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Ethical conflict and response in community health nursing practice Duncan, Susan Maxine 1989

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ETHICAL CONFLICT AND RESPONSE IN COMMUNITY HEALTH NURSING PRACTICE By SUSAN MAXINE DUNCAN B.Sc.N., The U n i v e r s i t y of A l b e r t a , 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING In THE FACULTY OF GRADUATE STUDIES (SCHOOL OF NURSING) We a c c e p t t h i s t h e s i s as c o n f o r m i n g to the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1989 Susan Maxine Duncan, 1989 © In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT The purpose of the study was to d e s c r i b e the types of e t h i c a l dilemmas experienced by community h e a l t h nurses and t h e i r responses to them. S p e c i f i c a l l y , the resea r c h questions d i r e c t e d the i d e n t i f i c a t i o n of those c l i n i c a l s i t u a t i o n s which contained the dilemmas, the inherent e t h i c a l c o n f l i c t s , the nurses' responses to them, and the fo r c e s i n f l u e n c i n g t h e i r occurrence. Due to the e x p l o r a t o r y nature of the study, a d e s c r i p t i v e survey was s e l e c t e d as the re s e a r c h method. The C r i t i c a l I n c i d ent Technique (Flanagan, 1954) and the Model f o r C r i t i c a l E t h i c a l A n a l y s i s ( C u r t i n , 1978) were the b a s i s f o r the development of the data c o l l e c t i o n guide. The CHNs who r e c e i v e d copies of the guide were asked to d e s c r i b e i n w r i t i n g the p r a c t i c e s i t u a t i o n s which had contained dilemmas and t h e i r responses to them. T h i r t y CHNs p r a c t i c i n g i n communities throughout B.C p a r t i c i p a t e d by completing and r e t u r n i n g t h e i r responses to the guides. T h e i r w r i t t e n responses I n d i c a t e d they were able to i d e n t i f y common p r a c t i c e s i t u a t i o n s which had contained e t h i c a l dilemmas. Furthermore, these nurses were able to i d e n t i f y the c o n f l i c t s which had e x i s t e d f o r them, t h e i r i i i f e e l i n g s , a n d t h e i r e x p e r i e n c e s w i t h t h e d e c i s i o n - m a k i n g p r o c e s s . C o n t e n t a n a l y s e s o f t h e n u r s e s ' r e s p o n s e s r e s u l t e d i n t h r e e c a t e g o r i e s o f d i l e m m a s - c l i e n t s ' r i g h t s , s y s t e m i n t e r a c t i o n , a n d n u r s e s ' r i g h t s . W i t h i n t h e s e c a t e g o r i e s , t h e d i l e m m a s a r e c h a r a c t e r i z e d by one o r more e t h i c a l c o n f l i c t s w h i c h r e s u l t e d i n d i f f i c u l t c h o i c e s f o r t h e n u r s e s . D u r i n g d a t a a n a l y s i s , t h e s i t u a t i o n s w e r e f u r t h e r a n a l y z e d t o i d e n t i f y u n d e r l y i n g e t h i c a l t h e m e s a n d i n f l u e n t i a l f o r c e s . The e t h i c a l t h e m e s u n d e r l y i n g t h e n u r s e s ' d i l e m m a s f u n d a m e n t a l l y i n v o l v e d c o n f l i c t s b e t w e e n t h e p r i n c i p l e s o f a u t o n o m y , b e n e f i c e n c e a n d j u s t i c e . A d d i t i o n a l l y , human r i g h t s a n d v a l u e c o n f l i c t s a r e r e l e v a n t i n s i t u a t i o n s w h e r e t h e n u r s e s a r e c a r i n g f o r h i g h - r i s k c l i e n t g r o u p s ; i n t e r a c t i n g w i t h t h e h e a l t h c a r e t e a m ; a n d a s s e r t i n g t h e i r own r i g h t s as e m p l o y e e s , p r o f e s s i o n a l n u r s e s , a n d c i t i z e n s . K e y r e s t r a i n i n g a n d d r i v i n g f o r c e s i n f l u e n c e d t h e C H N s ' e x p e r i e n c e w i t h t h e d i l e m m a s . R e s t r a i n i n g f o r c e s i n c l u d e d p o l i c y , a n d a l a c k o f i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n . D r i v i n g f o r c e s i n c l u d e d s u p p o r t i v e n u r s i n g l e a d e r s h i p , c o n s u l t a n t s f r o m o t h e r d i s c i p l i n e s , n u r s i n g k n o w l e d g e a n d s k i l l , t h e n u r s e - c l i e n t r e l a t i o n s h