conduct to be an essential com-
ponent in protecting the vulnerable and ensuring good
© 2010 Blackwell Publishing Asia Pty Ltd
AM Begley
behaviour in practice. Modern codes reflect an expecta-
tion that nurses will have the intellectual capacity to prac-
tice effectively and to advance the knowledge base of the
discipline. There is also evidence of concern in relation to
how we respect and value each other: the importance of
kindness and rejection of bullying and harassment of
colleagues are clearly articulated.
The Nursing and Midwifery Council32 maintains that
health-care professionals’ characters must be ‘sufficiently
good’ to be capable of safe and effective practice without
supervision. This indicates clearly that the focus is shift-
ing from a rule-based to a more virtue (or character)
based approach to professional conduct. More emphasis
is being placed on the character of the agent as a signifi-
cant factor in ensuring that we have professionals who
will act with integrity. The ANA states that in order to
be a good person one requires wisdom, honesty and
courage and that in order to be a good nurse compas-
sion, patience and skills are needed.28 Florence Nightin-
gale believed that to be a good nurse one must first be a
good person33 and the good nurse, therefore needs all of
these attributes. The good person is more than a rule
follower34 and the individual needs to consider what sort
of person he or she ought to be rather than simply what he
or she ought to do, such as follow rules and principles.35,36
The main issue to be addressed, then, is to identify
what it is that constitutes sufficiently good character
and what virtues or attributes are essential for good
conduct?
The good nurse today:
suggested attributes
Referring to the attributes of a good nurse de Raeve21
noted that this was relatively unexplored territory,
although there now seems to be a growing interest in the
subject. It is also clear that codes of ethics and conduct are
more virtue based, focusing more on the characteristics
of good practice and the character of the agents than on
simple rules and imperatives. In the existing literature
on the subject, candidates for consideration as virtues
(attributes, character traits in nursing) have been sug-
gested by various authors.9,18–25
Themes
It is suggested here that the virtues or attributes required
so as to exemplify excellence of character can be catego-
rized into the following themes:
On being a good nurse
• An Intellectual and Practical Theme (with attributes
such as Aristotelian theoretical and practical wisdom
and the ability to integrate theory with practice)
• A Dispositional Theme (with attributes such as
compassion, courtesy, empathy approachability and
kindness)
• A Moral Theme (with attributes such as justice, moral
courage and veracity).
The virtues listed within these themes are inspired by
Aristotle’s account of the virtues or attributes required to
live a good life and are congruent with those virtues cited
by modern codes of conduct. Some of them might not fit
neatly with the modern conception of ‘virtue’ but they are
presented here as attributes of character in an Aristotelian
conception of virtue—arete, or excellences of character.
When we think of virtue as being an ‘excellence of char-
acter’ and as something which permeates the whole of life,
then it makes sense to include such virtues or attributes as
cleverness, courtesy and patience. After all, nurses who are
incompetent, or lacking in the ability to deliberate and
make wise decisions, can have a very negative impact on the
progress of people in their care.9 Similarly, grumpy or rude
nurses will not be approachable and it would be impossible
to nurture a therapeutic relationship (with the patient)
successful mentorship (with the student) or effective inter
professional collaboration with such a character.
The ‘good’ nurse requires a synthesis of science and
sensitivity. Excellence cannot be achieved without a
balance between the Intellectual, Practical, Dispositional
and Moral attributes. The intellectual and practical
attributes are presented as one theme because it is not
possible to be competent without the capacity to acquire
theoretical knowledge and apply it appropriately (practi-
cal wisdom) to practice.
Although many virtues which reflect a vocational
approach to nursing have been rejected by the modern
profession, some of the attributes such as courtesy, dili-
gence and fidelity which were valued by nurses in the past
have been included in these themes. There has been a shift
from the servile ‘nun-ish’ virtues often associated with a
religious vocation and evident in the ‘Nightingale Pledge’
but some of these virtues continue to be important today
and, although ‘sanctimonious’ in nature, it is argued here
that they are not incompatible with professional practice.
In addition to this, such intellectual attributes as imagina-
tion and intuition are essential if the nurse is to be capable
of empathy, insight into complex contexts and emotions
and ultimately, advocacy.
529
Learning from the past and preparing
for the future
Attributes that were not encouraged in the past (such
as having the courage to challenge unsafe practice) are
now considered to be professional virtues and conversely,
many of the virtues extolled up until the 1950s and into
the 1960s and 1970s in the UK are now considered to
denote weakness in character. It is clear that certain
attributes required by the modern conception of ‘good’
nurse were missing, even actively discouraged. For
example, a nurse who questioned the accuracy of a pre-
scription, or had the courage to put the patient safety
before deference and obedience was likely to be consid-
ered a trouble maker, not a ‘good nurse’. On the other
hand, today’s good nurse is assertive, having the courage
to raise concerns in the interest of patient safety, although
failing to do this would be considered unsafe practice.
The ‘good nurse’ was not encouraged to cultivate the
following attributes (virtues), and these can be referred
to as the ‘Four As’, or Attributes that are essential for
caring and good professional conduct (Fig. 1b). These are
highlighted in today’s codes of ethics and conduct, and in
exercising these virtues professional nurses draw on those
virtues listed in the themes presented (Fig. 1a).
Advocacy and the necessary virtues associated with it
This was clearly not part of the moral repertoire of
the profession in the past. Successful advocacy requires
compassion, courage and a commitment to caring for and
empowering clients and colleagues. Advocacy is most
often associated with the nurse–client relationship, but it
is also important in our relationships with colleagues.
