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Ethical problems encountered by public health nursing administrators Cutler, Allison Jean 1992

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ETHICAL PROBLEMS ENCOUNTERED BYPUBLIC HEALTH NURSING ADMINISTRATORSbyALLISON JEAN CUTLERB.S.N., The University of British Columbia, 1977A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESThe School of NursingWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust 1992© Allison Jean Cutler, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department of NursingThe University of British ColumbiaVancouver, CanadaDateDE-6 (2/88)iiAbstractThe intent of this study was to explore the ethicalproblems encountered in public health nursingadministration. A qualitative study, incorporating criticalincident design, was conducted. The data was collectedduring audio-taped interviews with twenty public healthnursing administrators.The data were analyzed, utilizing the technique ofcontent analysis, to identify common themes. Themes wereidentified in relation to the ethical problems experienced,the public health administrators' responses to the ethicalproblem, and the variables which influenced the publichealth administrators' experience of the problem.The themes which emerged in relation to the ethicalproblems experienced were categorized according to thesources of nursing obligations, as identified by theCanadian Nurses Association [CNA] (1991). These obligationsincluded clients, nursing roles and responsibilities,nursing ethics and society, and the nursing profession. Themajority of ethical problems related to nursing obligationsto clients and nursing roles and responsibilities. Oneethical problem was identified in relation to nursing ethicsand society; no problems were identified in relation to thenursing profession. Three of the participants did notperceive that they had experienced an ethical problem intheir administrative practice in the past year.iiiThe participants' responses were categorized accordingto how they acted, felt or thought about the ethical problemthey experienced. The responses included stress, regret anduncertainty, utilization of a decision making approach,values clarification, failure to act, and the use ofpersonal and external resources. The variables whichinfluenced the participants' experience of the ethicalproblem were categorized according to personal,professional, organizational, and system variables.The findings indicated that: the public health nursingadministrators who participated in this study were able toidentify ethical problems in their practice and toretrospectively analyze their experiences; the majority ofpublic health nursing administrators in this studyidentified ethical problems related to lack of autonomy andconflicting role obligations; the public health nursingadministrators all found the experience of the ethicalproblem difficult; the majority of public health nursingadministrators did not feel supported in their experience ofthe ethical problem; the responses of public health nursingadministrators showed a lack of systematic referral toethical principles as they worked to resolve the problem;and organizational factors existed which made the experienceof the ethical problem particularly difficult for publichealth nursing administrators who held their position on anacting basis.Implications for nursing practice, education andresearch arising from these findings were outlined.ivVTABLE OF CONTENTSPageABSTRACT 	TABLE OF CONTENTS 	LIST OF TABLES 	  viiiACKNOWLEDGEMENTS 	  ixCHAPTER ONE: INTRODUCTION  	 1Background to the Problem  	 1Significance  	 3Conceptual Framework  	 4Problem Statement  	 4Purpose of the Study  	 5Research Questions  	 5Definition of Terms  	 6Assumptions  	 6Limitations  	 7Summary  	 7CHAPTER TWO: LITERATURE REVIEW  	 8Ethics  	 8Ethical Theories  	 9Ethical Principles  	 10Autonomy 	  11Beneficence  	 12Justice  	 13Ethical Approaches 	  15Egoism 	  15Deontology 	  15Utilitarianism  	 17Ethics of Health Care  	 18Common Bioethical Issues 	  19Nursing Ethics 	  23Ethical Problems 	  25Ethical Decision Making  	 30Frameworks for ethical decision making 	 33Moral Basis of Nursing  	 34Codes of ethics for nursing 	  34Public Health Nursing 	  35Research and Public Health Nursing 	  36Nursing Administration 	  38Research and Nursing Administration 	  40Research and Public Health NursingAdministration 	  42viSummary 	  43CHAPTER THREE: METHODOLOGY 	  45Study Design 	  45Selection of Participants  	 46Criteria for Selection  	 47Selection Procedure 	  48Data Collection  	 48Data Analysis 	  49Rationale for Classification System  	 50Reliability and Validity 	  51Protection of Human Rights 	  53Summary 	  54CHAPTER FOUR: FINDINGS 	  55Characteristics of Participants 	  55Ethical Problems Experienced 	  58Clients  	 59Respect for needs and values 	  59Respect for client choice 	  60Confidentiality  	 60Nursing Roles and Relationships  	 61Protecting clients from incompetence 	  61Conditions of employment  	 62Job action 	  65Nursing Ethics and Society 	  65Advocacy of the interests of clients  	 66Summary 	  66Response to Ethical Problems 	  66Stress  	 67Use of a Decision-Making Approach 	  68Values Clarification 	  69Regret and Uncertainty 	  70Failure to Act 	  71Use of Personal Resources 	  71Use of external resources 	  71Summary 	  73Variables Influencing the Experience 	  73Personal  	 73Previous administrative experience 	  73Personal experience 	  74Support 	  74Professional Practice  	 75Organizational  	 76Acting positions 	  77Staffing levels 	  77Role of Central office 	  78Nature of relationship 	  78Resources 	  79viiPolicies  	 79System 	  80Availability of alternate services 	  80Communication systems 	  81Summary 	 81CHAPTER FIVE: DISCUSSION OF FINDINGSEthical Problems Experienced 	Ethical Themes 	Beneficence 	Autonomy 	Justice 	No Ethical Problem Identified 	Response to Ethical Problems 	Stress 	Utilization of a Decision-Making Framework 	Regret and Uncertainty 	Failure to Act 	Utilization of Personal/External Resources 	Variables Influencing the Experience 	Personal Variables 	Professional Practice Variables 	Organizational Variables 	System Variables 	Summary 	CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FORNURSING 	  101Summary 	  101Conclusions 	  105Nursing Implications 	  106Implications for Nursing Practice 	  106Implications for Nursing Education 	  108Implications for Nursing Research 	  109Summary 	  110FOOTNOTESREFERENCESAPPENDICES   111112120         AppendixAppendixAppendixAppendixA: Information Letter 	  120B: Consent Form 	  122C: Interview Guide 	  124D: Letter of Permission 	  1268282848585868890909193939495959697100100viiiLIST OF TABLESTable 	 Page1: Years of Experience in Nursing, Public HealthNursing, and Public Health NursingAdministration 	  562: Comparison of Years of Nursing Experience BetweenPublic Health Nursing Administrators and PublicHealth Nursing Assistant Administrators 	  563: Educational Preparation of Participants 	  564: Status of Position Held by Participant 	  57ixACKNOWLEDGEMENTSI wish to acknowledge the special people whocontributed to this project. Many thanks to the PublicHealth Nursing Administrators who took time from their busyschedules to share their experiences with me; to my thesiscommittee, Janet Ericksen, Ray Thompson, and AngelaHenderson who provided support and guidance as well aschallenging me to clarify my ideas; to my husband, Ross, andmy children, Mike and Erin, who cheerfully adjusted to myfrequent absences; and to my parents, David and Marie, whoinstilled in me the desire for life long learning.1CHAPTER ONEIntroductionBackground to the ProblemPublic health nursing is an art and science thatsynthesizes knowledge from the public health sciences andprofessional nursing theories (Canadian Public HealthAssociation [CPHA], 1990). The context of public healthnursing practice is complex, including a broad focus of care(communities, groups, families and individuals across theirlifespan) as well as a focus on the variables that affecthealth (lifestyle, family interaction patterns, communityresources, economic and social factors, and public policy)(Aroskar, 1979; CPHA, 1990). Public health nursesexperience ethical problems in their everyday work. Issuessuch as health inequities and confidentiality, as well asthe conflicting priorities which multidisciplinary teammembers assign to ethical principles, are potentiallyproblematic.Nursing is a moral art (Curtin, 1979). It involves theseeking of good, and it involves our relationship with otherhuman beings (Curtin, 1979). As such, it is not surprisingthen, that nurses face complex ethical issues on a dailybasis. Levine (1977) stated that "to be a nurse requiresthe willing assumption of ethical responsibility in every2dimension of practice" (p. 845).The moral obligations of nursing are written in nursingcodes of ethics. The Canadian Nurses Association [CNA](1991) Code of Ethics for Nursing, strongly based on theprinciple of autonomy, identifies values, obligations, andlimitations in relation to the sources of nursingobligations. The sources of nursing obligations includesclients, nursing roles and responsibilities, society, andthe nursing profession. The code also delineates specialethical responsibilities borne by nursing administrators.Although it is acknowledged that nurses in all practicesettings experience ethical problems, there has been littlefocus on the ethical problems faced by public health nurses(Aroskar, 1979, 1989; Duncan, 1989). In the author'sexperience, as a public health nursing administrator ethicalproblems have been encountered in relation to staffcompetence, allocation of resources, and program and policyissues. These problems led to a questioning of what ethicalissues were facing other public health nursingadministrators and how other public health nursingadministrators were dealing with ethical problems.Nursing research on ethical problems of nursingadministrators, thus far, has focused on ethical problems,ethical dilemmas, and ethical decision making amongst nurseadministrators in acute care settings (Sietsema & Spradley,1987; Youell, 1984, 1986). There are significant3differences in the nature of nursing practiced in publichealth settings and acute care settings. Therefore,differences exist in the nature of nursing adminsitrativepractices in these settings as well. The nature of thenursing role in public health is more automonous and, inpublic health, the client includes individuals, families,and the community. It follows, then, that the nature ofethical problems experienced in public health nursingadministration are different than those experienced bynursing administators in acute care settings. There is nonursing research focused on the ethical problems experiencedby public health nursing administrators. Therefore, thisstudy focused on the ethical problems encountered in publichealth nursing administration.Significance It is intended that this study will contribute to adeveloping awareness of the ethical dimension of publichealth nursing administrative practice. Theoretically, thiswill enhance the growing body of knowledge related toethical issues and provide further questions for research.Practically, the results of this study will provide usefulinsights to assist public health nursing administrators indealing with ethical problems. Also, the informationprovided by this study will be useful in the educationalpreparation of public health nursing administrators.4Conceptual FrameworkCurtin's (1978) model for critical ethical analysis hasbeen used as the conceptual framework for this study.Duncan (1989) utilized Curtin's model in her study onethical conflict and resolution in public health nursingpractice. As this study is an adaptation of Duncan's studythe same conceptual framework has been chosen.Curtin's model identifies six factors which shouldalways be considered in the analysis of ethical problems.These factors include the background information which isrelevant to the situation of concern, identification of theethical components of the problem, the ethical agents orpersons involved in the decision making, identification ofoptions, application of ethical principles, and resolution.As such, this model lends itself well to the researchquestions. In this study Curtin's (1978) model was utilizedto identify the ethical components of the problems describedby the nursing administrators, the resources used, and thefactors influencing the public health nursingadministrators' experience of the problem.Problem Statement Public health nursing administrators hold key positionswithin community health organizations and, as such, have thepotential to impact on nurses, nursing practice, healthcare, and health policy. Public health nursing5administrators experience ethical problems and are in aposition to set an ethical climate for nursing staff. Itis, therefore, important to understand public health nursingadministrators' perceptions of the ethical dimensions oftheir administrative practice. No research to date existson the specific ethical problems of public health nursingadministrators.Purpose of the StudyThe purpose of this study is to explore, from theperspective of public health nursing administrators, theethical problems experienced in public health nursingadministration, the responses of public health nursingadministrators to ethical problems and the variablesinfluencing the public health nursing administrators'experience of the ethical problem.Research Questions 1. What ethical problems do public health nursingadministrators encounter in their administrativenursing practice?2. What are the public health nursing administrators'responses to these problems?3. What variables influence the public health nursingadministrators' experience of the problem?6Definition of Terms Public health nursingAn art and a science that synthesizes knowledge fromthe public health sciences and professional nursingtheories. Its goal is to promote and preserve the health ofpopulations and is directed to communities, groups, familiesand individuals across their life span, in a continuousrather than episodic process. The main focus of publichealth nursing is health promotion, illness and injuryprevention, and health maintenance (CPHA, 1990, p. 3, 19).Public health nursing administratorA nurse working in a provincial health unit in theposition of Public Health Nursing Administrator or PublicHealth Nursing Assistant Administrator. The position may beheld on a permanent or acting basis.Ethical problemAny problem identified as ethical in nature by thepublic health nursing administrator.Response The ways in which public health nursing administratorsact, think, or feel about ethical problems.Assumptions 1. Public health nursing administrators experience ethicalproblems.2. Public health nursing administrators understand the7concept of ethical problems.3. Public health nursing administrators can accuratelyrecall their experience of an ethical problem.4. Public health nursing administrators canretrospectively analyze their response to an ethicalproblem.5. Public health nursing administrators will truthfullyrespond to the interview questions.Limitations The generalizability of this study is limited by thefact that the sample consists of public health nursingadministrators working in provincial health units. Thefindings of this study cannot be generalized to publichealth nurse administrators who work in other settings.SummaryIn this chapter, the research study has beenintroduced. This introduction included a discussion of thebackground to the problem, the proposed significance of thestudy, the conceptual framework, the problem statement,purpose of the study, research questions, definition ofterms, assumptions, and limitations.8CHAPTER TWOReview of Selected LiteratureIntroductionThe literature review included the concepts of ethics,health care ethics or bioethics, nursing ethics and ethicalproblems. Research in the area of nursing ethics, ingeneral, and ethics in relation to public health nursing andpublic health nursing administration, specifically, wasreviewed.Ethics Ethics is a branch of philosophy known as moralphilosophy (Frankena, 1973). Ethics is the systematicexamination of the moral life and is designed to illuminatewhat we ought to do by asking us to consider and reconsiderour ordinary actions, judgement, and justifications(Beauchamp & Childress, 1983). According to Benjamin andCurtis (1986) ethics is "an attempt to formulate and justifysystematic responses to the following question: What, allthings considered, ought to be done in a given situation?"(p. 9). The following themes can be identified within thedefinitions of ethics found in the literature: ethics isconcerned with morality and ethical theory, ethicsencompasses reasoned thinking and moral justification,9ethics requires a decision or action based on moralreasoning (Silva, 1990).The word "ethics" often becomes synonymous with theword "morals". In the broadest sense, these two words referto conduct, character, and motives involved in moral actsand include the notion of approval or disapproval of a givenconduct, character, or motive that we describe by such wordsas good, desirable, right, and worthy, or conversely by suchwords as bad, undesirable, wrong, evil, and unworthy (Davis& Aroskar, 1991).Differences between morality and ethics have been notedby several authors (Jameton, 1984; Thompson & Thompson,1985). According to Thompson & Thompson (1985) moralityconsists of what a person ought to do in order to conform toacceptable social standards, whereas ethics consists of thephilosophical reasons for and against the moral ought andought nots proposed by society. Jameton (1984) used theterms professional and personal to contrast ethics andmorals. He identified ethics as the publicly stated andformal sets of rules and values, such as a professional codeof ethics, while morals are the set of values to which oneis personally committed.Ethical Theories Within the field of ethics three categories of ethicscan be distinguished. These are referred to as descriptiveethics, meta-ethics, and normative ethics (Frankena, 1973).1 0Descriptive ethics refers to empirical inquiry of ahistorical or scientific nature (Frankena, 1973). It is afactual investigation of moral behaviour and beliefs.Anthropologists, sociologists, psychologists, and historiansdetermine whether, and in what ways, moral attitudes andcodes differ from society to society (Beauchamp & Childress,1983).Meta-ethics, also called analytical or critical ethics,tries to answer logical, epistemological, or semanticalquestions such as "What is the meaning or use of theexpressions "morally right" or "good"? How can ethical andvalue judgement be established or justified?" (Frankena,1973, p. 4). This ethical field involves analysis ofcrucial ethical terms such as "right", "obligation","virtue", and "responsibility" (Beauchamp & Childress, 1983,p. 8).Normative ethics prescribes what ought to be done, whatis good, right, or obligatory (Frankena, 1973). Normativeethical theories allow us "to formulate and to defend asystem of fundamental moral principles and rules thatdetermine which actions are right and which are wrong"(Beauchamp & Childress, 1983, p. 8). Ideally, normativetheory will provide us with a complete set of action-guideswhich are universally valid (Beauchamp & Childress, 1983).Ethical Principles A number of ethical principles can be identified in the11literature. The principles of autonomy, beneficence, andjustice are discussed here.Autonomy.Autonomy is based on the idea that individuals areself-directing and therefore capable of choosing and actingupon decisions they themselves have decided on (Fry, 1983).An autonomous decision is based on the individual's values,utilizes adequate information and understanding, is