i p a n d m o s t i m p o r t a n t l y t h e n u r s e s ' i n t e r a c t i o n w i t h c o l l e a g u e s . T h e s e CHNs saw t h e i r r o l e as one o f an a d v o c a t e f o r t h e i r c l i e n t s . i v A l t h o u g h the e t h i c a l dilemmas d e s c r i b e d by t h i s sample of CHNs a r e n o t n o t a b l y d i f f e r e n t from t h o s e e x p e r i e n c e d by n u r s e s i n o t h e r s e t t i n g s , t h e way i n wh i c h t h e s e n u r s e s e x p e r i e n c e them i s i n f l u e n c e d by u n i q u e f e a t u r e s o f t h e i r r o l e . These u n i q u e f e a t u r e s r e s u l t from t h e CHN's p o s i t i o n i n the h e a l t h c a r e s y s t e m . The CHN i s o f t e n a p r i m a r y c o n t a c t f o r c l i e n t s , and t h e r e f o r e o f t e n assumes a r o l e i n i n i t i a t i n g and c o o r d i n a t i n g r e f e r r a l s to s o c i a l w o r k e r s , p h y s i c i a n s , and o t h e r s . F u r t h e r m o r e the i n d e p e n d e n t n a t u r e of community h e a l t h n u r s i n g p r a c t i c e i n c r e a s e s t h e i r needs f o r c o l l a b o r a t i o n w i t h o t h e r s who a r e o f t e n removed from t h e i r s e t t i n g o f p r a c t i c e . F i n a l l y , b e c a u s e t h i s group of n u r s e s see c l i e n t s i n t h e i r n a t u r a l community s e t t i n g s , t h e y have an awareness of community h e a l t h c o n d i t i o n s w hich a r e d e t e r m i n a n t s of h e a l t h . Based on t h e s e f i n d i n g s , i m p l i c a t i o n s f o r community h e a l t h n u r s i n g p r a c t i c e , n u r s i n g e d u c a t i o n , and n u r s i n g r e s e a r c h a r e p r o p o s e d . TABLE OF CONTENTS A b s t r a c t . i i T a b l e o f C o n t e n t s v L i s t o f T a b l e s . v i i i A c knowledgements i x CHAPTER ONE: INTRODUCTION 1 B a c k g r o u n d to the P r o b l e m 1 C o n c e p t u a l Framework 5 P r o b l e m S t a t e m e n t . 6 P u r p o s e . • . 6 R e l e v a n c e 6 D e f i n i t i o n of Terms 7 A s s u m p t i o n s 8 O r g a n i z a t i o n o f the T h e s i s . ... 9 Summary 9 CHAPTER TWO: LITERATURE REVIEW 10 E t h i c a l T h e o r y 10 E t h i c a l T h e o r y and H e a l t h Care 14 N u r s i n g E t h i c s 16 Codes o f E t h i c s 19 The E t h i c a l Dilemma 21 R e s e a r c h i n N u r s i n g E t h i c s 23 A S o c i a l and H i s t o r i c a l P e r s p e c t i v e 24 The C l i e n t ' s P e r s p e c t i v e 25 N u r s e s ' R e s p o n s e s 26 D e c i s i o n - M a k i n g i n Dilemmas 28 The Dilemma 29 D e c i s i o n - m a k i n g models 33 The N a t u r e of Community H e a l t h N u r s i n g 39 E t h i c a l I s s u e s 44 Summary 47 CHAPTER THREE: METHODS 49 S e l e c t i o n of P a r t i c i p a n t s 49 Development of the Data C o l l e c t i o n G u i d e 51 Data C o l l e c t i o n 52 Data A n a l y s i s 55 L i m i t a t i o n s 57 E t h i c a l C o n s i d e r a t i o n s 58 Summary 5 9 v i CHAPTER FOUR: FINDINGS 60 C h a r a c t e r i s t i c s of the P a r t i c i p a n t s 60 Types of Dilemmas and Responses 62 C l i e n t s ' Rights 63 High-Risk P a r e n t i n g 63 C o n f l i c t s 64 Responses 67 Mental Health Concerns 69 C o n f l i c t s 70 Responses 71 A d o l e s c e n t s ' Rights 72 C o n f l i c t s 72 Responses 74 System I n t e r a c t i o n 75 Team R e l a t i o n s h i p s 75 C o n f l i c t s 75 Responses «... 7 7 A l l o c a t i o n of Resources 78 C o n f l i c t s 78 Responses 80 Nurses' Rights 81 C o n f l i c t s 81 Responses . . 83 Summary 84 CHAPTER FIVE: DISCUSSION 86 E t h i c a l Themes 86 C l i e n t s ' Rights 87 System I n t e r a c t i o n 91 Nurses' Rights 94 Forces 96 R e s t r a i n i n g Forces 97 S o c i e t a l Values and P o l i c y 97 I n t e r d i s c i p l i n a r y R e l a t i o n s h i p s 102 D r i v i n g Forces . 103 Leadership . 104 Resources 104 Knowledge and S k i l l 105 The N u r s e - C l i e n t R e l a t i o n s h i p ... 105 Colleagues 105 Nursing Role 106 No E t h i c a l Dilemmas 109 Summary m v i i CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING 113 Summary . 