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Ethical issues encountered by nurses Hollands, Deborah 1994

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ETHICAL ISSUES ENCOUNTERED BY NURSESByDeborah HollandsB.S.N., The University of Victoria, 1987A THESIS SUBMUTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGINTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAAugust 1994©Deborah Hollands, 1994In presenting this thesis in partial fulfillment of therequirements for an advanced degree at the University of BritishColumbia, I agree that the Library shall make it freely availablefor reference and study. I further agree that permission forextensive copying of this thesis for scholarly purposes may begranted by the head of my department or by his or herrepresentatives. It is understood that copying or publication ofthis thesis for financial gain shall not be allowed without mywritten permission.Department of /L/i/s’r’The University of Bri’tish ColumbiaVancouver, CanadaDate‘// /Ethical Issues11ABSTRACTThe purpose of this study was to describe the nature of ethical issues encountered bynurses working on medical/surgical nursing units and the degree to which they foundthese issues disturbing. Relationships among demographic variables and nurses’experience with specific ethical issues were also examined.A survey of a stratified random sample of 400 Registered Nurses in BritishColumbia working on medical/surgical nursing units was completed. The “Survey ofEthical Issues in Nursing - Revised” (SEIN- R) and a demographic form were mailed toeach participant. Two hundred and two questionnaires (50.5%) were returned and 196(49%) used in the analysis.The findings indicate that nurses perceive that they “rarely” encountered ethicalissues as identified in the instrument. The five most frequently encountered ethicalissues that nurses reported were: (1) unsafe staffing patterns, (2) family demands forfutile treatment, (3) prolongation of life when death was inevitable, (4) unprofessionalconduct of a colleague, and (5) disagreements with physicians over patient care. Overall,nurses reported being at least “somewhat” disturbed about the ethical issues theyencountered or would have become so if they had encountered these situations in thepractice setting. When asked to identify how disturbed they were or would be by the 26ethical issues included in the SEIN- R, the five most disturbing issues were: (1)working with physicians who demonstrated inadequate knowledge and skills, (2) unsafestaffing patterns, (3) prolongation of life when death was inevitable, (4) caring for apatient whose family was demanding futile treatment, and (5) knowing that informationabout a patient’s prognosis was being withheld from the patient and/or family.Ethical Issues111The findings also suggest that a number of statistically significant but weak relationshipsexist between the five most frequent and the five most disturbing ethical issues, andselect demographics.The most common resource nurses use when addressing ethical issues is theirnursing colleagues. Relatively few nurses used their Canadian Nurses Association Codeof Ethics for Nursing to guide them in their ethical decision-making; more used theRegistered Nurses Association of British Columbia Standards for Nursing Practice.TABLE OF CONTENTSEthical IssuesivABSTRACTTABLE OF CONTENTSLIST OF TABLESACKNOWLEDGEMENTS• 11ivvivi’CHAPTER ONE: INTRODUCTION.Background to the ProblemStatement of the ProblemPurposeConceptualization of the ProblemResearch QuestionsDefinition of TermsSignificance of the StudyAssumptionsOrganization of Thesis ContentEthical Issues Encountered by NursesResponses to Ethical IssuesSummary of Literature ReviewCHAPTER THREE: METHODSResearch DesignSampling ProcedureData Collection InstrumentPilot TestData Collection ProcedureData AnalysisLimitationsEthical ConsiderationsSummary of Methods11333567889991117191920283435353536383939404041424242CHAPTER TWO: REVIEW OF THE LITERATUREIntroductionThe Professional ModelEthical TheoryCodes of Ethics for NursingResearch on Nursing EthicsCodes of EthicsCHAPTER FOUR: PRESENTATION OF FINDINGSIntroductionCharacteristics of the SampleFindingsResearch Question 1: Frequency of Ethical IssuesNurses EncounterResearch Question 2: The Extent to Which Nurses are Disturbed byAdditional Ethical Issues Faced in the Past YearResearch Question 3: Nurses’ Use of Codes ofEthics and Standards of PracticeResearch Question 4: Resources Used by NursesResearch Question 5: Relationship BetweenDemographic Variables and Nurses’Experience With Specific Ethical Issues .Summary of FindingsAPPENDIX A: Survey of Ethical Issues in Nursing - Revised 94Ethical IssuesVEthical Issues 5047485257575862CHAPTER FIVE: DISCUSSION, CONCLUSIONS, IMPLICATIONSAND RECOMMENDATIONSIntroductionDiscussion of FindingsConclusionsImplicationsNursing PracticeNursing EducationNursing AdministrationRecommendations for Further Research676767798080828384REFERENCES 87APPENDIX B Letter to Subjects 101Ethical IssuesviLIST OF TABLESTable 1 Age Distribution 43Table 2 Highest Nursing Education Levels 44Table 3 Years of Nursing Experience 45Table 4 Years Worked in Medical/Surgical Nursing 46Table 5 Hospital Bed Size 47Table 6 Frequency of Ethical Issues Nurses Encountered 49Table 7 Degree of Disturbance Related to Ethical Issues 51Table 8 Additional Ethical Issues Faced in the Past Year 53Table 9 Resources Used by Nurses to Resolve Ethical Issues 58Table 10 Correlations Between Frequency and Disturbance Items, andYears Practiced as a Nurse, Years Worked in Medical!Surgical Nursing, Age, and Hospital Bed Size 60Table 11 Means and Standard Deviations for the Five Most Frequentand the Five Most Disturbing Ethical Issues with Respect tothe Three Types of Units Where Respondents Worked 63Ethical IssuesviiACKNOWLEDGEMENTSI wish to thank Dr. Sonya Acorn and Dr. Joan Bortorff for the ongoing supportand encouragement they have given me. Their support of this thesis topic provided theinspiration I needed to maintain focus and direction. Their love of nursing researchprovided momentum throughout this learning process. Appreciation is also extended toDr. Joy Johnson for clear and meaningful feedback. Additionally, I wish to thank PaddyRodney for acting as a consultant in ethics.I wish to thank my best friend and husband, Wayne, whose unfailing love andsupport is always with me. Without you, this thesis would not have been possible.I wish to thank Lori Amdam for being with me for the past five years. For themany times you dried my tears or made me laugh - thank you.To Sherre Friberg who believed in me and made me believe in myself - thankyou.My exceptional family and friends have also contributed much to myachievements both in school and in life. Having parents like you who invested their lifeguiding, nurturing and teaching me to love life and to strive for the goals that are rightfor me, has been extremely significant. I also thank my friends and colleagues, CathyWeir and Colleen Varcoe, for caring about me and sharing your insights with me.I would also like to extend my sincere thanks to Sheila, who spent many hourstyping and re-typing this thesis.Ethical Issues1CHAPTER ONE: INTRODUCTIONBackground to the ProblemProfessional ethics are considered by many to be a critical component ofconceptualizations of professionalism (Lewis & Maude, 1952; Quinn & Smith, 1987;Valiga, 1982). Lewis and Maude stated that most emphasis in defining professionalismhas been centered on standards of conduct or professional ethics. Moreover,professional codes of ethics can serve a variety of purposes for professional groups(Notter & Spalding, 1976). First, they act as guides for new practitioners inunderstanding their professional responsibilities, rights, and privileges. Second, theyprovide a basis for determining appropriate or inappropriate professional conduct.Third, they can serve as a basis for regulating the relationships of practitioners toconsumers, to the profession itself, to society and to their colleagues. Finally,professional codes of ethics serve as guides for the public in understanding thecharacteristics of professional conduct.Nursing ethics have been a major concern since the practice of nursing developedin North America. Nurses have always encountered moral dilemmas in caring for thesick, whether it be in slums or small communities, in industries, during war or disaster, athome or in hospital (Fowler, 1989). Throughout the century, nurses have identifiedsome of the ethical concerns they face in practice, education, and society.Many changes in the past two decades have intensified the focus on nursing ethicsand consequently, the quantity of literature published on this subject has expanded.Nurses are now educated about nursing ethics in basic nursing programs, duringinservice sessions, and at nursing conferences. In many health care settings, nurses areEthical Issues2members of bioethical committees.Various and complex changes in society and the health care system necessitateincreased attention to ethical issues (Benoliel 1983, 1993; Storch, 1982). Since medicaltechnology has advanced so dramatically during the past two decades, patients can nowlive well beyond their expected capacity to survive (Gaul & Wilson, 1990). For example,mechanical ventilators force oxygen into non-functioning lungs, dialysis takes over forfailing kidneys, and pacemakers stimulate failing hearts (Strother, 1991). These advancesin technology, combined with limited resources, an increased emphasis on consumerrights, and changing relationships among health care professionals produce complexsituations that require nurses to make difficult choices and decisions when ethicalquestions about patient care arise (Buchanan & Cook, 1992). Consequently, nurses haveidentified important ethical concerns involving honest communication, the withholding oftreatment, technological advances and working conditions (Buchanan & Cook).According to Mayberry (1986), nurses are faced with ethical issues that no longer can beresolved by previous strategies such as guessing, relying on past experience, or intuition.Because nurses experience ethical issues that vary from ordinary to sensational, nursesmust be knowledgeable and skillful at making ethical decisions.Although in recent literature it is suggested that nurses face increasing numbersof ethical issues (Berger, Severson, & Chvatal, 1991; Davis, 1988; Erickson, 1993; Holly,1993) and more complex issues (Aroskar, 1980; MacPhail, 1988), little nursing researchhas focused on describing the ethical issues nurses commonly encounter. Studies areneeded to identify the kinds of ethical issues nurses face, the frequency with which theydeal with them, and the emotional impact various kinds of ethical issues have on nurses.Ethical Issues3In particular, studies of the emotional impact of ethical issues experienced by Canadiannurses are lacking. Without this knowledge, the profession lacks a sound foundation fordeveloping educational programs and resources to help nurses deal with ethical issues.Therefore, investigation on the emotional impact of ethical issues, a topic which has notto date been explored in Canada, is required.Statement of the ProblemAs nursing struggles to stay abreast with rapid advances in technology andchanges in the health care system, nurses are faced with an increasing number of ethicalissues. The literature reveals that nurses are concerned about the variety of ethicalissues they encounter in the clinical setting (Fowler, 1989). There is little research toidentify the ethical issues Canadian nurses experience in their practice settings. Sincethe kinds of ethical issues faced by nurses are likely to be directly related to the clinicalareas and health care system in which they work, there is a need to explore some of theethical issues faced by Canadian nurses and what they think about them.PurposeThe purpose of this study was to describe the experiences of British Columbiannurses working on medical/surgical units in relation to ethical situations encountered andtheir responses to them.Conceptualization of the ProblemA profession is often described in terms of a composite of characteristics orattributes. For over 70 years, various scholars have attempted to develop and refine aset of characteristics or attributes which would define the degree of professionalism orthe professional status of a discipline (Hall, 1982; Stinson, 1970; Valiga, 1982). SinceEthical Issues4Flexner developed a list of characteristics in 1915, various other experts have offeredlists of characteristics which occupations could use to determine their achievement ofprofessional status (Bixler & Bixler, 1959; Flexner, 1915; Greenwood, 1957; Hall, 1968;Moore, 1970; Notter & Spalding, 1976; O’Houle, 1980).Greenwood’s (1957) work has been extensively quoted by scholars examiningprofessionalism (Buick-Constable, 1969; Etzioni, 1969; O’Houle, 1980; Stinson, 1970;Vollmar & Mills, 1966). He postulated that five characteristics of a profession form thebasis of a profession model: systematic theory, authority, community sanction, ethicalcodes, and culture. Attainment of professional status is measured by the extent to whichthe identified characteristics of a profession are seen to be present (Jodouin, 1991). Thepresent study is concerned with the professional characteristic of ethics.Although there has been no clear consensus on what is required to characterizecertain activities as professional, a few experts agree that a principal characteristic of aprofession is that its practitioners act as morally responsible agents committed to thepurposes of the professional group (Murphy & Hunter, 1983; Quinn & Smith, 1987;Valiga, 1982). Thus, a professional person cannot simply do a job or follow orderswithout careful consideration and reflection. ‘To be a professional person is to acceptthe difficult and demanding need to think through the implications of every phase ofone’s professional activities” (Murphy & Hunter, p. 5).With various and complex changes in society and the health care system, nursesare more frequently encountering ethical issues including the prolongation of life,inadequate staffing, the inappropriate allocation of resources, fragmented team decisionmaking, a lack of informed consent, and unethical or incompetent activities of colleaguesEthical Issues5(Aroskar, 1989; Berger et al., 1991; Crisham, 1981; Davis, 1981, 1988; Haddad, 1992;Youell, 1986). Researchers have identified that nurses facing such ethical issuesexperience a variety of feelings such as anger, frustration, helplessness, powerlessness,anxiety or guilt (Duncan, 1989; Erlen & Frost, 1991; Fenton, 1987; Holly, 1989; Martin,1989; Quinn, 1993; Wilkinson, 1985). These feelings may be a response to encounteringincreasingly complex and often emotionally laden ethical issues. Nurses’ perceived oractual lack of involvement in moral decision-making, and their inability to resolve ethicaldilemmas or moral distress may also cause these feelings. Nurses may experience moraldistress when they have made a moral decision but are unable to perform the moralbehaviour indicated by that decision (Wilkinson, 1985). Frequently, institutionalconstraints make it nearly impossible for nurses to pursue their preferred course ofaction (Jameton, 1984). It has been suggested that these emotional responses to ethicalissues are a major source of job stress and an important factor in nurses choosing toleave the nursing profession (Wilkinson). It also is possible that these emotionalresponses may have a significant impact on the quality of care nurses provide to patientsand their families.Although the literature is replete with anecdotal information about ethical issues,no quantitative research examining nurses’ perceptions of ethical issues has beenconducted in British Columbia. Therefore, this study focused on the ethical issuesnurses encounter in the workplace and how disturbed they were by them.Research QuestionsThe research questions were as follows:1. How frequently do nurses encounter specific ethical issues?Ethical Issues62. How disturbed are nurses by the identified ethical issues?3. Do nurses use their code of ethics and standards of practice?4. What resources do nurses report using in resolving specific ethical issues?5. What are the relationships among select demographic variables and nurses’experience with specific ethical issues?Definition of TermsMorals- ‘refers to professional and personal conviction about how one ought to act andwhat one ought to believe” (Levine-Ariff & Groh, 1990, p. 19).Ethics- refers to the systematic study of principles and values. Ethicists question andstudy what we ought to do, thus providing guidelines for moral conduct (Levine-Ariff &Groh, 1990).Ethical Issue- a dispute involving different points of view about what constitutes idealmoral conduct or behaviour.Ethical Dilemma - a situation that arises from conflicting moral obligations, rights andclaims. It raises such questions as “what ought I to do? What is the right thing to do?What harm and benefit result from this decision or action?” (Davis & Aroskar, 1983, p.6). There are no right or wrong answers, only choices between equally unacceptablesolutions or alternatives (Fenton, 1987).Disturbed - to be upset mentally or emotionally; to be made uneasy or anxious(Newfeldt & Guralnik, 1988).Resource - any thing, person or action to which one turns for aid in times of need oremergency (Newfeldt & Guralnik, 1988).Ethical Issues7Significance of the StudyThe findings of this research will interest staff nurses, educators andadministrators. For example, administrators are concerned about the emotional impactvarious ethical issues may have on staff nurses. Knowledge about those issues whichdisturb nurses could help administrators develop strategies to reduce nurses’ stress andburnout in the workplace. Ensuring that resources are available and accessible to staffnurses to assist them in resolving specific ethical issues could have a significant effect onthe quality of patient care provided and on costs related to turnover. Educators are alsoconcerned about the need to teach nursing ethics based on nursing research. Bothstudent and staff nurses will benefit from educational opportunities that focus on whatnurses perceive to be the most commonly experienced ethical issues and those whichproduce the greatest distress.Finally, knowledge about what ethical issues disturb staff nurses most could helpthem and others understand nurses’ needs, as well as the emotional impact ethical issuesmay have both on themselves and on the patients they care for. Indeed, failure toaddress these issues could negatively influence the quality of care provided by nurses.Although investigators have begun to associate ethical issues with the phenomenaof moral distress, burnout, and job turnover (Wilkinson, 1985), the serious emotionalimpact of these issues has yet to be adequately investigated. The ethical problemsencountered by nurses permeate every facet of the workplace and must be addressed byeducators, administrators and staff nurses.Ethical Issues8AssumptionsFor the purpose of this study, it was assumed that:1. The responses of the subjects would reflect their actual beliefs.2. Staff nurses from medical/surgical units experience ethical issues in their nursingpractice.3. Nurses are able to identify clinical situations where ethical issues occur.Organization of Thesis ContentThis study was designed to describe the nature of ethical issues encountered bynurses working on medical/surgical units and how disturbed they were by them. ChapterOne delineates the background and significance of the research problem.Conceptualization of the problem, research questions, definitions of terms, significanceof the study and assumptions were also identified. In Chapter Two, a review of therelevant literature is presented. In Chapter