freefrom coercion or restraint, and is based on reason anddeliberation (Wright, 1987). An autonomous action is onewhich results from an autonomous decision.To respect persons as autonomous individuals is toacknowledge their personal rights to make choices and actaccording to individual determinations. Respect for personsrequires that each individual be treated in consideration ofhis or her uniqueness and as an equal to every otherindividual, and that special justification be required forinterference with an individual's own purpose, privacy, orbehaviour (Jonsen & Butler, 1975).This principle requires that a minimum consideration indecision-making affecting an individual is that theindividual's own values and goals be considered in any majordecision that affect his present or future welfare (Davis &Aroskar, 1991). Paternalism in health care is seen whenhealth professionals or others make decisions for a patientthat they consider to be in the patient's best interest,12with no consideration of the individual patient's own valuesand goals (Davis & Aroskar, 1991).Beneficence.Beneficence may be viewed on a continuum extending fromnoninfliction of harm (nonmaleficence) to benefitting others(positive beneficence) (Davis & Aroskar, 1991). Accordingto Frankena (1973) the principle of beneficence states that"one ought not to inflict evil or harm, one ought to preventevil or harm, one ought to remove evil, one ought to do orpromote good" (p. 47). The duty not to inflict evil or harmtakes precedence over the other three aspects, with otherthings being equal in a situation.Beauchamp and Childress (1983) treat nonmaleficence andbeneficence as two separate principles that indicate dutiesand moral obligations. Nonmaleficence is seen as theprohibition of intentional harm except in specialcircumstances and as requiring justification of risks by theprobable benefits to be gained. This position is similar toFrankena's (1973). Beauchamp and Childress (1983) also takethe position that nonmaleficence requires that agents suchas health care professionals be thoughtful and take carefulactions.The beneficence principle requires the provision ofbenefits and a balancing of harms and benefits, as definedby the individual (Beauchamp & Childress, 1983). Benefitsare considered to have positive value that promotes health13or welfare while risks refer to possible future harms (Davis& Aroskar, 1991). Sometimes when maximizing benefits andminimizing risk of harm, there are also questions ofjustice.Justice.Simply stated, justice means giving others their due(Jameton, 1984). There are essentially two principles ofjustice (Beauchamp & Childress, 1983). Attributed toAristotle, the formal principle of justice holds that equalsought to be treated equally and unequals unequally; inproportion to their relevant differences. Although theformal principle of justice is useful, it is also limitingbecause it does not specify who is equal and who is unequal,and what are morally relevant differences among persons thatallow one to determine what each person is due.The material principles of justice are useful inovercoming these problems. The material principles assumethat not all persons are equal for the purpose ofdistributing all of the goods and services in society.Material principles include an equal share to each person,according to effort, according to societal contribution,according to need, and according to free market exchange(Beauchamp & Childress, 1983).Justice has three primary areas of application.Distributive justice focuses on the allocation of goods andservices. Retributive justice is primarily concerned with14punishment for wrongdoing. Procedural justice focuses onhow things are done independent of final outcome (Jameton,1984).The principles of distributive justice are mostapplicable for health care. Three dominant theoreticalperspectives of distributive justice can be identified.These are libertarian, utilitarian, and egalitarian. Eachof these theories gives priority to certain ethicalprinciples over others. The libertarian views individualsas having inherent worth and as having certain moral rights.Free choice is a central concept, and libertarians believethat people freely choose to contribute as they wish toeconomic matters and that this freedom should not beinterfered with.The utilitarian perspective can be reduced to two majortheses; an action is right if it leads to the greatestpossible balance of good consequences or to the leastpossible balance of bad consequences for all personsinvolved with the action, and that which maximizes the gooddetermines what is right to do.Equality plays a central role in egalitarian theoriesand thus egalitarians place high value on the concept ofjustice as equality. Rawls (1971), the major theoristadvocating this position, equates justice with fairness. Hehas proposed two principles. First, each person is to havean equal right to basic liberties. Second, social and15economic inequities should be arranged to the greatestbenefit of the least well off, and there must be equalopportunity for all to gain the advantages of treatingpeople unequally (Veatch & Fry, 1987).Ethical Approaches Health care ethics, in general, and nursing ethics, inparticular, are based on normative ethics. This discussiontherefore focuses on normative ethical theories. Thetraditional positions or theories of egoism, deontology, andutilitarianism can be found within normative ethics.Egoism.The ethical egoist believes that an individual's oneand only basic obligation is to promote for himself thegreatest possible balance of good over evil (Frankena,1973). When answering the question of what is the morallyright thing to do, the ethical egoist says that something isgood because the individual desires it. The right act isthe one that is most comfortable for the individual (Davis &Aroskar, 1991). This approach is not seen as relevant forhealth care because in health care the focus in on doinggood for others.Deontology.The deontologic or formalist ethical approach suggeststhat "features of some acts other than their consequencesmake them right or wrong" (Beauchamp & Childress, 1983, p.33). The rightness or wrongness of actions depends on more16than the agent's pleasure or the consequences of theproposed action, it depends on the nature or form of theseactions in terms of their inherent moral significance, suchas keeping a promise (Davis & Aroskar, 1991). According tothis approach, one should act according to principles,rules, or duties.Immanuel Kant, the major deontologist, originated thisapproach. Kant (1981) ascribed less significance to theconsequences of actions and emphasized the duty to treatpeople as ends, never as means to an end. He maintainedthat persons have absolute value and that the principle thatshould guide our actions is to be found in the ability tomake an action universal (categorical imperatives). Kantproposed that rational beings should always ask the question"How would things stand if my maxim became universal law?"(Storch, 1982a, p. 27). Kant (1981) stated that thesecategorical imperatives are unconditional commands, morallynecessary, and obligatory under any circumstances.There are two kinds of deontology, act and rule. Thedifference focuses on whether moral demands arising fromduty can be applied to specific acts in specific situationsor to rules of conduct that determine the rightness orwrongness of an act. Act-deontological theories maintainthat the basic judgments of obligation are all purelyparticular ones like "In this situation I should do so andso" (Frankena, 1973, p. 15). Rule deontologists hold that17the standard of right and wrong consist of one or more rulessuch as "Always tell the truth".Utilitarianism.Utilitarianism, the theory of utility, defines "good"as happiness or pleasure, and "right" as maximizing thegreatest good and least amount of harm for the greatestnumber of persons. This position assumes that one can weighand measure harm and benefit and come out with the greatestpossible balance of good over evil for most people. Eachindividual counts as one in the utilitarian approach (Davis& Aroskar, 1991).There are two types of utilitarianism - act and rule.The difference focuses on whether the principle of utilityis to be applied to specific acts in specific situations orto rules of conduct that determine the rightness orwrongness of an act. In act utilitarianism, specific actsin specific situations are viewed as unique, and theprinciple of utility is applied directly to each act. Inact utilitarianism, one must ask "What effect will my doingthis act in this situation have on the general balance ofgood over evil?" not "What effect will everyone's doing thiskind of act in this kind of situation have on the generalbalance of good over evil?" (Frankena, 1973, p. 30).In rule utilitarianism, the principle of utility isapplied to the rule and not to the individual act. A ruleutilitarian asks "What would happen if everyone were to do18that in such cases?" not "What will happen if I do that inthis case?" (Frankena, 1973, p. 30).John Stuart Mill has presented the major historicalarguments for the classical utilitarian approach. Accordingto Mill (1979) the morally correct action is determined bywhat he called the greatest happiness principle:"...actions are right in proportion as they tend to promotehappiness; wrong as they tend to produce the reverse ofhappiness" (p. 7). Today this principle is more frequentlystated as "Do the greatest good for the greatest number ofpeople" (Wright, 1987).Many forms of rule utilitarianism and rule deontologycan lead to identical rules and action, albeit for differentreasons (Beauchamp & Childress, 1983). According to Storch(1982a) the "actual selection of a theory is not asimportant as the process of investigating, valuing, andchoosing an approach, through principles or theory, thatbest matches the individual's work situation and assists inunderstanding of the complexities of a dilemma" (p. 28).Ethics of Health Care Health care ethics, also called bioethics, "can bedefined as the systematic study of human conduct in the areaof...health care, insofar as this conduct is examined in thelight of moral values and principles" (Reich, 1982, p. xix).The ethics of health care addresses four interrelated areas:19issues in clinical practice, allocation of scarce resources,human experimentation, and health policy (Davis & Aroskar,1991). The task of health care ethics is neither todiscover some new moral principles on which to build atheoretical ethical system nor to evolve new approaches toethical reasoning, but to prepare the ground for theapplication of the established general moral rules (Closer,1975).The origin of systematic work in health care ethics isfairly recent, however many issues in this applied fieldhave been debated for decades and, in some cases, forcenturies. Professional codes of ethics have evolved fromthis reflection on problems of health care ethics (Beauchamp& Childress, 1983).Common Bioethical Issues The literature on bioethics commonly identified severalmajor issues. The issues of confidentiality, truthtelling,informed consent, and refusal of treatment are brieflydiscussed here.Rules of confidentiality were mentioned in the earliestprofessional codes. Confidentiality "is understood as ameans of controlling access to sensitive information thatone party has discolsed to another party with theunderstanding that the information will be kept inconfidence" (Beauchamp & Walters, 1989, p. 375). In healthcare relationships, however, the duty to observe the rule of20confidentiality is not always an absolute duty, it may beoverridden when in conflict with other duties that aremorally stronger. For example when the duty to preservelife outweighs the duty to respect confidential informationconcerning self-destructive wishes of the client orthreatened harm against others.The duty to tell the truth (veracity) and not lie ordeceive people, at times, in health care, becomesproblematic. Several arguments were usually given for aduty to tell the truth (Beauchamp & Childress, 1983). Oneargument claimed that we tell the truth because this is partof the respect we owe persons. Because we respect personsand their autonomony we have a duty to veracity. Anotherargument claimed that relationships of trust are necessaryfor cooperation between clients and health professionals.Thus truthful relationships must be maintained in order tostrenghten and maintain therapeutic relationships betweenclients and health professionals. Another argument claimedthat the duty of veracity is related to the duty of promisekeeping. Therefore, in order to maintain the implicitcontract between the client and the health professional, theduty of veracity must be upheld.However, health professionals often have difficulty inobserving a duty of veracity. Information is sometimeswithheld from the client or the client is deceived becausethe health professional may think certain information will21cause the client harm. For example, when a diagnosis of aterminal illness would cause the client anxiety or lead toan act of self-destruction, a physician may withhold theinformation that would cause the harm.Informed consent is primarily gounded in the ethicalprinciple of automony. This means that individuals have theright to information and, on the basis of this input, theright to agree or to refuse to participate in research or toundergo the treatment being proposed. As previouslydiscussed, autonomy means that persons have the right todetermine their course of action on the basis of a planwhich they have developed for themselves. From an ethicalperspective, health professionals are obligated to respectthe clients' decisions even in those situations where theydisagree with the client. There are complex exceptions tothese general rules, such as when parents decide on a courseof action for their child which is harmful and might evenlead to death. Another exception can be found in emergencysituations where the health professionals have the primaryobligation to treat. The situation also becomes problematicwhen there is concern that the individual is physically ormentally incapacitated and unable to make a reasonabledecision for themselves.The literature discussed situations in which theclient's refusal of treatment becomes problematic for healthprofessionals. According to the principles of autonomy,22veracity, and informed consent it seems logical that anindividual has a right to accept or reject the interventionsoffered by health professionals. However, this is notalways the case, particularly when the refusal of treatmentwill likely lead to death. This conflict was discussed inthe literature as the conflict between autonomy andpaternalism. According to Reich (1982), an examination ofthe right to refuse treatment necessitated an examination ofthe conflicting rights of the individual versus thecollective rights of society. These collective rightsincluded:1. the need to protect people from their ownimprudence,2. maintaining a healthy population to supportsociety,3. avoiding harm to third parties,4. minimizing health care and other costs,5. safeguarding public morality and decency, and6. reinforcing the principle the life is sacred(p. 1499-1500).In recent years ethical issues related to health promotionhave been given attention in the literature (Anderson & Fox,1987; Becker, 1986; Burdine, McLeroy, & Gottlieb, 1987;Doxiadis, 1987; Guidotti, 1989). In Canada, Epp's (1986)paper, Achieving health for all: A framework for healthpromotion, has had a significant impact on political andprofessional acceptance of the ideals of health promotion.In contrast to the life and death dilemmas frequentlyassociated with health care technology, the dilemmasassociated with health promotion are of a more social23nature. Doxiadis (1987) identifies value conflicts insocial policies, paternalism in health education, conflictsbetween personal and public health goals, and the allocationof health care resources as ethical issues related to healthpromotion.Nursing Ethics Nursing ethics are part of the larger field of healthcare ethics. As noted earlier, ethical problems are not newor unique to nursing. Lamb (1981), in studying thehistorical evolution of nursing ethics in Canada, found thatnursing ethics initially focused on the service ideal, dutyto the community, and the individual behaviour of nursesand, over the years, has shifted focus to person-centeredcare, patient rights, and quality of care.Within the literature controversy exists as to thescope of nursing ethics. Some believe that nursing ethicssignifies the uniqueness of moral problems that nurses faceand reflects the uniqueness of moral reasoning in women(Gilligan, 1987); others argue that there is little that ismorally unique to nurses (Veatch & Fry, 1987). Veatch(1981) stated that "nursing ethics is a legitimate, if verylimited, term referring to a field that is a sub-category ofmedical ethics" (p. 17). Other authors have stated thatnursing ethics is clearly distinct from medical ethics(Levine-Ariff & Groh, 1990).24Aroskar (1990) defined nursing ethics as "systematicreflection on what is the right conduct in nursingeducation, service, and research in relation to what we doourselves, to each other, to other individuals and groups,and to environments in which nursing is practiced" (p. 36).Lamb (1981) stated that nursing ethics refers to "beliefsabout the moral values, ideals, virtues, obligations, andprinciples identified by nurses as important" (p. 3).Bishop and Scudder (1987) contended that the "moral sense ofnursing practice is affirmed as the primary focus of nursingethics" (p. 34). Support for this argument is found in theliterature (Baker, 1987; Donahue, 1990; Fowler; 1990).Yarling and McElmurry (1986) urged that nursing ethicsbe viewed as reform ethics. They argued that nurses areoften not free to be moral, and that the fundamental moralproblem of nursing is a consequence of the structure andpolicies of the social institution in which nursing ispracticed. They contend that nurses should focus on thereform of the health care system rather than on individualmorality. The argument that nurses are not free moralagents is supported elsewhere in the literature (Davis &Aroskar, 1978; Curtin, 1980).The concept of caring is important in any discussion ofnursing ethics. Caring is a form of doing good and avoidingharm and so is central to nursing ethics (Bandman & Bandman,1990). Gadow (1985) contends that "caring is attending to25the 'objectness' of persons without reducing them to themoral status of objects" (p. 33-34). Accordingly Gilligan(1987) asserted that the 'ethic of caring' is unique towomen and develops differently than the predominantly male'ethic of justice'. Fry (1988) stated that an ethic ofcaring serves as a universal value that guides nursingpractice.The role of nurses as advocates is also central tonursing ethics (Curtin, 1979; Gadow, 1980a, 1980b; Murphy,1983). Gadow (1980a) proposed that existential advocacy isthe essence of nursing. To Gadow (1980a, 1980b) advocacymeans that individuals are assisted by nursing toauthentically exercise their freedom of self-determinationand that the nurse is morally aligned with the patientrather than with the physician, family or hospital. Curtin(1979) stated that the "philosophical foundation and idealof nursing is the nurse as advocate" (p 2).Ethical Problems Ethical problems arise for nurses in fulfilling themoral sense of nursing practice. The literature presentsvarious conceptualizations of ethical problems, conflictsand dilemmas (CNA, 1991; Curtin, 1982; Davis & Aroskar,1991; Jameton, 1984; Storch, 1982a). Curtin (1982) definedethical problems as problems which cannot be resolved solelythrough an appeal to empirical data; are inherentlyperplexing with conflict of values and uncertainty about the26amount or type of information