113 Conclusions 117 I m p l i c a t i o n s 120 Nursing P r a c t i c e 120 Nursing Education 123 Nursing Research 125 Concluding Remarks . . 126 REFERENCES . . 127 APPENDICES 135 Appendix A L e t t e r of Information 135 Appendix B Data C o l l e c t i o n Guide 136 Appendix C Consent Form 145 Appendix D L e t t e r of Approval-CHNIG 146 LIST OF TABLES v i i i C h a r a c t e r i s t i c s of P a r t i c i p a n t s TABLE I. Response Rates f o r Two Samples 61 I I . Years of General and Community Health Nursing Experience • 61 I I I . L e v e l of Education 62 i x ACKNOWLEDGEMENTS Many i n d i v i d u a l s s u p p o r t e d me t h r o u g h t h i s c h a l l e n g i n g p r o c e s s . F i r s t , I would l i k e to ac k n o w l e d g e the community h e a l t h n u r s e s who p a r t i c i p a t e d i n the s t u d y . T h e i r e f f o r t s r e q u i r e d s i g n i f i c a n t amounts of t i m e , and t h e i r c o n c e r n s f o r t h e i r c l i e n t s ' r i g h t s and the h e a l t h o f t h e i r c o m m u n i t i e s a r e i m p r e s s i v e . A d d i t i o n a l l y , I v a l u e a l l t h a t I have l e a r n e d a b o u t e t h i c s i n n u r s i n g from my c l i e n t s and the many e x c e l l e n t n u r s e s I have had the p r i v i l e g e of w o r k i n g w i t h . I w i s h to e x t e n d my t h a n k s to the members o f my t h e s i s committee - P r o f e s s o r s H e l e n E l f e r t , B e t t y D a v i e s , and Ray Thompson. They p r o v i d e d t h e r i g h t b a l a n c e of c r i t i q u e and a c c e p t a n c e of my i d e a s . F u r t h e r m o r e t h e y s h a r e d t h e i r wisdom, e x p e r i e n c e and e n t h u s i a s m f o r r e s e a r c h . I w i s h to e x p r e s s my g r a t i t u d e to the f r i e n d s and f a m i l y members who e n o u r a g e d me. To Paddy, N o r a , Wendy, L o r i f o r s h a r i n g i n s i g h t s and e n t h u s i a s m . And to D a v i d f o r g e n e r o u s l y g i v i n g h i s time and e x p e r t i s e to the p r o c e s s i n g of t h i s t h e s i s and f o r the i n s p i r a t i o n of h i s f r i e n d s h i p . F i n a l l y , my p a r e n t s ' l i f e l o n g s u p p o r t of my e d u c a t i o n d e s e r v e s s p e c i a l m e n t i o n . 1 CHAPTER ONE INTRODUCTION B a c k g r o u n d to the P r o b l e m Over the p a s t t h r e e d e c a d e s n u r s e s , p h y s i c i a n s , consumers of h e a l t h c a r e and o t h e r s have become i n c r e a s i n g l y aware of m o r a l i s s u e s a r i s i n g w i t h i n a c h a n g i n g h e a l t h c a r e s y s t e m . R a p i d t e c h n o l o g i c a l change, r i s i n g h e a l t h c a r e c o s t s , p l u r a l i s t i c s o c i e t a l v a l u e s , and a g r e a t e r u n d e r s t a n d i n g of the r e l a t i o n s h i p between consumer r i g h t s and p r o f e s s i o n a l r e s p o n s i b i l i t i e s a r e c i t e d as f a c t o r s i n f l u e n c i n g t h i s e x p a n d i n g awareness o f m o r a l i s s u e s ( S t o r c h , 1982; E n g l e h a r d t , 1 9 8 6 ) . P h i l o s o p h i c a l i n q u i r y i n t o the n a t u r e of m o r a l i s s u e s i n h e a l t h c a r e has ac c o m p a n i e d t h i s a w a r e n e s s . " E t h i c s i s a b r a n c h of p h i l o s o p h y ; i t i s p h i l o s o p h i c a l t h i n k i n g a bout m o r a l i t y , m o r a l p r o b l e m s , and m o r a l j u d g e m e n t s " ( F r a n k e n a , 1973, p. 4 ) . P h i l o s o p h i c a l e t h i c s d i r e c t s i n q u i r y i n t o m o r a l i t y , a t r a d i t i o n o f b e l i e f s a bout r i g h t and wrong human c o n d u c t (Beauchamp and W a l t e r s , 1982; E n g l e h a r d t , 1986; F r a n k e n a , 1 9 7 3 ) . As E n g l e h a r d t d e s c r i b e s , " p h i l o s o p h y done w e l l i s a c u l t u r e e x a m i n i n g i t s own c o n c e p t u a l and v a l u e p r e s u m p t i o n s " (1986, p. 8 ) . E t h i c s i n h e a l t h c a r e has been termed b i o - e t h i c s , a f i e l d w h i c h e n d e a v o u r s to i n t e r p r e t the m o r a l l y p e r p l e x i n g i s s u e s a r i s i n g d i r e c t l y f r o m c o n c e r n s of p a t i e n t s , 2 p h y s i c i a n s , nurses, and others ( E n g l e h a r d t , 1986, p. 1). The r e c o g n i t i o n of human r i g h t s to s e l f d e t e r m i n a t i o n and the a l l o c a t i o n of h e a l t h care resources are examples of these moral concerns. Fundamentally, the f i e l d of b i o e t h i c s addresses the q u e s t i o n : "How can I c o n s i s t e n t l y understand what i s r i g h t conduct i n the h e a l t h care p r o f e s s i o n s , and i n the b i o m e d i c a l s c i e n c e s and j u s t i f y i t to o t h e r s ? " ( E n g l e h a r t , 1986, p. 9). Nursing e t h i c s , a subsystem w i t h i n the l a r g e r system of b i o e t h i c s , has evolved i n r e l a t i o n to nursing's development as a p r o f e s s i o n (Lamb, 1981) and as a r e s u l t of s o c i e t a l f o r c e s i n f l u e n c i n g the nursing r o l e ( S t o r c h , 1977; 1982). These f o r c e s i n c l u d e those p r e v i o u s l y d e s c r i b e d as i n f l u e n c i n g the h e a l t h care system as w e l l as s p e c i a l i z a t i o n , changing pat t e r n s of care w i t h i n n u r s i n g , and the women's movement ( S t o r c h , 1977). Furthermore, the r e c e n t l y developed Code of E t h i c s of the Canadian Nurses A s s o c i a t i o n (CNA) attempts to c l a r i f y those e t h i c a l p r i n c i p l e s that are d e f i n i t i v e of e t h i c a l n u r s i n g a c t i v i t y (C.N.A., 1985). The preamble to the Code of E t h i c s r e f e r s to the need f o r ongoing r e f l e c t i o n and d e l i n e a t i o n of s p e c i f i c circumstances i n cases r e p r e s e n t i n g e t h i c a l problems and dilemmas f o r nurses. Various c o n c e p t u a l i z a t i o n s of e t h i c a l problems v i s - a -v i s dilemmas appear i n the n u r s i n g l i t e r a t u r e (C.N.A., 1985; C u r t i n and F l a h e r t y , 1982; Davis and Aroskar, 1978; Murphy, 3 1978), and the d i s t i n c t i o n between the two i s not made c o n s i s t e n t l y . The dilemma i s most f r e q u e n t l y d e s c r i b e d as a s i t u a t i o n i n v o l v i n g a choice between u n s a t i s f a c t o r y a l t e r n a t i v e s , r e s u l t i n g i n c o n f l i c t , t e n s i o n , and questions such as: " What i s the r i g h t t h i n g to do?", and "What harm and b e n e f i t w i l l r e s u l t from t h i s choice or d e c i s i o n ? " (Aroskar, 1980; Davis and Aroskar, 1978; C u r t i n , 1978; 1982). These c h a r a c t e r i s t i c s of c o n f l i c t and choice i n e t h i c a l dilemmas can be best understood w i t h i n the context of an e t h i c a l decision-making process which f a c i l i t a t e s the a p p l i c a t i o n of e t h i c a l theory and concepts w i t h i n the stages of decision-making (Aroskar, 1980; Crisham, 1985; C u r t i n , 1978,1982; Thompson and Thompson, 1985). It i s apparent that nursing may b e n e f i t from f u r t h e r understanding the nature of e t h i c a l dilemmas and decision-making a s s o c i a t e d with d i f f e r e n t p r a c t i c e s e t t i n g s and n u r s i n g r o l e s . Furthermore, i t has been suggested that f u t u r e i n v e s t i g a t o r s might examine the u n d e r l y i n g e t h i c a l p r i n c i p l e s , t h e o r i e s , and r u l e s f o r a c t i o n that nurses a r t i c u l a t e i n r e l a t i o n to t h e i r c o n c e p t u a l i z a t i o n of the e t h i c a l dilemma (Gortner, 1985). Community h e a l t h nursing can be d i s t i n g u i s h e d as a unique typology of p r a c t i c e by i t s broad focus of care f o r i n d i v i d u a l s , f a m i l i e s , and groups w i t h i n v a r i o u s community s e t t i n g s (A.N.A., 1985; Anderson, 1983; Archer and Fleshman, 1976; C.P.H.A., 1983). In her d i s c u s s i o n of e t h i c a l i s s u e s 4 i n community h e a l t h n u r s i n g , Aroskar r e f e r s to t h i s broad focus of care and concern f o r h e a l t h with v a r i a b l e s such as f a m i l y , l i f e s t y l e , and community resources i n f l u e n c i n g the kinds of e t h i c a l dilemmas encountered by community h e a l t h nurses (Aroskar, 1979). E t h i c a l