Three, the research method is described,including the research design and sampling procedure, data collection instruments andprocedures, data analysis techniques, limitations of the study and ethical considerations.Chapter Four contains the presentation of the findings of this study. In Chapter Five,discussion of the findings and the conclusions of the study are presented. linplicationsfor nursing practice, education, administration and research are also included in thischapter.Ethical Issues9CHAPTER TWO: REVIEW OF LITERATUREIntroductionThe purpose of this literature review is to provide a framework within which toexamine the ethical issues nurses face in the clinical setting. The professional modelthat was used as a framework for this study is described. Then, a review of ethicaltheory, the Canadian Nurses Association Code of Ethics for Nursing, and ethicalresearch in nursing is presented.The Professional ModelExperts have extensively analyzed a profession in terms of its characteristics orattributes, often referring to those characteristics as the professional model. Greenwood(1957) suggested that all professions seem to possess the following characteristics:systematic theory, authority, community sanction, ethical codes, and culture.Greenwood’s identification of these characteristics helped scholars better understand thenature or “essence” of professions. More importantly, many occupational groups haveused this professional model to evaluate their progress towards professional status.Greenwood’s model emphasizes the importance of regulatory ethical codes forprofessionals. He believed that all professionals are compelled to act ethically inaccordance with built in regulative codes. The profession’s ethical code is partly formaland partly informal. The formal element is a written code of ethics that professionalsuse to guide them in their practice. The informal code is an unwritten standard ofconduct. Greenwood suggested that this imperative carries the same weight as a writtendocument.Greenwood (1957) fully explored the implications of “professionalism” on theEthical Issues10conduct of the individual. For example, he stated that the professional must remain“emotionally neutral” when working with a client. The professional “must provide serviceto whoever requests it, irrespective of the client’s age, income, kinship, politics, race,religion, sex, and social status” (p. 50). He also believed that the professional ismotivated less by self interest and more towards providing a ‘maximum calibre service.”Ethics as one characteristic of professionalism will be examined in this thesis.Nursing ethics have expanded dramatically since the development of Greenwood’s(1957) criteria of a profession. Ethical practice is a concern to not only the individualnurse, but also to professional organizations. For example, because professionalorganizations direct nursing practice, they play a key role in supporting the developmentof ethical standards that guide nurses in ethical decision-making.Nursing has always been faced with ethical issues. Fowler (1989) stated that “foralmost 100 years, we have seen nurses living out their ethical concerns in urban slumsand tenements, in the backwoods and mountains, in factories and mines, in war anddisaster, at home and in more recent times in hospital, and now in the public arena” (p.956). Although ethics have always been an issue, focus on nursing ethics and ethicaldecision-making significantly increased in the 1980s (Greipp, 1992).A number of reasons including the dramatic changes occurring in health caredelivery, may explain why ethical issues are now more prevalent for the practicing nurse.The ethical issues of health care, in part, result from new technology, increased costs, acultural emphasis on individual rights, conflicting social values, and changingrelationships among health care professionals (Buchanan & Cook, 1992). Nurses requireknowledge and skill about ethical principles to participate with other health careEthical Issues11professionals in making decisions with patients and families. Therefore, as professionals,nurses must be able to “apply appropriate ethical concepts to the cultures in which theywork and to be sensitive to the need for thoughtful and sound decision-making in theface of ethical dilemmas” (Curtin & Flaherty, 1982, p. 76).Ethical TheoryThe concept of ethics has many meanings for both the individual and theprofessional group. “It carries models of moral behaviour, implications of what is rightand wrong, and messages related to professionalism and professional rules of conduct”(Fenner, 1980, p. 21). In much of the literature, the tenns “morals” and “ethics” are usedinterchangeably (Davis & Aroskar, 1983; Kelly, 1991; Levine-Ariff & Groh, 1990; Storch,1982). The word “ethics” comes from the Greek word “ethos,” meaning customs, habits,conduct and character (Davis & Aroskar, 1983). The English word “morals” comes fromthe Latin word “moralis,” meaning “manners;” ethics is the theoretical component andmorals the applied or practical concern (Thompson & Thompson, 1985).Health care ethics, also called biomedical ethics, are ethics that are specific tohealth care situations. Questions are raised regarding what is right or what ought to bedone in situations that require action involving others (Davis & Aroskar, 1983). Fourinterrelated areas that health care ethics specifically address are: the clinical area,allocation of scarce resources, human experimentation, and health policy. According toDavis and Aroskar, discussions of health care ethics function: “(1) to sensitize or raisethe consciousness of health professionals (and the lay public) concerning ethical issuesfound in health care settings and policies, and (2) to structure the issues so that ethicallyrelevant threads of complex situations can be drawn out” (p. 4). Applying the principlesEthical Issues12and theories of ethics can assist health care professionals to systematically reasonthrough ethical dilemmas.Ethical theories do not resolve ethical dilemmas, but provide nurses with guidancein their decision-making. Ethical theories consist of sets of principles that attempt toexplain relationships among principles, rules, judgments and actions (Jacobs & Severson,1988). Some of these theories draw on the principles of autonomy, beneficence,nonmaleficence, and justice (Davis & Aroskar, 1983).Over the centuries, ethicists have developed broad based theories such asdeontology and utilitarianism, which apply ethical principles in a consistent manner(Winters, Glass, & Sakurai, 1993). Deontology is a system of ethical decision-makingthat is based on moral rules and unchanging principles (Catalano, 1992). Deontologistsbelieve in the ethical absoluteness of principles regardless of the consequences of thedecision. In other words, they generally believe that certain actions are inherentlywrong, regardless of any positive consequences that may result. For example, adeontologist might believe that it is always wrong to lie to a patient regardless of thecircumstances.Utilitarian ethical theory is based on two underlying principles: one acts in orderto achieve the greatest good for the greatest number of people, and the end justifies themeans (Thompson & Thompson, 1985). “In practice, the utilitarian does not believe inthe validity of any system of rules. That is because the rules can change, depending oncircumstances surrounding the decision to be made” (Catalano, 1992, p. 91).The usefulness of ethical theories for nurses facing ethical dilemmas fragmentswhen theories such as deontology and utilitarian theory compete with each other. ForEthical Issues13example, the right of the patient to autonomy may conflict with the nurse’s obligation toprovide safe care (Cooper, 1991). Thus, the usefulness of traditional principle basedtheories in addressing ethical issues in nursing has been questioned and has led somenurse ethicists to focus on developing theories specifically for nurses (Fry, 1989a, 1989b).Nursing ethics refer to the expressed ethical norms of the nursing profession; thevalues, virtues, and principles that should govern and guide nursing in the practicesetting (Yeo, 1991). “These are typically phrased as moral injunctions of the sort ‘betruthful with clients’ or ‘respect client confidentiality.’ They may also be expressed asexhortations to adopt and practise particular virtues, such as caring or fairness” (p. 2).The terms “ethical dilemma,” “moral dilemma,” “ethical issues” and “ethicalproblems” are not used in a standardized manner in the nursing literature (Rodney,1989). Therefore, it is necessary to define them as they pertain to this study. “Ethicalissue” is a term frequently used in the nursing literature, although rarely defined. Thedictionary states that an issue refers to a point of debate, discussion or dispute (Morris,1985). As discussed earlier, ethics relate to the study of moral principles and rules ofconduct (Levine-Ariff & Groh, 1990). Therefore, for the purpose of this study, ethicalissues are defined as disputes involving different points of view about what constitutesideal moral conduct.Davis and Aroskar (1983) stated that a dilemma can be defined as “(1) aseemingly difficult problem incapable of a satisfactory solution, or (2) a choice orsituation involving choices between equally unsatisfactory alternatives” (p. 6). Ethicaldilemmas are situations that arise from conflicting moral obligations, rights and claims.They raise such questions as “what ought I to do? What is the right thing to do? WhatEthical Issues14harm and benefit result from this decision or action?” (Davis & Aroskar, p. 19). Thereare no right or wrong answers, only choices between equally unacceptable solutions(Aroskar, 1980). It is important to note that an ethical dilemma may or may not involvea legal issue. Storch (1982) stated, “In some cases the law demands more than ethicalstandards would demand; in some cases the law differs from ethical standards; and insome cases the law is silent with respect to any ethical standards” (p. 29). According toAroskar (1980), there are many limitations in law. “Legal decisions often do not provideanswers to specific ethical dilemmas confronting health professionals and may create newdilemmas by their very nature” (p. 658).Although nurses have always been faced with ethical dilemmas, these dilemmasare more complex today for several reasons. First, rapidly expanding medical knowledgeand new technologies have made possible dramatic interventions to save or prolong life.This raises the issue of quality verses length of life. Second, the availability of educationhas created a better informed public demanding more information and involvement indecision-making about its health care. Finally, the quantity of available resources raisesquestions about the priorities of the health care system, who should receive treatment,and how funds ought to be spent (MacPhail, 1988).Storch (1988) contended that basic problems, such as prolonging life and treatingor ensuring patient autonomy are shared by all health care professionals. She suggested,however, that there is a uniqueness to nursing’s ethical dilemmas given their function of“being there,” their multiple obligations, and their ceaseless and daily dilemmas aboutcare. When Storch used the term “being there,” she referred to the nurse’s role inproviding 24-hour nursing care. Nurses are, in fact, the only health care providers thatEthical Issues15are with their patients on a continual basis. This vantage point offers unique privilegesand responsibilities because nurses are privy to patients’ hopes, fears and regrets(Bandman & Bandman, 1990). Frequently, nurses form significant relationships withpatients and families, demonstrating concern and respect both for those individuals andabout fundamental human dignity. Some argue that nurses are, in fact, distinguished bya predominant caring ethic (Canadian Nurses Association, 1980, 1985, 1991). Thenurse’s continual and caring relationship with the patient and family frequently placeshim or her in the middle of ethical dilemmas (Storch, 1982). According to Storch,nurses must assume different roles and take on responsibilities that involve obligations topatients, families, colleagues, doctors, and employing institutions. The problem ofsetting priorities with multiple obligations is the basis of many ethical dilemmas fornurses. More significantly, nurses daily experience ethical dilemmas that vary from theordinary to the sensational. Their daily obligations require that they understand and beskilled in using ethical principles.Ethical decision-making is a complex process. “It is based on the concept ofmoral reasoning: sorting out what is good, what the preferred action is and why, andwhat are the consequences of the action if it is taken” (Thompson & Thompson, 1988, p.245). This reasoning process, however, is significantly influenced by the individual’spersonal, professional and societal values, and his or her level of moral development.Moreover, the individual’s knowledge and use of ethical theories will influence his or herchoice of what is morally correct action to take in a given situation. Winters et al.(1993) also suggested that “nurses’ personal experience and professional education, aswell as their background in examining professional statements and working withinEthical Issues16institutions, can all affect the manner in which they express or act upon their values” (p.22). Any of these factors may influence nurses as they choose between competingethical alternatives.Decision-making models have been developed as guides for analyzing ethicalproblems and reaching solutions. One example is a model developed by Curtin (1978a).She suggested that the process incorporates seven factors, including the following:background infonnation on the situation, identification of the ethical components in thesituation, identification of those persons involved in the decision-making, identificationof possible options and consequences of each option, application of ethical principlesand theories, resolution, and action. This model is similar to others in that itincorporates the key elements of situational information, decision-making questions andunderlying ethical theories referred to by Aroskar (1980).Ethical dilemmas involve conflicting moral claims; they may involve moraluncertainty or moral distress. Jameton (1984) stated that “moral distress arises whenone knows the right thing to do but institutional constraints make it nearly impossible topursue the right course of action” (p. 6). This is supported by Wilkinson (1985, 1987/88),who defines “moral distress” as the negative feeling state a person experiences aftermaking a moral decision, but not being able to perform the moral behaviour indicated bythat decision due to factors such as institutional constraints. Curtin (1978b) suggestedthat these constraints come from institutional policies, physicians’ orders, and a generaldisregard for the legitimate authority of the nurse regarding nursing care. In response tothis distress, nurses may experience feelings of anger, resentment, guilt, frustration,sorrow, or powerlessness (Erlen & Frost, 1991; Jameton, 1984; Rodney, 1988; Rodney &Ethical Issues17Starzomski, 1993; Rushton, 1992; Wilkinson, 1985). For nurses, moral distress maylower their self esteem and affect their personal relationships. It may alter theirbehaviour and cause physical symptoms. More importantly, their patient care may suffer(Wilkinson, 1987/88).Only recently have nursing scholars begun to explore nurses’ emotional responsesto ethical issues, including the moral distress nurses may experience (Fenton, 1988;Jacobs & Severson, 1988; Rodney, 1989; Rodney & Starzomski, 1993; Wilkinson,1987/88) and the overwhelming impact these responses can have on both nurses andpatients. More significantly, emotional responses, such as moral distress may bedetermining factors in job satisfaction, retention of nurses in clinical practice and qualityof patient care (Fenton).Codes of Ethics for NursingA code of ethics consisting of beliefs and laws that regulate conduct is anessential characteristic of a profession. An ethical code is a framework fordecision-making and is “by nature of its use, action oriented” (Fenner, 1980, p. 22).According to Beauchamp and Chuldress (1989), a professional code providesaction-guides for a particular group. These action-guides should be justified by referenceto more general principles and rules, although these may not be explicitly identified inthe codes themselves.Historically, nursing practice has its roots in an ethical tradition of service toothers through promoting and restoring health, alleviating suffering, and comforting ofthe dying. Isobel Hampton Robb (1860-1910), an outstanding leader in nursing and inthe education of students in nursing, wrote the first book on nursing ethics in 1903Ethical Issues18(Dolan, 1963; Jamieson & Sewell, 1954; Robb, 1903). Although Hampton Robb (1916)recognized that ethics were intrinsic to nursing practice, no formal code of ethics waswritten in either the United States or Canada until 1950. In early nursing literature,ethics were referred to as Christian morality. Virtue, purity and discipline wereesteemed in the early days of nursing. In other words, nurses were moral and virtuouspeople who treated their patients accordingly. Nursing then embraced the militaryphilosophy associated with virtues such as loyalty, and norms such as obedience to thoseof “higher rank” (Winslow, 1990). “Nursing education valued obedience, submission torules, social etiquette, and loyalty to the physician” (Kelly, 1991, p. 209).Not until after World War II were formal codes of ethics adopted by national andinternational nursing associations. In 1955, the Canadian Nurses Association (CNA)adopted the International Council of Nurses (ICN) Code of Ethics which guided nursesin ethical decision-making until the 1970s (MacPhail, 1988).Despite having a code of ethics, nurses had little voice in ethical decisionsregarding their patients prior to the 1970s. In fact, it was during the 1970s that manyunethical actions occurred. For example, in an experiment conducted at a Montrealinstitute in the late 1940s, patients were given drugs without their knowledge, such aslysergic acid diethylamide (LSD) which had serious long term effects (MacPhail, 1988).Since the late 1970s, nurses have more fully embraced their role as patientadvocates (Murphy, 1990; Schattschneider, 1992). Murphy (1990) believed that thegeneral restructuring of societal values and organizational management encouraged thischange. “Change began to occur in health care bureaucracies because nurses attemptedto gain some authority to make clinical judgements and to involve themselves in clinicalEthical Issues19decisions. Nurses wanted to be morally accountable and responsible for the care theyprovided” (p. 60).With societal changes occurring in the late 1970s, developing a code of ethicsbecame a priority at the 1978 CNA biennial convention. In 1980, the CNA published itsfirst Code of Ethics, based on the concept of caring. This code was revised in 1985 and1991 with content changes reflecting the evolution of nursing and its philosophy (Dunphy& Mercer, 1992). Nurses in Canada are now guided by the Canadian NursesAssociation Code of Ethics for Nursing. When faced with ethical dilemmas, the code ofethics articulates standards that nurses are to uphold.Research on Nursing EthicsAlthough much anecdotal literature offers guidance in making moral decisions,relatively few research studies have been conducted focusing on the ethical issues nursesface in the workplace (Davis, 1981; Duncan, 1992). A number of studies have addressedthe issue of moral judgement and ethical decision-making (Crisham, 1981; Ketefian,1981; Lamb, 1985; Mayberry, 1986; Murphy, 1984). Since this research was