Pain assessment in critical care is organised primarily around patient self-report and numerical scoring, an arrangement that protects the patient's first-person authority. In neurocritical care, however, critically ill patients with stroke may be unable to communicate because of aphasia, impaired consciousness, sedation, mechanical ventilation, or delirium. Under these conditions, the absence of a numerical score may reflect limitations in the systems through which pain is made visible rather than the absence of pain. This paper offers an empirically informed philosophical analysis of what a missing numerical pain score means in neurocritical care and asks how nursing can preserve clinically and ethically meaningful distinctions when a number cannot be responsibly produced. As an empirical point of departure, an extracted adult ischaemic-stroke ICU-stay dataset from MIMIC-IV (6054 ICU stays, 5065 patients) was used, focusing on the first pain score, defined as the earliest documented numerical pain score within the first 24 h after ICU admission among patients with stroke. The empirical material is treated not as epidemiological evidence but as an occasion for conceptual analysis. Of 6054 ICU stays, 2415 (39.9%) had no documented first pain score in the first-24-h structured field. This pattern is not interpreted as evidence that pain was absent, unassessed, or unrecognised in any individual case. Drawing on this finding, the paper develops a five-fold conceptual taxonomy of missingness: absence of pain, absence of self-report, absence of assessment, absence of documentation, and risk of non-recognition. Nursing management is presented as a moral-epistemic practice in which electronic record categories, quality indicators, staffing, education, and workflow shape whether possible pain becomes visible, documentable, auditable, and answerable. The central task is not to force every patient into a number, but to preserve clinically and ethically meaningful differences when a number cannot be responsibly produced.
Active learning and professional citizenship are widely discussed in nursing education, yet the conditions under which they converge have not been theoretically specified. In this paper, we advance a structural account of that relation, drawing on deliberative theory, philosophy of education, and nursing scholarship. The relation we describe is one of shared enabling conditions rather than causal production: active learning and professional citizenship converge not because one produces the other, but because each depends on arrangements that require public justification through reasons, engagement with competing claims, and answerability for the consequences of action. We trace a conceptual movement from professional accountability to professional citizenship, and from participatory learning to deliberative practice, specifying a set of conditions that can be instantiated in nursing education but have rarely been theorised as the basis of this relation. In doing so, we give theoretical form to a relation more often enacted than articulated.
The discipline of nursing has entered a historical moment in which two profound forces converge: the global rise of digital platform labour and the resurgence of relational, communitarian ontologies rooted in African philosophy. Yet these forces are rarely theorised together, despite shaping the same discipline. This paper integrates African philosophical thoughts which conceptualise personhood as a dynamic, communal, and relational achievement, with ideas around platformized nursing, which explains how digital platforms restructure nursing labour, relationships, and professional identity through algorithmic governance and datafication. Through a digital-relational synthesis, the paper argues that platformization disrupts the communal and relational foundations of personhood and care, while simultaneously creating new socio-technical spaces in which relationality must be renegotiated. An integrated model, the Digital-Relational Nursing Framework is presented which offers a multilevel lens for understanding how nurses and patients become persons within increasingly digitalised health systems. This synthesis provides conceptual grounding for empirical research, ethical analysis, workforce policy, and curriculum reform aimed at safeguarding relational accountability and communal wellbeing in the digital era.
Presence is widely affirmed as a core moral value of nursing, yet dominant conceptualizations in both nursing philosophy and clinical practice consistently collapse it into observable intervention and active engagement, underpinned by an implicit subject-object dualist ontology. Derivative concepts such as silent presence and holding space have sought to recover non-interventional modes of care, yet most remain trapped within an action-oriented logic and stop short of fundamental ontological reorientation. Drawing on classical Daoist concepts of wu-wei (non-coercive action) and ziran (naturalness), this paper critiques the interventionist framing of presence and develops the Presence in Absence (PiA) framework. It articulates the dialectical relationship between presence and absence, arguing that deliberate withdrawal from the centre of action, positions of control, and the authoritative subject role constitutes not a deficit of care, but a fuller, ontologically deeper form of presence. By distinguishing PiA from adjacent nursing concepts and anchoring the argument in dementia care narratives, the paper further explores its implications for existential nursing knowledge, an ethics of existence, and existential intersubjectivity. This cross-cultural reconstruction restores the ontological depth of nursing presence, offering a philosophical anchor for addressing contemporary nursing's crisis of excessive action.