dilemmas f o r community h e a l t h nurses may o r i g i n a t e i n s i t u a t i o n s where the focus of care i s ambiguous. For example, the q u e s t i o n may a r i s e : i s the c l i e n t an i n d i v i d u a l , a f a m i l y , or a group? A focus on h e a l t h care f o r groups appeals to the u t i l i t a r i a n e t h i c of the g r e a t e s t good f o r the g r e a t e s t number. A l t e r n a t i v e l y , concern f o r the i n d i v i d u a l or f a m i l y c l i e n t i s most o f t e n based on a d e o n t o l o g i c a l p e r s p e c t i v e which emphasizes p r i n c i p l e s of autonomy and beneficence and i s more compatible with nursing's codes of e t h i c s (Aroskar, 1979; Fry, 1985). These two p o t e n t i a l l y c o n f l i c t i n g e t h i c s o r i g i n a t i n g from p u b l i c h e a l t h and nursing s c i e n c e s r e s p e c t i v e l y may r e s u l t i n s i g n i f i c a n t e t h i c a l t e n s i o n f o r the nurse (Aroskar, 1979; Fry, 1983, 1985). A d d i t i o n a l e t h i c a l dilemmas i n community h e a l t h nursing may a r i s e when the nurse i s c a r i n g f o r disadvantaged, h i g h - r i s k , or immigrant p o p u l a t i o n s . Issues of c o n f i d e n t i a l i t y , a c c e s s i b i l i t y to h e a l t h care, and i n t e r - p r o f e s s i o n a l communication are p o t e n t i a l l y dilemmatic i n a v a r i e t y of c l i n i c a l s i t u a t i o n s . Examples of these c l i n i c a l s i t u a t i o n s may i n c l u d e : the r e p o r t i n g of c h i l d 5 a b u s e , i n t e r p r e t i n g the h e a l t h c a r e s y s t e m f o r i m m i g r a n t c l i e n t s , or a d d r e s s i n g the l a c k of a c c e s s i b l e c a r e f o r t h o s e a t g r e a t e s t r i s k . However, whether community h e a l t h n u r s e s p e r c e i v e any or a l l of t h e s e c l i n i c a l s i t u a t i o n s to r e p r e s e n t e t h i c a l dilemmas i s unknown. To d a t e , t h i s w r i t e r has been u n a b l e to l o c a t e any s t u d i e s d o c u m e n t i n g the community h e a l t h n u r s e s ' p e r c e p t i o n of the n a t u r e of the e t h i c a l dilemma. C o n c e p t u a l Framework C u r t i n ' s (1978) model f o r c r i t i c a l e t h i c a l a n a l y s i s w i l l p r o v i d e the c o n c e p t u a l framework f o r t h i s s t u d y . T h i s model i d e n t i f i e s the f o l l o w i n g e s s e n t i a l components o f the a n a l y s i s of s i t u a t i o n s i n v o l v i n g e t h i c a l dilemmas or p r o b l e m s : d e s c r i b i n g b a c k g r o u n d i n f o r m a t i o n w h i c h c o n t r i b u t e s to u n d e r s t a n d i n g the p r o b l e m o r dilemma, i d e n t i f i c a t i o n of the e t h i c a l components o f t h e p r o b l e m , i d e n t i f i c a t i o n of the e t h i c a l a g e n t s or a l l t h o s e i n v o l v e d i n d e c i s i o n - m a k i n g , i d e n t i f i c a t i o n of o p t i o n s , a p p l i c a t i o n of e t h i c a l p r i n c i p l e s , and r e s o l u t i o n . The p u r p o s e of u s i n g the model i s to i d e n t i f y the e t h i c a l components of the dilemmas d e s c r i b e d by the n u r s e s , t h e r i g h t s and v a l u e s of t h o s e i n v o l v e d , and the n u r s e s ' r e s p o n s e s w i t h i n the c o n t e x t of the d e c i s i o n - m a k i n g p r o c e s s . 6 Problem Statement In order to d e s c r i b e the nature of the e t h i c a l dilemmas and decision-making i n community h e a l t h n u r s i n g , the focus of the study w i l l be to i n v e s t i g a t e the f o l l o w i n g q u e s t i o n s : What c l i n i c a l s i t u a t i o n s or circumstances comprise e t h i c a l dilemmas f o r community h e a l t h nurses? What e t h i c a l c o n f l i c t s c h a r a c t e r i z e the dilemmas? What are the nurses' responses to these dilemmas? What f a c t o r s i n f l u e n c e the nurses' experience of the e t h i c a l dilemma? Purpose of the Study The purpose of t h i s study i s to begin to d e s c r i b e the nature of the e t h i c a l dilemmas i n community h e a l t h n u r s i n g p r a c t i c e and