notspecifically related to the research questions posed in this thesis, it was not included inthe literature review. This section of the literature review examines the existing researchon ethical issues within nursing. Areas reviewed were the following: (a) codes of ethics;(b) ethical issues encountered by nurses; and (c) responses to ethical issues.Codes of EthicsAn extensive review of the literature revealed only one study that examinednurses use of codes of ethics. In an American study examining nurses use of a code ofethics, 1,600 nurses from eight western U.S. states were asked if they had a copy of theirEthical Issues20Code For Nurses (Miller & Adams, 1991). The findings revealed that, of the 514responding nurses, only 205 (40%) knew much about their code. Although mostrespondents did not have a copy of their code, they indicated that adherence to the codewas essential to the professional nurse.Ethical Issues Encountered by NursesDuring the 1980s, 17 studies were completed describing the kinds of ethical issuesnurses face in their workplace. These included eight quantitative surveys, some of whichhad sample sizes ranging from 100 to 319 nurses (Aroskar, 1989; Berger et al., 1991;Davis, 1981, 1988; Haddad, 1992; Holly, 1989; Miya, Boardman, Harr & Keene, 1991;Sietsema & Spradley, 1987) and seven qualitative studies (Crisham, 1981; Erlen & Frost,1991; Holly, 1993; Martin, 1989, 1990; Rodney, 1987; Youell, 1986). Two of the studiesspecifically focused on ethical issues faced by nurse administrators (Sietsema & Spradley,1987; Youell, 1986).Davis (1981) conducted a survey of 205 staff nurses, administrators, teachers andother clinical nurses. Her research focused on both the extent to which nursesunderstand the concept of ethical dilemma and the content of the ethical dilemmas theyconfront. An open-ended question format was used to gather data so that participantscould indicate those ethical dilemmas they found to be particularly troublesome. Theparticipants, rather than the researchers, defined the ethical dilemmas. The findingsrevealed that the majority of respondents clearly understood what constitutes an ethicaldilemma. One of the most frequently occurring dilemmas nurses reported involvedwhether or not life should be prolonged using heroic measures. Another major dilemmainvolved nurses’ choices about the unethical or incompetent activity of colleagues.Ethical Issues21However, the exact nature of those conflicts was not reported in the study. Davisconcluded that nurses need to be involved in more dialogue about ethicaldecision-making and ethical reasoning to help them clearly articulate their ethicalpositions.Crisham (1981) interviewed 130 volunteer staff nurses during which they wereasked to describe a nursing dilemma they had experienced. From these interviews, 21recurrent nursing moral dilemmas were identified. These were grouped according tofour underlying ethical issues: ‘deciding right to know and determining right to decide,defining and promoting quality of life, maintaining professional and institutionalstandards, and distributing nursing resources” (Crisham, p. 106).Youell (1986) interviewed 31 senior-and middle-level nurse administrators todetermine their most common and difficult ethical problems. The findings were similarto those of Davis (1981) and Crisham (1981) and revealed that the competence ofnursing staff, resource allocation, and issues related to death and dying were difficultethical issues for administrators. However, Youell’s study also identified other difficultissues unique to administrators. These issues related to clinical areas, informationsharing about staff, honesty, and the appropriate use of information.Sietsema and Spradley (1987) conducted a survey of the chief nurse executives of176 acute care hospitals in Minnesota. The instrument developed by the investigatorsconsisted of closed-and open-ended questions based on information gathered from theliterature. The instrument was pretested by a group of nursing executives. Face validitywas established through the use of content experts. Of the 176 questionnaires mailed,127 (72%) were returned. The findings indicated that hospital chief executives mostEthical Issues22often cited the use of resources and quality of care as their potential major dilemmas.Nurse executives also reported that in addressing ethical issues, they drew on theirpersonal values and turned to nursing and administrative colleagues for support.Based on the questionnaire used in her 1981 California study, Davis (1988)surveyed 100 nurses in eastern Canada to determine the types of ethical dilemmas facedby Canadian nurses, the factors affecting such dilemmas, and the nurses’ understandingof the concept “ethical dilemma.” Most respondents worked with adult patients inhospitals as staff nurses or head nurses and had been practicing at least 15 years. Aswith the previous study, the participants, rather than the researcher, defined whatconstituted an ethical dilemma. Contrary to the 1981 study findings, Davis founddiscrepancies between nurses’ definitions and their understanding of the concept ofethical dilemma. Rather than define the term ethical dilemma, some respondentsdescribed specific ethical dilemmas to demonstrate their understanding of the concept.The four most commonly cited situations were the sustaining of life without regard forthe quality of a person’s life, participating in abortions, following doctors’ orders withwhich the nurse did not agree, and breaking promises of confidentiality. In her earlierstudy, Davis (1981) found that the unethical or incompetent activity of colleagues was amajor dilemma for nurses. This was not identified as a commonly cited concern for therespondents in the latter study.Some of the more recent research includes Aroskar’s (1989) survey. In this study,questionnaires were sent to over 1,000 staff nurses employed in community and publichealth agencies to determine what nurses considered their most significant ethicaldecision-making problem. The response rate for this study was not clearly stated. OfEthical Issues23the numerous concerns this study identified, some of the emerging themes were similarto those in previous studies. Significant ethical problems included conflicts regardingresuscitation orders, patients not being fully informed about their health status, the rightof patients to make decisions about their treatment, incompetent nurses, and theallocation of resources.Rodney (1987, 1988) explored nurses’ views about prolonging life. Aphenomenological approach involving unstructured interviews with eight critical carenurses was used to generate the data. The participating nurses were employed intertiary hospitals in the Vancouver area. Rodney determined that nurses’ ethicaldilemmas generally relate to an overall theme of “senselessness.” The term“senselessness” was used to describe the experiences of patients and family members, theactivities nurses found themselves involved in to implement treatment regimes; and, inparticular, the decision-making processes nurses experienced. From her interviews withintensive care nurses, Rodney identified the following themes: inadequate involvementof the patient, family, and nurse; and fragmentary team decision-making.Erlen and Frost (1991), Holly (1989), and Martin (1989) reported similar findingsto those of Rodney (1987). In Martin’s qualitative study, 83 registered nurses from fiveneonatal intensive care units were asked to discuss their participation in resolving ethicaldilemmas for infants with severe congenital anomalies. The findings revealed that 85%of the nurses did not participate substantially in decisions to initiate or forego lifesustaining treatment for their infant patients, yet they were primarily responsible forimplementing those decisions.Likewise, Holly (1989), in her survey of 45 critical care nurses from six hospitalsEthical Issues24in New York State, sought to determine how ethical decisions were made in hospitals,and to describe nurses’ participation in that decision-making. The majority of nurses(74%) reported that most ethical decisions were made by physicians and that there waslimited involvement of patients, families, or nurses. Erlen and Frost (1991), in theirqualitative study of 25 nurses working in medical/surgical and critical care settings, alsoreported that nurses often felt powerless when unable to participate in decisions relatedto patient care. In each of these four studies, the fact that nurses were excluded fromthe decision-making process was a significant ethical issue for them.Martin (1990) examined the nature and prevalence of ethical dilemmasencountered by nurses who care for patients hospitalized with AIDS-related illnesses.Additionally, she considered the intensity and duration of ethical dilemmas in relation tothe respondents’ perceptions of occupational stress and burn-out. Coping strategiesemployed by nurses in response to their stress were also studied. Seventy-five registerednurses employed in a large urban hospital provided the sample. Data were collectedusing three different methods: a) semi-structured interviews with a sample of 25 nurses,b) a series of group interviews with three sets of 10 to 15 nurses, and c) nurses’responses to the AIDS Ethical Dilemma Scale. Martin found that most respondentsexperienced many ethical dilemmas when caring for AIDS patients. Most frequentlyreported were dilemmas related to dying and the inevitability of patient death. Onedilemma arose from conflicts with physicians and family members over decisions to useaggressive treatments. Other dilemmas included whether or not to resuscitate patients,withdraw therapies, or assist in patient suicide. A second category of reported ethicaldilemmas related to the nurses’ attempts to help control patients’ pain and illnessEthical Issues25symptoms.In a recent study conducted by Miya et al. (1991), 37 volunteer registered nurseswere asked to describe those ethical issues they faced in a neonatal intensive care unit,and to identify conflicts for those who faced those issues. The participants wereemployed both full-and part-time in a 34 bed medical center. Respondents were askedto complete both a demographic form and the Moral Conflict Questionnaire (MCQ).The open-ended MCQ was designed by S. Fry to elicit nurses’ descriptions of ethicalissues in nursing practice (Miya et al., 1991). A qualitative approach for analysis wasused to interpret the descriptive data. The nurses in this study identified a number ofissues related to the treatment of infants. Most frequently identified issues included thefollowing: issues involving suffering, pain, and humane treatment; issues of futiletreatment and the withdrawal of treatment; issues of treatment versus non-treatment;issues of ordinary versus extraordinary treatment; and issues related to the quality ofpatients’ life. Miya et al. concluded that occasionally nurses found it difficult to functionobjectively as caregivers when faced with unresolved treatment and communicationissues. More significantly, the nurses’ conflict in such situations affected stress levels andsubsequent job satisfaction.Berger et al. (1991) conducted a survey of 52 nurses from a large metropolitanhospital in order to identify the frequency with which they experienced specific ethicalissues in their practice. These investigators reported that the five most frequentlyencountered ethical issues, in order of importance, involved inadequate staffing patterns,life prolonged through heroic measures, inappropriate resource allocation, situationswhere patients were being discussed inappropriately, and irresponsible activities ofEthical Issues26colleagues. Nurses in this study also reported that they consulted nursing colleagues anddrew on their own personal values in resolving ethical issues. Finally, neither education,age, nor experience was significantly related to the frequency of issues reported. Thesefindings need to be interpreted with caution because of the response rate and smallsample size, and the use of only one hospital to obtain a sample.In a pilot study, Haddad (1992) surveyed 30 home care providers in order todescribe ethical problems from their perspective and to refine a survey instrument for afurther study of home care providers. The instrument was an 18-item questionnairedeveloped by the author. To ensure clarity, the tool was pretested with communityhealth nursing students and several community health nurses. The author establishedface validity based on a review of the literature and personal experience as a home careprovider. A random sample of 50 home care providers, from home health aides toagency administrators, was chosen from ten home care agencies. Of the 50 surveys, 30were returned for a 60% response rate. Haddad reported that the most commonly citedethical problems were difficulties with payer regulations and the competence ofco-workers. The findings also revealed that only six respondents were registered nursesand three were nursing supervisors. Hence, because of the small sample size, thesefindings cannot be generalized to home care practice or other health care settings.More recently, Holly (1993) conducted a qualitative study that also asked nursesto describe both a personally encountered, work-related ethical situation and theirfeelings about being in that situation. Sixty-five full-time acute care nurses employed infour suburban and urban hospitals volunteered to participate in the study. Sixty-sevenpercent of the sample worked in critical care areas. Three categories derived from theEthical Issues27ethical situations described were exploitation, exclusion, and anguish. Exploitation wasdefined as treating seriously ill patients or families without considering them asindividuals. For example, patients were often subjected to painful and invasiveprocedures when their prognosis was poor. Nurses were also concerned about theaggressive treatment of terminally ill patients. Of most concern, however, was theemotional and physical harm aggressive treatment often inflicted on patients and theirfamilies. Exclusion was defined as a disregard for patients’ choices to accept or refusetreatment, and the failure to provide enough information for patients and their familiesto make informed decisions. For example, nurses reported instances in which physiciansand families used personal sets of values rather than addressing the patients’ wishes.Because only 17 studies that explored ethical issues were found, the findings maynot accurately reflect what the majority of nurses view as ethical issues. However,similarities about what constitutes ethical issues for nurses participating in theseinvestigations include the allocation of resources (Aroskar, 1989; Berger et al., 1991;Crisham, 1981; Sietsema & Spradley, 1987; Youell, 1986), the competence of nursingstaff (Aroskar, 1989; Berger et al., 1991; Davis, 1981; Haddad, 1992; Youell, 1986), andissues related to death and dying (Berger et al., 1991; Crisham, 1981; Davis, 1981, 1988;Holly, 1993; Martin, 1990; Miya et al., 1991; Youell, 1986). Nurses also identified theirlack of involvement or exclusion from participating in ethical decision-making about theirpatients as ethical issues (Erlen & Frost, 1991; Holly, 1989; Martin, 1989; Rodney, 1987).Nurse administrators also identified infonnation sharing about staff, honesty, and theappropriate use of information (Youell, 1986), and quality of care (Sietsema & Spradley,1987) as ethical issues. Davis (1988), Haddad (1992), Martin (1990), and Miya et al.Ethical Issues28(1991) had study findings that differed markedly from the others. Davis (1988), in herCanadian study, reported that nurses encountered issues related to participating inabortions, following doctors’ orders with which they did not agree, and breakingpromises of confidentiality. Haddad identified difficulties with payer regulations as amajor ethical issue for American nurses. Martin (1990) found that nurses experiencedethical dilemmas related to conflicts with physicians and family members over decisionsto use aggressive treatments; whether or not to resuscitate patients, withdraw therapies,or assist in patient suicide; and nurses’ attempts to control patients’ pain and illnesssymptoms. Miya et al. concluded that nurses found it upsetting and difficult, at times, tofunction objectively as caregivers when faced with unresolved treatment andcommunication issues.Responses to Ethical IssuesRecently, nursing researchers have begun to identify the need to explore hownurses respond to the ethical issues they face in their practice settings. In order toaddress this problem, researchers are focusing on nurses’ emotional responses, theirexperience of “moral distress,t’and the impact these responses have on both nurses andpatients.Over the past ten years, 11 studies were conducted describing ethical issuesexperienced by nurses, as well as their feelings about those issues. Eight of the studieswere qualitative, four of which focused on the concept of moral distress (Fenton, 1987;Quinn, 1993; Rodney, 1987; Wilkinson, 1985). All of the studies were conducted in largeurban hospitals.Wilkinson (1985) conducted the first study focused on the concept of moralEthical Issues29distress as experienced by staff nurses working in hospitals. The term “moral distress”referred to the negative feeling state a person experiences after making a moral decision,but not being able to perform the moral behaviour indicated by that decision. A randomsample of 382 nurses was chosen from two metropolitan areas. A letter was sent to eachof these nurses requesting a response from those who had experienced moral distress.Twenty-four nurses responded by postcard, indicating that they would be willing toparticipate in this qualitative study. Thirteen of the 24 nurses worked in various areas asstaff nurses and 11 were no longer practicing nurses. The researcher used asemi-structured interview format, opening the interview with a definition of moraldistress. Study findings revealed that subjects had frequently experienced moral distressin their practice. The most common situations producing this distress involved theprolongation of life, the performance of unnecessary tests and procedures, andtruth-telling. These nurses reported feeling angry, guilty, frustrated and saddened.Further, Wilkinson stated that the nurses experienced ongoing feelings of moral distressthat affected their personal wholeness; the patient care they provided; and, for some,their decision to leave bedside nursing. In some cases, the informants chose to leave thenursing profession altogether.Fenton (1987) and Rodney (1987) also explored the concept of moral distress.Fenton conducted semi-structured interviews with five instructors and five recentgraduates of an intensive care nursing program in a large acute care hospital. Resultsindicated that nurses were most distressed by situations involving excessive therapy andthe discontinuation of therapy. According to Fenton, the participants described periodsof emotional distress that sometimes required considerable time to resolve.Ethical Issues30Rodney (1987) offered another perspective from that of Fenton (1987). From heropen-ended interviews with eight intensive care nurses, Rodney identified that nurses’inability to function as free moral agents in our health care system was the main cause ofmoral distress. Rodney used Jameton’s (1984) definition of moral distress as “when oneknows the right thing to do, but institutional constraints make it nearly impossible topursue the right course of action (p. 6).Quinn (1993) conducted one of the more recent qualitative studies that sought todescribe how nurses explained their use of physical restraints with elderly patients, andto examine whether or not these nurses perceived the restraint decisions to be a moralproblem. Data were obtained from open-ended