needed to made a decision; andthe answer to which will have profound, far-reaching andoften unknown effects.The CNA (1991) identified three distinct categories ofethical problems: ethical violations which "involve theneglect of moral obligations"; ethical dilemmas which"arise when ethical reasons both for and against aparticular course of action are present"; and ethicaldistress which "occurs when nurses experience the impositionof practices that provoke feelings of guilt, concern ordistaste" (p. ii-iii).Jameton (1984) sorted ethical problems into threetypes, moral uncertainty, moral dilemmas, and moraldistress. Moral uncertainty "arises when one is unsure ofwhat moral principles or values apply, or even what themoral problem is" (p. 6). Moral dilemmas "arise when two(or more) clear moral principles apply, but they supportmutually inconsistent courses of action" (p. 6). Moraldistress "arises when one knows the right thing to do butinstitutional constraints make it nearly impossible topursue the right course of action" (p. 6).Aroskar (1980a) stated that an ethical dilemma"involves either a choice between equally unsatisfactoryalternatives or a difficult problem that seems to have nosatisfactory solution" (p. 658). Storch (1982a) defined anethical dilemma as "a choice between two equally undesirable27alternatives" (p. 39).Smith and Davis (1980) viewed ethical dilemmas in thecontext of conflict. They suggested that dilemmas arise inthe following situations:1. A conflict between two ethical principles oneholds.2. A conflict between two possible actions in which(a) there are some, not conclusive, reasonsfavoring a particular course of action and (b)some, not conclusive, reasons against the samecourse of action.3. A conflict between a demand for action and theneed for reflection in a situation.4. A conflict between two equally unsatisfactoryalternatives.5. A conflict between one's ethical principles andone's role obligations (p. 1463-1464).An ethical dilemma, thus, is a particular kind of ethicalproblem wherein there is a conflict of "right" choices.Bergman (1973) stated that nurses face ethical problemson two levels, daily practice and policy levels. Theliterature provided many examples of both levels of ethicalproblems (Allen, 1974; Bandman & Bandman, 1990; Boyd, 1977;Bishop & Scudder, 1987; Davis, 1981, 1989).Ethical problems were also presented from theperspective of individual and consumer rights (Benoliel,1983; Storch, 1977, 1982a; Wright, 1987). Storch (1982a)defined rights as justified claims that persons or groupsmay make upon each other or society. Storch (1982a)contended that the concept of rights spans the related, butdifferent, disciplines of ethics and law and is therefore ofcentral importance to ethics.28Through nursing research, clinical nurses' perceptionsof ethical problems, dilemmas, and decision-making have beenexamined (Allen, 1974; Boyd, 1977; Davis, 1981, 1989;Murphy, 1983, 1985; Scanlon & Fleming, 1990). Murphy (1983)studied nurses' responses when confronted with hypotheticaldilemmas which pitted patients' rights and interests againstthose of the institution and the physician. Murphy (1983)identified three models of nurse response; the bureaucraticmodel, the physician-advocate model, and the patient-advocate model. In the bureaucratic model the nurses'primary loyalty was to the institution. In this view, theinterests of patients could be sacrificed by the nurse inthe interest of keeping the peace and enabling theinstitution to function without disruption. Those nurseswho followed the physician-advocate model perceivedthemselves as accountable only to physicans. The purposeof nursing, in this model, was to follow doctors' orders andto promote the ends of science, research, or medicaltechnology, perhaps at the expense of patients' rights. Themodel of patient-advocate had the lowest incidence. In thismodel nurses perceived themselves as having moral and legalaccountabliity to the patient.Murphy (1985) conducted another study in which sheasked nurses to explain, in detail, the types of ethicaldilemmas they experienced in clinical practice. Of the 800cases studied, forty-nine percent were concerned with truth-29telling. The dilemmas associated with the right to refusetreatment (19%) and the prolongation of life (17%) ranked assecond and third most prevalent categories. The finding ofthis study are supported by Allen (1974).Boyd (1977) reported a survey in which nurses inScottish hospitals identified care of terminally illpatients, deciding whether or not to resuscitate, and truth-telling as the main moral dilemmas arising from theirnursing practice. Davis (1981) conducted a survey of 205nurses in California to determine those ethical dilemmasthat were particulary troublesome to them. The two mostfrequently cited dilemmas were prolonging life with heroicmeasures and unethical/incompetent activity of colleagues.A more recent study of 100 Canadian nurses surveyed thetypes of ethical dilemmas faced by the nurses, the factorsaffecting such problems and the nurses' understanding of theconcept (Davis, 1989). Twenty nine percent of therespondents reported weekly confrontations with ethicaldilemmas, twenty nine percent reported monthlyconfrontation, and forty two percent reported that theyrarely or never confronted ethical dilemmas. Davis foundthat the nurses definition of an ethical dilemma varied andthat the respondents used their personal religious beliefsand the code of ethics as a guide in dealing with thesedilemmas. Davis found that discrepancies existed betweenthe definitions and understanding of the concept of ethical3 0dilemmas, the importance placed on ethical issues, and thenumber of ethical confrontations.Nursing research has shown, that for some nurses, moralconflict may lead to moral distress (Fenton, 1988;Wilkinson, 1986). Moral distress is the disturbingemotional response which arises when one is required to actin a manner which violates personal beliefs and values aboutright and wrong (Wilkinson, 1986). Moral distress mayaffect the nurse's ability to care for the patient and mayrequire a significant period of resolution. Moral distresshas been identified as one reason that nurses choose toleave their jobs and occasionally to leave the profession(Fenton, 1988).Lamb (1985) found that nurses perceived the negativeeffects of the multiple and conflicting loyalties existingwithin various nursing practice settings. Lamb found thatthese conflicting loyalties resulted in limitations onnurses' abilities to uphold the value of patient autonomy.Ethical Decision-MakingEthical decisions should be made on the basis ofethical theory and careful thought rather than on the basisof medical, practical, financial, religious, or legalcriteria, though these types of criteria may influencedecision making (Bunting & Webb, 1988). The degree to whichthese other factors should influence decision making iscontroversial and will vary between disciplines. For31example, a physician may base a decision primarily onmedical factors while a lawyer may consider the legalaspects most important. An ethical decision-making systemhas the potential of offering a rigorous, rationalmethodology for resolving ethical problems (Hynes, 1980).Ethical reasoning is the process of applying decision-making techniques to problems with an ethical component(Ericksen, 1989). The process of ethical reasoning iscomplex for nurses because they must examine theircommitments at the same time that they act upon them inclinical practice (Jameton, 1984). However, as Jameton(1984) stated, "the process of ethical reflection canimprove the quality of professional decisions, raise thelevel of communication with others, increase sensitivity topatients, and give one a sense of clarity and enlightenmentabout one's work" (p. 152).Nursing research has shown that a rigorous and rationalapproach is not always utilized in nursing practice. Rodney(1987) undertook a master's thesis to explore nurses'perspectives in relation to one specific ethical issue,prolongation of life. Her study results showed a senselessor fruitless decision-making process. Inadequateinvolvement of the patient, inadequate involvement of thefamily, inadequate involvement of the nurse, and fragmentaryteam decision-making all contributed to nurses' concernsabout a senseless decision making process (Rodney, 1987,321989).Rodney (1989) stated that throughout any of our effortsto implement ethical decision-making in nursing we mustattend to the organizational climate for professionalnursing practice. This means fostering ethicalrelationships between nurses and physicians and also betweennurses and nursing administration (Aroskar, 1985; Rodney,1989).Nurses' level of moral development influences theirdecision-making (Crisham, 1981, 1985; Mahon & Fowler, 1979).Crisham (1981) found that education and previous experiencewith similar dilemmas increased the level of the nurse'smoral responses. Ketefian (1981) found similar results andalso found that strong professional role conceptions wererelated positively to both levels of education and moralreasoning.Rest (1979) suggested that differences in moraljudgement may be interpreted in terms of enriched versusimpoverished environments. In the enriched environment,persons are encouraged to examine their views morethoroughly and systematically; this process leads to morecomplex and advanced, or higher, thinking. It is a role ofnursing administrators and educators to foster thedevelopment of an enriched environment for ethical decisionmaking.Structures and mechanisms that have been suggested to33implement ethical decision-making include ethics rounds,institution ethics committees, and nursing ethics councils(Davis, 1982). In a recent study (Scanlon & Fleming, 1990)nurses were surveyed to determine how they were addressingethical concerns in their practice. The methods identifiedincluded nursing meetings (66%), inservice education (18%),hospital committees (9%), individual discussion (9%),hospital ethics committee (9%), and interdisciplinaryrounds(4%).Frameworks for ethical decision-making.Several frameworks for ethical decision making werepresented in the literature (Aroskar, 1980b; Bergman, 1973;Bunting & Webb, 1988; Curtin, 1982; Levine-Ariff & Groh,1990; Murphy & Murphy, 1976; Silva, 1990; Stanley, 1980;Sullivan & Brown, 199lb; Thompson & Thompson, 1985). Silva(1990) identified the criteria for validating decision-making frameworks as adequacy, consistency, coherence,comprehensiveness and practicality. Several frameworks aresimilar to the nursing process in that the nurse begins byidentifying the major aspect of the problem, identifies andgathers additional information, generates and selectsalternative courses of actions, implements decisions andevaluates outcomes (Bergman, 1973; Murphy & Murphy, 1976).Other frameworks are based on values clarification (Stanley,1980; Thompson & Thompson, 1985).Crisham (1985) presented an approach to ethical3 4decision making which she has termed the "MORAL model" (p.28). The steps of Crisham's (1985) model include Massagethe dilemma, Outline options, Review criteria and resolve,Affirm position and act, and Look back.Recently, in the nursing literature, Sullivan and Brown(1991b) described a model for decision making in ethicalproblems which they called a "common sense" approach. Theauthors stated that the model was not an attempt to apply aspecific ethical theoretical model but rather was inferredfrom reflections on readings, cases, and personalexperiences, in nursing and in business, that focused onethical issues.Moral Basis of NursingCodes of Ethics for NursingNursing obligations are written in nursing codes ofethics. According to Murphy (1985), a code of ethics fornurses serves as a contract between society and theprofession by setting forth the values and ethicalprinciples that guide the clinical decisions of practicingnurses. As Tate (1977) stated, "codes are not law but areguides to all nurses in making critical decisions pertainingto appropriate professional behaviour and actions" (p.viii).Codes, however, are merely guidelines that do notalways address the more troublesome issues inherent in the35ethical dimensions of practice and education. Thus, asDonahue (1990) stated "nurses cannot rely on codes of ethicto provide them with solutions or to prescribe correctactions to take when faced with ethical issues and dilemmas"(p. 580). Potential shortcomings of professional codes arefrequently discussed in the literature (Beauchamp &Childress, 1983; Hunt & Arras, 1977; Steele & Harmon, 1979;Storch, 1982a; Wright, 1987).Public Health NursingThe terms public health nursing and community helthnursing are often used interchangeably in the literature.However, it is currently accepted that the term commmunityhealth nursing refers to all nurses who work in communitysettings. The term community health nurse encompassespublic health, continuing care, occupational health, andfederal health nurses. The term public health nurse refers,more specifically, to nurses who work in community settings,and whose main focus is health promotion, illness and injuryprevention, and health maintenance.Public health nursing is an art and science thatsynthesizes knowledge from the public health sciences andprofessional nursing theories (CPHA, 1990). As previouslymentioned, the context of public health nursing practice iscomplex, including a broad focus of care as well as a focuson the variables that affect health (Aroskar, 1979; CPHA,361990). The ethical implications of social interventions(actions, planned or unplanned, which changes thecharacteristics of an individual or that changes the patternof relationships between individuals), health promotion, theprovision of care to aggregates versus individuals, as wellas the allocation of scarce resources are issues which facepublic health nursing practitioners and administrators(Armstrong, 1987; Aroskar, 1979, 1989, 1990; Duncan, 1989;Fry, 1983; Jenkins, 1989; Lanik & Webb, 1989; Schultz,1987).Research and Public Health NursingLittle nursing research has focused on the ethicalproblems experienced by public health nurses. Aroskar(1989) conducted the first such study which focusedexclusively on ethical problems in community health nursingand how nurses dealt with these issues in their everydaypractice. This descriptive study focused on the single mostsignificant ethical problem identified by individualrespondents in their practice, the ethical principles andvalues at stake and the types of resources used to deal withthe problem. Questionnaires were sent to over 1000 staffnurses employed in community health agencies. Three hundrednineteen responses were used in analysis of the data. Themajority of the respondents' caseloads were characterized byclients over the age of 65 years with long-term chronicillness. About 15% of the caseloads were identified as37primarily public health. Aroskar found that the mostsignificant ethical problems described by respondentsfocused primarily on the individual client and advocacy forthat individual. The categories of the most significantethical problem included: when autonomy and beneficenceconflict, when truth-telling and nonmaleficence conflict,and principles of distributive justice. The respondentsidentified religious values, life experience, laws,professional codes and common sense as sources of guidance.The respondents turned primarily to their nursing colleaguesfor assistance in dealing with significant ethical problems.They also used agency supervisors, administrators, friends,and family as resource people. As Aroskar noted, turning toagency supervisors and administrators for assistance wasnotable because close to half of the respondents reported alack of administrative support for establishing andmaintaining a working environment that enhanced quality ofclient care.A master's thesis by Susan Duncan (1989) focused onethical conflict and response in public health nursingpractice. The sample included twenty three staff nurses andseven nurses in middle management positions. Based on thissurvey of thirty public health nurses, Duncan found that theethical conflicts identified by the respondents could becategorized as: clients' rights (including ethical conflictsrelated to working with high-risk parents, adult clients38with mental health concerns, and adolescent clients); systeminteraction (including ethical conflicts related to healthteam relationships and the allocation of resources); andnurses' rights (including conflicts related to personal andprofessional rights and values). The category of clients'rights was the largest response category, and the categoryof system interaction included the responses of publichealth nurses in both staff and middle management positions.Duncan (1989) concluded that the situations containingethical dilemmas for public health nurses are potentiallyeveryday occurrences, as opposed to being rare orsensational. She also found that although the conflictsfaced by the respondents were not unique in themselves, theway in which the public health nurses experienced theconflicts may differ from nurses in other roles andsettings. Duncan attributed this to the primary position ofthe public health nursing role within the health caresystem.Nursing AdministrationNursing administrators are responsible for theeffective and efficient delivery of organized nursingservices within health care institutions and for theprofessional practice of its nursing personnel (CNA, 1988).The CNA (1991) Code of Ethics for Nursing charges nursingadministrators with special ethical responsibilities that39flow from concern for present and future clients. Ethicalaction of nurse administrators implies client advocacy,equitable allocation of scarce resources and considerationof the nursing staff (Clatterbuck & Proulx, 1981; Fry, 1986;Silva, 1984; Storch, 1982b). According to Christensen(1988) nurse administrators have a responsibility to nursingstaff for creating an ethical work environment in whichnurses' human welfare is promoted. Christensen (1988)identified the components of an ethical framework fornursing administration as including "the use of a principledreasoning process, a moral committment to the profession andto each other, and a primary consideration for human welfarewith strategies to promote it" (p. 51). Sullivan and Brown(1991a) suggested a number of steps which may limit thenumber or intensity of ethical dilemmas experienced by nurseadministrators. These steps include acting as a moralmodel; hiring, associating and consulting with moral people;stressing standards and the spirit of the law; and beingcommitted.Nurse administrators are faced with complex decisionsthat flow from their multiple loyalties to clients andfamilies, staff and the organization which employs them.Ethical issues are becoming increasingly complex for nursingadministrators because of escalating economic concerns suchas a scarcity of resources, and increased attention to legal40concerns, such as human rights and informed consent(Jenkins, 1989).Research and Nursing AdministrationNurse administrators have the potential to impact onnurses, nursing practice, health care and health policy. Itis, therefore, important to develop an understanding ofnurse administrators' perceptions of the ethical problemsthey face and the approaches and resources used to resolvethese problems.Youell (1984) studied the major ethical problems ofnursing administrators and resources used by them to dealwith these problems. In her research she conductedinterviews with thirty one middle and senior line nursingadministrators in five acute care urban general hospitals inAlberta. The nursing administrators in this studyidentified problems relating to patients, nursing staff,physicians, and the institution, with problems related tonursing staff being identified as the most difficult. Theseproblems included