Trans and gender diverse people experience persistent inequities across healthcare systems, including discrimination in care, barriers to access, and poorer mental and physical health outcomes. While nurses are well placed to influence the quality and inclusivity of healthcare encounters, responses to these inequities have often focused primarily on improving clinical knowledge. Such an emphasis, while important, is insufficient to account for the relational, ethical, and structural conditions that shape care for trans and gender diverse communities. This paper draws on Carper's patterns of knowing, extended through Chinn and Kramer's emancipatory knowing, to reconsider authentic allyship in nursing. Using the patterns of empirical, aesthetic, personal, ethical, and emancipatory knowing, the paper argues that allyship is not reducible to technical competence, respectful intention, or symbolic inclusion. Rather, it requires the integration of evidence-based understanding, compassionate and contextually attuned care, critical self-reflection, moral responsibility, and structural awareness. Through this framework, the paper examines how nursing responses to trans and gender diverse health inequities can move beyond fragmented or individualised approaches towards a more reflective, socially responsive praxis. The paper further considers implications for nursing education, professional leadership, and organisational practice, arguing that authentic allyship must be embedded across curricula, clinical environments, and disciplinary commitments to social justice. Integrating patterns of knowing provides nursing with a multidimensional framework for practice that is not only clinically competent but also affirming, ethically grounded, and attentive to the structural conditions that shape health and healthcare.
Nursing ethics has long taken the bedside encounter as the moral center of practice. Yet this focus becomes incomplete when the material conditions of care are treated as ethically external to nursing itself. Ordinary clinical supplies such as gloves, masks, gowns, syringes, drapes, and linens are commonly understood as neutral instruments of safe and competent care. This paper argues that such neutrality is philosophically misleading. The materials through which nursing is enacted are embedded in global systems of labor, extraction, manufacture, circulation, use, and disposal that may involve exploitation, ecological degradation, and unequal distributions of risk. Using gloves and personal protective equipment as an entry point, this paper asks: To what extent are nurses ethically responsible for challenging the use of clinical supplies produced through labor exploitation or environmental injustice? Drawing on feminist political economy, care ethics, and materiality-oriented perspectives, I argue that care is not only an interpersonal act but also a relational, material, and politically organized practice. From this standpoint, procurement is part of nursing's moral field rather than a merely managerial concern. The paper advances a bounded account of professional responsibility grounded in epistemic attentiveness, discursive engagement, advocacy, and collective political action. A nursing philosophy of procurement justice enlarges, rather than dilutes, the meaning of care, responsibility, and advocacy. If nursing remains committed to dignity, justice, and the reduction of harm, it cannot regard the workers and communities who materially sustain care as ethically invisible. Nursing ethics must therefore extend beyond the bedside into the hidden infrastructures through which care becomes possible.
Children's dignity in hospital care is often framed as a matter of privacy, etiquette, communication, or procedural compliance. A more demanding account is needed. Drawing on the philosophical framework of epistemic injustice, this conceptual article argues that dignity-related harms in paediatric nursing also arise when children are denied credibility, interpretive support, or meaningful authority over knowledge of their own embodied experiences. Children may not always describe pain, shame, embarrassment, fear, or boundary violation through adult-like verbal testimony. Their experiential knowledge may instead appear through silence, withdrawal, humour, bodily resistance, hesitation, gaze avoidance, or apparently compliant behaviour. When such expressions are dismissed as immaturity, difficulty, exaggeration, or non-compliance, the child is harmed not only as a vulnerable patient but also as a knower. This reframing connects paediatric dignity with children's rights to participation, privacy, and respect under the United Nations Convention on the Rights of the Child and the EACH Charter. It also positions paediatric nurses as central agents of epistemic repair because nursing work occurs at the intersection of intimate bodily care, sustained relational proximity, communication, documentation, and advocacy. The article proposes an epistemic justice practice bundle for paediatric nursing: credibility-oriented listening, embodied attunement, developmentally attuned communication, protected communicative spaces, minimal substitution by adult proxies, and voice-preserving documentation. The analysis extends nursing philosophy by showing that dignity is not only protected around the child but co-produced through relational practices that make children's experiences visible, credible, and actionable within clinical care.