interviews with 20 female registerednurses working on a medical-surgical unit. These nurses expressed that they dislikedphysical restraints, and that they experienced varying degrees of discomfort associatedwith restraint use. Most often, participants described feeling “bad,” “reallyuncomfortable” or “guilty” when a conflict arose between the patient’s right toseif-detennination and the nurse’s responsibility to act in the patient’s best interests.Although none of the nurses interviewed in this study used the terms “moral conflict” or“moral problem,” often in assessing restraint situations, participants were attempting tobalance conflicts among personal and professional values.In summary, the qualitative study findings revealed that nurses reported threecommon situations that produced moral distress. First, Rodney (1987) identified thatnurses’ inability to implement their moral choices resulted in expressions of moraldistress. Second, Quinn (1993) found that nurses experienced moral distress when aconflict arose between the patient’s right to self-determination and the nurse’sEthical Issues31responsibility to act on behalf of the patient. Third, nurses experienced moral distresswhen faced with specific situations, such as those involving the prolongation of life, theperfonnance of unnecessary tests (Fenton, 1987; Rodney, 1987; Wilkinson, 1985) and thediscontinuation of therapy (Fenton). Common feelings expressed by those nursesincluded anger, frustration, sadness (Wilkinson, 1985), guilt (Quinn, 1993; Wilkinson,1985), agitation (Fenton), and feeling bad or uncomfortable (Quinn). Further, bothFenton and Wilkinson reported that withdrawing from the situation, avoiding the patient,and leaving their jobs were behaviours that nurses used in order to cope with the moraldistress they were experiencing.Seven additional studies, although not specifically examining moral distress, haveidentified feelings nurses experience when facing ethical dilemmas. Martin (1989)investigated the extent and nature of nurses’ reported participation in resolvingtreatment dilemmas for infants with severe congenital anomalies. A semi-structuredinterview was conducted with 83 registered nurses from neonatal intensive care units infive large urban hospitals. Results indicated that 85% of the nurses did not participatesubstantially in decisions to initiate or forego life-sustaining treatment for their infantpatients, yet they were primarily responsible for implementing those decisions. Seventypercent of the nurses indicated that not participating in making decisions was a majorsource of occupational stress and ethical anguish. These nurses reported feeling angryand frustrated at how little they were involved in these decisions. Further, Martinsuggested that nurses’ “inability to participate in such critical decisions was serving as amajor source of stress and may have a substantial impact on burnout and turnoveramong this group” (p. 471).Ethical Issues32Holly (1989) administered a survey to 45 critical care staff nurses to determinehow they viewed their sources of support when they had to make ethical decisions. Shealso examined how ethical decisions were made in their hospitals, and how that affectednurses’ participation in ethical decision-making. The respondents represented a varietyof critical care areas from six hospitals in New York State. These nurses constituted a30% response rate. First, Holly found that nurses involved in ethical dilemmas feltfrustrated, angry and alone; and perceived that most support came from their nursingcolleagues. Second, the majority of nurses surveyed (74%) reported that most ethicaldecisions were made by physicians and that there were limited roles for the patient,family or nurse. These findings were similar to those of Rodney (1987).Duncan (1989) interviewed a purposive sample of 30 community health nurses.Her qualitative analysis revealed that community health nurses found their experienceswith ethical conflicts difficult. Feelings reported included anger, guilt, frustration andfear. Similar findings were reported by Erlen and Frost (1991) in their qualitative studyof 25 nurses practicing in medical, surgical and critical care settings. Nurses indicatedthat they often felt powerless when unable to participate in decisions related to patientcare. Although these investigators focused on powerlessness, they found that nurses’inability to resolve ethical issues resulted in anger, frustration, and exhaustion.Martin (1990) interviewed 75 registered nurses from a large urban hospital todetermine the nature and prevalence of ethical dilemmas encountered by nurses whocare for patients hospitalized with AIDS-related illnesses. Martin found that mostrespondents reported many ethical dilemmas when caring for AIDS patients. Thesenurses also consistently reported being frustrated and feeling powerless because theyEthical Issues33were frequently unable to comfort many of the patients, especially those who wereextremely ill and dying.Berger et al. (1991) completed a quantitative study to determine the frequencywith which nurses experienced specific ethical issues in their practice, and to examinehow much those issues disturbed them. Nurses were asked to describe how disturbedthey felt when encountering certain ethical dilemmas. Subjects responded to eachquestion using a Likert scale ranging from 0 = “not at all” disturbed to 4 = “a greatdeal” disturbed. This study was conducted in one hospital in a large metropolitan areain the United States. Of the 104 questionnaires distributed, 50% were completed. Thestudy findings revealed that the five most disturbing ethical issues were inadequatestaffing, the provision of treatment despite patients’ objections, the prolongation of lifewith heroic measures, acting in opposition to one’s personal principles, and incidents ofpatient abuse. Education, age nor experience were related to the amount of disturbancereported.Recently, Holly (1993) conducted a quantitative study which asked 65 full-timeacute care nurses to describe both a personally encountered, work-related situation, andtheir feelings about being in that situation. Nurses’ emotional experience surroundingethical situations emerged as a major theme in this study and was labelled as “anguish.”This theme reflected nurses’ personal feelings arising from situations where nurses feltpowerless to assist patients or practice in a professional manner. “Nurses used suchwords and phrases as nightmare, grief, headache, miserable, painful, sad, dread, sorrowand ineffectiveness in describing the practice situations” (p.113). Holly concluded thatdealing with these issues on a daily basis frustrated nurses and that, although nursesEthical Issues34wanted to participate in ethical decision-making, many environmental barriers impedetheir involvement. “The barriers identified included lack of support, time pressures,personal concerns over security, and hierarchic forces within the institution” (p. 110).More importantly, Holly suggested that nurses’ inability to act on the patient’s behalfmay be contributing to high turnover rates and the nursing shortage.In summary, common feelings expressed by the nurses from these studies includedanger (Duncan, 1989; Erlen & Frost; Martin, 1989), frustration (Duncan, 1989; Erlen &Frost; Holly, 1989; Martin, 1989, 1990), guilt, fear (Duncan), being alone (Holly), andexhaustion (Erlen & Frost). Holly reported that nurses’ experience of anguish wasreflected in their expressed words and phrases.Summary of Literature ReviewAlthough a limited number of studies have been completed, the findings providean important foundation for further research. The kinds of ethical issues that nursescommonly encounter have been identified. In addition, researchers are focusing moreattention on nurses’ responses to ethical issues, including the phenomenon of moraldistress, and the overwhelming impact it has on nurses in the practice setting. Nursingresearchers have significantly contributed to our understanding of the impact moraldistress can have on nurses.Most of the research studies directly relate to intensive care nurses and to theAmerican health care system. Few studies have focused on medical or surgical nursesand how disturbed they are by the ethical issues they face caring for their patients andfamilies. This study was based on research conducted by Berger, Severson and Chvatal(1991) and conducted with a Canadian sample of nurses.Ethical Issues35CHAPTER THREE: METhODSResearch DesignA descriptive design with a structured, mailed survey questionnaire was used forthis study.Sampling ProcedureThe population for this study consisted of the 6,463 practicing medical/surgicalstaff nurses registered with the Registered Nurses Association of British Columbia(RNABC) on March 1, 1993. A Registered Nurse is a person who is a graduate of anapproved school of nursing, a member of the RNABC, and licensed to practice nursingin British Columbia. A stratified random sample of 400 nurses employed full time wasdrawn from this population. To ensure that an equal number of staff nurses were drawnfrom small and large hospitals, the RNABC divided the sample population into twogeographical areas, urban and rural. The urban area was comprised of the LowerMainland and Victoria. The rural area included northern Vancouver Island, as well asthe north and the interior of the province. From each of these areas, a random sampleof 200 staff nurses was drawn.The number of subjects required for this study was calculated according to Cohen(1977) so that there was an adequate power for tests of significance for all calculatedPearson’s Product-Moment Correlation Coefficients (r). A sample size of 250 wasdesirable at a significance level of 0.05 (alpha), with a medium effect size of 0.30, andpower of at least 99.5%, using a two-tailed test. Given an expected return rate of 60%,400 questionnaires were mailed to ensure this sample size and an adequaterepresentation of nurses from both rural and urban hospitals.Ethical Issues36Data Collection InstrumentThe study instrument, Survey of Ethical Issues in Nursing (SEIN), consisted offour sections. Section one was designed by Jacobs and Severson (1988), and revised forthe present study. Sections two, three and four were developed by the investigator.In the first section of the questionnaire, the respondents were presented with 26statements, each comprising an ethical issue that nurses may encounter in their practicesettings. For each statement, respondents were asked to make two responses. The firstresponse referred to how frequently they encountered each stated ethical issue. Subjectsresponded by using a five-point Likert scale, ranging from 0 = “never” to 4 = “veryfrequently,” the total resulted in a “Frequency” Subscale score. The second responsesought to elicit how disturbed nurses were by each issue encountered or would get ifthey encountered it, resulting in a “Disturbed” Subscale score. Subjects also respondedto these statements using a Likert scale ranging from 0 “not at all?? disturbed to 4 = “agreat deal?? disturbed. Possible scores for each of the two subsections ranged from 0 to104. One additional question (27) was added to this section by the investigator andrequested respondents to identify ethical issues faced in the past year which were notdescribed in the preceding 26 questions.The second section of the questionnaire consisted of four questions (28-3 1) thatasked the participants about their familiarity with and use of the Canadian NursesAssociation (1991) Code of Ethics for Nursing and the RNABC (1992) Standards forNursing Practice in British Columbia. Respondents were asked to circle yes or no foreach of the statements. Section three (question 32) asked the respondents to indicate,from a list of resources, those which they had used in the past year to help them resolveEthical Issues37ethical issues.Questions on demographics formed the basis of section four of the instrument.Subjects were asked for information about their age, gender, highest level of nursingeducation completed, areas of current employment (i.e., medical, surgical ormedical/surgical unit), number of years as a practicing nurse, length of experience in amedical or surgical area, size of hospital according to bed numbers, and the city/townwhere their hospital was located.Jacobs and Severson (1988) developed the original questionnaire (ie. section oneof SEIN-R) based on personal experience, the literature, and input from practicingnurses and colleagues. The original instrument contained 28 statements. The authorsreported that face validity for the SEIN was established by asking a panel of Americanexperts to review the instrument for completeness of domain, and for clarity andunderstanding of items. All recommendations were incorporated into the instrument.No reliability or other forms of validity for the tool were reported.For the purpose of this study and prior to content experts reviewing the SEINquestionnaire, minor revisions were made in the wording of statements and onestatement was deleted because it was deemed redundant. Three clinical experts whowere knowledgeable about ethics in Canadian nursing were then asked to review thequestionnaire for relevance and clarity of items. Each expert reviewed all statementitems for their relevance by using a three point ordinal rating scale, as suggested by Lynn(1986), where 1 = “not relevant” and 3 = “very relevant.” Second, the experts rated allitems for their clarity by using a three point scale, where 1 = “not clear” and 3 = “veryclear.” In addition, the experts were asked to identify areas of omission and to suggestEthical Issues38areas of item improvement or modification.The three content experts rated all statements as highly relevant. However, whenexamining the statements for clarity, they indicated that many were repetitious orinappropriately worded. Several areas of omission were also identified. Based onrecommendations from the content experts, the questionnaire was revised. Tenstatements were completely rewritten and six required minor changes in wording. Sixstatements were deleted, and five new statements added, resulting in 26 statements.Pilot TestThe “Survey of Ethical Issues in Nursing - Revised” (SEIN- R) (see Appendix A)and the other items developed for this research were pilot tested at a Lower Mainlandacute care hospital with a sample of ten volunteer medical/surgical staff nurses. Toestablish test-retest reliability, the nurses in the pilot sample completed the revisedversion of the questionnaire and completed it again two weeks later. The Pearson’sProduct-Moment Correlation Coefficient (r) was used to compute the reliabilityestimates of each subscale. Results of the reliability analysis indicated moderately lowcoefficients; the Frequency Subscale was 0.57 and the Disturbed Subscale was 0.35. Thisspuriously low estimate of stability could result from the small sample size in this pilottest. Streiner and Norman (1992) cited sources that recommend having 200-300 subjectsin order to establish test-retest reliability. In addition, the subjects were asked to makerecommendations regarding the clarity and relevance of the statements. Minor wordingchanges were made to Sections II and III of the tool. The confidentiality of completedquestionnaires was protected by the investigator. The nurses who completed the pilottest were exempted from the sample selection for the study.Ethical Issues39Data Collection ProcedureThe RNABC mailed a package to each of the selected subjects and theiridentities were not revealed to the investigator. The package sent to each subjectincluded a letter of explanation, which informed the subjects of their random selectionand explained the purpose of the study (see Appendix B), the SEIN-R, and anaddressed, stamped return envelope. Participants were asked to answer all questionsand to return the questionnaire within a four week time period.When the questionnaires were received, each was checked for completeness. Thedate and number of incoming questionnaires were recorded in a log book. Responserates were also noted. Two weeks following the original mail-out, a thank you/reminderletter was sent to each participant. The investigator thanked those who had returned thequestionnaires and reminded those who had not yet mailed in the questionnaires tocomplete and return them.Data AnalysisThe raw data obtained from the questionnaires were entered into a computer file.The Statistical Package for the Social Sciences (SPSS) computer program was used toanalyze the data. Both non-parametric and parametric tests were used. To answerresearch questions 1 through 3, frequency distributions and descriptive statistics wereused. To answer question 4, Pearson’s Product-Moment Correlation Coefficient (r),Hotelling’s t test, Multivariate Analysis of Variance (MANOVA), and Fisher’s LeastSignificant Difference (LSD) were used.Ethical Issues40LimitationsThe limitations of this study relate to the following:1. Nurses who participated in this study were those willing to give their time andenergy for research, and thus may not represent all nurses. It is also not known how therespondents may have differed from the non-respondents. This limits the generalizabilityof the findings.2. The sample did not include staff nurses working in all clinical areas. Therefore,conclusions can only be generalized to other staff nurses working in similarmedical/surgical areas.3. Perceptions of the participants are those held at one point in time. No attemptwas made to study changes over time.Ethical ConsiderationsThe names of staff nurses were randomly selected from the computer bankmaintained at the RNABC. To ensure confidentiality and anonymity, the studyquestionnaires were mailed by RNABC personnel. A cover letter to explain the purposeof the study, to request the subjects’ participation, and to promise anonymity wasincluded. It was acknowledged in the letter that the completion and submission of aquestionnaire indicated consent to participate in the study. The proposal for this studywas approved by The University of British Columbia Behavioural Sciences ScreeningCommittee for Research and Other Studies Involving Human Subjects before datacollection began.Ethical Issues41Summary of MethodsThis chapter described the research design used, the sampling procedure, datacollection instruments and procedures, the pilot test, methods of data analysis,limitations of the study, and ethical considerations. A descriptive design with astructured, mailed survey questionnaire was used for this study. A stratified randomsample of 400 medical/surgical nurses employed full-time in British Columbia wasgenerated by the Registered Nurses Association of British Columbia. The “Survey ofEthical Issues in Nursing - Revised” (SEIN-R) was used to determine the frequency withwhich nurses experienced specific ethical issues in their practice, and to examine howmuch those dilemmas disturbed them. The questionnaire was modified from onedesigned by Jacobs and Severson in 1988. Sections two, three and four were developedby this investigator. The SEIN-R was pretested at a Lower Mainland acute carehospital. Once the proposal for this study was approved by The University of BritishColumbia Behavioural Sciences Screening Committee for Research and Other StudiesInvolving Human Subjects, the questionnaire, cover letter and stamped return envelopewere sent to the selected random sample of staff nurses. Both non-parametric andparametric tests were used to analyze the data.Ethical Issues42CHAPTER FOUR: PRESENTATION OF FINDINGSIntroductionThe presentation of the findings is arranged in three sections. In the first section,a description of the demographic characteristics of the sample is provided. Next, thefindings related to each of the five research questions are presented. Finally, a summaryof the findings is provided.Characteristics