当善良变得有毒时，如何有效地让护士保持沉默，并维持现状| J Adv Nurs

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共同成长

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Niceness has been referred to as our ‘most fundamental social dysfunction’ (Summers, 2005) and in nursing, niceness can be (and often is) toxic and disabling. Niceness is powerfully reinforced in nursing by spoken and unspoken discourses that control who can speak and when, and how that voice will be heard and responded to. Niceness is not to be confused with attributes such as collegiality or friendliness because unlike these qualities, niceness has very real malignant and malevolent connotations that act to silence and oppress those caught in its web and to strongly maintain the status quo.

Nursing is beleaguered by niceness, and issues with niceness in nursing have been previously articulated. Racine and Vandenberg (2021) link niceness in nursing to the culture of anti-intellectualism that is an ongoing concern in nursing. Nursing is thought to be particularly affected by niceness because of how nurses are socialized into cultures that still demand docility, subservience, compliance and that are underpinned by ideologies of servitude and caring. Walker (1997) highlighted the oppressive nature of the emphasis on caring, and its link to disabling niceness and docility in nursing:

A ‘caring’ nurse who is always ‘nice’ to people is not likely to be an agent of conflict and change, of critique and opposition. To engage these activities means ‘rocking the boat’, ‘making waves’, ‘speaking out’ and not necessarily ‘being nice’. Thus the ‘tyranny of niceness’ masquerading as ‘caring’ often severely disables a nurse in securing the material and social conditions her (sic) work requires. It also renders her (sic) ‘docile’ and submissive; it makes her (sic) a compliant and willing agent for domination. A ‘good’ nurse, a ‘nice’ nurse, does as she (sic) is told and seldom questions the authority of others (Walker, 1997:8).

As Walker (1997) notes, the desire to be nice means that people remain silent when they should speak out. It also means that when people do show courage and speak out, they can be silenced by others who (in enacting their own ‘niceness’) may be uncomfortable with authentic communication or with the issues being raised. In environments shaped by niceness, speaking out can involve considerable personal risk, because in environments of niceness, any speaking up that can be perceived as challenging in any way is likely to be taken as a breach of the code of niceness.

Breaches of the niceness code do not come without consequences. In cultures shaped by niceness, those nurses who will speak up and raise issues can come to be cast as a ‘problem to be managed’ (Jackson et al., 2013:577) and themselves become the focus of scrutiny and even investigation up to and including disciplinary action. This means those raising issues are quickly silenced, often with accusations they are unprofessional, unsupportive, negative, splitting the profession, breaching codes of conduct, breaching confidentiality or similar (Jackson et al., 2011). Once this happens, the initiation of measures designed to silence the dissenting voice is justified, as are any actions needed to restore and maintain the organizational status quo (Jackson et al., 2013). The flow-on effects can also mean that others who witness the fallout from speaking up will likely be dissuaded from doing so.

Literature suggests cultures of niceness affect people from minoritized groups more than those from the dominant group. Amongst other things, being nice means avoiding conflict (Walker, 1997) and in ground-breaking work on racism in the United States nursing, Barbee (1993) linked entrenched and continuing racist practices and behaviours in nursing to a culture of conflict avoidance (Barbee, 1993). Writing more recently, Perlow (2018) argues that niceness is not harmless or benign—rather, Perlow positions niceness as a racialized and gendered tool used to disguise power relations and a powerful means to silence and oppress people of colour. This should be evident to many of us in nursing, because despite the mantras of diversity, equity and inclusion that are often prominent in the mission (and other guiding) statements of most nursing organizations, we still see widespread inequity and lack of inclusion. We still have way too many (so-called) peak nursing bodies that are monocultural, with only minimal (if any) engagement with any persons from minoritized or marginalized communities.

For many years there has been increasing recognition of the need for nurses to speak up and speak out. Despite the general acceptance that nurses should speak up to raise concerns, or to challenge various behaviours and actions, even very contemporaneous research suggests that nurses can perceive speaking up as a ‘challenging behaviour’ and that nurses may remain silent, ‘even when speaking up is needed for patient safety’ (Lee et al., 2022). The importance of nurses speaking up is recognized as so crucial to safe and affective health care that there is increasing awareness of the need to foster ‘speaking up’ skills in undergraduate student nurses (Fagan et al., 2016).

Speaking up should be ‘business as usual’, but it actually requires considerable confidence and enormous courage (Lee et al., 2022). Yet speaking up reflects exactly what we want from nurses—we want and society needs nurses who are critical thinkers, change agents, problem solvers—politically astute advocates who will stand up and speak out for social justice. We need nurses to speak up and speak out right from the bedside to broader more societal-level advocacy and active political engagement. In order to speak up and speak out; however, there is a need to contravene the niceness agenda and raise issues that we ourselves, and others may find uncomfortable. If we want nurses and students of nursing to speak up and speak out, we really must eradicate disabling cultures that are underpinned by toxic forms of niceness.

Niceness is strongly entrenched and harmful. It does violence to any who are seen to breach the powerful discourses of niceness. Disabling toxic niceness acts to continue to oppress and silence nurses and in turn, short-changes those we serve. Nurses need to be able to exchange information, ideas and raise issues in climates and with colleagues who are willing to authentically engage with relevant information and issues, and with new and different ideas. Instead of enculturating our colleagues and our students into niceness, lets model and create healthier cultures that are underpinned by collegiality, friendliness and authentic, respectful communication that welcomes and actively listens to dissenting or seldom heard voices. These courageous and important voices are the very voices that we need, to ensure that nursing can fulfil its social imperative and maximize the contribution of nursing to human health and well-being. Because without these voices, nothing will ever change.