competence, substance use, theft, andinformation sharing.The resources used to deal with these problems wereone's superiors, medical staff, peers, continuing educationcourses and workshops, literature, pastoral care services,personnel departments, and confidantes. However, even withthe large number of resources listed, some participants felta lack of resources or support for dilemmas faced.41The principles and values that participants listed asguiding their approach to ethical problems related to thecategories of professional, personal, institutional, andgeneral values, with the most common being centered aroundpatient rights, individuality, respect, hospitalphilosophy/values, employee-related values, and personalbeliefs/values. Youell (1984) noted that senior nursingadministrators more frequently espoused institutional andgeneral principles or values, while middle managers morefrequently listed personal values.When analyzing the approaches used by theadministrators to deal with the problems Youell (1984) foundthat the approaches "revealed a lack of systematic referralby participants to ethical principles" (p. 82). Youellconcluded that further education regarding ethics and theopportunity for mutual sharing of problems would bevaluable. She also recommended that nursing administratorsshould continue to recognize their importance as role modelsof ethical behaviour and be willing to enhance their ownskills and knowledge in order to be effective role models.Youell (1984) concluded that attention should be directed tofurther assessment of the adequacy of resources used bynursing administrators and that the vehicle of hospitalethic committees needs to be enhanced to meet nursingadministrators' needs.Sietsema and Spradley (1987) surveyed one hundred42twenty five hospital nurse executives. These nursingadministrators experienced ethical dilemmas on a regularbasis in a wide range of situations. The dilemmas mostfrequently cited were: staffing level and mix decisions,development and maintenance of care standards, andallocation and rationing of scarce resources. Therespondents indicated that they rely on personal values(their own and those of administrative colleagues) toresolve these dilemmas. Sietsema and Spradley (1987)conclude that "the most critical thing nurse executives cando is discuss at meetings and in the nursing literature, theethical premises on which they should build their practice"(p. 31).Other studies, already discussed in this review, haveimplications for nursing administration as well (Fenton,1988; Rodney, 1989). As these studies point out, moraldistress may be a factor in job satisfaction and retentionof nurses in clinical practice.Research and Public Health Nursing AdministrationThe author was unable to locate any research focusedspecifically on ethical problems experienced by publichealth nursing administrators. However, the findings ofAroskar (1989) and Duncan (1989) have implications forpublic health nursing administration. As previously noted,Aroskar (1989) found that public health nurses turned totheir agency supervisors and administrators as resource43people in dealing with ethical problems. Aroskar concludedthat knowing the types of situations that respondentsidentified as major ethical problems provides public healthadministrators with clues as to ethical issues thatcommunity health nurses are confronting in their practice.Aroskar recommended that this information be used byagencies to develop an individualized needs assessment forstaff development programs, for review of existing agencypolicy, and for making determination about development ofnew policies that take ethical problems into account.Duncan (1989) included seven middle managers in hersample of thirty public health nurses. As previouslydiscussed, these middle managers identified conflictsinvolving health care team relationships and the allocationof resources as significant. Duncan concluded that thesupport of administrators was important to public healthnurses dealing with ethical problems. Also, becauseattempts to resolve many of the dilemmas were frustrated bythe influence of external forces existing at the systemlevel, the importance of public health nursingadministration developing policies and organizationalstructures which support the staff is clear.SummaryLiterature related to ethics, nursing ethics, publichealth nursing and nursing administration was reviewed. The44literature showed that although ethical problems exist inall areas of nursing, little research to date has focused onethical issues specific to public health nursingadministration.45CHAPTER THREEMethodologyQualitative research theory guided the methodologicalapproach of this study. This chapter describes theselection of participants, the data collection and dataanalysis process, reliablility and validity of the study,and the ethical considerations.Study DesignA qualitative study, incorporating critical incidentdesign, was conducted. Qualitative research methods aredefined as the "descriptive analytical investigations of theworld of human experience" (Field & Morse, 1985, p. 125).Qualitative research "seeks to gain insight throughdiscovering the meanings attached to a given phenomenon"(Burns & Grove, 1987, p. 75).	 The critical incidenttechnique "is a method of gathering information aboutpeople's behaviours by an examination of specific incidentsrelating to the behaviour under investigation" (Roberts &Ogden Burke, 1989, p. 348). The critical incident is onewhich has had a significant impact on some outcome; it mustmake either a positive or negative contribution to theaccomplishment of some activity of interest. The criticalincident in this study was the ethical problem encountered,46in the past year, by the public health nursingadministrator. The critical incident technique iscompatible with Curtin's (1978) model, the conceptualframework for this study, in that it requires thatbackground information be collected to develop the contextof the incident.The study design was adapted from a study completed byDuncan (1989). Duncan's study was also a qualitative studywhich utilized critical incident design. The populationsvaried somewhat between the two studies. This study focusedspecifically on public health nursing administrators.Duncan's study population includined staff andadministrative public health nurses, as well as nurses inspecialty positions (such as school health).	 Duncan'sinterview guide was adapted to reflect this study's specificfocus on the ethical problems experienced by public healthadministrators. Specifically, the public health nursingadministrators were asked to recall an ethical problem theyhad experienced in their administrative practice.Selection of Participants A convenience sample was used. Convenience sampling isthe selection of the most readily available persons assubjects (Polit & Hungler, 1989). Convenience sampling isconsistent with the qualitative study design and also withthe data collection method of critical incident technique.47This sampling technique was chosen because the researcherhad access to the study population. The sample was limitedto public health nursing administrators working inprovincial health units. Public health nursingadministrators working in other settings (such as municipalhealth departments or the federal health system) and inother areas of community health (such as continuing care andmental health) have a different perspective and, therefore,may experience different ethical problems. For thesereasons the study population was strictly defined.Criteria for SelectionThe study population consisted of public health nursingadministrators currently employed by the provincial Ministryof Health in the capacity of Public Health NursingAdministrator or Public Health Nursing AssistantAdministrator. Both of these positions are responsible forthe management of the Public Health Nursing program at thehealth unit level and it was, therefore, consideredappropriate to include subjects who held either position.The subjects held the position on a permanent or actingbasis. Public health nursing administrative positions arefrequently held on an acting basis, often for long periodsof time. It was, therefore, decided to include those whoheld administrative positions on an acting basis in thesample population. The sample pool size consisted of fortyfour public health nursing administrators.48Selection Procedure Prospective subjects were contacted by letter (AppendixA). The letter outlined the study and prospective subjectswere asked to sign a consent form indicating theirwillingness to participate (Appendix B). All public healthnursing administrators who met the sample criteria and whoconsented to participate were eligible to be included in thestudy.Twenty four public health nursing administrators agreedto participate in the study. However, interviews could notbe arranged with four of the prospective participants withinthe time frame of this study. Therefore, the actual samplesize was twenty public health nursing administrators.Data Collection To obtain the data needed to answer the studyquestions, audio-taped interviews were used. Eightinterviews were conducted in person and the remaining twelveinterviews were conducted by telephone. A speaker phone wasused for the telephone interviews to allow the interview tobe taped. The interviews lasted from thirty to sixtyminutes.A semi-structured interview was used as the datagathering technique. The interview guide, attached inAppendix C, was adapted from the questionnaire used byDuncan (1989). Permission was received to adapt and utilize49this tool (Appendix D). Duncan (1989) utilized Curtin's(1978) Model of Critical Ethical Analysis as a basis for thedevelopment of her data collection guide. Curtin's (1978)Model of Critical Ethical Analysis has been discussed inChapter One.Duncan (1989) designed the questions included withinthe data collection tool to guide the participants throughthe process of describing and analyzing the critical ethicalelements of the situation. In Duncan's (1989) study thepublic health nurses were asked to recall an ethical dilemmaand "describe retrospectively the circumstances, their role,the perceived conflict, options considered, actions taken,outcome, feelings, and supportive or inadequate resources"(p. 52). In this study public health nursing administratorswere guided through a similar process, focussingspecifically on an ethical problem they had experienced, intheir administrative practice, in the past year.Data Analysis The content of the interviews was qualitativelyanalyzed to determine themes and to answer the researchquestions. Thematic content analysis was the data analysistechnique utilized (Field & Morse, 1985). Content analysisis a method for "the objective, systematic, and quantitativedescription of communications and documentary evidence"(Roberts & Ogden Burke, 1989, p.344). Themes emerge from50the content analysis. The themes might be phrases,sentences, or paragraphs embodying ideas or making anassertion about the topic of study (Roberts & Ogden Burke,1989). The themes identified are organized around thecontent of the messages conveyed as the participantsresponded to the interview questions. For example, in thisstudy, some of the themes which emerged to describe theparticipants' responses to the ethical problem theyexperienced included stress, regret and uncertainty, and useof a decision-making approach.In this study the following steps were taken:1. The data were examined and themes identified. Thethemes related to the ethical problems encountered, theparticipants' responses to the ethical problem, and thevariables which influenced the participant's experience;2. A categorization system was developed for classifyingand organizing the units of content (themes).These steps were consistent with those recommended in theliterature (Polit & Bungler, 1989; Roberts & Ogden Burke,1989).Rationale for Classification SystemThree categorization systems were developed to enablethe classification of content in relation to the researchquestions. The rationale for the development of thesecategory systems is discussed here.The themes which emerged from analysis of the51participants' descriptions of the ethical problems theyexperienced were classified according to the sources ofnursing obligations as identified by the CNA (1991) in theCode of Ethics for Nursing. These obligations areidentified as "clients, nursing roles and responsibilities,society, and the nursing profession" (CNA, 1991, p.vii).Nurses experience ethical problems as they attempt to meetthese obligations. It is therefore appropriate to utilizethese obligations as the classification system for thepartipants' descriptions of the ethical problems theyexperienced.The themes which emerged from analysis of theparticipants' responses to the ethical problems wereclassified according to how the participants acted, thoughtor felt about the ethical problem experienced. Thisclassification system developed from the definition of theterm "response" utilized in this study and previouslydiscussed in Chapter One.The variables influencing the experience were groupedinto personal, professional, organizational, and systemvariables. This classification system naturally emerged asthe data analysis proceeded.Reliability and ValidityFindings are considered valid and reliable in52qualitative research when findings aid in knowing andunderstanding the phenomena as fully as possible and"consistently reveal meaningful and accurate truths aboutparticular phenomena" (Leininger, 1985, p.69). Thereliability and validity of the findings of this study weredependent on the ability of the subjects to answer theinterview questions. As identified in the assumptions, itwas anticipated that the subjects would be able toretrospectively recall and analyze ethical problems they hadexperienced, and would, in fact, answer the interviewquestions truthfully. The validity of this study waslimited by the use of a convenience sample and wasinfluenced by the researcher's ability to delimit theinfluence of her personal experience as a public healthnursing administrator in the analysis of the data. Theresearcher utilized a technique known as bracketing (Oiler,1982) to overcome this source of bias. To bracket, aresearcher suspends or lays aside what is known about theexperience being studied. This procedure facilitates"seeing" all the facets of the phenomenon. In this study,the process of bracketing was operationalized by theresearcher engaging in periods of reflective thinking priorto and following each interview. Additionally, during theinterviews the researcher clarified participants' responsesin order to accurately reflect the participants' thoughtsand feelings.53Miles and Huberman's (1984) strategies for examiningthe validity of qualitative measures were employed. Theseincluded checking for representativeness, checking forresearcher efforts, triangulating, weighting the evidence,making contrasts/comparisons, checking the meaning ofoutliers or exceptions to the findings, ruling out spuriousexplanations, looking for negative evidence, and obtainingfeedback from informants.Protection of Human Rights The protection of human rights in this study wasassured in a number of ways. Authorization to conduct thestudy was obtained from the University of British ColumbiaBehavioural Sciences Screening Committee for Research andOther Studies Involving Human Subjects. In addition,approval was obtained from the Ministry of Health of theProvince of British Columbia.Prospective subjects received a letter inviting theirparticipation in the study. Potential participants weregiven an opportunity to ask questions and clarify anyconcerns about the study. Then, each participant signed aconsent form. The written consent clearly indicated thatthe participant could withdraw from the study at any time,that participation or non-participation in the study wouldin no way affect the participant's employment status, andthat the participant could refuse to answer any question.54Each participant received a copy of the consent form. Priorto every interview the researcher reaffirmed with eachparticipant that each was still willing to participate inthe study.Confidentiality was ensured in a number of ways. Allinterview transcripts were coded and any identifyinginformation was deleted from the transcripts. Theresearcher was the only one who had access to the mastersheet on which the identities of the subjects were matchedwith the code numbers. This master sheet and the consentforms were stored separately from the interview transcriptsand all research data (master sheet, consents, tapes andtranscripts) were kept in a locked filing cabinet in theresearcher's office. Interview tapes were erased andtranscripts shredded following the acceptance of theresearcher's thesis.Summary This chapter discussed the selection of participants,the processes involved in data collection and analysis, thereliability and validity of the study, as well as theethical considerations of the study.55CHAPTER FOURFindingsThe first section of this chapter contains demographicinformation about the participants. In the second sectionthe themes which emerged as a result of analysis of theparticipants' responses are discussed. These themes arepresented in relation to the study questions and, therefore,describe the ethical problems the participants experienced,their responses to these problems and the variables whichinfluenced the participants' experience of the ethicalproblem.Characteristics of Participants Twenty public health nursing administratorsparticipated in this study. All participants were women.The characteristics of the participants, including theiryears of general and public health nursing experience andlevels of education are presented in Tables 1, 2, 3, and 4.Table 1Years of Experience in Nursing, Public Health Nursing andPublic Health Nursing Administration56Total Public Health PHNAdmininstration4 - 3010 - 36Range .3 - 207Mean 1722Table 2Comparison of Years of Nursing Experience Between PublicHealth Nursing Administrators (PHN/A) and Public HealthNursing Assistant Administrators (PHN/AA) Total Public Health PHNAdministrationPHN/A PHN/AA PHN/A PHN/AA PHN/A PHN/AARange 10 - 36 11 - 34 9 - 29 4 - 30 2 - 20 .3 - 12Mean 22 22 19 16 12 2.8Table 3Educational Preparation of ParticipantsAll(N=20)PHN/A(N=10)PHN/AA(N=10)B.S.N. 13 (65%) 4 (40%) 9 (90%)Master's 7 (35%) 6 (60%) 1 (10%)57As noted in Table 3, the nursing education of theparticipants included thirteen with a baccalaureate degreein Nursing and seven with master's degrees in either PublicHealth, Public Administration, or Health ServicesAdministration.Table 4Status of Position Held by ParticipantsAll(N=20) PHN/A(N=10) PHN/AA(N=10)Permanent 13 (65%) 8 (80%) 5 (50%)Acting 7 (35%) 2 (20%) 5 (50%)Differences between Public Health Nursing Administrators andPublic Health Nursinq Assistant Administrators Ten of the participants were employed in the positionof Public Health Nursing Administrator, and ten of theparticipants were employed in the position of Public HealthNursing Assistant Administrator. As noted in Tables 2, 3,and 4, differences existed between the characteristics ofthe participants holding the position of public healthnursing administrator and those holding the position ofpublic health nursing assistant administrator. The twogroups had similar years of general nursing and publichealth nursing experience. However, the administrators hadsignificantly more years experience in administration than58did the assistant administrators. The mean years ofexperience were 12 years for the administrators compared to2.8 years for the assistant administrators.Differences in educational preparation existed as well.Sixty percent (60%) of the administrators were prepared atthe Master's level as compared to ten percent (10%) of theassistant administrators.Differences