of the SampleThe study sample consisted of 196 registered medical/surgical staff nurses whoworked full-time in hospitals throughout British Columbia. A total of 400 questionnaireswere mailed, and two weeks later a reminder letter was sent. Of the 202 questionnairesreturned, four were returned not completed. Two additional completed questionnaireswere disqualified as the respondents worked in areas other than medical/surgical nursing.Two hundred and two questionnaires were returned for a return rate of 50.5%,and 196 (49.0%) were used in the statistical analysis. This is a satisfactory response rateconsidering the lack of contact participants had with the researcher. However, since it isdifficult to determine how the responses from the 196 respondents would differ fromthose of the 204 non-respondents, the generalizability of these findings is limited.The following demographic information was collected from the subjects: age,gender, highest level of nursing education, area of current work, number of years ofnursing experience, number of years worked on medical and/or surgical nursing units,hospital bed size where the subject is employed, and city or town in which the hospital islocated. Respondents ranged in age from 23 to 65 with a mean age of 38 years (S12 =9.58). Forty percent of the nurses were under the age of 35. Nurses between the agesEthical Issues43of 35 and 44 comprised the second largest group at 32.1%. Approximately 20% of thenurses were between the ages of 45 and 54, and only 5.1% were over 55 years (see Table1).Table 1Age DistributionAge (Years) Frequency PercentUnder 35 79 40.335 - 44 63 32.145 - 54 39 19.955 and over 10 5.1Missing data 5 2.6Total 196 99.9Of the 196 respondents, 185 (94.4%) were female and seven (3.6%) were male.Four of the respondents (2.0%) did not indicate their gender.The highest level of nursing education of the respondents is presented in Table 2.The majority of nurses (86.2%) possessed a diploma in nursing, having completed eithertwo or three years of nursing education. Thirteen nurses (6.6%) had graduated from afour year baccalaureate degree program in nursing and six nurses (3.1%) had completeda post-diploma baccalaureate degree program in nursing. Four of the respondents didnot answer this question.Ethical Issues44Table 2Highest Nursing Education LevelsEducation Level Frequency Percent2 year diploma 82 41.83 year diploma 87 44.4Post-basic baccalaureate degree 6 3.14 year baccalaureate degree 13 6.6Masters degree 1 0.5Other 3 1.5Missing data 4 2.0Total 196 99.9Respondents were equally distributed amongst medical, surgical or combinedmedical/surgical units (32.7%, 35.2%, 30.1% respectively). Two respondents did notindicate the type of unit they worked on. The number of years respondents practicednursing ranged from 1 to 40 years (see Table 3). The mean number of years worked asa practicing nurse was 12.7 years (SJ = 8.95), the median being 10 years. The majorityof respondents had been practicing nurses for 10 years or less (55.1%). Forty-threepercent of the total sample worked in nursing for more than 10 years.Ethical Issues45Table 3Years of Nursing ExperienceYears Frequency Percent1-5 44 22.46-10 64 32.711-15 18 9.216- 20 27 13.821 - 25 24 12.326-30 6 3.031 and over 10 5.0Missing data 3 1.5Total 196 99.9The number of years worked in medical/surgical areas for these respondentsranged from 1 to 38 (see Table 4). The mean number of years worked as a nurse inmedical/surgical nursing was 10.9 years (SD = 7.64), the median being 8.0 years. Themajority (60.8%) of the respondents have worked in medical/surgical nursing for 10 yearsor less. Those nurses working 10 years or longer in medicine and/or surgery constituted37.4% of the total sample.Table 4Years Worked in Medical/Surgical NursingEthical Issues46Years Worked Frequency Percent1-5 53 27.16-10 66 33.711 -15 27 13.916 - 20 21 10.821-25 16 8.226-30 4 2.031 and over 5 2.5Missing data 4 2.0Total 196 100.2Respondents worked in hospitals ranging in size from 8 to 1100 beds (see Table5). Almost one-half of the respondents (45.8%) working in hospitals with a bed size ofbetween 100 and 400. Nurses who worked in hospitals with 500 or more beds comprisedthe next largest group (20.4% of this sample).Ethical Issues47Table 5Hospital Bed SizeNumber of Beds Frequency PercentLess than 50 15 7.750-99 14 7.1100 - 199 23 11.7200 - 299 34 17.3300 - 399 33 16.8400 - 499 12 6.1500 - 1100 40 20.4Missing data 25 12.8Total 196 99.9Most respondents, 182 (92.9%), provided the location of their hospital on thedemographic form. The 38 different locations reported were coded into two categories,urban and rural. One hundred and three respondents worked in rural areas and 79respondents worked in urban areas.FindingsIn the following section, findings related to the five research questions posed inthis study are presented. Narrative responses to question 27 are discussed andsummarized.Ethical Issues48Research Question 1: Frequency of Ethical Issues Nurses EncounterDescriptive statistics were used to analyze the responses to the statements relatedto how frequently nurses encountered the ethical issues presented. Nurses responded toeach statement by using a five-point Likert scale, ranging from 0 = “never” to 4 = “veryfrequently.” The reported frequency distributions, as well as the means and standarddeviations for each issue can be found in Table 6. The overall frequency with whichethical issues were encountered was determined by averaging the frequency scores forthe 26 issues. The overall mean was 1.09, with a median of 1.08 and a standarddeviation of 0.46. These findings indicate that in general nurses believed that theyencountered few ethical issues in the past year. The average frequency with whichparticular issues were encountered ranged from 0.27 to 2.40.Nurses ranked unsafe staffing patterns as the most frequently encountered ethicalissue with a mean of 2.40 (SJ = 1.12). The next four most frequently occurring ethicalissues encountered related to family demands for futile treatment for the patient (M1.97, SD = 1.03), the prolongation of life when death was inevitable (M = 1.76, SD =1.07), working with a nurse who regularly behaved irresponsibly (M 1.58, SD = 1.01),and disagreeing with a physician over patient care (M = 1.57, SD = 0.90).Nurses indicated that the five least frequently encountered issues were knowingthat a colleague was affected by substance abuse (M = 0.27, SD = 0.57), being aware ofthe illegal activity of a nursing colleague (M = 0.33, SD = 0.61), being asked to violateone’s personal values (M = 0.36, SD = 0.73), knowing that a family was seeking powerof attorney (M = 0.36, SD = 0.62), and being aware of unreported incidents of patientabuse (M = 0.39, SD = 0.75).Ethical Issues49Table 6Frequency of Ethical Issues Nurses Encountered n = 196Variable Mean* Standard Valid N LabelDeviationQ1A 1.286 0.945 196 F:Colleague failed to report an errorQ2A 0.959 0.849 195 F:Faced a decision re: reporting a colleagueQ3A 0.270 0.567 196 F:Knowmg a colleague is affected by substance abuseQ4A 0.769 1.002 195 F:Asked to participate in a slow/partial codeQ5A 0.364 0.622 195 F:Family seeking power of attorneyQ6A 1.260 0.933 196 F:Colleague failed to report an error of omissionQ7A 0.332 0.605 196 F:Aware of a colleague’s illegal activityQ8A 1.487 1.007 195 F:Knowing prognosis/information is being withheldQ9A 0.847 0.975 196 F:Aware confidentiality of patient records is violatedQ1OA 2.403 1.117 196 F:Faced with unsafe staffmg patternsQ 1 1A 1.572 0.898 194 F:Disagreeing with a physician re: patient careQ12A 1.469 1.010 196 F:Knowing a patient consented without understandingQ13A 1.510 0.990 196 F:Patient has incomplete info re: procedureQ14A 1.492 1.150 195 F:Working with inadequate/outdated equipmentQ15A 1.969 1.028 194 F:Family demands for futile treatment for the patientQ16A 1.577 1.007 196 F:Working with a nurse who behaves irresponsiblyQ17A 0.388 0.746 196 F:Aware of unreported incidents of patient abuseQ18A 1.755 1.072 196 F:Patient’s life is prolonged but death is inevitableQ19A 1.010 0.942 195 F:Patient is receiving treatment despite objectionQ2OA 0.434 0.680 196 F:Family convincing patient to refuse treatmentQ21A 0.362 0.728 196 F:Nurse asked to violate personal valuesQ22A 1.071 1.060 196 F:Knowing confidential patient matters are made publicQ23A 1.219 0.943 196 F:Working with a physician with inadequate skillsQ24A 0.791 0.855 196 F:Working in a clinical setting without proper skillsQ25A 0.556 0.732 196 F:Aware a patient is being restrained unnecessarilyQ26A 1.164 1.455 189 F:Not being consulted about personal ethical conflicts* Scale has a range from 0-4Ethical Issues50Research Question 2: The Extent to Which Nurses are Disturbed by Ethical IssuesDescriptive statistics were used to analyze the responses concerning how disturbednurses became or would have become if they had encountered the 26 ethical issues.Nurses were asked to respond to each of these statements using a Likert scale. Issueswere rated as: 0 = “not at all” disturbed, 1 = “a little” disturbed, 2 = “somewhat”disturbed, 3 = “quite a bit” disturbed, and 4 = “a great deal?? disturbed. The averagelevel of disturbance experiences for each of the 26 statements ranged from 2.00 to 3.41(see Table 7). The overall mean was determined by averaging the disturbance scores forall items. The resulting mean was 2.69 (SD 0.82), with a median of 2.92. Thesescores indicate that for all of the questions, nurses were at least “somewhat” disturbedabout the ethical issues they encountered or would have become so if they hadencountered these situations in the practice setting.The three issues that nurses found most disturbing were working with physicianswho demonstrated inadequate knowledge and skills (M = 3.41, SD = 1.10), being facedwith unsafe staffing patterns (M = 3.36, SD = 0.95), and the prolongation of patient lifewhen death was inevitable (M = 3.18, SD = 1.11). Nurses indicated that, on average,they were “quite a bit” disturbed by these three ethical issues. Nurses were alsodisturbed about issues such as caring for a patient whose family was demanding futiletreatment (M = 2.96, SD = 1.08), and knowing that information about prognosis wasbeing withheld from a patient and/or family (M = 2.91, SD = 1.25). The five ethicalissues that nurses found the least disturbing were being asked to violate one’s personalvalues (M = 2.00, SD = 1.59), having a colleague fail to report a medication error (M =2.11, S]2 = 1.20), knowing a colleague failed to report an error of omissionEthical Issues51Table 7Degree of Disturbance Related to Ethical Issues n = 196Variable Mean* Standard Valid N LabelDeviationQ1B 2.108 1.197 185 D:Colleague failed to report an errorQ2B 2.774 1.277 177 D:Faced a decision re: reporting a colleagueQ3B 2.780 1.679 159 D:Knowing a colleague is affected by substance abuseQ4B 2.431 1.573 167 D:Asked to participate in a slow/partial codeQ5B 2.654 1.595 159 D:Family seeking power of attorneyQ6B 2.160 1.170 181 D:Colleague failed to report an error of omissionQ7B 2.369 1.673 157 D:Aware of a colleague’s illegal activityQ8B 2.909 1.247 186 D:Knowing prognosis/information is being withheldQ9B 2.649 1.303 174 D:Aware confidentiality of patient records is violatedQ1OB 3.361 0.946 191 D:Faced with unsafe staffing patternsQ1IB 2.817 1.129 186 D:Disagreeing with a physician re: patient careQ12B 2.715 1.212 186 D:Knowing a patient consented without understandingQ13B 2.656 1.122 189 D:Patient has incomplete info re: procedureQ14B 2.530 1.289 181 D:Working with inadequate/outdated equipmentQ15B 2.962 1.079 182 D:Family demands for futile treatment for the patientQ16B 2.683 1.162 183 D:Working with a nurse who behaves irresponsiblyQ17B 2.752 1.688 161 D:Aware of unreported incidents of patient abuseQ18B 3.176 1.112 188 D:Patient’s life is prolonged but death is inevitableQ19B 2.876 1.313 177 D:Patient is receiving treatment despite objectionQ2OB 2.458 1.504 166 D:Family convincing patient to refuse treatmentQ21B 2.000 1.593 165 D:Nurse asked to violate personal valuesQ22B 2.657 1.349 178 D:Knowing confidential patient matters are made publicQ23B 3.413 1.103 184 D:Working with a physician with inadequate skillsQ24B 2.626 1.499 171 D:Working in a clinical setting without proper skillsQ25B 2.337 1.436 160 D:Aware a patient is being restrained unnecessarilyQ26B 2.161 1.457 168 D:Not being consulted about personal ethical conflicts* Scale has a range from 0-4Ethical Issues52(M = 2.16, SD = 1.17), not being consulted about personal ethical conflicts (M 2.16,S12 = 1.46), and being aware that a patient is restrained unnecessarily (M = 2.34, S1 =1.44).Additional Ethical Issues Faced in the Past YearRespondents were also asked to describe any ethical issues they had faced in thepast year which had not been included in the 26 items listed in the questionnaire. Fiftysix nurses (29%) described one or more ethical issues they had encountered in theirpractice setting. Of those who responded to this question, 21 respondents also wroteadditional comments in the margins of the questionnaire. Of those not responding toquestion 27, 15 respondents wrote comments throughout the questionnaire.Responses to question 27 were grouped into a number of categories as shown inTable 8. Only issues reported by more than one nurse are included in the table. Issuesare listed in order of frequency. The three ethical situations mentioned most frequentlywere those concerned with active euthanasia, Do Not Resuscitate (DNR) orders, and thewithholding of medical interventions deemed necessary by the respondent.Ethical Issues53Table 8Additional Ethical Issues Faced in the Past Year n = 56Nature of the Comment Number ofRespondentsActive euthanasia 6Issues related to DNR Orders 6Withholding of medical interventions deemednecessary 6Inappropriate use of hospital beds 4Inappropriate health care for the elderly 4Safety of staffing levels and patterns 4Informed consent 3Physician/nurse relationships 3Non-accessibility/non-responsiveness ofphysicians 3Intervening against patients’ wishes 3Physician incompetence and unethical conduct 3Inappropriate pain relief 2Patient Care Associates 2Family interference in care of a competentpatient 2Patient abuse against nurses 2Negative consequences of reporting ethicaldilemmas 2Nursing team relationships 2Prolongation of life when futile 2Physician over billing Medical Services Plan 2Total 61** Responses total 61 as some respondents gave more than one answer.Six nurses identified active euthanasia as a significant ethical issue. One nursedescribed the following situation: “A family requested that I call a doctor to provide - orgive myself - medication to end a life.” A similar comment described circumstances inwhich the nurse was asked by the family or patient to administer an injection that wouldEthical Issues54end the patient’s life. A third nurse made the following related comment: “It has oftenbeen suggested by the family, or sometimes other nurses and occasionally doctors, to‘speed things up’ for a dying, palliative care patient.” Another ethical issue nursesreported concerned DNR orders. One nurse expressed several concerns about DNRorders, including physicians’ refusal to write DNR orders on patients who are terminallyill or to discuss such an order with a patient or family.The withholding of a medical intervention that was deemed necessary by therespondent was identified as an ethical issue by six nurses. For one nurse, this ethicalproblem was posed when physicians did not send critically ill patients to larger, betterequipped hospitals. Another nurse described an instance where a patient required aconsultation and the physician was unwilling to request one. A third nurse discussedcases when patients requested a second medical opinion and their physicians discouragedthem from obtaining one. Additional specific ethical issues, which at least four nursesidentified, included the inappropriate use of hospital beds, inappropriate health care forthe elderly, and unsafe staffing levels and patterns. Arising from new developments inhealth care are issues related to Patient Care Associates (PCA’s) (identified by twonurses), and physician over-billing of the Medical Services Plan (identified by twonurses).Eighteen percent of the respondents added comments along the margins of thequestionnaire. Every question on the tool was commented on by at least one nurse.Numbers of “written in” comments ranged from 1 to 12. Questions 1, 4, 6, 8, 12 and 13received the largest number of comments. Twelve nurses commented on question onewhich stated, “You know that a nursing colleague has failed to report a medicationEthical Issues55error.” Eleven indicated that whether or not they would report this incident dependedon the “severity of the error” or the “magnitude of the error.” Question six, “You knowthat a nursing colleague has failed to report an error of omission,” produced similarcomments. Of the 12 comments on this question, eight qualified that reporting “dependson the importance of the drug or treatment.” Nurses also responded emphatically toquestion four regarding a direction to participate in a “slow code” or “partial code”.Although some of the nurses wrote specific examples they had experienced, five statedthat participation “depended on the situation” or that it depended “on the age of thepatient and surrounding circumstances.” In response to question eight, “You knowinformation about prognosis is being withheld from the patient and/or family,” nursesalso wrote similar comments such as “it would depend on the information andcircumstances.” For questions 12 and 13 regarding patients’ understanding and consentto treatment, nurses tended to provide examples of their values and experiences.Although they wrote comments about all of the questions, many nurses wrote briefexamples of situations they had encountered in their practice setting. For example, onenurse made the following comment:Just recently, a colleague altered her charting and another nurse’s charting tocover up a drug overdose. Thankfully, with encouragement, the younger nursereported the error, but not the alteration made by her older colleague who didthe altering. That is tough.Another nurse stated:Over the past year, one of our surgeons had numerous patient complications aswell as a couple deaths. He has a serious heart condition and is of, or beyond,Ethical Issues56retirement age. It was veiy difficult caring for his patients, who had come forelective surgery, when I felt they had little or no understanding of the risk theywere facing...Three nurses wrote comments to indicate how angry, frustrated, and powerlessethical issues made them feel. One nurse stated, “My biggest concern is the constantand continuing increase in the amount and complexity of the workload we have tocontend with, and the powerlessness we feel to do anything about the unsafe situation.”Another nurse expressed concerns about the difficulties she faced in her workplace:I went through an actual experience where a colleague was using drugs on the joband a few of us reported her and had to go through subsequent trials... .This wasby far the hardest, most difficult experience in my nursing career.From another nurse:I work on a CTU with some resident physicians who refuse to consult when theirknowledge or skills are inadequate. We have had two incidents in the past threeweeks where nurses are “begging” residents for intensive care unit (ICU) consultsand nurses’ requests are shrugged off. Both patients coded and one expired onthe same shift that the requests were made. Extremely frustrating andunnecessary.In summary, 36% of respondents either identified additional ethical issues orwrote comments on the margins of the questionnaire. The specific examples of ethicalissues provided by these nurses offer valuable insight into some of the concerns nursesare facing at the bedside. Findings