develop some understanding of the context of these dilemmas and how i t i n f l u e n c e s the nurses' p e r c e p t i o n s of elements of the e t h i c a l decision-making process. Relevance It i s intended that t h i s study w i l l c o n t r i b u t e to a developing awareness of the nursing e t h i c s a s s o c i a t e d with the community h e a l t h nursing r o l e . Community h e a l t h nurses o f t e n have a broad p e r s p e c t i v e on the f u n c t i o n i n g of the h e a l t h care system. Therefore awareness of the dilemmas they i d e n t i f y could c o n t r i b u t e to understanding the problems c l i e n t s encounter while n e g o t i a t i n g t h e i r care and the n u r s i n g r e s p o n s i b i l i t i e s i n advocating f o r human r i g h t s concerns i n h e a l t h c a r e . Since the Code of E t h i c s of the Canadian Nurses A s s o c i a t i o n c a l l s f o r ongoing e t h i c a l r e f l e c t i o n i n r e l a t i o n to s p e c i f i c moral s i t u a t i o n s , the 1 . 2 . 3 . 4 . 7 study may c o n t r i b u t e to understanding how the Code gives d i r e c t i o n f o r making d e c i s i o n s about e t h i c a l dilemmas i n community h e a l t h n u r s i n g p r a c t i c e . D e f i n i t i o n of Terms Community Health Nurse: A nurse employed i n the p r e v e n t i v e h e a l t h program i n a suburban h e a l t h department or who i s a member of the Community Health Nursing I n t e r e s t Group (CHNIG) of B.C. and i s c u r r e n t l y p r a c t i c i n g community h e a l t h n u r s i n g . Community h e a l t h nursing p r a c t i c e c o n s i s t s of nursing a c t i v i t i e s i n long term care, p r e v e n t i o n , and h e a l t h promotion programs. The focus of care encompasses a broad p e r s p e c t i v e on the h e a l t h of the community while the u n i t of s e r v i c e may be the i n d i v i d u a l , f a m i l y , or group i n a v a r i e t y of s e t t i n g s . Context of the e t h i c a l dilemma: The context of the e t h i c a l dilemma w i l l r e f e r to s p e c i f i c f e a t u r e s of the community h e a l t h nursing r o l e and s e t t i n g . In p a r t i c u l a r , the f o r c e s i n f l u e n c i n g the nurses' decision-making i n e t h i c a l l y p roblematic c l i n i c a l s i t u a t i o n s w i l l be analyzed i n r e l a t i o n to c u r r e n t l i t e r a t u r e and s o c i a l i s s u e s r e l e v a n t to the context of nursing and h e a l t h care d e l i v e r y . E t h i c a l Dilemma: Any c l i n i c a l s i t u a t i o n or i n c i d e n t that i s p e r c e i v e d by the nurse to be m o r a l l y p e r p l e x i n g and p r o b l e m a t i c , and which r a i s e s questions about how the needs 8 of c l i e n t s may be met while r e s p e c t i n g t h e i r human r i g h t s and those values considered to be the most important. The e t h i c a l dilemma t y p i c a l l y i n v o l v e s a choice between seemingly e q u a l l y u n s a t i s f a c t o r y a l t e r n a t i v e s , and evokes f e e l i n g s of c o n f l i c t . The d e c i s i o n maker(s) grapple with the q u e s t i o n : "What i s the r i g h t t h i n g to do?. E t h i c a l c o n f l i c t : The c o n t r a d i c t i o n or d i s c r e p a n c y between v a l u e s , p r i n c i p l e s , or human r i g h t s e x i s t i n g w i t h i n a choice between two or more courses of a c t i o n . One or more types of e t h i c a l c o n f l i c t s may c h a r a c t e r i z e the dilemma. Nurses' responses: The nurses' responses c o n s i s t s of t h e i r involvement i n the e t h i c a l decision-making process i n c l u d i n g the a l t e r n a t i v e s they i d e n t i f i e d , s e l e c t e d , and t h e i r p e r c e p t i o n s of the f a c t o r s i n f l u e n c i n g t h e i r r o l e i n these s i t u a t i o n s . Assumptions Three assumptions were inherent i n the design and r a t i o n a l e f o r t h i s study. The most fundamental assumption was that community h e a l t h nurses experience e t h i c a l dilemmas i n t h e i r p r a c t i c e . Secondly, i t was assumed that nurses understand the concept of e t h i