in position status were also evident.Fifty percent (50%) of the assistant administrators heldtheir position on an acting basis as compared to twentypercent (20%) of the administrators.In general, the participants who held the position ofpublic health nursing administrator had more administrativeexperience, a higher level of educational preparation, andwere more likely to hold their position on an permanentbasis than were the participants who held the position ofpublic health nursing assistant administrator.Ethical Problems ExperiencedSeventeen of the twenty public health nursingadministrators interviewed were able to describe an ethicalproblem they had experienced in the last year. Oneparticipant, although able to recall an ethical problemexperienced in the last five years, was not able to recallone experienced in the last year. Two of the participantsdid not believe that they had experienced an ethical problem59in their administrative practice. The followingpresentation of the findings of this study are based on theresponses of the seventeen public health nursingadministrators who had experienced an ethical problem in thepast year.The themes which emerged from analysis of theparticipants' descriptions of the ethical problems theyexperienced are presented according to the sources ofnursing obligation as identified by the CNA (1991). Thesources of nursing obligations are clients, nursing rolesand relationships, nursing ethics and society, and thenursing profession.Clients Four participants (23.5%) described ethical problemsrelated to clients. Specifically, problems related torespect for needs and values of clients, respect for clientchoice, and confidentiality were identified.Respect for needs and values of clients.One participant described a problem experienced whenstaffing a Sexually Transmitted Disease Clinic and a FamilyPlanning Clinic:Some of the nurses have a real problem working in thoseclinics. I can appreciate that but my issue is thatethically in practice, in community health, a nurse isgoing to have to accept that she is going to be upagainst issues that run contrary to how she would runher own life. Ethically, we are not to judge ourclients but merely to provide information and supportin decision making.Another participant identified a conflict between60personal beliefs and Ministry policy which she hadexperienced during an outbreak of a communicable disease. Aprophylactic vaccine was made available to certain riskgroups; however, parents of children outside the specifiedrisk groups were demanding vaccine for their children aswell. She stated:My ethical problem was that many confusing statementshad been made by the Ministry of Health, my problem wasin dealing with the parents. I could sympathize withtheir concerns and wants, but I was bound by Ministrypolicy.Respect for client choice.One participant identified an ethical problemexperienced when a community agency was widely offeringinaccurate information related to teen sexuality andattempting to limit teens' access to information:It has to do with the whole area of personal choice forpeople...we have had to examine what our role is interms of family planning and sexuality. Our role isnot to make decisions for people, it is to givebalanced information. The issue is autonomy for theclient.Confidentiality.One participant described an ethical problemexperienced as she provided support to a staff nurse who wasworking with a complex client problem. The public healthnurse was working with the family on an identified problem(grief) and, at the same time, the nurse was being asked byCrown Counsel, the police, and Ministry of Social Servicesstaff to provide information about the family. Theadministrator expressed her concerns this way:61You are put in a situation where on the one hand youknow that information is confidential and on the otherhand, at times, you must give confidential information.So it's a matter of what you do and what you don't doand how, with this sort of over-riding umbrella, yourcare is affected.The category of ethical problems related to the nursingobligations to clients was the second largest category ofresponses. Three of the four responses in this categorywere given by public health nursing assistantadministrators.Nursing Roles and Relationships This was the largest response category with twelve(70.5%) participants identifying problems in this area.Participants identified ethical problems related toprotecting clients from incompetence, conditions ofemployment, and job action.Protecting clients from incompetence."Nurses are obliged to take steps to ensure that theclient receives competent and ethical care" (CNA, 1991, p.15). Participants described four ethical problems relatedto staff incompetence and one situation in which theparticipant perceived that a family was receiving unjusttreatment by Ministry of Social Services staff.Three participants described situations in which theyobserved new and long term employees who were unsafe intheir immunization practices. The participants stated:I was routinely observing a nurse who had somethinglike thirty plus years experience, expecting that itwould be just a kind of routine thing. I was just62extremely taken a back when I went into clinic becauseher practice was terrible. She gave misinformation,she missed some of the basic things like properscreening before immunizing. I was just aghast, Icouldn't imagine how anyone could practice that longand do so poorly in something as basic as immunizationclinic.It was a nurse who, during her probation, was judged bymyself and my supervisor to be unsafe to practice,specifically in her administration of immunizations.We had an incident where a nurse really didn't believein immunization, which makes it impossible to work incommunity health. She didn't give clients all theinformation so that they could give informed consent.Two of these situations occurred shortly after theparticipants had assumed the position of public healthnursing assistant administrator.Another participant described a situation in which astaff nurse was dealing with so much personal stress thather ability to practice safely was questioned by theadministrator:I had a staff member whose practice was fine and thenhome life stress caused extended stress and extendedproblems. This caused me concern with safety topractice issues.One participant identified a situation in which sheperceived another professional's (Social Worker) treatmentof a family as unjust and unethical. As she stated:It seems what they (Ministry of Social Services) aredoing is such a judgement call...The conflict thatexists is what a healthy family situation is versuswhat I see Social Services doing. It's also what is thenorm for other families versus what we're seeing inthis situation.All five responses in this category were given by63public health nursing assistant administrators.Conditions of employment.Conditions of employment should contribute in apositive way to client care and the professionalsatisfaction of nurses. Six participants gave responses inthis category.One participant described an ethical problem related toallocation of resources. The manager was faced with makinga decision about a particular client service. She expressedher concerns as follows:We didn't have the staff and the resources to offer allthe other services in the other programs. We felt thetype of service we were offering was less thansatisfactory, that really it was difficult to keep thestaff updated with current information. We didn't feelthat the service that we were giving to clients was asuperior service so we had to make a decision. Itcertainly wasn't one that we took very lightly. Reallywhat we needed to do was expand (this service) but whenwe saw that other service areas were dropping we werecaught there. All of them provide services to clients,but which one were we going to continue giving. Givingat a level expected of a professional.Another administrator described the ethical problem sheexperienced in trying to balance the sometimes conflictingneeds of programs and service provision versus the needs ofstaff. She said:The problem between servicing the public, prioritizingthe issues that have to be dealt with, within theresources we have, and yet still allowing the nurses todo those things in their work which makes them feelgood and gives them the rewards they need...Of coursewe (nursing administrators) are the meat in thesandwich. We're getting the message from up abovesaying "thou shall create this community development,live within your FTE resources, do the whole bit", andyou have this other group down there saying but we need64to provide service, we can see the problems with thepeople we're dealing with.Two participants described situations involving aconflict of values with the Medical Health Officer(MHO)/Director related to the role and value of public healthnurses. The administrators said:Setting public health nursing priorities with theknowledge of what you believe Public Health Nursingshould be, or preventive programs should offer, versusthe more limited view of XX (MHO/Director). He seespublic health nursing as primarily communicable diseasefollow-up and immunization versus the preventiveapproach that addresses both health prevention andpromotion issues.The conflict for me is the lack of appreciation andvaluing of Public Health Nursing and the differentvalue set between the MHO and I. It becomes a problemwhen there is a serious impact on our planning or inhow effective I am in managing the program. SometimesI feel as if I'm being sabotaged from the side.One participant identified an ethical problem sheexperienced when she and the rest of the Public HealthNursing staff in the office perceived that a support staffmember was being unfairly treated. She stated:The situation contradicts what I believe in, my values,my work ethic, and my sense of fairness. The mostdifficult thing about this has been the amount of timethat's been spent on it, seeing someone being very,very hurt, and seeing the impact on the staff, how ithas started to reflect on the nursing staff morale.Another participant described an ethical problem sheexperienced when a letter of reference was requested for astaff member who the participant was "having a lot ofdifficulty with" and that the participant "really didn'twant to keep on staff". The participant's response65illustrated the conflict between her obligations to truth-telling and her obligations to the other staff members. Shestated:The nurse was causing an awful lot of difficulty withother staff...other staff were requesting transfers outof that office on a regular basis because they couldn'tdeal with this one person...We had tried everythingover the years...I found that (the request for a letterof reference) a real ethical dilemma. You know youhave to be honest, it would be unfair to the otheragency not to be...Yet, in another sense, she may wellbe good at that job...I was thinking I can't think ofany other solution...I thought, if I do this (write areference letter) it will be a good solution for thatoffice. Who was my responsibility most to?Job action.One participant discussed the conflicting loyalties andobligations experienced being a manager and a member of aunion. She described her problem as follows:You have to function outside the union in a big part ofthe job that you do as a PHN Administrator. If you aremaking decisions regarding management of the unioncontract or if you are undertaking disciplinary action,then you are functioning as a manager, not as a unionmember. When it comes to how the staff perceive you orhow the union perceives you, especially in a strikesituation, then you are a union member. The conflictis that as a PHN you should have some loyalties to theunion because they do the negotiating for you in termsof your salary, and benefits, and all the other thingsthat are within the union contract. But the fact isthat there is very little loyalty there. They don't doa whole lot for me in terms of my role in management.In fact they undermine that role in a lot ofsituations.Nursing ethics and societyNurses have ethical obligations to advocate for theinterests of clients, the community and society. Oneparticipant gave a response in this category.66Advocacy of the interests of clients/community.One participant discussed the ethical problem sheexperienced when the local hospital proposed an earlypostpartum discharge program. It would have been reasonableand acceptable, within the health unit mandate, for theadministrator to have stated that she did not have theresources to participate in the local initiative. However,she did not feel this was in the best interests of thecommunity. As she stated:I thought to treat it as if that's the hospital'sproblem was not good enough because I felt it reallywas a women's issue and it was a nursing issue.SummaryThe participants reported ethical problems related toclients, nursing roles and relationships, and nursing ethicsand society. The largest response category was nursingroles and relationships, with 71% of the identified ethicalproblems in this category. No ethical problems related tothe nursing profession, as a source of nursing obligations,were identified.Response to Ethical Problems The themes which developed from analysis of theparticipants' responses to the ethical problems theyexperienced are discussed here. As discussed in ChapterOne, the term "response" is defined to mean the ways inwhich public health nurse administrators act, think, and67feel about the ethical problem experienced. The categoriesof responses discussed in this section are not mutuallyexclusive.Stress More that half of public health nursing administrators(52%) reported feeling a significant amount of stress whileexperiencing the ethical problem. The following excerptsare illustrative:The situation was very stressful. Looking back, I'mnot sure how I got through it.It's stressful on a personal level to be critical ofsomeone's practice.I did a lot of thinking and it caused me stress, so Ihad to deal with my own stress.I thought how can this be allowed to happen and I had asick feeling inside of myself.All of the administrators who identified an issue ofstaff incompetency reported feelings of stress associatedwith the role conflict they experienced when ensuring clientsafety and, at the same time, supporting and advocating forstaff members. As the participants stated:The most difficult thing was thinking of the personalstress that it would cause the nurse. I knew it would,but I had to draw these things to her attention.It's very stressful...I think it's the concern over howyou are going to affect them personally, as opposed toyou know you have to draw this to their attention, youcan't not do that, it wouldn't be ethical not tobecause then you're putting the clients at risk.You have to balance it...the safety issues for theclients versus the staff saying don't cut my lifeline.Another component of the stress the participants68experienced was related to the amount of work and personaltime the experience of the ethical problem consumed. Oneparticipant stated "I spent a lot of time thinking aboutit...I spent a lot of time at night trying to decide what todo". Another participant said "I thought about nothingelse for two days".Use of a decision-making approach.All the participants attempted to resolve their ethicalproblems by utilizing a rational decision-making approach.One participant utilized an ethical decision-making process.In response to a situation involving concerns about astaff nurse's immunization practice one participant took thefollowing steps:The immunization errors were discussed with the staffmember, plans were made to improve her practice...Idocumented it and consulted my immediate supervisor andI talked to our personnel officer as well.When faced with a decision about withdrawing a clientservice a participant reported the following process:We (management team) had lots of discussions..this wenton for about 6 months as we explored alternatives... weconsidered staffing levels and program activities...wediscussed it with staff...we made the decision to cutthis program because it was self contained, we hadproblems updating staff...the clients often receivedconflicting or inaccurate information...there was asuperior service available to our clients nearby...weweren't just removing a service and not offering analternative... we are continuing to monitor thesituation.As previously stated, only one participant reportedutilizing an ethical decision-making process. Ethicaldecision-making is intended to apply various skills of69ethical analysis and reasoning in an attempt to reach awell-grounded solution to an ethical problem (Benjamin &Curtis, 1986). The following excerpts illustrate theprocess:I could appreciate their (some staff members) moraldifficulty...I had to ensure that proper, responsive,and adequate services are delievered to the clientgroup.My issue was do you allow nurses who feel uncomfortablein certain situations, because of their aversion withpeoples lifestyles to avoid working with these groups.Is that okay? The answer is no...ethically we're nothere to judge our clients but to provide informationand support in decision-making.The conflict for me was to make the staff happy or tomake sure that the client group was okay, and for me,the client group had to come first.We talked about it in an open meeting...I consideredallowing staff to opt out of those clinics...We set upsupport systems for existing staff...We made ourexpectations clear in hiring new staff.An administrator has to be an ethical model, we have totake ethical stands that may not always be popular, butif we are standing on good ground in terms of ourethics and making decisions people understand...it'snot alway easy but it is part of being a professionalnurse.We are here to provide a service to the public, that'sour mandate.This is about our client's right to choice...our roleis to provide information so they can make achoice...not to judge whether the choice is right orwrong.These steps are consistent with ethical decision-making(Ericksen, 1990).Values clarification.Values clarification is the systematic process of70choosing, prizing, and acting on one's own values (Steele &Harmon, 1983). Two responses showed evidence of a valuesclarification process:We spent time as a working group clarifying valuesrelated to the issue. We now have a plan of actionthat we feel comfortable with. I think that'simportant, for the nurses to feel comfortable in whatthey are doing.I could understand the discomfort some of the staffwere having in this situation. We explored the issuein an open meeting. I could understand their moraldifficulty, but we are not asking the staff to make thedecision for the client, and we are not asking thatthey approve or disapprove of the clientslifestyle...But what we are asking them to do is toprovide information for people to make decisions and tosupport them in what decisions they make...that is partof being a professional nurse.Regret and uncertainty.Five administrators expressed feelings of regret oruncertainty about the decisions they had made, as thefollowing excerpts illustrated:There are lots of times when I still think that I madethe wrong decision...I guess that is part of the thingwith ethical decisions is that even when you make thedecision you think is the right one ethically, youstill may have a lot of regrets, and I do.The most difficult thing was coming to the realizationthat I would have to give up what I really would haveliked to have done. There are lots of times when Istill think I made the wrong decision.What if she said "No"? What would I have done? Idon't know what I would have done. To this day I think"what if".The difficult thing is...seeing the impact on thestaff. I don't want to let the staff down.You ask yourself, "What else could