EDITORIAL NOTE

Editorials are opinion pieces. This piece has not been subject to peer review and the opinions expressed are those of the authors. Debra Jackson is Editor-in-Chief of JAN. The author does not have relevant political or other affiliations to declare.

全文翻译（仅供参考）

善良被认为是我们“最基本的社会功能障碍”（萨默斯，2005），在护理方面，（而且经常是）有毒和致残的。在护理中，善良通过口头和无声的话语得到了有力的加强，这些话语控制着谁可以说话，什么时候说话，以及如何听到和回应这种声音。善良不能与合作或友好等属性混淆，因为与这些品质不同，善良有着非常真实的恶意和恶毒的内涵，它的作用是压制和压迫那些陷入它的网中的人，并强烈地维持现状。

护理工作被“好”所困扰，而“好”在护理工作中的问题先前已经被阐明。2021）将护理中的“和善”与反智主义文化联系起来，反智主义文化是护理界一直关注的问题。护理被认为特别受“和善”的影响，因为护士是如何融入到仍然要求顺从、服从、顺从的文化中的，而这种文化的基础是奴役和关怀的意识形态。1997）强调了强调关怀的压迫性本质，以及它与护理中的善良和顺从的联系：           

一个总是对人“好”的“有爱心"的护士不太可能成为冲突和改变、批评和反对的代理人。参与这些活动意味着“摇船”、“制造风波”、“大声说话”，而不一定是“友善”。因此，伪装成“关怀”的“善良暴政”往往严重阻碍了护士获得她工作所需的物质和社会条件。它也使她（原文如此）“温顺”和顺从;它使她成为顺从和愿意支配的代理人。一个“好”的护士，一个“好”的护士，她照做，很少质疑别人的权威 （沃克，1997：8）。

正如沃克（1997）指出，"想做好人“意味着人们在该说出来的时候保持沉默，也意味着当人们表现出勇气并说出来时，他们可能会被其他人压制住。（在表现自己的“善意”时）可能会对真实的交流或提出的问题感到不舒服。在由善意塑造的环境中，说出来可能会带来相当大的个人风险，因为在善意的环境中，任何可能被认为具有挑战性的发言都可能被视为违反了友好准则。

违反友善准则并非没有后果。在由友善塑造的文化中，那些敢于直言并提出问题的护士可能会被视为“需要管理的问题”（杰克逊等，2013这意味着那些提出问题的人很快就被压制了，他们常常被指责为不专业、不支持、消极、分裂专业、违反行为准则、违反保密或类似行为（Jackson等人，2011一旦发生这种情况，就有理由采取旨在压制反对声音的措施，以及采取恢复和维持组织现状所需的任何行动（杰克逊等人，1999年）。2013）。这种流动效应还意味着，其他目睹了发言后果的人可能会被劝阻不要这样做。

文学作品表明，友善的文化对少数群体的人的影响要大于对占统治地位的群体的人的影响.除此之外，友善意味着避免冲突（步行者，1997）和在美国护理种族主义方面的开创性工作，Barbee（1993）将护理工作中根深蒂固和持续存在的种族主义做法和行为与避免冲突的文化联系起来（Barbee，1993）。最近，Perlow（2018）认为，友善并非无害或仁慈--相反，珀洛将友善定位为一种种族化和性别化的工具，用于掩盖权力关系，是压制和压迫有色人种的有力手段。这一点对我们许多从事护理工作的人来说应该是显而易见的，因为尽管多样性、公平和包容的信条在护理使命中往往很突出（和其他指导）声明，我们仍然看到广泛的不平等和缺乏包容性。我们仍然有太多的（所谓的）高峰护理机构是单一文化的，只有很少的（如果有的话）参与任何人从少数族裔或边缘化社区。

多年来，越来越多的人认识到护士有必要大声说出自己的想法。尽管人们普遍认为护士应该大声说出自己的想法，以引起人们的关注，或挑战各种行为和行动，但即使是非常现代的研究也表明，护士可能会认为大声说出自己的想法是一种“挑战性的行为”，护士可能会保持沉默。“即使为了患者安全需要大声说出来”（Lee等人，2022）。护士大声说话的重要性被认为对安全和有效的卫生保健是如此关键，以至于越来越多的人意识到需要在本科生护士中培养“大声说话”的技能（Fagan等人，2016）.

说出来应该是“一切照旧”，但实际上需要相当大的信心和巨大的勇气（Lee等人，2022）。然而，“大声说出来”恰恰反映了我们对护士的期望--我们希望，社会也需要那些批判性思考者、变革推动者、问题解决者--政治上精明的倡导者，他们会站出来为社会正义大声疾呼。我们需要护士大声说出来，从床边就大声说出来，以更广泛地进行社会层面的倡导和积极的政治参与。为了大声说出来;然而，我们有必要违背友善议程，提出我们自己和其他人可能感到不舒服的问题。如果我们想让护士和护理专业的学生大声说话，我们真的必须根除那些以有毒的友善形式为基础的不良文化。

善良是根深蒂固的，有害的。它会对任何被认为违背善良的强大话语的人施加暴力。禁用有毒的善良会继续压迫和沉默护士，反过来，会对我们所服务的人造成伤害。护士需要能够在气候中交流信息、想法并提出问题，并与愿意真正参与相关信息和问题的同事交流。与其让我们的同事和学生接受友善的文化熏陶，不如让我们树立和创造更健康的文化，这种文化的基础是平等、友好和真诚、尊重的交流，这种交流欢迎并积极倾听不同意见或很少听到的声音。这些勇敢而重要的声音正是我们所需要的声音。以确保护理能够履行其社会责任，并最大限度地为人类健康和福祉作出贡献。因为没有这些声音，什么都不会改变。