c a l dilemma and can i d e n t i f y the c l i n i c a l s i t u a t i o n s i n which they occur. T h i r d l y , i t was assumed that nurses can r e t r o s p e c t i v e l y analyze t h e i r responses to the e t h i c a l dilemma and d e s c r i b e these i n 9 r e l a t i o n to the components of the e t h i c a l decision-making p r o c e s s . O r g a n i z a t i o n of the Thesis The f o l l o w i n g chapters d e s c r i b e the phases of the r e s e a r c h process as i t was undertaken to answer the questions descibed i n the problem statement. To t h i s end, chapter two c o n t a i n s a review of n u r s i n g , p h i l o s o p h i c a l , h e a l t h and s o c i a l s c i e n c e s l i t e r a t u r e . Chapter three i s a d e s c r i p t i o n of the methodological approach. The f i n d i n g s w i l l be presented i n chapter four and d i s c u s s e d i n chapter f i v e . F i n a l l y , the e n t i r e process w i l l be summarized, concluded, and the i m p l i c a t i o n s f o r nursing p r a c t i c e , e d u c a t i o n , and r e s e a r c h w i l l be proposed i n the s i x t h and f i n a l chapter of the t h e s i s . Summary This chapter has presented the background f o r understanding the r e s e a r c h problem. C u r t l n ' s (1978) Model fo r C r i t i c a l E t h i c a l A n a l y s i s was i n t r o d u c e d as the conceptual framework f o r the study. A d d i t i o n a l l y , the study's purpose, relevance and u n d e r l y i n g assumptions were c l a r i f i e d . F i n a l l y , key terms used to d e l i n e a t e the research problem and purpose were d e f i n e d and the o r g a n i z a t i o n of the t h e s i s was o u t l i n e d . 10 CHAPTER TWO REVIEW OF THE LITERATURE The l i t e r a t u r e review develops the context f o r the research problem presented i n the previous chapter. This r e q u i r e s an comparative a n a l y s i s of i n f l u e n t i a l conceptual and i n v e s t i g a t i v e works i n the f o l l o w i n g areas: an overview of e t h i c a l t h e o r i e s and concepts and t h e i r r elevance to h e a l t h care, the d e f i n i t i o n of nursing e t h i c s and the e t h i c a l dilemma, nu r s i n g responses to e t h i c a l dilemmas and f i n a l l y what i s known about e t h i c a l c h a l l e n g e s i n community h e a l t h n u r s i n g . The development of the l a t t e r t o p i c w i l l n e c e s s a r i l y e n t a i l a d e s c r i p t i o n of the nature of community h e a l t h nursing i t s e l f . E t h i c a l Theory P h i l o s o p h i c a l l i t e r a t u r e c ontains v a r i o u s d e f i n i t i o n s of e t h i c s , morals, e t h i c a l theory, law, p r i n c i p l e s , r u l e s , as w e l l as e x p l a n a t i o n s of the r e l a t i o n s h i p s between these concepts. This d i s c u s s i o n begins with some c l a r i f i c a t i o n of the fundamental components and how they may be a p p l i e d . It i s necessary to make a d i s t i n c t i o n between e t h i c s and morals; these terms are o f t e n used i n t e r c h a n g e a b l y i n the l i t e r a t u r e as w e l l as i n c o n v e r s a t i o n . E t h i c s may be viewed as the formal study of the more i n f o r m a l t r a d i t i o n of m o r a l i t y . An e t h i c a l q u e s t i o n i s a why q u e s t i o n , whereas a moral que s t i o n i s a what ques t i o n ( S t o r c h , 1984). It 11 f o l l o w s that e t h i c s i s not to be confused with codes of behaviour or personal o p i n i o n s and b e l i e f s . Rather, " e t h i c s uses codes, b e l i e f s , o p i n i o n s , d e c i s i o n s , and g u i d e l i n e s as the raw m a t e r i a l f o r i t s a n a l y s i s , seeking norms by which to judge the adequacy of these c o n s t i t u e n t s of the morals of groups and i n d i v i d u a l s " (Campbell, 1987, p. 16). How should e t h i c s be a p p l i e d to moral questions? A h i e r a r c h i c a l approach to moral reasoning begins with a judgement or c o n c l u s i o n about an a c t i o n and works up through the l e v e l s of r u l e s , p r i n c i p l e s , and f i n a l l y t h e o r i e s (Beauchamp and C h