I have done"?71Failure to act.Two of the responses indicated that although theinitial problem was resolved to a certain end point, ethicalconcerns persisted and these were not resolved. Oneadministrator, who had to deal with a staff members'incompetency, noted:I do think that any staff member who had been there forany length of time and had worked with her was awarethat she was not a very competent person.However, staff colleagues had not "whistle-blown". Thefailure of staff members to fulfill their professionalobligation was not dealt with. Another administratorstated:This happened just over a year ago. The file has justsat in my drawer. I know she isn't practicingnursing...I haven't had time to think it through...Whatdo I do about this now? Am I obligated to report thisto the professional organization?Use of personal resources.Several participants identified that they utilizedpersonal resources, such as personal experience andspiritual beliefs, in dealing with the ethical problem.Previous personal experience was utilized by 47% of theparticipants. One participant stated that she would havefound more personal experience a helpful resource. Oneparticipant relied upon her spiritual beliefs and prayer asa source of support.Use of external resources.All participants sought out resources to assist them in72resolving the ethical problem. The most commonly usedresource was public health nursing administrative colleagues(76%). Staff members (29%) were also utilized by severalparticipants. Participants also identified the PublicHealth Nursing Central Office staff, the Medical HealthOfficer, the Health Unit management team, spouses,management colleagues outside of health care, friends, andclassmates as resource persons utilized. Ministry of Healthpolicy, the Registered Nurses Association of B.C., and theCode of Ethics were also identified.It is also interesting to note that six participantsidentified the resources of the Medical Health Officer andthe Public Health Nursing Central Office staff as nothelpful or not approached because it was expected that theirinput would be not helpful. In reference to the MedicalHealth Officer, one participant stated:In my experience most of the medical health officersI've dealt with wouldn't be helpful in this situation.Their attitude would be, this is the practice, justbloody well get on with it. And that's not veryhelpful.In reference to the Public Health Nursing Central Officestaff a participant said:It was an in-house problem and it wouldn't haveoccurred to me to use the consultants in Victoria. Wehaven't had that kind of relationship with them for solong that it wouldn't even enter my head. And also Ithink ...they are not up on the practice and it istherefore difficult for them to relate.Participants were also able to identify externalresources they wished they had available to them. These73resources included access to a medical ethicist, anobjective mediator, supportive policy, and materialresources such as inservice training for the staff.SummaryThe participants responded in a variety of ways to theethical problems they experienced. These responses includedfeelings of stress, regret and uncertainty; utilization of adecision-making approach; values clarification; the use ofpersonal and external resources; and failure to take actionto completely resolve the ethical problem.Variables Influencing the ExperienceA number of themes emerged related to the variableswhich influenced the public health nursing administrators'experience of the problem. These themes were grouped intopersonal, professional, organizational, and systemvariables.Personal variables The personal variables identified included the presenceor absence of previous administrative experience, personalexperience, and the amount and type of support available.Previous administrative experience.Participants who lacked administrative experiencereported feelings of acute stress associated with theexperience. The following excerpts illustrate:It was within a very few months of assuming the actingposition...I was basically thrown into a situation that74I had never had to deal with before...Looking back I'mnot sure how I got through it. It was a very acutestressful situation.I'd been in the position about four months...I wasgetting used to a new job, in a new health unit, andthen these problems came up...it was very stressful.The participants also identified that a significant amountof their time was taken up with the ethical problem and theprocess of trying to resolve it. As the participantsstated:I spent a lot of time thinking about it..I spent a lotof time at night trying to decide what to do.I thought about nothing else for two days.Personal experience.As previously discussed, several participants (47%)utilized personal experience as a resource to assist indealing with the ethical problem. One participant expressedthe belief that, perhaps, with more life experience theresolution of ethical problems would be easier. Anotherparticipant was aware that her experiences as an adolescentwere influencing her experience of the current ethicalproblem of lack of respect for autonomy. She stated:The most difficult thing for me was that I had comefrom the same sort of background myself. I had toface, as a young adult, the same kind of pressure thatI now see being put on these young girls. Otherpeople's opinions and decisions being put on me insteadof allowing me to make my own decisions.Support.Six of the participants (35%) stated that they feltsupported by the resource people they had sought out. For75this group the support contributed, in a positive way, tothe experience of the ethical problem. One participantstated "I'm feeling really fortunate that I've had supportby the people I've been able to seek out. This has helpedmy to hang in and resolve this to the very best of myability."The remaining participants commented that, despite thenumber of resources utilized, they either had no support orthat the support available wasn't helpful. As participantsstated:I'm not sure where that support would come from, Ithink that it's something that I have had to workthrough myself.My peers were as supportive as much as they could be,but the decisions and actions were mine to take. Thesupport was there but it wasn't all that practical. Ijust had to do it myself.No, I didn't feel supported. I was it, and in myexperience, in public health nursing, as theadministrator, that's the way it is.For one participant, who was faced with a problem ofstaff incompetency, an overt lack of support negativelyinfluenced the experience. She commented:One of the other staff members said something to me tothe effect that it had been noticed that XX had goneoff immediately after I had been supervising her andthey were wondering if it had anything to do with that.Professional practice variables The professional practice variables relate to thedegree to which staff and administrative nurses fulfilledtheir professional practice obligations. This variable was76particularly related to situations of staff incompetency.As previously discussed, one participant identified asituation in which she, as a new public health nursingassistant administrator, became aware of an incompetantstaff nurse, who had been employed for many years. Thefailure of previous nurse administrators and staffcolleagues to address the safety to practice issues was anegative contributing factor. The participant stated:I had gone back to her previous evaluation...it was afairly reasonable evaluation...it was probably over twoor three years old...there was no mention of basicincompetence and the unsafe practice I'd observed...Ithink that any staff member who had been there for anylength of time was aware that she was not a verycompetent person...They were all aware of herincompetency.In fact, after the participant had taken actions to ensureclient safety, staff nurses did not support her. As shedescribed:After this particular nurse had been off for a coupleof months one of the other staff members said somethingto the effect that it had been noticed that XX had goneoff immediaitely after I'd been "supervising" her andthey were wondering if it had anything to do with that.Nurses are professionally and ethically bound to supportnurses who attempt to protect clients from harm. Thefailure of these nurses to fulfill their obligations was anegative contributing factor.Organizational variables The organizational variables include acting positions,staffing levels, the role of Central Office, the nature ofthe relationship between the administrator and the medical77health officer, resources, and policies.Acting positions.As previously discussed (35%) of the participants werein acting positions. Participants who were inadministrative positions on an acting basis found this tohave a negative impact on their experience. The negativeimpact was, in part, related to the fact that thoseadministrators in acting positions often had littleadministrative experience. The negative aspects of thesituations were exacerbated by the fact that there were noorganizational structures in place to support theparticipants who held acting positions. Two participantsreported that the ethical problem they experienced occurredwhen they were acting as Assistant Administrators and thendue to illness or another unexpected event, had to act asthe Administrator. They reported they had no support and noorientation. One of the participants stated:In an acting position you are not quite sure becauseyou never have dealt with it before. As an assistantadministrator you never have the final authority.Suddenly, without an orientation and with no support, Iwas expected to make these decisions. You have to findout by error and by that time your acting position isover.Staffing levels.A lack of staff was identified by four participants asnegatively influencing the experience of the problem. Fortwo participants, a lack of nursing administration staffrelated to a lack of support. Two other participants, who78were dealing with issues of staff incompetency, identifiedthe increasing caseloads of their staff as a majorcontributing factor.Role of Central Office.As previously discussed, several participantsidentified the role of the Public Health Nursing CentralOffice staff as an influencing factors. The supportive andconsultive expertise provided by the Public Health NursingCentral Office staff was identified by two participants as apositive influence. Several participants did not look tothe Central Office for assistance as they anticipated theinput would not be helpful. The roles of Public HealthNursing Central Office staff have changed significantly inrecent years from that of consultants to that of programmanagers. In the view of several participants the currentrole did not enable the Central Office staff to provideappropriate and helpful consultation on the ethical problemsthe field staff experience.Nature of relationship between the administrator andthe medical health officer.One participant identified consultation with themedical health officer as a helpful part of the process ofdealing with the ethical problem. Two participantsidentified the nature of their relationship with the medicalhealth officer as a negative influence on their experience.In these situations the participants perceived that the79medical health officers did not view or value the role ofpublic health nursing in the same way that the participantsdid. For these participants this value conflictprecipitated the ethical problem. For others, this inherentvalue conflict meant that the participants did not considerthe medical health officer, who is the public health nursingadministrator's supervisor, as a resource in resolving theethical problem experienced.Resources.Generally, the increased availability of resources hada positive effect on the experience of the problem. Thishas been previously discussed. One participant commentedthat the lack of ongoing staff education opportunitiescontributed to the development of the ethical problem. Shestated:I think it presents a dilemma too, because once you setpriorities that require skills that all staff don'tautomatically have then you also have to commiteducation and training to help them develop thoseskills. And that is something that had been reallydifficult in our system.The lack of support and absence of orientation forparticipants holding acting positions also relates toresources and has previously been discussed.Policies.Both the absence and presence of policies had anegative impact on the administrators' experience of theethical problem. Participants identified clear policydirection as a resource they wished they had available to80them. For one participant, an existing personnel policycontributed significantly to the negative experience of theethical problem. The participant was dealing with an issueof staff incompetency. The staff member had gone off onstress leave, and in the mean time, the decision had beenmade to terminate the employee. According to personnelpolicy, the administrator was not allowed to advise theemployee of the decision to terminate her employment untilthe employee had advised the employer of her intention toresign or return to work. As the administrator stated:Wanting what was best for her as an employee and aperson, not being able to share that information withher...I just felt that either way it wasn't being fairto her...if she was continuing on thinking that she wascoming back. Not being able to say anything to her onthat sick leave at all was really difficult.System variables The system variables related to factors at the healthand human service system level. They included theavailability of alternate client services within communitiesand communication systems with allied agencies such as theMinistry of Social Services.Availability of alternate client services.For one participant, the availability of alternateclient services was a positive contributing factor to theresolution of the resource allocation problem experienced.Conversely, the lack of available alternate client serviceslimited the options one participant felt she had in81resolving the ethical problem.Communication systems with allied agencies.For one participant, the communication systems betweenthe Health Unit and the Ministry of Social Services wereproblematic. The participant perceived that a family wasbeing treated unfairly by a social worker but was unable toaccess information from the Ministry of Social Serviceswhich might have clarified the situation.SummaryIn this chapter the research findings have beenpresented. Demographic information about the participantsand the themes which emerged as a result of content analysisof the participants' responses have been presented. Theparticipants in this study reported ethical problems relatedto clients, nursing roles and relationships, and nursingethics and society. The particpants' responses to theethical problems experienced included feelings of stress,regret and uncertainty; utilization of a decision-makingapproach; values clarification; the use of personal andexternal resources; and the failure to take action tocompletely resolve the ethical problem. The variables whichinfluenced the participants' experience of the ethicalproblem included personal, professional, organizational, andsystem variables.82CHAPTER FIVEDiscussion of the FindingsThe findings of this study will be discussed inaccording to the ethical problems experienced, theparticipants' responses to these problems, and the variableswhich influenced the participants' experience of theproblem. 1Ethical Problems ExperiencedThe ethical problems the participants experienced werecategorized according to the sources of nursing obligations,as identified by the CNA (1991) in the Code of Ethics forNursing. According to the CNA (1991), the sources ofnursing obligations included clients, nursing roles andresponsibilities, nursing ethics and society, and thenursing profession. In this study, the majority ofparticipant responses (70.5%) were classified in thecategory of nursing roles and responsibilities. The ethicalproblems identified related to protecting clients fromincompetence, conditions of employment, and job action. Thesecond highest response category was clients (23.5%). Inthis category the ethical problems identified related torespect for needs and values of clients, respect for client83choice, and confidentiality. Only one response (6%) couldbe classified in the nursing ethics and society category.This was an ethical problem related to advocacy of theinterests of clients and community. No responses related tothe nursing profession were identified. These findings wereconsistent with studies reported in the literature (Arsokar,1989; Duncan, 1989, Sietsema & Spradley, 1987; Youell, 1984)wherein the ethical problems identified focused primarily onthe individual client and advocacy for that individual;ethical conflicts related to health team relationships; theallocation of and rationing of resources; staff competency(both nurses and physician); and patient rights (such asinformed consent and the right to refuse treatment).The values and obligations presented in the Code of Ethics for Nursing (CNA, 1991) were presented by topic andnot in order of importance. Therefore, it could be expectedthat the responses in this study would have fallen into allfour categories. However, this was not the case. It isinteresting to note that, in this study, the ethicalproblems described by nursing administrators were primarily(94%) classified in the response categories of clients andnursing roles and responsibilities. The findings of thisstudy suggested that problems exist in public health nursingadministration, as in other areas of nursing, related toconflicting loyalties and lack of autonomy.Several authors have questioned the freedom of nurses to84practice nursing within bureaucratic settings, whichthreaten their professional and personal well-being(Christensen, 1988). The findings of this study supportedYarling and McElmurry's (1986) contention that nurses arenot free moral agents. Yarling and McElmurry asserted thatthe fundamental moral problem of nursing is a consequence ofthe structure and policies of the social institution inwhich nursing is practiced. This premise is supported bythe work of Lamb (1985) who found that nurses perceived thenegative effects of the multiple and conflicting loyaltiesexisting within various nursing practice settings and thelimitations on nurses' abilities to uphold the value ofpatient autonomy.Ethical autonomy, or the freedom to choose or toindependently endorse a given course of action, is basic tothe practice of professional nursing (Benjamin & Curtis,1986). Professional competence includes both practical andethical dimensions. Thus nurses cannot be totallycompetent, or autonomous, until they are able to be moreethical (Jameton, 1984). The results of this studyindicated that public health nursing administratorsexperience problems with lack of autonomy, as do nurses inother practice settings.Ethical Themes The ethical problems identified in this study involvedthe ethical principles of beneficence, autonomy, and justice85Beneficence.According to Frankena (1973) the principle ofbeneficence says that "one ought not to inflict evil orharm, one ought to prevent evil or harm, one ought to removeevil, one ought to do or promote good" (p. 47). Oneparticipant described a situation wherein a vaccine wasavailable to prevent illness but, due to Ministry policy,the vaccine was only available to specific groups who weredeemed "at risk". In this situation the administrator wasconcerned that she was not fulfilling her obligation toprevent harm and was not able to universally "promote good".The ethical problem related to confidentiality also involvedthe principle of beneficence. The administrator's duty toprevent harm (through possible