Caring is commonly described as the ethical core of nursing and as a fundamentally human way of relating to others. As social assistive robots are increasingly introduced into healthcare, questions emerge regarding the role these technologies can play in caring practices. Drawing on Katie Eriksson's theory of caritative caring, this paper examines how social assistive robots may be understood in caring and discusses the ethical boundaries that should guide their use. Caritative caring, grounded in Caritas, emphasizes human dignity, the care relationship, invitation, responsibility, virtue, obligation or duty, and ethical freedom. It presupposes an ethical orientation and relational openness that robots cannot possess as ethical subjects. Social assistive robots may simulate relational behaviors and support certain aspects of care, but they lack the moral agency and compassionate intentionality required for caritative caring in its full sense. At the same time, this does not mean that robots have no place in healthcare. When designed and used within a value-sensitive and care-oriented framework, social assistive robots may complement caregivers by supporting safety, autonomy and routine care tasks. Caritative caring theory thus offers a framework for clarifying the ethical boundaries of robot use in healthcare, not as substitutes for human compassion and responsibility, but where social assistive robots may support the conditions for human caring without replacing the relation and ethical responsibilities of caregivers.
Nursing values include commitment to care for all and facilitation of healthy environments. The actualisation of these values, however, is often constrained by healthcare systems when overly influenced by neoliberal priorities for revenue generation. Assuming this context, the dynamics of two ontological nursing motives, loving service (agape) and creative agency (eros), are considered as they relate to nursing axiology, lived experience, and practice. Transversal analysis is engaged to further explore the implications that posthumanist philosophy may have for the relationship of eros-agape dynamics. Consequences for nursing practice and qualitative experience are considered. The analysis concludes in three propositions. The first, that in realigning loving service (agape) aspects of nursing with the nurse person's development of creativity and agency (eros), the nurse-person may be more satisfied in ego reward, and the actualisation of nursing values that hold commitment to all persons, facilitation of healthy environments, and actions of human caring, could be better supported. The second, that posthumanism, particularly the aspects of intersubjectivity and co-being, may transform the possibilities of eros and agape ontological motives in nursing to support greater emergence of connected multidirectional caring; so that the nurse-person is less alienated in providing care and, instead, is an active member of caring ecologies. The third, that in realigning loving service (agape) aspects of nursing with the nurse person's development of creativity and agency (eros), the nurse-person may be more satisfied in ego reward, and the actualisation of nursing values that hold commitment to all persons, facilitation of healthy environments, and actions of human caring, could be better supported.
This paper examines the relevance of Gadamerian hermeneutic philosophy for caring science by clarifying how understanding, interpretation, and ethical responsiveness are implicated in nursing practice. Drawing on key Gadamerian concepts, including prejudice, language, dialog, and the fusion of horizons, the paper explores the ontological and epistemological foundations of caring as a relational process of coming to understanding within historically and culturally situated nurse-patient encounters. Caring is articulated not as a discrete action or technical competence, but as a mode of being that unfolds through dialogical engagement and openness to the other. While Gadamerian hermeneutics has been widely employed within qualitative nursing research, this paper argues that its significance for caring science lies less in methodological prescription than in its philosophical orientation to understanding and application as inseparable. By examining interpretive approaches to studying caring and critically reflecting on the tendency to treat the fusion of horizons as an endpoint, the paper highlights how Gadamerian hermeneutics sustains caring as an ongoing, ethically consequential practice rather than a finalized interpretive outcome. Clinical Trial Registration: N/A.
This paper examines how camp, an aesthetic grounded in exaggeration, humor, and theatricality, functions as a legitimate nursing practice that challenges the cisheteronormative seriousness embedded in professional nursing culture. I begin by tracing how seriousness became a dominant aesthetic standard in nursing, shaping expectations for comportment, emotional restraint, and professionalism in ways that marginalize queer and trans nurses. Drawing from Sontag's Notes on Camp, I argue that seriousness is not an objective requirement of safe or ethical care but a culturally specific performance that restricts who and what count as 'professional'. I then introduce camp as a counter-aesthetic that exposes the performative nature of these norms. Through playfulness and intentional artifice, camp destabilizes the boundaries of professional conduct and opens space for alternative, culturally grounded expressions of care. To illustrate this, I examine the work of Bobbi Campbell, known as Sister Florence Nightmare RN, as a historical exemplar of a drag nurse who promoted health education, reduced stigma, and community resilience during the early HIV/AIDS epidemic. I then pull on Nurse Anne Thracks and Mandy Mango as contemporary examples of drag-as-nursing. These examples demonstrate how queer nurses use drag and camp to strategically engage communities, communicate health information, and model radically inclusive care. I extend this analysis to contemporary nursing contexts, arguing that integrating camp is a form of ethical authenticity aligned with the profession's commitments to dignity, self-regard, and social justice. I show how campy and drag nurses actively subvert restrictive norms by transforming the figure of the nurse-through language, attire, and performance-while still providing effective, culturally relevant care. Ultimately, I propose camp as a generative framework for reimagining nursing aesthetics and practice. Embracing camp expands the boundaries of what is considered professional, ethical, and therapeutic, offering a model of nursing that honors joy, relationality, sociopolitical wellness.