of the Likert scale questions were augmented bynarrative answers to question 27 and “written in” comments.Ethical Issues57Research Question 3: Nurses’ Use of Codes of Ethics and Standards of PracticeNurses were asked if they possessed and referred to their code of ethics andstandards of practice. One hundred and twenty-eight (65.3%) of the nurses in this studyindicated they possessed a copy of the Canadian Nurses Association Code of Ethics.However, only 35 (17.9%) of the respondents indicated that they had referred to theircode of ethics in the past year. By comparison, 162 (82.7%) of the respondents werefamiliar with their RNABC Standards for Nursing Practice and 89 (45.4%) indicated thatthey had referred to their standards of practice in the past year. Eight nurses did notrespond to question three.Research Question 4: Resources Used by NursesDescriptive statistics were used to analyze the responses that nurses used in thepast year to resolve ethical issues (see Table 9). Most nurses (93.2%) consulted nursingcolleagues as a resource when trying to resolve ethical issues. Head Nurses were alsoused as a resource by 170 (89.5%) of the respondents, followed by physicians, familymembers, and social workers. Nurses who responded to the ‘other’ category reportedusing resources such as patients, friends, the clergy, the chief of staff (medicine),psychiatrists, psychologists, and legal counsel.Ethical Issues58Table 9Resources Used by Nurses to Resolve Ethical Issues n= 196Resources Number of PercentResponsesNursing colleagues 177 93.2Head/Nurse/Nurse Manager 170 89.5Physician 121 63.7Family members 116 61.1Social Worker 98 51.6Clinical Nurse Specialist 67 35.3Literature 51 26.8Hospital Chaplain 45 23.7Director of Nursing 30 15.8Nursing instructor 30 15.8Educational sessions regarding ethics 19 10.0Other 17 8.9Nursing ethics rounds 11 5.8Nursing Consultant 4 2.1Research Question 5: Relationship Between Demographic Variables and Nurses’Experience With Specific Ethical IssuesSince nurses were asked to respond to 26 ethical statements for each of the twoSubscales (Frequency and Disturbed), the investigator decided that it would be moreuseful to examine the relationships between the five most frequent and the five mostdisturbing ethical issues, and the selected demographics. Relationships between the fivemost frequent and the five most disturbing ethical issues, and years practiced as a nurse,years worked in medical/surgical nursing, age of the nurse and hospital bed size wereassessed using Pearson’s Product-Moment Correlation Coefficient (see Table 10).Although most of the associations between the variables are weak, the findings suggestthat the longer nurses practice, and the longer they work in medical/surgical nursing, theEthical Issues59less frequently they report encountering these particular ethical issues. Significantnegative weak relationships between age and the frequency of encountering four of thefive ethical issues were also demonstrated. The frequency of encountering unsafestaffing patterns was unrelated to a nurse’s age. None of the five most frequentlyoccurring ethical issues related to hospital bed size.Four significant negative weak relationships were identified between the five mostdisturbing ethical issues and specific demographic variables. First, it was found that aninverse relationship exists between the nurse’s age and the ethical issue presented instatement 23 which refers to working with physicians who demonstrated inadequateknowledge and skills. Second, a negative relationship was also found between the lengthof time nurses practiced, the number of years nurses worked in medical/surgical nursingand the nurse’s age, and their level of disturbance related to ethical situations wherenurses are aware that information regarding prognosis is being withheld from the patientand/or family.A Hotelling’s t test was used to determine if there was a difference between thefive most frequent and the five most disturbing ethical issues, and level of nurses’education and hospital location. The Hotelling’s is a t test, modified so that it can beused to look at two or more dependent variables at the same time (Norman & Streiner,1986). In order to conduct a Hotelling’s t test, the five levels of nursing education werecollapsed into two groups (diploma or degree). The findings indicate that the profile ofthe top frequency scores does not depend on whether the nurse’s education is either adiploma or a degree (p = 0.94). There was also no significant difference betweendegree and diploma education with respect to the top five disturbance scores (p = 0.34).Ethical Issues60Table 10Correlations Between Frequency and Disturbance Items, and Years Practiced as aNurse, Years Worked in Medical/Surgical Nursing, Age, and Hospital Bed SizeYEARS YEARS WORKED IN AGE HOSPITALPRACTICED MEDICAL/SURGICAL BED SIZEAs A NURSINGNURSEMost Frequently Occurring Issues:1OA Unsafe staffing patterns _.16* _.13* —.08 —.0215A Family demanding futile —. 19** —. 17** _.24*** .03treatment18A Prolonginglifewith _.20** _.16* .003heroic measures16A Nurse who behaves _.16* _.16* .13irresponsibly1 1A Physician/nurse conflict—. 07regarding patient careMost Disturbing Issues:23B Incompetentphysician —.04 —.02 —.001lOB Unsafe staffingpatterns —.09 —.02 —.10 —.00518B Prolonging life with —. 03 —. 05 —. 06 —. 10heroic measures15B Family demanding futile —. 04 —. 06 —. 10 .05treatment8B Withholding infonuation —. 19 * * —. 20 * * . 02regarding prognosis* p < .05 ** p < .01 p < .001Ethical Issues61No significant difference was found between urban and rural hospital location withrespect to either the top five frequency items (p = 0.41) or disturbance items (p = 0.56).Multivariate Analysis of Variance (MANOVA) was used to determine if therewas an association between the independent variables, types of units where nursesworked, and the dependent variables, scores on the five most frequent and five mostdisturbing ethical issues. A significant difference (p<O.Ol) was found between the unitsand the top five frequency items. Further investigation using univariate Analysis ofVariances (ANOVA) revealed a highly significant difference between the units on theFrequency Subscale of statement 15 (caring for a patient whose family is demandingfutile treatment) [F(2, 185) = 7.39; p = <0.0011, and marginally statistically significantdifferences between units on the Frequency Subscale of statement 18 (prolonging apatient’s life when death is inevitable) [F(2, 185) = 3.62; p = <0.028], and statement 11(physician/nurse conflict regarding patient care) [F(2, 185) = 4.56; p = <0.012]. Fisher’sLeast Significant Difference (LSD) was then performed to determine exactly which ofthe units were different on these three statements. The findings suggest that thedifferences were due to nurses working on surgical units having lower frequency scores(p<O.OS) on these items than those working on either medical or combinedmedical/surgical units. In addition, the nurses working on medical and combinedmedical/surgical units were not significantly different. For example, on statement 15(caring for a patient whose family is demanding futile treatment), the mean frequencyfor nurses working on a surgical unit is 1.64, compared with means of 2.30 for thoseworking on medical units and 2.02 for those on combined medical/surgical units (seeTable 11). Therefore, nurses working on surgical units encounter issues related toEthical Issues62families demanding futile treatment, prolonging a patient’s life with heroic measures, andphysician/nurse conflict regarding patient care less frequently than nurses working onmedical or combined medical/surgical units. There was no significant difference betweenany of the three nursing units and the top five disturbance items (p=O.l5).Summary of FindingsA sample of 196 registered medical/surgical staff nurses who worked full-time inhospitals throughout British Columbia participated in this study. Two hundred and twoquestionnaires were returned for a response rate of 50.5%, with 49% used in thestatistical analysis. Demographic information collected from the respondents included:age, gender, highest level of nursing education, area of current employment, number ofyears of nursing experience, number of years worked on medical and/or surgical nursingunits, hospital bed size, and hospital location.Descriptive statistics were used to answer the first research question that askedhow frequently nurses encountered ethical issues. The five most frequently encounteredethical issues that nurses reported were: (1) unsafe staffing patterns, (2) caring for apatient whose family was demanding futile treatment, (3) the prolongation of a patient’slife when death was inevitable, (4) working with a nurse who regularly behavedirresponsibly, and (5) disagreeing with a physician over patient care.Descriptive statistics were also used to answer the second research question thatasked how disturbed nurses became or would become if they encountered these specificethical issues. The five most disturbing issues that nurses reported were: (1) workingwith physicians who demonstrated inadequate knowledge and skills, (2) being faced withunsafe staffing patterns, (3) the prolongation of a patient’s life when death wasEthical Issues63Table 11Means and Standard Deviations for the Five Most Frequent and the Five MostDisturbing Ethical Issues with Respect to the Three Types of Units Where RespondentsWorkedUNIT N MEAN SDMost Frequently Occurring Issues:1OA Unsafe staffing patterns Medical 64 2.34 1.21Surgical 69 2.36 1.10Combined 59 2.49 1.0615A Family demanding futile Medical 64 2.30 0.89treatment Surgical 67 1.64 1.12Combined 59 2.02 0.9618A Prolonging life with heroic Medical 64 1.97 1.08measures Surgical 69 1.45 1.09Combined 59 1.85 1.0016A Nurse who behaves Medical 64 1.55 0.91irresponsibly Surgical 69 1.51 1.02Combined 59 1.64 1.08hA Physician/nurse conflict Medical 64 1.81 0.85regarding patient care Surgical 68 1.34 0.86Combined 58 1.60 0.94Most Disturbing Issues:23B Incompetent physician Medical 63 3.60 0.79Surgical 65 3.06 1.43Combined 52 3.60 0.87lOB Unsafe staffing patterns Medical 62 3.29 1.11Surgical 68 3.37 0.84Combined 57 3.44 0.8918B Prolonging life with heroic Medical 63 3.21 1.15measures Surgical 65 3.08 1.29Combined 56 3.21 0.8515B Family demanding futile Medical 63 3.13 0.98treatment Surgical 60 2.92 1.14Combined 55 2.89 1.078B Withholding information Medical 62 2.97 1.24regarding prognosis Surgical 65 2.69 1.40Combined 56 3.07 1.06Ethical Issues64inevitable, (4) caring for a patient whose family was demanding futile treatment, and (5)knowing that information about prognosis was being withheld from the patient and/orfamily.Fifty-six nurses (29%) identified additional ethical issues encountered in the pastyear. The three additional ethical situations mentioned most often were those concernedwith active euthanasia, DNR orders, and the withholding of medical interventionsdeemed necessary by the respondents.The findings of this study indicated that 65.3% of the study sample possessed acopy of the Canadian Nurses Association Code of Ethics. However, only 17.9% of therespondents indicated that they had referred to this code of ethics in the past year. Bycomparison, 82.7% of the respondents were familiar with the RNABC Standards forNursing Practice, with 45.4% indicating that they had referred to them in the past year.When trying to resolve ethical issues most nurses consulted nursing colleagues(93.2%) or their head nurse (89.5%). Respondents also reported frequently consultingwith physicians, family members, and social workers.Pearson’s Product-Moment Correlation Coefficients were used to determine ifthere was a relationship between the five most frequent and the five most disturbingethical issues reported, and the number of years practiced as a nurse, the number ofyears in medical/surgical nursing, the age of the nurse, and the bed size of the hospital inwhich she or he was employed. The findings suggest that the longer nurses practicedand the longer they work in medical/surgical nursing, the less frequently they reportedlyencountered the five top ethical issues. Significant but weak negative relationshipsbetween the nurses’ age and the frequency of encountering four of the five ethical issuesEthical Issues65were also identified.Four significant but weak negative relationships were identified between the fivemost disturbing ethical issues and select demographics. First, it was found that the oldernurses get, the less disturbed they reported being about the issues related to incompetentphysicians, and knowing that information regarding prognosis is being withheld from thepatient and/or family. Second, the findings suggest that the longer nurses practice andthe longer nurses work in medical/surgical nursing the less disturbed they are aboutknowing that information regarding prognosis is being withheld from the patient and/orfamily.Hotelling’s t test was used to determine if there was difference between the firstfive most frequent and the five most disturbing ethical issues, and the level of nurses’education and hospital location. The findings revealed that the profile of the topfrequency and disturbance scores does not depend on whether the nurse’s education iseither diploma or degree. No significant difference was found between urban and ruralhospital locations with respect to their profile or either the top five frequency ordisturbance items.MANOVA was used to determine if there was a relationship between the fivemost frequent and the five most disturbing items, and the type of unit where nursesworked. A significant difference was found between the units and the profile of the topfive frequency items. These differences occurred in three of the statements. Results ofthe Fisher’s Least Significant Difference test revealed that differences were due tonurses working on surgical units having lower frequency scores on these items than thenurses who worked on either medical or combined medical/surgical units. No significantEthical Issues66difference was found between any of the nursing units and the top five disturbanceitems.Ethical Issues67CHAPTER FIVE: DISCUSSION, CONCLUSIONS, IMPLICATIONS ANDRECOMMENDATIONSIntroductionThis study was designed to investigate the experiences of nurses working onmedical/surgical units in relation to the ethical issues they encounter and how they feelabout them. A discussion of the research findings is presented in this chapter; theconclusions, the implications for nursing practice, education, administration, andrecommendations for further research follow.Discussion of FindingsThe purpose of this study was to describe the experiences of nurses working onmedical/surgical units in relation to ethical situations encountered and their responses tothem. Relationships between nurses’ experience with specific ethical issues anddemographic characteristics of the nurses were also examined.Eighty-eight percent of the respondents possessed a diploma in nursing, havingcompleted either two or three years of nursing education. Those nurses with abaccalaureate degree in nursing comprised 9.9% of the total sample. In 1991, 8.5% ofall British Columbian nurses possessed a baccalaureate degree in nursing (University ofBritish Columbia, Health Human Resources Unit, 1992). Therefore, the educationalcharacteristics of the sample appear to be representative of nurses in this province. Thenumber of respondents were almost equally distributed among medical, surgical, andcombined medical/surgical units (33.3%, 35.9%, and 30.7% respectively), and thus,comparisons between these groups can be made.Respondents who completed the questionnaire were experienced nurses. NursesEthical Issues68with more than five years experience comprised 76.0% of the sample. Seventy-onepercent of the sample had worked for five or more years in medical/surgical nursing. Ofthe respondents, 45.8% worked in hospitals with a bed size of between 100 and 400.The findings in this study indicate that, in general, nurses reported that they“rarely” encountered the identified ethical issues. This is consistent with the findings ofBerger et al. (1991) who found that nurses “rarely” encountered ethical issues. Thefindings, however, are inconsistent with other authors who suggest that nurses are facingincreasing numbers of ethical issues (Davis, 1988; Erickson, 1993; Holly, 1993), and awider range and variety of ethical issues (Storch, 1988). Whether this sample of nursesdid not experience many ethical issues or whether they did not recognize them in theirpractice setting is not known. With 24% of the respondents 45 years of age and older,and 86% diploma prepared, the question of whether or not they have received ethicaleducation in their nursing programs is raised. Although data were not collected todetermine respondents’ educational background with respect to ethics, it is conceivablethat nurses who have not had ethics education may be less sensitive to ethical issues.Three of the five most frequently encountered ethical issues (inadequate staffingpatterns, life prolonged with heroic measures, and irresponsible activities of colleagues),were reported by Berger et al. (1991). Other researchers also found that issues relatedto death and dying were important ethical issues for nurses (Crisham, 1981; Holly, 1993;Miya et al., 1991; Youell, 1986). More specifically, the prolongation of a patient’s lifeusing heroic measures has been identified as an ethical issue in several investigations(Davis, 1981, 1988; Fenton, 1987; Rodney, 1987; Wilkinson, 1985). The present study’sfindings that nurses encounter ethical issues surrounding family demands for futileEthical Issues69treatment for the patient and disagreements with physicians about patient care have notbeen identified as significant issues by previous researchers.Although findings from both the present study and Berger et al. (1991) indicatethat nurses encountered ethical issues related to inadequate staffing and irresponsibleactivities of nursing colleagues, this was not specifically identified by previous research.A number of researchers identified the allocation of resources as an ethical issueencountered by nurses (Aroskar, 1989; Crisham, 1981; Sietsema & Spradley, 1987;Youell, 1986), but whether this includes inadequate staffing patterns is difficult toascertain. Two findings that researchers reported as significant ethical issues in earlierstudies, but which were not found to be encountered frequently by nurses in the presentstudy, included the competence of nursing staff (Aroskar; Berger et al., 1991; Davis,1981; Haddad, 1992; Youell), and nurses’ lack of involvement in ethical decision-makingabout their patients (Erlen & Frost, 1991; Holly, 1989; Martin, 1989; Rodney, 1987).Overall, nurses reported being at least “somewhat” disturbed about the ethicalissues they encountered or would have become so if they had encountered thesesituations in the practice setting. In fact, nurses were “quite a bit” disturbed by the firstthree ethical issues reported which were related to working with physicians whodemonstrated inadequate knowledge and skills, being faced with unsafe staffing patterns,and prolonging a patient’s life when death was inevitable. Nurses were also disturbed byissues such as caring for a patient whose family is demanding futile treatment, andknowing that information about prognosis is being withheld from the patient and/orfamily.Three of the five most disturbing issues were those frequently encountered:Ethical Issues70unsafe staffing patterns, families demanding futile treatment for the patient, and theprolongation of life with heroic measures. These findings support the work of Berger eta!. (1991) who revealed that nurses were disturbed by issues related to inadequatestaffing and prolonging life with heroic measures. She also found, however, that