child abuse by parent) was inconflict with her duty to promote or do good (throughcontinued interventions with family). The situationsrelated to protecting clients from incompetence alsoinvolved the principle of beneficence.Autonomy.The principle of autonomy is based on the idea thatindividuals are self-directing and therefore capable ofchoosing and acting upon decisions they themselves havedecided on (Fry, 1983). To respect persons as automonousindividuals is to acknowledge their personal rights to makechoices and act according to individual determinations. Oneadministrator described a situation in which some staff86members expressed concern about working with particularclient groups. The administrator believed that the nurses'obligation was to provide information and support theclients in whatever choice they made for themselves.Another participant described a situation in which acommunity group was offering inaccurate information relatedto teen sexuality and attempting to limit teens' access toinformation, These actions violated the principle ofautonomy and, therefore, these actions were unacceptable tothe administrator.Other examples involving the principle of autonomy arefound in the situations involving a conflict of values withthe Medical Health Officer related to the roles and valuingof public health nurses. In these situations the rights ofself determination of nurses and nursing was beinginterferred with by another discipline. The ethical problemrelated to the administrator being part of a union alsoinvolved the principle of autonomy.Justice.The administrators also described situations in whichthe principle of justice was involved. Situations relatedto conditions of employment, in which the administratorswere attempting to decide who should receive which services,for which reasons, involved the principle of distributivejustice. Distributive justice focuses on the allocation ofgoods and services (Jameton, 1984). From a utilitarian87perspective, the principle of distributive justice directsthat an action is right if it leads to the greatest possiblebalance of good consequences or to the least possiblebalance of bad consequences for all persons involved withthe action, and that which maximizes the good determineswhat is right to do.The principle of justice was involved in the situationinvolving a letter of reference for a troublesome employee.In this situation, the administrator struggled with theconflict between the good consequences for her staff if thisemployee left versus the unfairness to the agency requestingthe reference letter.Another example of the principle of justice wasillustrated by the situation in which the administrator andthe rest of the public health nursing staff in the officeperceived that a support staff member was unfairly treated.Rawls (1971) definition of justice as fairness if mostappropriate here.The ethical problem related to advocacy of theinterests of clients and community involved elements ofbeneficence, autonomy, and justice. The principle ofbeneficence was demonstrated by the administrator's concernabout doing good (for postpartum families) and avoiding harm(caused by early hospital discharge without adequatecommunity service). Autonomy was demonstrated by theadministrator's desire to ensure that families had choices88in type of postpartum experience they had (versus this beingdictated by a bed utilization committee). Finally, justicewas involved because the administrator was concerned withthe equitable distribution of health care resources in thecommunity.No Ethical Problem IdentifiedThree of the twenty public health nursingadministrators, interviewed for this study, could notidentify an ethical problem they had experienced in the pastyear. As previously discussed, one participant was able toidentify an ethical problem experienced in the past fiveyears, but was unable to identify one experienced in thepast year. Two participants did not believe they hadexperienced an ethical problem in their public healthnursing administrative practice. The response of oneparticipant bears further discussion. This administrator,after thoughtful consideration, stated that she experiencedproblems that had an ethical component, but that theeconomic or legal components of these problems were ofprimary importance. The participant also described theproblems as amenable to a rational problem solving process.This participant acknowledged that although some might callthese problems ethical problems, in her mind, they were not.The findings of this study are similar to the findingsof other studies reported in the literature (Davis, 1989;Duncan, 1989). Davis (1989) reported that discrepancies89existed between participants definition and understanding ofthe concept of ethical dilemma. Duncan (1989) found thatfive of the thirty participants in her study reportedexperiencing no ethical problems.In both this study and Duncan's (1989) study,interesting similarities existed in the demographiccharacteristics of the participants who reportedexperiencing no ethical problems. In this study, the threeparticipants who reported experiencing no ethical problem inthe past year had more years of public health nursingexperience than did the total sample (mean = 20.6 versus 17)and significantly more years of public health nursingadministrative experience than did the total sample (mean =17 versus 7). Duncan also found that the participants whoreported experiencing no ethical problems had slightly moreyears of public health nursing experience than the totalsample of her study (mean = 11.5 years versus 9.8 years).Duncan postulated that perhaps nurses who work in a settingfor many years become desensitized to the experience ofethical problems in their nursing practice. Duncanconcluded that further study was warranted to identify thosefactors which may influence public health nurses' ability ortendency to perceive the ethical dilemmas in their practice.The findings of this study also suggest that furtherresearch in this area is needed.90Public Health Nursing Administrator's Responses to Ethical Problems As discussed in Chapter Four, the Public Health NursingAdministrators' responses to the ethical problems theyexperienced were categorized according to how they acted,thought, or felt about the experience. The responsesincluded stress, utilization of a decision making framework,values clarification, regret and uncertainty, failure toact, use of personal resources, and use of externalresources.Stress In this study, all the participants reported feelingsof stress as they experienced the ethical problem. Thisreaction is similar to the findings reported in otherstudies. Several of the participants reported feelings ofmoral distress. Fenton (1988) and Wilkinson (1986) havereported this response to moral conflict. Moral distress isthe disturbing emotional response which arises when one isrequired to act in a manner which violates personal beliefsand values about right and wrong (Wilkinson, 1986).As discussed in Chapter Four, the stress reported bythose participants who were dealing with issues of staffincompetency was related to the conflict they felt betweentheir conflicting obligations to clients and their desire tosupport and advocate for staff. Lamb (1985) also identified91this problem of multiple and conflicting loyalties.According to the CNA (1991) "nurse managers bear specialethical responsibilities that flow from a concern forpresent and future clients" (p. 11). When faced withconflicting loyalties between clients and staff, the nurseadministrators in this study decided that their obligationto the client had higher priority.Utilization of a Decision-Making FrameworkAlthough all participants utilized a decision makingframework in dealing with the ethical problem, only oneparticipant in this study reported a response, to theethical problem they experienced, which could be classifiedas an ethical decision making process. These findings areconsistent with the findings of Youell (1986) who reportedthat the approaches used by nursing administrators toresolve ethical problems revealed a lack of systematicreferral to ethical principles. All participants in thisstudy attemtped to resolve their ethical problem byutilizing a rational decision-making approach . Thesefindings did not support the findings of Sietsema andSpradley (1987) who found that nurse administrators basedthe resolution of the ethical problems they faced on theirown and others' personal values and beliefs. Nor wereDavis' (1989) findings nurses primarily utilized religion astheir moral guide in responding to ethical problemssupported by the findings of this study.92The educational preparation of the participants of thisstudy may be a factor which influenced the ways in which thenursing administrators resolved the ethical problems theyexperienced. As discussed in the previous chapter, 65% ofthe participants had a baccalaureate degree in nursing. Themajority of participants had completed this degree more thanten years ago when nursing ethics may not have had a greatdeal of emphasis in their nursing curriculum. The remainingparticipants (35%) had completed master's degrees, however,none of these degrees were earned in nursing. Instead,these participants had chosen to complete master's degreesin Public Health, Public Administration, or Health ServicesAdministration. Therefore, although ethics may have beenpart of the curriculum, nursing ethics was not.According to Fry (1986), most nursing executives havelearned about values and their fundamental role in ethicaldecision making through business management courses, theirown insight, and socialization into the nursing managementrole. As Fry (1986) pointed out, these modes of learninghave not been supported by research on the types of moraldecisions made by nurses executives and their preparationfor these decisions.The decision-making approach utilized by participantsin this study is similar to the model advocated by Sullivanand Brown (1991b) for administrative decision-making inethical issues. This type of decision making for ethical93issues in nursing administration warrants further study.Regret and UncertaintyTwo of the participants in this study expressed regretwith the decisions they had made in order to resolve theethical problem. Both participants felt they made themorally correct decision; however, there was a price to payfor making the decision that they did for bothadministrators. This is not an unexpected response, asethical 'oughts' are not always congruent with personal'wants'.Three of the participants stated that they feltuncertain about the decisions they had made. Possibly, thiswas related to the fact that they had not utilized anethical decision making approach in resolving the ethicalproblem. The use of an ethical decision making approach"enables the nurse to make a decision that is morallydefensible and can be communicated in a rational manner"(Ericksen, 1990, p. 396).Failure to ActIn this study, two participants' responses indicatedthat although the initial problem was resolved to a certainpoint, ethical concerns persisted which were not resolved.This lack of action could be related to a lack of awarenessof, or concern about, the ethical issues remaining. Otherpossible explanations are that the administrators were notable to develop any strategies to resolve the problem, or94perhaps, as one participant stated, there was no time todeal with the problem.Utilization of Personal and External Resources Participants in this study sought out a variety ofpersonal and external resources to help them with theethical problems they faced. The types of resourcesutilized are similar to those reported in other studies(Aroskar, 1989; Duncan, 1989; Sietsema & Spradley, 1987;Youell, 1984). However, the two resources which are mostfrequently mentioned in the literature, namely the code ofethics and ethics committees, were rarely or never mentionedby the participants in this study.Despite the number and variety of resources utilized,most participants stated that they did not feel supported.Similar findings were reported by Aroskar (1989) and Duncan(1989). Sietsema and Spradley (1987), in their study ofethics and administrative decision making, reported that71.2% of the respondents judged the resources available assufficient. Unfortunately the term sufficient was notdefined, nor was the concept of support considered.Youell (1984) found that the hospital nursingexecutives she studied identified the medical staff as oneof the primary resources utilized. In this study, themedical health officer (MHO) was not utilized frequently.In fact, several participants responded that they did notconsider using the medical health officer as a resource95because they perceived that this would not be useful. Oneparticipant's comment was particularly interesting. Shestated that the anticipated response of the MHO was "This isthe practice, just bloody well get on with it". Thevariance in approach between the female nursingadministrator and the MHO, who is generally male, may beexplained by the work of Gilligan (1987). Gilligan (1987)asserted that the female 'ethic of caring' is different thatthe predominantly male 'ethic of justice'.Variables Influencing the Experience A number of variables which influenced the publichealth nursing administrators' experience of the ethicalproblem were identified in the previous chapter. Thesevariables included personal, professional, organizational,and system factors.Personal Variables This study found that previous administrativeexperience was identified by participants as having apositive effect on their experience of the ethical problem.The studies by Sietsema and Spradley (1987) and Youell(1984) did not examine influencing variables. Duncan (1989)reported that experience and professional competence wereviewed by participants as positively influencing theirexperience.The presence of support was identified as a variable96which positively influenced the participants' experience ofthe ethical problem, however, for most participants thissupport did not exist. Duncan (1989) reported similarfindings. The nursing administrators included in Duncan'ssample identified their need for support. The support theseadministrators found happened on an informal basis and, asin this study, no formal mechanisms existed to provide thisneeded support to administrators who were oftengeographically isolated from their peers.Professional Practice VariableThe professional practice variables related to thedegree to which staff and administrative nurses fulfilledtheir professional practice obligations. As discussed inthe previous chapter, one participant found herself, as anew administrator, inheriting a long term problem of staffincompetency. The CNA (1991) Code of Ethics was clear andspecific about the obligations of nurses to protect clientsfrom incompetence. The Code also acknowledged that thenurse who attempts to protect clients or colleaugesthreatened by incompetent or unethical conduct may be placedin a difficult position. The Code advised that colleaguesare morally obliged to support nurses who fulfil theirethical obligations (CNA, 1991). The results of this studyindicated that situations existed in which public healthnurses and public health nursing administrators had notfulfilled these obligations.97Organizational Variables The organizational variables identified in this studyincluded acting positions, staffing levels, the role ofCentral office staff, and the nature of the relationshipbetween the public health nursing administrator and themedical health officer. The influence of organizationalvariables on nurses' experience of ethical problems was notexamined in the nursing literature reviewed. However theoverall impact of the organization in which nursing ispracticed was discussed in the literature.Clatterbuck and Proulx (1981) stated that ethicalaction of nurse administrators implied client advocacy,equitable allocation of scarce resources, and considerationof the nursing staff. It seems that this could be appliedto health care organizations as well. In an ethical healthcare organization the principles of client advocacy,equitable allocation of resources, and consideration ofstaff well-being would be paramount. The findings of thisstudy unfortunately indicate that the environment in whichpublic health nursing administration was practiced was, to acertain degree, unethical. The frequency of actingpositions and the lack of orientation and support for publichealth nursing administrators holding acting positions areexamples of an unethical work environment. The previouslydiscussed lack of autonomy in nursing practice is anotherexample of an unethical work environment. Christensen98(1988) asserted that the considerations for human welfare,which are central to nursing practice, must be applied tonursing staff as well as clients. This study illustratedthat consideration for human welfare must apply to nursingadministrators as well.Nursing administrators' obligations to promote anethical work environment are discussed in the literature(Christensen, 1988; Rodney, 1989). However, within thenursing literature, there is a paucity of information aboutthe obligations of organizations to provide an ethical workenvironment and the factors which contribute to an ethicalenvironment for nursing administrators.The findings of this study indicated that inadequatestaffing levels had negatively impacted on the participants'experience of the ethical problem. Sietsema and Spradley(1987) also found that nursing adminstrators identifiedstaffing levels as a concern. In this study, staffinglevels appeared to impact the ethical problem in two ways.In situations where there was a shortage of nursingadminstrative staff in the Health Unit, this impact wasrelated to support. In situations where the administratorsidentified a shortage of staff public health nursingpositions to fulfill the expected program requirements, thestaff shortage actually precipitated the ethical problem.Another organizational factor which influenced thepublic health nursing administrators experience of the99ethical problem was the role of the Central Office PublicHealth Nursing staff. As previously discussed, in recentyears the role of these senior public health nursingadministrators had changed from that of a consultant to thatof a program manager. In the current role, opportunitiesexisted for the Central Office staff to develop andimplement policies which supported ethical nursing practice.Unfortunately, many of the public health nursingadministrators in the field did not perceive that thisrelationship was supportive. Valuable opportunities todevelop an ethical work environment were missed when thesesenior public health nursing administrators were notutilized.In two of the situations described by nursingadministrators in this study, actions of the Medical HealthOfficer were perceived to have precipitated the ethicalproblem experienced (see pages 63 - 64). In analyzing thesituations described, it appeared that there was not anethical relationship between the nursing administrator andthe Medical Health Officer. Rodney (1989) stated that inorder to implement ethical decision making in nursing wemust attend to the organizational climate for professionalnursing practice. To Rodney, this meant fostering ethicalrelationships between nurses and physicians to move nursingout if its powerless position. Aroskar (1985) stated thatone component of ethical relationships between nurses and100physicians was mutual respect, based on the inherent worthof all participants in the nurse/physician relationship. Inthe situations described by two participants in this study,this type of mutually respectful relationship was notevident.System Variables The system variables identified in this study relatedto the availability of alternate client services and thecommunication systems