Despite technical and regulatory advances in pain assessment, persistent challenges in recognizing, interpreting, and documenting the experience of pain continue to reveal a structural gap in nursing practice. Traditionally, these difficulties have been addressed from biomedical approaches focused on nociception and objective measurement, without questioning the linguistic and normative conditions that shape what counts as pain in clinical contexts. This article argues that the problem is not primarily technical or instrumental, but conceptual and linguistic. Drawing on the philosophy of language, it proposes to understand pain assessment and diagnosis as language games governed by rules of use that shape the conditions under which certain expressions become intelligible, legitimate, and clinically valid. Based on a conceptual analysis of the pain diagnosis in the NANDA-I taxonomy, the article examines how the interpretive stratification of pain among nociception, subjective experience, and diagnostic categories produces grammatical mismatches that affect clinical communication and foster forms of epistemic injustice, particularly when the patient's testimony does not fit available normative criteria. Through an analytical comparison of different nursing diagnoses and the development of a conceptual case, it is shown that the diagnosis of pain operates more as a normative linguistic device than as a neutral description of experience. The analysis supports the argument that difficulties in pain assessment do not stem from the lack of more precise instruments, but from the rigidity of the rules governing the diagnostic language game. In this sense, the article does not propose a new theory of pain or a clinical prescription, but a philosophical reconfiguration that makes visible the normative character of nursing language and opens the possibility of interpretive practices more sensitive to the patient's lived experience. Understanding pain as a grammatically mediated phenomenon makes it possible to recognize the distinctive contribution of nursing in the clinical encounter and to rethink diagnosis as a relational, interpretive, and ethically situated practice.
Western-centric knowledge paradigms in nursing perpetuate epistemic injustice by systematically excluding racialized, Indigenous, and Global South ways of knowing from legitimate nursing discourse. Despite growing critical scholarship on this problem, no widely cited framework has yet translated foundational theories of epistemic injustice and social justice into a discipline-specific, operational governance tool for nursing institutions. This discursive paper examines how Western-centric knowledge paradigms in nursing contribute to epistemic injustice and develops an operational framework for epistemic justice in nursing education, research, and practice. A critical interpretive synthesis of literature from nursing philosophy, decolonial studies, critical pedagogy, and global health ethics was conducted using theoretical sampling across CINAHL, PubMed, Scopus, and Web of Science (1990-2025). The single-author interpretive synthesis was appropriate for theory generation, with saturation understood as the point at which additional texts did not introduce new framework-relevant constructs, rather than implying comprehensive coverage of the field. The paper develops three concrete outputs: a three-pillar framework for epistemic justice comprising Recognition, Redistribution, and Representation; measurable operational indicators for each pillar including citation equity indices, syllabus diversity audits, and leadership representation metrics; and a six-question decision audit tool designed to support institutional self-assessment of epistemic justice. The framework is explicitly positioned as an initial synthesis intended to support future collaborative development with Global South, Indigenous, and racialized nursing scholars. Achieving epistemic justice demands structural change to what counts as legitimate nursing knowledge. The paper further argues that decolonizing nursing knowledge requires not merely diversifying existing frameworks but interrogating the colonial foundations upon which dominant nursing epistemologies have historically rested. No patient or public involvement occurred in the design or writing of this discursive article.
Nursing practice is increasingly enacted within environments structured by intelligent technologies that filter perception, generate classifications and shape clinical priorities. While nurse scholars have begun to examine moral agency in the context of artificial intelligence, much of the broader ethical discourse on AI in healthcare continues to foreground governance, safety and institutional accountability, leaving the conditions under which nurses exercise professional moral responsibility comparatively under-theorized. This paper argues that technology-mediated care constitutes a moral environment that reshapes how responsibility is distributed, interpreted and enacted in clinical practice. Drawing on nursing ethics and socio-technical thought, it distinguishes between technical delegation and moral delegation, clarifying that while intelligent systems may inform action, they cannot assume moral answerability. Nursing moral agency is reconceptualized as relationally oriented moral perception, interpretive judgement and accountable action that remains fundamentally non-delegable, even under conditions of extensive mediation. Boundary-setting is advanced as a disciplined ethical practice through which nurses delineate the limits of technological authority and sustain professional responsibility. By articulating moral agency as both situated and irreducible, this analysis contributes a conceptual framework for understanding ethical responsibility in the Fifth Industrial Revolution and re-centres the nurse as the accountable moral subject within technology-mediated care.