Nurses have a duty of care towards colleagues and the
abuse of power, bullying and harassment are to be chal-
lenged robustly.30 Advocacy also requires intuitive skills
and a capacity for empathy.
Accountability and the necessary virtues associated
with it
Lacking in the literature from the past is the notion that as
professionals we are responsible for our actions and the
outcomes of these actions. We can not simply obey orders
or ignore failures in governance in practice, research and
management. In addition to clinical competence and skills
the practitioner requires the intellectual virtues of practi-
cal and theoretical wisdom, integrity, honesty, trustwor-
thiness, veracity and moral courage.
© 2010 Blackwell Publishing Asia Pty Ltd
530
Assertiveness and the necessary virtues associated
with it
All of the above require assertiveness and this in
turn depends on moral courage and good interpersonal
skills such as those listed in Dispositional Attributes,
or virtues. Assertiveness requires, for instance, courtesy
and patience, otherwise it becomes another concept—
aggression, which is completely counterproductive in pro-
fessional relationships.
Autonomy (professional) and the necessary virtues
associated with it
This is more often discussed in relation to patient
autonomy, but here the emphasis is on the morally
autonomous practitioner. The nurse requires discern-
ment, judgement and wisdom (practical and theoretical)
culminating in the ability to make wise choices. This more
than the other attributes represents the shift from an obe-
dience model of the past and is presented here in a central
and supporting role to the other professional attributes.
Being morally autonomous does not mean that the nurse
acts alone, or fails to collaborate. The ANA code28 states
that:
Collaboration is not just cooperation, but it is the concerted
effort of individuals and groups to attain a shared goal. In
health care, that goal is to address the health needs of the
patient and the public. . . . by its very nature, collaboration
requires mutual trust, recognition, and respect among the
health care team, shared discussion-making about patient
care, and open dialogue among all parties who have an
interest and a concern for health outcomes.(Provision 2.3)
Ultimately, however, the decision rests with the indi-
vidual nurse and accountability, advocacy and assertiveness
depend on the professional being an autonomous agent.
The nurse cannot compromise his or her integrity in def-
erence to colleagues or other professionals. This is sup-
ported by the ANA in relation to acting on questionable
practice:
The nurse’s primary commitment is to the health, wellbeing,
and safety of the patient across the lifespan and all settings in
which health care needs are addressed. As an advocate for the
patient, the nurse must be alert to and take appropriate action
regarding any instances of incompetent, unethical, illegal, or
impaired practice by any member of the health care team or
© 2010 Blackwell Publishing Asia Pty Ltd
AM Begley
health care system or any action on the part of others
that places the rights or best interests of the patient in
jeopardy.(Provision 3.5)
The professional nurse has therefore emerged as an
autonomous moral agent who engages and collaborates
with other health-care professionals and clients: advocacy
and assertiveness have replaced the deference, sometimes
blind obedience, and misplaced loyalty evident in the past.
CONCLUSION
The conception of the good nurse has evolved and
there has been a shift from etiquette to ethics, from obe-
dience to moral autonomy, assertiveness accountability
and advocacy. These attributes (qualities or virtues) are
grounded in Aristotle’s approach to ethics9,18,20 and devel-
oped through considering those attributes cited in profes-
sional codes28–31 and other professional accounts.
Within the context of modern professional nursing one
of the most attractive elements of an Aristotelian approach
to ethics is the emphasis on practice: ethics is something
that we do—we do not learn the theory and then put it
away in a file.37 Acquiring excellence of moral character
and intellect is, as Carper’s work38 highlighted, about
influencing hearts as well as minds, and it requires a
dynamic and sensitive approach which goes beyond that
which is needed for pure theoretical knowledge. Profes-
sional ethics is grounded in every day practice and nur-
tured by exemplary practitioners and clinical teachers.
In Aristotle’s conception of ethics, the moral life
requires a balance of intellectual and moral excellences,
or attributes, and it maps out progression from novice to
expert.20,39 The nurse is an autonomous moral practitio-
ner who collaborates and is assertive, operates in partner-
ship with patients and acts as advocate when they are
unable to speak for themselves. The nurse is accountable,
takes responsibility and is not subservient. The Nursing
and Midwifery Council29 indicates clearly that good char-
acter is essential for registered practitioners and for entry
to and continuation on pre-registration programmes23 and
there is now, in modern codes, more emphasis on articu-
lating the qualities required for ‘good character’.
Having reviewed historical and modern accounts of
‘good character’ and the values that they are expected
to uphold, it seems that de Raeve’s21 concern that this
is relatively unexplored territory is true. High value
is placed on the attributes that a nurse might bring to
On being a good nurse
nursing by virtue of the persons they are, and identifying
the nature of the ‘good nurse’ requires more investiga-
tion.40 There will be readers who will suggest that other
attributes should be included in the lists cited, or indeed
that some of those listed should not be included. There
will be others who will challenge the portrayal of the
‘Nightingale nurse’, and there is indeed evidence that
Nightingale herself did not promote, for example, the
mindless obedience found in later literature.41 There is
much room for debate here, and it would be difficult to
present a list to satisfy all nurses, particularly when we
consider the many different roles within this discipline.
The ‘Four As’ Framework, drawn from the thematic table
of attributes (Fig. 1a,b) represent an attempt to move
closer to identifying the attributes, which, in the context
of modern professional practice, exemplify the ‘good’
nurse and indicate the paradigmatic shift in professional
ethics from the obedience model to a dynamic profes-
sional model of ‘good’ nursing.
ACKNOWLEDGEMENTS
My colleagues Daphne Martin and Richard Henry for their
helpful comments on earlier versions of this paper.
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