with allied agencies. Duncan (1989)also identified communication systems with allied agencies(Ministry of Social Services) as a factor which influencedthe participants' experience of the ethical problem. Theinfluence of this variable illustrated the need for ethicalrelationships between all health care team members. Amutually respectful relationship between health care teammembers recognizes the significant contributions that eachteam member can make, thereby enhancing client care.SummaryIn this chapter the study findings were analyzed anddiscussed in relation to the literature. This discussionincluded the ethical problems experienced by the publichealth nursing administrators, the responses to theseproblems and the variables which influenced the publichealth nursing administrators' experience of the ethicalproblem.101CHAPTER SIXSummary, Conclusions, and Implications for NursingIn this chapter, a summary of the study is reported andconclusions arising from the study are presented. Finally,implications for nursing practice, education, and researchare proposed.SummaryThe intent of this study was to explore the ethicalproblems encountered in public health nursingadministration, public health nursing administrators'responses to these ethical problems, and the variables whichinfluenced the public health nursing administrators'experience of the ethical problem.Public health nursing is an art and science thatsynthesizes knowledge from the public health sciences andprofessional nursing theories (CPHA, 1990). The context ofpublic health nursing practice is complex, including a broadfocus of care (communities, groups, families and individualsacross their lifespan) as well as a focus on the variablesthat effect health (lifestyle, family interaction patterns,community resources, economic and social factors, and publicpolicy) (Aroskar, 1979; CPHA, 1990). Public health nursesexperience ethical problems in their everyday work. Issues102such as health inequities and confidentiality, as well asthe conflicting priorities multidisciplinary team membersassign to ethical principles, are potentially problematic.Although it is acknowledged that nurses in all practicesettings experience ethical problems, there has been littlefocus on the ethical problems encountered by public healthnurses (Aroskar, 1979, 1989; Duncan, 1989). Nursingresearch thus far has focused on ethical problems, ethicaldilemmas and ethical decision making amongst nurseadministrators in acute care settings (Sietsema & Spradley,1987; Youell, 1984, 1986). There is no nursing researchfocused on the ethical problems experienced by public healthnursing administrators. Therefore, this study focused onthe ethical problems encountered in public health nursingadministration.A qualitative study, incorporating critical incidentdesign, was conducted. Data were collected during audio-taped interviews with twenty public health nursingadministrators. The participants in the study were employedby the Ministry of Health in the position of Public HealthNursing Administrator or Public Health Nursing AssistantAdministrator. The participants held the position on eithera permanent or acting basis.This study was an adaptation of a study done by SusanDuncan (1989) on ethical conflict and response in publichealth nursing. The study populations varied somewhat103between the two studies. This study focused on publichealth nursing administrators. Duncan's study populationwas broader, including staff and administrative publichealth nurses, as well as nurses in specialty positions(such as school health).A semi-structured interview was used as the datagathering technique. An interview guide, developed byDuncan (1989), was adapted for use in this study. Thepublic health nursing administrators were asked to recall anethical problem they had experienced in the past year. Theparticipants were then asked to describe retrospectively thecircumstances, their role, the perceived conflict, optionsconsidered, actions taken, outcome, feelings and supportiveor inadequate resources.The audio-taped interviews were transcribed and thedata collected during the interviews were analyzed utilizingcontent analysis to identify common themes. Themes wereidentified in relation to the ethical problems experienced,the public health nursing administrators' responses to theethical problem, and the variables which influenced thepublic health nursing administrators' experience of theproblem.The themes which emerged in relation to the ethicalproblems experienced were categorized according to thesources of nursing obligations as identified by the CNA inthe Code of Ethics for Nursing (1991). These obligations104included clients, nursing roles and responsibilities,nursing ethics and society, and the nursing profession. Theresponse categories, in order of frequency, were nursingroles and responsibilities (70.5%), clients (23.5%), andnursing ethics and society (6%). No problems wereidentified in relation to the nursing profession. Threeparticipants stated they had not experienced an ethicalproblem in the past year.The ethical problems identified in the category ofnursing roles and relationships included issues related toprotecting clients from incompetence, conditions ofemployment, and job action. The ethical problems identifiedin the category of clients included issues related torespect for needs and values of clients, respect for clientchoice, and confidentiality. Finally, the single responsein the category of nursing ethics and society related to anissue of advocacy of the interests of clients/community.The participants responses were categorized accordingto how they acted, felt or thought about the ethical problemthey experienced. The responses included stress, regret anduncertainty, utilization of a decision making framework,values clarification, failure to act, the use of personalresources, and the use of external resources.The variables which influenced the participants'experience of the ethical problem were categorized accordingto personal, professional, organizational, and system105variables. The personal variables included the presence orabsence of previous administrative experience, personalexperience, the type and amount of support available. Theprofessional variables related to the degree to which nurseshad fulfilled their professional practice obligations. Theorganizational variables included acting positions, staffinglevels, the roles of central office staff, the nature of therelationship between the administrator and the medicalhealth officer, resources, and policies.Conclusions The following conclusions were based on the analysis ofthe findings of this study.1. The public health nursing administrators whoparticipated in this study were able to identifyethical problems in their practice and toretrospectively analyze their experiences.2. The majority of public health nursing administrators inthis study identified ethical problems related to lackof autonomy and conflicting role obligations.3. The public health nursing administrators all found theexperience of the ethical problem difficult. Theyreported feelings of stress, regret, and uncertainty,and also commented on the amount of work and personaltime which was taken up by the experience.4. The majority of public health nursing administrators106did not feel supported in their experience of theethical problem.5. The responses of public health nursing administratorsin this study showed a lack of systematic referral toethical principles as they worked to resolve theproblem.6. Organizational factors existed which made theexperience of the ethical problem particularlydifficult for public health nursing administrators whoheld the position on an acting basis.Nursing Implications The findings of this study suggest implications fornursing practice, education, and research. The followingsection will outline these implications.Implications for Nursing PracticeThe findings of this study suggest that in publichealth nursing administrative practice, as in nursinggenerally, nurses must continue to clarify roles and worktowards increased power in decision making as it affectsnursing practice. These steps are part of the process ofincreasing the autonomy of nursing practice. It is onlywhen nurses are truly autonomous that they can become moreethical.Public health nursing administrators are leaders in thepublic health system. As such, they are positioned to107effect change in practices, policies, and organizationalstructures which do not support nursing practice andtherefore do not enable nurses to be ethical. The findingsof this study suggest that public health nursingadministrators, individually and as a group, must identifyand address those issues which interfere with ethicalnursing practice.One primary area of concern which was identified inthis study is the phenomenon of acting positions. Publichealth administrators must address the organizationalpractices and policies related to acting positions.Participants in this study described situations in whichthey were placed in acting positions without orientation andwithout support. Public health nursing administrators mustdevelop policies, orientation packages, and formal supportmechanisms which address these concerns. Public healthnursing administators must exercise their considerablepositional and political power within the organization toensure that all staff, including public health nursingadministrators themselves, are treated ethically, and thatin fact, an ethical organizational culture exists.The findings of this study also indicated that there isa need for increased awareness of, and attention to, theethics of public health nursing practice. This role couldbe fulfilled by the recently organized Public Health NursingAdministrators' Council or, as recommended by Sietsema and108Spradley (1987), public health nursing administrators coulddiscuss at meetings and in the nursing literature theethical premises on which they should build their practice.The findings of this study suggest that public healthnursing administrators must continue to explore ways inwhich to improve the organization and delivery of health andsocial services. It is suggested as well that public healthnursing administrators, continue to develop ways to buildand maintain ethical relationships with multidisicplinaryteam members.Implications for Nursing EducationThe findings of this study suggest that there is a needfor basic and continuing education to increase the ethicalknowledge of practicing public health nursing adminstrators.Of particular importance is information about the process ofethical reasoning and the application of ethical decisionmaking models.The findings of this study indicate that organizationalchange is required to address some of the ethical problemswhich are prevalent in public health nursing administrativepractice. In order to initiate and facilitate the changeprocess nurses must develop, strengthen, and utilize skillsrelated to organizational change and the effective use ofpower and politics. Nursing education can provide thisinformation and provide a mileau in which these skills canbe practiced in a non-threatening environment.109Additionally, nursing education, at both the baccalaureateand graduate levels, should provide nurses with theinterpersonal and communication skills necessary so thatthey are able to clearly and confidently express and defendtheir moral choices.The findings of this study indicate that public healthnursing administrators are seeking further education outsideof nursing in order to prepare themselves educationally fortheir positions. Nursing education must develop relevantmaster's programs which meet the needs of public healthnursing administrators. In order to meet these needs,relevant curriculum must be presented, and the programdelivery system must be flexible, including opportunitiesfor part time and distance education.Implications for Nursing Research This study provided only a beginning exploration of thenature of ethical problems and response in public healthnursing administrative practice. This study focused on theethical problems experienced by public health nursingadministrators employed in one organization. Further study,focused on public health nursing administrators employed inother organizations, would help determine whether theethical problems experienced were organization specific ordiscipline specific.The findings of this study indicate that further studyto identify those factors which may influence public health110nursing administrators' ability or tendency to perceive theethical problems in their practice is needed.This study did not attempt to examine, in detail, thedifferences which may exist in the ways in which publichealth nursing administrators in senior and middlemanagement positions experience and respond to ethicalproblems. This is another area for nursing research.The findings of this study suggest that furtherresearch is needed to examine the appropriateness andeffectiveness of ethical decision making models in publichealth nursing administrative practice.Policy and its effects on ethical problems in publichealth nursing practice is an area for further research, aswell. Ethical analysis of organizational policies, as wellas the policies which influence the health of communities,could be investigated.SummaryIn this chapter a summary of the research process waspresented and the conclusions were discussed. Implicationsfor nursing practice, education, and research arising fromthese findings were also outlined in this chapter. It isthrough reflection upon, and discussion of, the ethicalissues faced in nursing practice that competent, confidentand ethical practitioners are developed.FOOTNOTES 1111. 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London: Lippincott.Wilkinson, J. (1986). Moral distress in nursing practice: Experience and effect. Unpublished masters's thesis,University of Missouri, Kansis City.Wright, R. A. (1987). The practice of ethics: Human valuesin health care. New York: McGraw-Hill.Yarling, R., & McElmurry, B. (1986). The moral foundationof nursing. Advances in Nursing Science, 8(2), 63-73.Youell, L. (1984). Major ethical problems faced by nursingadministrators. Unpublished master's thesis,University of Alberta, Edmonton.Youell, L. (1986). A question of balance. Canadian Nurse,82(3), 27-33.120APPENDIX AInformation LetterMy name is Allison Cutler. I am a Registered Nurse anda student in the Master of Nursing Science program at theUniversity of British Columbia. For my Master's thesis Ihave chosen to study ethical problems encountered by publichealth nursing administrators. Although there is a growingamount of nursing literature on the topic of ethical issuesand dilemmas, the majority of this literature focuses on theexperiences of acute care nurses and hospital nursingadministrators. Your perspective as a practicing publichealth nursing administrator will provide valuable insightsinto the ethical dimensions of public health nursingadministration.I would like permission to interview you. This willtake approximately 45 - 60 minutes of your time. Theinterviews will be taped and transcribed. All informationobtained will remain confidential through the use of codenumbers on the interview transcripts. Your name and thename of the Health Unit in which you work will not beidentified in the study. Any names which are inadvertentlymentioned during the interview will be deleted when thetapes are transcribed.You are under no obligation to participate in thestudy. You may refuse to participate or discontinue yourparticipation at any time. Your participation or non-121participation in this study will not affect your employmentstatus. The names of those participating will not bereleased.If you have any questions about this study now or at alater time, please contact me at 758-0042 (home) or 755-6253(work) or Janet Ericksen at 822-7505.If you are willing to participate in this study pleasesign the enclosed consent form and return to me in theenclosed envelope. I will then contact you to arrange amutually convenient time and location for the interview.I look forward to hearing from you.Sincerely,Allison Cutler122APPENDIX BConsent FormProject Title: Ethical problems encountered by communityhealth nursing administrators My name is Allison Cutler. I am a Registered Nurse anda student in the Master of Nursing Science program at theUniversity of British Columbia. For my Master's thesis Ihave chosen to study ethical problems encountered by publichealth nursing administrators. Although there is a growingamount of nursing literature on the topic of ethical issuesand dilemmas, the majority of this literature focuses on theexperiences of acute care nurses and hospital nursingadministrators. Your perspective as a practicing publichealth nursing administrator will provide valuable insightsinto the ethical dimensions of public health nursingadministration.I would like permission to interview you. This willtake approximately 45 - 60 minutes of your time. Theinterviews will be taped and transcribed. All informationobtained will remain confidential through the use of codenumber on the interview transcripts. Your name and the nameof the Health Unit in which you work will not be identifiedin the study. Any names which are inadvertently mentionedduring the interview will be deleted when the tapes aretranscribed.You are under no obligation to participate in the123study. You may refuse to participate or discontinue yourparticipation at any time. Your participation or non-participation in this study will not affect your employmentstatus. The names of those participating will not bereleased.If you have any questions about this study now or at alater time, please contact me at 758-0042 (home) or 755-6253(work) or Janet Ericksen at 822-7505.I understand that nature of this study and give myconsent to participate. I acknowledge receipt of a copy ofthis consent form.Signed: 	Date:124APPENDIX CInterview GuideCODE:Date:I. Demographic Data:Number of years experience as a nurse:Number of years experience as a public health nurse:Position currenctly held: PHN/A 	PHN/AA 	Number of years experience in public health nursingadministration:Nursing education: (Highest level attained)II. Research Data:NOTE: It is important to maintain confidentiality for allpersons involved in the situation. Please avoid includingnames of persons, identifying circumstances, or otherinformation that may result in the identification of thoseinvolved.1. Do you encounter ethical problems in youradministrative practice?2. Recalling an ethical problem you encountered in thepast year, please begin by describing where thesituation occurred and how you came to be involved?1253. What happened? (describe the circumstances)4. Who was involved?: (please alter names and otheridentifying information to maintain confidentiality):5. What was your role in the situation?:6. What was the conflict of choice that existed for you inthis situation?:7. What were the options or possible actions youconsidered? (please describe what you intended as theprobable consequences of each alternative youconsidered):8. Please describe what in your mind was the best decisionand what actions were taken.9. What was the outcome of the situation (if known):10. What resources were helpful to you as you dealt withthis situation? Did you feel you had adequate support?11. Are there any other resources that may have beenhelpful to you?12. What was most difficult about this situation for you?13. Please describe any other feelings you have or have hadabout this situation:126APPENDIX DLetter of PermissionApril 5, 1991.Dear AllisonRe: Permission to use thesis questionnaireAs per your request, you have my permission to utilize andadapt the questionnaire I developed for my thesis Ethical conflict n• I ) Sincerely,

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