Contemporary nursing is increasingly shaped by performance pressures, demands for traceability, and technological mediation. These developments do more than add tasks to everyday clinical work. They also shape what nurses can attend to, how they judge situations, and whether they are able to sustain the care they believe a patient needs. This article examines moral distress as a structural restriction of moral agency: nurses may recognise what a situation requires yet find themselves unable to act accordingly. Drawing on Byung-Chul Han's analyses of performance, psychopolitics, infocracy, and the palliative society, we develop a tetradic matrix that relates these contemporary logics to four goods of nursing care: attention, clinical judgement, alterity, and hope. In practice, these goods refer to sustained presence, prudent deliberation, recognition of the patient as a singular person, and hope understood as non-abandonment. Applied to the nursing metaparadigm, the matrix shows how clinical time, attention, documentation, and technological mediation can become places where moral agency is either supported or weakened. The article therefore argues for a shift in the ethical evaluation of nursing work: from a narrow focus on individual resilience towards the governance of attention and the institutional conditions that make responsible care possible.
This study draws on data from a study about the experiences of pregnant people in United States immigration detention from 2017 to 2022. While the original research questions focused on the impact of US immigration enforcement on pregnant migrants, interviews with healthcare workers offered unexpected insights into their own responses to the moral distress they felt when caring for pregnant women in immigration custody. Their responses were varied, from distressed observation to humanitarian mitigation to circumscribed advocacy to active resistance; for a few labour and delivery nurses, this resistance entailed significant professional risk-taking on behalf of their patients. Healthcare workers navigated the power dynamics of healthcare institutions which mandate compliance with law enforcement and their own fears, misgivings and conditioning as they attempted to blunt and subvert the violence and reproductive oppression of the carceral state's immigration enforcement regime. Drawing on recent literature on abolition nursing, medicine and midwifery, and in the context of Donna Haraway's philosophical contributions, this article will explore how healthcare workers engaged in a constellation of practices towards a situated, feminist abolitionist ethic of care.
The evidence-based practice (EBP) paradigm has become a dominant approach to clinical care, organizing healthcare around the production, synthesis, and implementation of evidence. Yet despite sustained efforts to standardize practice in terms of evidence, variability in care delivery, outcomes, and decision-making persists. Nursing scholarship has critically examined EBP as a dominant epistemological orientation to practice, often identifying variability as that which troubles the evidentiary aspiration to standardize, generalize, and govern practice. Building on this work, I take variability as a starting point for examining how healthcare is configured as an evidentiary domain in the first place. Drawing on Michel Callon's concepts of framing and overflowing, EBP is approached as an ongoing effort to make clinical practice sufficiently calculable, comparable, and actionable. The analysis shows how variability appears not simply as what exceeds or opposes evidence, but as that which is directly operative in the processes through which evidentiary arrangements are developed, enacted, and transformed. In this way, evidence and practice emerge not as pre-existing domains requiring reconciliation, but as ongoing accomplishments produced through processes of framing and overflowing. What then becomes visible is the continual formation of healthcare, where evidentiary arrangements, clinical practices, problems, and possibilities are continually encountered, enacted, and made consequential, inviting inquiry into the ways nursing participates in these processes.
Nursing is a profession grounded in a vocation of caring, altruism and moral responsibility. However, contemporary nursing practice occurs largely within a healthcare system structured by neoliberal, productivity-driven imperatives-commonly described as the healthcare-industrial complex. As market-oriented logics continue to shape healthcare delivery and access to care, tensions emerge between the moral foundations of nursing and the economic rationalities that govern healthcare institutions. This paper presents a philosophical analysis of the bioethical contradictions that nurses experience in practising within the healthcare-industrial complex. Drawing on bioethical principles, nursing ethics and critical social theory, the analysis examines how neoliberal healthcare structures create moral distress, ethical dissonance and constrained moral agency among nurses. This paper argues that nurses' ethical struggle is not a failure of professional integrity but a predictable outcome of structural forces that compel participation in systems that are misaligned with nursing's moral commitments. By elucidating these dynamics, this analysis offers a conceptual framework for understanding nurse moral distress and identifies pathways for ethical agency, resistance and professional advocacy within contemporary healthcare.