nurseswere disturbed by situations involving treatment against patients’ objections, actingagainst personal principles and incidents of patient abuse. These differences in findingsmay be related to the fact that 27% of the respondents were critical care nurses and21% were administrators. Nurses from other studies also reported that issues related toprolongation of life of their patients were of concern to them (Holly, 1991; Martin, 1990;Miya et al., 1991).Clearly, urban and rural nurses alike are disturbed about what they perceive to beinadequate staffing patterns encountered in hospital settings throughout BritishColumbia. Not only was inadequate staffing reported as being the number one issue inthe Frequency Subscale and the number two issue in the Disturbed Subscale, but it wasalso identified by a number of nurses in question 27. Other than the findings of Bergeret al. (1991), this ethical issue has not been identified in either the anecdotal literatureor recent research studies. British Columbian nurses’ concern about this ethical issuemay be increasing because of recent hospital and bed closures, the influence ofbudgetary constraints on staffing patterns, and imminent changes to the health caresystem in this province.Additional information gathered from responses to an open-ended questionindicated that nurses felt angry, frustrated, and powerless when they encountered specificethical situations. These feelings were congruent with those reported by nurses inEthical Issues71previous studies (Duncan, 1989; Erlen & Frost, 1991; Martin, 1989, 1991; Wilkinson,1985). Although the concept of ??powerlessnessH was not specifically referred to in thequestionnaire, the ethical issues nurses identified as being the most frequent anddisturbing, as well as those situations nurses described, suggest that they are experiencingfeelings of powerlessness. Nurses used expressions such as “begging,” “being shruggedoff,” “not being consulted on any level,?? and ??the powerlessness we feel to do anything.??Those feelings of powerlessness may be attributed to an underlying problem related tohow much input nurses have into ethical decision-making. Further research thatexplores the emotional responses to ethical issues nurses encountered in the clinicalsetting is required.Nurses used the RNABC Standards for Nursing Practice more frequently than theCNA Code of Ethics in their practice. Only 17.9% indicated that they had referred totheir code of ethics when facing an ethical issues, while 47.3% had used their standardsof practice. The Code of Ethics for Nursing?? delineates the obligations of nurses touse their knowledge and skills for the benefit of others, to minimize harm, to respectclient autonomy and to provide fair and just care for their clients?? (Canadian NursesAssociation, 1991, p. ii). It is regrettable that so few nurses refer to this code as itoutlines the basic moral commitments of nurses, and provides guidance for nurses facingethical issues. The RNABC Standards for Nursing Practice (1992), however, are writtenstatements that outline the criteria according to which all registered nurses will beevaluated. ??The statements are descriptions of nursing actions and, as a whole, they areintended to describe the practice of nursing?? (Registered Nurses Association of BritishColumbia, 1992, p. 1). One of six standards refers specifically to nursing ethics, outliningEthical Issues72the nurse’s responsibility to adhere to the ethical standards of the nursing profession.RNABC practice consultants use the standards of practice when guiding nursesthrough the process of resolving problems in the workplace. The RNABC StandardsProject may account for the high percentage of nurses who use the standards. In 1992,the RNABC developed and implemented the Standards Project to educate BritishColumbian registered nurses about their standards of practice, as well as how to usethem to resolve problems in the workplace. To educate nurses on use of the standards,the RNABC conducted three hour workshops throughout the province. Since June 1991,1509 registered nurses have completed this workshop (R. McKay, personalcommunication, June 27, 1994). Both administrators and staff nurses receive educationabout the standards of practice. Commencing January 1993, the RNABC also beganoffering all day workshops that focused on “training the trainer”. The 111 nurses whoattended the trainer program learned how to teach nurses in their own facility about howto use their standards of practice in the workplace.Nurses reported they used nursing colleagues, head nurses, physicians, and familymembers as resources when addressing ethical issues. In response to a similar question,Berger et al. (1991) found that subjects used nursing colleagues and family mostfrequently as resources. Sietsema and Spradley (1987) also listed nursing colleagues asthe third most common resource used by nursing executives in resolving ethical issues.Although the findings of the present study identify the resources medical/surgical nursesuse in resolving ethical issues, it can not be determined from the data what resourcesnurses need and what resources are available to nurses in their hospital. Since 85% ofthe respondents worked in hospitals with at least 100 beds, it is possible that otherEthical Issues73resources such as ethics committees may have been available to them. However, even ifnurses have the resources available to them in their hospitals, are they actually able orknow how to use them? Further, do administrators and other health care providers (eg.physicians) impede staff nurses from accessing the resources they need to participate inand resolve ethical issues? Storch and Griener (1992) found that few nurses were awareof the presence of ethics committees in their hospitals. In addition, in one of the fivehospitals, 61% of the nurses surveyed were not aware of any ethical education beingoffered by the hospital, even though ethical programs were being offered.Although a weak association exists between the five most frequently encounteredethical issues, and years practiced as a nurse and years worked in medical/surgicalnursing, conclusions can still be drawn from these results. These findings suggest thatthe longer the nurses practice, and the longer they work in medical/surgical nursing, theless frequently they report encountering ethical issues of unsafe staffing patterns, familydemanding futile treatment, working with a nurse who behaves irresponsibly andphysician/nurse conflicts regarding patient care. A significant weak relationship existsbetween age and the frequency of encountering four of the five ethical issues. It ispossible that older, more experienced nurses encounter these ethical issues lessfrequently than younger nurses because of their educational background. Older nursesmay not recognize particular ethical issues because they have not received education onethics in their nursing diploma programs. It is also possible that frequent exposure tothese issues over time with the development of habitual patterns of coping has decreasedtheir sensitivity to them. These findings, however, should be interpreted with cautionbecause of the inconsistent patterns of results in the literature. While Berger et al.Ethical Issues74(1991) found no relationship between age or experience and the frequency of issuesreported, Davis (1981) found that age was related to frequency with which dilemmasoccur in different interactions for nurses who worked in acute care, operating room,inpatient and outpatient departments, community and non-traditional facilities. Davisstated that a “significant positive correlations between age group and infrequency ofethical dilemmas were found for dilemmas related to interaction with patients, families,physicians, and the institution?? (p. 403).A significant relationship was also identified between the type of unit on whichnurses work and the five most frequently encountered ethical issues. The findingssuggest that nurses working on surgical units encounter issues related to familiesdemanding futile treatment, prolonging life with heroic measures, and physician/nurseconflict regarding patient care less frequently than do nurses working on medical orcombined medical/surgical units. This may be due to the fact that many patients onmedical units are elderly and suffer from long tenu chronic illnesses. Situationsinvolving issues such as DNR orders, prolongation of life, and family demanding futiletreatment are understandably common. In contrast, patients admitted to surgical wardsfrequently have shorter hospital stays and a different profile. This finding would suggestthat nurses working on medical units or combined medical/surgical units may need moreethics education and psychological support to deal with the ethical issues encountered.This researcher was gratified to note that 71(36%) nurses took the time toanswer question 27, as well as to add hand written comments along the margins of thequestionnaire. This indicates that the questions were thought-provoking, and that thenurses cared enough about the topic to provide more information than was asked ofEthical Issues75them. In some cases, respondents provided three or four examples of ethical issues.The three most frequently identified additional ethical issues were those relatedto active euthanasia, DNR orders, and withholding of medical interventions which thenurse deemed necessary. Nurses described situations where they were asked by patients,family members and physicians to give medications to patients in order to speed up thedying process. Although many experts have written about the issue of euthanasia(Bandman & Bandman, 1990; Beauchamp & Childress, 1989; Beauchamp & Walters,1982; Davis & Aroskar, 1983; Storch, 1982; Tschudin, 1992; Veatch & Fry, 1987), thishas not been identified as an ethical issue in previous research. Martin (1991) however,reported in a study of 75 registered nurses that the most problematic issues for nursesinvolved patients asking them for assistance in committing suicide; but since she does notdefine “assisted suicide,?? it may not be synonymous with “euthanasia”. Active euthanasiais the “act of directly killing a person for reasons of mercy?? (Special Advisory Committeeon Ethical Issues in Health Care, 1994, p. 1). Whereas the phrase “assisted suicide”refers to situations in which a health care professional assists a patient, directly orindirectly, to take his or her own life. The main difference between these two terms isthat in active euthanasia another person, for example, a health care professional is thedirect cause of the patient’s death and in assisted suicide another person assists thepatient in causing his or her own death. Because, questions about euthanasia were notincluded in the present study, they must be included in future revisions of the tool sincepatients’ rights related to euthanasia are becoming an issue of great concern to society.Future research needs to explore in more depth the context of both assisted suicide andeuthanasia.Ethical Issues76The nursing and medical community need to talk openly about active euthanasiafor a number of reasons. First, it offers each discipline the opportunity to understandother perspectives on active euthanasia and specific experiences individual professionalshave encountered. Second, through collaboration, mutual decision-making cancommence. Third, open dialogue may create an environment whereby health careprofessionals can express their concerns and feelings. Fourth, in order to determine themagnitude of the issue, or the number of requests related to active euthanasia, thenursing and medical community need to discuss each case.Nurses also identified concerns about ethical issues related to Do Not Resuscitate(DNR) orders. The questionnaire included only one statement about resuscitationorders: “your patient has unclarified code orders and you are asked to participate in aslow code or partial code.?? This statement does not address situations where physiciansrefuse to write code orders or fail to obtain input from patients or family members aboutcode status. Subjects who described DNR orders indicated concern about these broaderissues. Findings by Aroskar (1989) and Martin (1991) also indicated that DNR ordersposed significant ethical problems for nurses. Further revisions to this tool should bothexpand the number of questions about DNR orders and increase their specificity.Six nurses also identified the withholding of medical intervention which the nursedeemed necessary as an ethical issue. Previous studies have not identified this as anethical issue for nurses, and it is also not commonly discussed by many experts in nursingethics (Benjamin & Curtis, 1992; Kelly, 1991; Storch, 1988; White, 1992). Furtherresearch should explore changing relationships and decision-making models betweendoctors, nurses and patients.Ethical Issues77Additional specific ethical issues identified by nurses included the inappropriateuse of hospital beds, inappropriate health care to the elderly (over and under treatment),lack of safety in staffing levels and patterns, and problems related to informed consent.A number of concerns not identified in previous research were also reported. Theserelated to “Patient Care Associates” (a new category of health care worker), negativeconsequences of reporting ethical dilemmas, and physician overcharging the MedicalServices Plan (MSP). According to one nurse:The introduction of PCA’s has introduced many, many conflicts in thishospital. To have someone with four hours training, who worked atKentucky Fried Chicken last week and is now doing pen care, or assistingwith transfers of patients with very complex problems. ...We have had PCAsdisconnect tubes...without the nurse being aware...and without the PCAhaving any knowledge of what the tubes are for.Ethical issues not identified in previous research, such as those related to PCA’s andphysician overcharging of MSP, need to be explored further to determine nurses’concerns when they encounter these issues in the workplace.Eighteen percent of respondents added comments along the margins of the tool.Every question on the tool was commented on by at least one nurse. Davis (1981) alsofound that nurses wrote numerous and often lengthy comments on the back of thequestionnaire. Comments were made to questions such as “depends on the severity ofthe error,” “depends on the importance of the drug or treatment,” and “depends on theage of the patient and surrounding circumstances.” These comments may indicate thatsome questions need to be reworded for increased clarity or expanded to explore nurses’Ethical Issues78use of judgement when faced with ethical issues.Although the original instrument (SEIN) developed by Jacobs and Severson(1989) was revised by this investigator, and with input from content experts, a number ofapparent limitations in the tool emerged as a result of this study. First, it was evidentfrom the written responses to question 27 which asked nurses to describe any ethicalissues in the past year not discussed in the questionnaire, that there were some keyethical issues that should be either included or expanded in number in section one of theSEIN-R. For example, additional questions related to active euthanasia, DNR orders,and the withholding of medical interventions nurses deemed necessary need to beincluded in section one. Second, further consideration must be given to the ordering ofthe ethical statements presented in section one. Both the ordering and number ofstatements related to nursing competence may evoke a negative response fromrespondents, and thus result in a lower response rate.Third, the findings indicated that a number of respondents did not answer someof the items for the Disturbed Subscale (see Table 4). For example, only 165 nurses(84%) responded to question 21B which related to nurses being asked to practicenursing in a way that violates their personal values. Another 168 nurses (86%) onlyresponded to statement 26B which related to nurses’ not being consulted about theirpersonal ethical conflicts related to the care they are required to give. These responserates are relatively low in comparison to response rates for other items in the survey andmay indicate that the non-respondents did not understand or know how to answer thesequestions. Therefore, items that elicited low response rates for the Disturbed Subscalemust be examined for their clarity and the overall instructions may require revision.Ethical Issues79Lastly, although it could be determined from the SEIN-R what resources nursesused to resolve ethical issues, it could not be ascertained from these results, theresources that nurses want or need in helping them to work through difficult ethicalissues. Knowledge about the resources nurses need when faced with ethical issues wouldhave strengthened the results of this research. Therefore, given some of the limitationspresented throughout the discussion section, the SEIN-R should be used with cautionand if used in future research further revision of this tool is recommended.ConclusionsFindings of this study lend partial support to results of other research whichdescribe nurses’ experiences in relation to the ethical situations they encounter. Thefollowing conclusions must be interpreted with caution when generalizing to othernurses, particularly those who work in areas other than medical/surgical units and inother institutions outside the Canadian health care context.1) Overall, nurses report encountering ethical issues “rarely.” The two mostfrequently occurring ethical issues are unsafe staffing patterns and family demands forfutile treatment for the patient.2) Overall, nurses are at least “somewhat’ disturbed by the ethical issues theyencounter in the workplace. Nurses are “quite a bit” disturbed about the issues relatingto working with physicians who demonstrate inadequate knowledge and skills, unsafestaffing patterns, and prolongation of a patient’s life when death is inevitable.3) The longer nurses practice and the longer they work in medical/surgical nursing,the less frequently they report encountering ethical issues.4) Nurses working on surgical units report encountering ethical issues related toEthical Issues80families demanding futile treatment, prolonging life with heroic measures, andphysician/nurse conflict regarding patient care less frequently, than do nurses working onmedical or combined medical/surgical units.5) Nurses report that they do not rely heavily on their codes of ethics to resolveethical dilemmas. Nurses more frequently use standards of practice as a resource.Additional resources used are nursing colleagues, head nurses, physicians, and familymembers.6) Active euthanasia, DNR orders, and withholding of medical intervention deemednecessary appear to be significant ethical situations for nurses not included in the SEIN -R.ImplicationsThe findings of this study suggest many implications for nurses facing ethicalissues in their clinical settings. Implications for nursing practice, education andadministration are presented in the following sections.Nursing PracticeNurses may face increasingly difficult and complex ethical issues in the practicesetting because of significant changes occurring in British Columbia’s health care system.Ethical issues that have been documented both empirically and anecdotally such asallocation of resources, competence of nursing staff, and issues related to death anddying will continue to pose ethical dilemmas for nurses. This research indicates,however, that new ethical issues are emerging as the health care system evolves. Forexample, the emergence of “Patient Care Associates” was identified as a new ethicalissue. Identification and clarification of new ethical issues is needed. Staffing patternsEthical Issues81are also of great concern to nurses in this sample. These concerns must be documentedand pursued. Nurses must take responsibility for addressing situations and practiceswhich they identify as unacceptable. Nurses need to act cohesively to make changes atboth the unit and organizational level.According to this research, 93.2% of the respondents reported that in the pastyear they have used their nursing colleagues as a resource when faced with ethical issues.In fact, ??nursing colleagues” were the resource most often used by nurses in this sample.It is evident from this that nurses rely on each other in difficult situations.Nurse-to-nurse communication and collaboration in clinical settings should beencouraged and promoted. Further exploration of other resources that may be useful inhelping nurses resolve ethical issues and their access to these resources is imperative.Nurses should no longer have to rely solely on colleagues for support and guidance whenencountering difficult ethical issues. Nurses should be encouraged to use both theircode of ethics and standards of practice to guide them in addressing and resolvingethical issues.To promote effective problem solving about ethical dilemmas, nursingcommunication and team collaboration should be encouraged in all practice settings.Nurses should insist on involvement in ethical rounds and membership on hospital ethicscommittees. Staff nurses could develop their own unit-based ethical rounds. Suchforums would enable nurses to discuss ethical issues specific to their specialty area.Frequency of meetings would reflect the needs of the staff. According to the findings ofthis study, nurses on medical units or combined medical/surgical units more frequentlyencounter ethical issues than do the surgical units; and therefore, may need additionalEthical Issues82education and support to help them resolve ethical issues. Expert nurses could teach orfacilitate group discussion.Nurses must also accept responsibility for developing their understanding ofethical problem solving. “Gut level feelings, ready made answers and personal opinionsare not adequate in resolving ethical problems” (Fenton, 1987, p. 11). Nurses mustrecognize and meet their own learning needs. Institutions and organizations mustprovide opportunities for discussion and professional growth.Nursing EducationFor nurses to participate in ethical decision-making with other health care teammembers, they must be able to articulate their professional perspective in a logical andrational manner. To do so requires knowledge of ethical theories and principles. Basicnursing education programs attempt to address this need by offering programs that teachnurses how to make ethical decisions. Strengths of these educational experiences includeexploration of students’ clinical experiences and the opportunity to address ethical issuesin groups. This assists students to build their confidence for future dialogue with otherhealth care team members.Nursing educators should use the findings of studies such as this one to critiquethe adequacy of current curricula related to nursing ethics and nursing practice.Educators cannot rely exclusively on anecdotal literature to develop educationalprograms; they must also identify current ethical issues that nurses face in the practicesetting. Nursing courses on ethical theory should also provide information about theimportance of resolving ethical issues, and the emotional and physical impact on nursesif they are unable to do so.Ethical Issues83Practicing nurses also have significant educational needs related to ethics. Forexample, because of the type of patient population that exists on medical units, nursesmay need educational programs which could help them resolve ethical issues. Theyshould be supported by employers to attend continuing education programs. Currently,ethics courses are offered through open learning institutions which enable practitionersto continue working while upgrading their education. Nurses should also be encouragedto attend inservices and nursing forums related to nursing ethics. By attending ethicalrounds within their organization, nurses would have the opportunity to explore situationsas they arise in the practice setting. Nurses should also attend interdisciplinary courseson ethics in order to understand the professional perspectives of other members of thehealth care team.Nurses must also be aware of the resources available to them when confrontedwith an ethical issue. Findings of this research indicate that nurses use a select fewresources when facing ethical issues. Therefore, hospital orientations should includeinformation on accessing and using available ethical resources.Nursing AdministrationNurse administrators should provide nurses with the tools and support they needto resolve ethical issues with confidence. They need to understand that ethical issueshave an emotional impact on nurses. Hence, nurse administrators should conduct needsassessment in their organizations to determine what kinds of support, resources, andeducational programs nurses need. Nurse administrators must ensure all nurses haveaccess to ethics committees. Policy review and development should also be conductedwith staff nurses’ input.Ethical Issues84Head nurses are the most important resource persons for staff nurses. Given that89.5% of the respondents in this study indicated that they consulted their head nurseswhen confronted with an ethical issue, head nurses must understand and be able to applyethical theory. They should act as role models in interdisciplinary interaction to resolveethical issues, demonstrating a clear and open style of communication.Both head nurses and administrators must encourage involvement of staff nursesin interdisciplinary group meetings on ethics and clinical practice, nursing ethics rounds,and nursing forums. They must also encourage nurses to use their professional codes ofethics and nursing practice standards as guides when addressing ethical issues.Opportunities for nurses to explore and discuss the application of codes of ethics couldbe incorporated into orientation programs and inservice educational sessions.Finally, nurse administrators must be alert to the distress experienced by nurseswhen they face unresolved ethical dilemmas. Administrators should be available tolisten to and validate staff members’ concerns, and provide support for nurses to workthrough the issues. Administrators should examine all organizational factors whichmight impede the power and ability of nurses to confidently address ethical issues. Onlywhen these factors are identified can strategies be implemented to support nurses inclarifying their values, examining issues and dealing with their feelings. Nurseadministrators and staff nurses must join forces to develop support systems andstructures.Recommendations for Further ResearchThis descriptive study is the first in British Columbia to describe the experiencesof medical/surgical nurses about the ethical situations they encountered and howEthical Issues85disturbed they were by them. As first level research, this study has identified a numberof areas that warrant further investigation. It also provides direction for refinement ofthe survey questions. Therefore, based on the findings of this study, the followingrecommendations are made:1) Before being used again, the questionnaire requires further revision. Questionson the additional ethical issues nurses identified in this survey should be added. Forexample, additional questions related to active euthanasia, nurse/physician relationships,and Patient Care Associates should be formulated. The number of questions on DNRorders needs to be expanded and made more specific. Questions which elicited frequentcomments in the margins should be examined for clarity and specificity. Surveyquestions should be re-ordered. Presently, questions 1, 2, and 3 relate to nursingcompetence. This initial focus could evoke a negative reaction, influencing the numberand quality of subsequent responses. Finally, a “case history” question could be added tothe questionnaire. Nurses would be asked to describe the single most disturbing ethicalissue they had encountered in the past five years.2) This study should be replicated with a larger sample size of medical/surgicalnurses from rural and urban hospitals, and with nurses in other practice settings in orderto increase the generalizability of findings and to compare experiences of nurses acrossthe health care continuum.3) Future studies need to explore some of the additional ethical issues that nursesdescribed encountering in their practice setting (e.g. active euthanasia, DNR orders,withholding of medical intervention deemed necessary).4) Qualitative research should be conducted to explore more fully the ethical issuesEthical Issues86related to: (a) unsafe staffing patterns; (b) caring for a patient whose family isdemanding futile treatment; (c) prolonging a patient’s life when death is inevitable; (d)disagreeing with physicians about patient care; and (e) working with nurses who behaveirresponsibly. These five areas were revealed as the most distressing for this sample ofnurses. Focus group interviews would be an appropriate means of exploring andclarifying these areas.5) Future research needs to explore in more depth resources nurses need to resolveethical issues, their access to resources already available, and nurses’ input into ethicaldecisions.6) Future research needs to examine the different types of ethics educationprograms offered to nurses, in order to determine the effectiveness of differentapproaches in teaching nurses both to identify and to resolve ethical issues.7) Further research which explores the emotional responses to ethical issues nursesencounter in the clinical setting is required.8) Future research needs to examine and clarify terminology such as activeeuthanasia and patient assisted suicide.Ethical Issues87ReferencesAroskar, M.A. (1980). Anatomy of an ethical dilemma: The theory. American Journalof Nursing, 80, 658-660.Aroskar, M.A. (1989). 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Canadian Nurse, 82(3), 27-33.94Appendix ASURVEY OF ETHICAL ISSUES IN NURSING - REVISEDThank you for agreeing to participate in this study. Your input is important and Iappreciate your commitment.Directions:Ethical issues are disputes involving different points of view about what constitutesideal moral conduct. Listed on the following pages are some common situations involvingethical issues nurses may encounter in their practice.For each ethical issue please make two responses.• The first response refers to how frequently this specific situation hashappened in your practice during the past year.• The second response is your evaluation of how disturbed (i.e. uneasy; upset,mentally or emotionally) you get or would get if you did encounter this issue.Please circle the number that best represents your response in each category. Feelfree to make any comments next to any item.How FREQUENTLY How DISTURBEDhas this did you get whenhappened in the you encounteredlast year? this situation?o Never 0 Not at All1 Rarely 1 A Little2 Occasionally 2 Somewhat3 Frequently 3 Quite a Bit4 Very Frequently 4 A Great DealSection 1 Issues1. You know that a nursing 0 1 2 3 4 0 1 2 3 4colleague has failed toreport a medication error.2. You are facedwithmaking 0 1 2 3 4 0 1 2 3 4a decision about reportingan incompetent colleague (e.g. clinicallyoutdated, poor technical skills, etc.).95Survey of Ethical Issues in Nursing - Revised (Cont’d.)How FREQUENTLY How DISTURBEDhas this did you get whenhappened in the you encounteredlast year? this situation?0 Never 0 Not at All1 Rarely 1 A Little2 Occasionally 2 Somewhat3 Frequently 3 Quite a Bit4 Very Frequently 4 A Great Deal3. You know that a nursing colleague’s 0 1 2 3 4 0 1 2 3 4work performance is affected bysubstance abuse (alcohol and/or drugs).4. Your patient has unclarified code orders 0 1 2 3 4 0 1 2 3 4and you are asked to participate in aslow code or partial code.5. You are aware that the family of a 0 1 2 3 4 0 1 2 3 4competent elderly patient areseeking power of attorney withouthis/her knowledge.6. You know that a nursing colleague has 0 1 2 3 4 0 1 2 3 4failed to report an error of omission(e.g. missed drug/treatment).7. You are aware of illegal activity of 0 1 2 3 4 0 1 2 3 4a nursing colleague(s) (e.g.altering patient’s records, stealingfrom hospital supplies, etc.).8. You know information about prognosis 0 1 2 3 4 0 1 2 3 4is being withheld from the patientand/or family.9. You are aware that confidentiality of a 0 1 2 3 4 0 1 2 3 4patient’s records is violated.96Survey of Ethical Issues in Nursing - Revised (Cont’d.)How FREQUENTLY How DISTURBEDhas this did you get whenhappened in the you encounteredlast year? this situation?0 Never 0 Not at All1 Rarely 1 A Little2 Occasionally 2 Somewhat3 Frequently 3 Quite a Bit4 Very Frequently 4 A Great Deal10. You are faced with unsafe staffing 0 1 2 3 4 0 1 2 3 4patterns (e.g. high patient-nurseratios, frequent double shifts,excessive overtime, etc.).11. You advocate on a patient’s behalf 0 1 2 3 4 0 1 2 3 4and face a disagreement with aphysician over patient care.12. You know one of your patients has 0 1 2 3 4 0 1 2 3 4consented to a medical procedurewhich he/she does not understand.13. You know that the patient and/or 0 1 2 3 4 0 1 2 3 4family has not received completeinformation about a scheduledprocedure/treatment.14. You have to work with inadequate 0 1 2 3 4 0 1 2 3 4and/or out-dated equipment.15. You are caring for a patient whose 0 1 2 3 4 0 1 2 3 4family is demanding futile treatment.16. You work with a nurse who regularly 0 1 2 3 4 0 1 2 3 4behaves irresponsibly (e.g. inappropriatesick calls, extended break periods, etc.).97Survey of Ethical Issues in Nursing - Revised (Cont’d.)How FREQUENTLY How DISTURBEDhas this did you get whenhappened m the you encounteredlast year? this situation?0 Never 0 Not at All1 Rarely 1 A Little2 Occasionally 2 Somewhat3 Frequently 3 Quite a Bit4 Very Frequently 4 A Great Deal17. You are aware of unreported incidents 0 1 2 3 4 0 1 2 3 4of patient abuse (psychological orphysical) by nursing staff.18. You have a patient whose life is being 0 1 2 3 4 0 1 2 3 4prolonged with heroic measures althoughdeath is inevitable.19. You are caring forapatientwho is 0 1 2 3 4 0 1 2 3 4receiving treatment despite his/herobjection.20. You know that family members of an 0 1 2 3 4 0 1 2 3 4elderly patient are trying toconvince him/her to refuse necessarytreatment.21. You are asked to practice nursing in 0 1 2 3 4 0 1 2 3 4a way that violates your personal values(e.g. caring for a patient who is havingan abortion, assisting with ECT, etc.).22. You know that confidential patient 0 1 2 3 4 0 1 2 3 4matters are being discussed in public.23. You are working with a physician who 0 1 2 3 4 0 1 2 3 4demonstrates inadequate knowledgeand skills to provide safe medical care.98Survey of Ethical Issues in Nursing - Revised (Cont’d.)How FREQUENTLY How DISTURBEDhas this did you get whenhappened in the you encounteredlast year? this situation?0 Never 0 Not at All1 Rarely 1 A Little2 Occasionally 2 Somewhat3 Frequently 3 Quite a Bit4 Very Frequently 4 A Great Deal24. You are asked towork inaclinical 0 1 2 3 4 0 1 2 3 4setting for which you do not havethe specialized skills and knowledge.25. You are aware that a patient is 0 1 2 3 4 0 1 2 3 4being restrained unnecessarily.26. As the patient’s nurse, you have not 0 1 2 3 4 0 1 2 3 4been consulted about your personalethical conflicts related to the careyou are required to give.27. What ethical issues have you faced in the past year that were not described in thequestions above?99Section II DirectionsCircle yes no for each of the following four statements.28. Do you possess a copy of the CNA Code of Yes NoEthics?29. Have you referred to the Code of Ethics Yes Noin the past year?30. Are you familiar with the R.N.A.B.C. Yes NoStandards for Nursing Practice (1992)?31. Have you used the R.N.A.B.C. Standards Yes Nofor Practice in the past year?Section III32. Please check the resource(s) you have (‘I) if usedused in trying to resolve ethical issuesin the past year.A. Hospital ChaplainB. Head Nurse/Nurse ManagerC. Nursing colleaguesD. Nursing InstructorE. Clinical Nurse Specialist/Clinical Resource NurseF. Director of NursingG. Nursing ConsultantH. PhysicianI. Social Worker3. Nursing ethics roundsK. Educational sessions on ethical principlesL. Consultation with an ethicistM. Institutional ethics committeeN. Literature0. Family MembersP. Other____________(specify)100Section IVBACKGROUND INFORMATIONI would like to know a few facts about yourself. This information is for statistical analysisonly. Please check whichever description applies to you and fill in the requestedinformation.1. Nursing EducationPlease check the highest level of education you have completed._____Two year diploma programThree year diploma programPost-basic baccalaureate programFour year university programMaster’s program or higherOther (please specify):__________________________2. Area in Which You Currently WorkMedical Unit_____Combined Medical/Surgical UnitSurgical Unit3. Number of years you have practiced as a nurse.______years4. Number of years you have worked in medical and/or surgical nursing. years5. What was your age on your last birthday? years6. GenderFemale Male7. How many beds does your hospital have?__________beds8. In what city/town is your hospital located?____________________ _____Thank you for completing the questionnaire. Please return in the envelope provided.101Appendix BDear Colleague:My name is Debbie Hollands. I am a graduate student at the University of BritishColumbia School of Nursing, and I am conducting a research study entitled “Survey ofEthical Issues in Nursing” for my Master’s thesis. My faculty advisor is Dr. Sonia Acorn.Medical/Surgical nurses face many complex and difficult ethical dilemmas in their practice.The purpose of my research is to identify which ethical issues nurses face most frequentlyand describe how disturbed they are by these situations.Your name has been randomly selected to receive this package by the RNABC computerbank. This service is paid for by the investigator. I am not aware of the identities of thenames selected in order to ensure complete anonymity. Your participation in this study isvoluntary. A completed questionnaire will be viewed as an indication that you haveconsented to participate.Please find enclosed in the package a questionnaire consisting of three sections. SectionOne asks you about the frequency with which you have encountered specific ethical issuesin the past year, and how disturbed you were by these issues. Section Two asks you fourquestions relating to your understanding of professional standards. Section Three asks youto check the resource(s) you have used in trying to resolve ethical issues in the past year.Also enclosed is a biographical information form; results will be correlated with yourresponses to the questions about ethical issues.Should you agree to complete this questionnaire as part of my study, your contribution willbe most appreciated. You have the right to decide not to participate, or to refuse to answerany questions. All information is confidential and you are not required to identify yourselfin any way. A copy of the research results, when completed, can be made available uponrequest.We need to know more about the ethical dilemmas nurses face. By understanding theperspective of bedside nurses, our profession can develop better strategies to helpcaregivers, patients and families work through difficult choices and decisions. Please take15 minutes to complete these questionnaires.If you have any questions about this study, please contact me at XXX-XXXX or Dr. SoniaAcorn at XXX-XXXX. Thank you in advance for your cooperation.Sincerely,D. Hollands, R.N., B.S.N.End.

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