i l d r e s s , 1983). Rules s p e c i f y that c e r t a i n a c t i o n s should or should not be taken on the b a s i s of whether they are r i g h t or wrong (Beauchamp and C h i l d r e s s , 1983, p. 5). Examples of r u l e s i n c l u d e : t r u t h - t e l l i n g , m a i n t a i n i n g c o n f i d e n t i a l i t y or p r i v a c y , and f i d e l i t y or m a i n t a i n i n g l o y a l t y i n r e l a t i o n s h i p s . P r i n c i p l e s are more general and encompassing than r u l e s and provide a b a s i s f o r t h e i r j u s t i f i c a t i o n (Beauchamp and C h i l d r e s s , 1983, p. 5). As components of these e t h i c a l t h e o r i e s , the p r i n c i p l e s of autonomy or u l t i m a t e respect f o r personhood, beneficence or the o b l i g a t i o n to do good and prevent harm, and j u s t i c e are fundamental to e t h i c a l analyses of moral i s s u e s (Beauchamp and Walters, 1982; Englehardt, 1986; Frankena, 1973). Furthermore, such concepts as p a t e r n a l i s m , personhood, and human r i g h t s are inherent i n these p r i n c i p l e s ( S t o r c h , 1982). 12 E t h i c a l t h e o r i e s , then, provide a framework of p r i n c i p l e s and r u l e s which can guide det e r m i n a t i o n of r i g h t and wrong conduct i n moral s i t u a t i o n s (Beauchamp and C h i l d r e s s , 1983, p. 5). The a p p l i c a t i o n of e t h i c a l t h e o r i e s as " a c t i o n guides" to s p e c i f i c problem areas i s d e f i n e d as a p p l i e d normative e t h i c s (Beauchamp and C h i l d r e s s , 1983). Deontology and u t i l i t a r i a n i s m are recognized as the two primary t h e o r i e s by most e t h i c i s t s . U t i l i t a r i a n i s m , a form of c o n s e q u e n t i a l i s m , d e f i n e s u l t i m a t e standards of r i g h t , wrong, and o b l i g a t i o n on the b a s i s of that which achieves the consequence of the g r e a t e s t balance of b e n e f i t f o r the g r e a t e s t number - i t appeals to the p r i n c i p l e of u t i l i t y (Beauchamp and C h i l d r e s s , 1983; Frankena, 1974, p. 34). D e o n t o l o g i c a l t h e o r i e s d e s c r i b e a c t i o n s as morally r i g h t or wrong on the b a s i s of the type of a c t i o n through an appeal to the u n d e r l y i n g r u l e s . Therefore an act i s r i g h t only i f i t conforms to a r u l e which may be f u r t h e r j u s t i f i e d by a moral p r i n c i p l e (Beauchamp and Walters, 1982, p. 19). John Rawl's theory of j u s t i c e , which has been d e s c r i b e d as a d e o n t o l o g i c a l c h a l l e n g e to u t i l i t a r i a n i s m , presents the e g a l i t a r i a n view of j u s t i c e as the b a s i s f o r the d i s t r i b u t i o n of b e n e f i t s and harms i n s o c i e t y (Beauchamp and Walters, 1982, p. 23; Rawls, 1971). The method of a n a l y z i n g e t h i c a l i s s u e s i n r e l a t i o n to o p p o s i t i o n a l t h e o r i e s has been r e - c o n s i d e r e d . Two e t h i c i s t s have i d e n t i f i e d four ways of c o n s i d e r i n g a moral i s s u e or 13 dilemma: an appeal to consequences, an appeal to r i g h t s , an appeal to j u s t i c e or e q u a l i t y and f i n a l l y an appeal to v i r t u e s of compassion, i n t e g r i t y , honesty, and courage (Englehardt and Brody, 1987, p. 2). These authors f u r t h e r suggest that the s i g n i f i c a n c e of each of these four modes should be examined i n r e l a t i o n to both deontology and u t i l i t a r i a n i s m as a way of moving beyond the tendency to focus on t h e i r c o m p e t i t i v e and c o n t r a d i c t o r y t r a i t s i n the f i e l d of a p p l i e d e t h i c s . An appeal to human r i g h t s as a d i s t i n c t mode of e t h i c a l i n q u i r y i s becoming more p r e v a l e n t i n the l i t e r a t u r e (Brody and Englehardt, 1987; Cranston, 1983; C u r t i n and F l a h e r t y , 1982; S t o r c h , 1984). In a d i s c o u r s e on the q u e s t i o n : "are there any human r i g h t s ? " , Cranston (1983) proposes two t e s t s . In the de t e r m i n a t i o n of a r i g h t , i t must f i r s t be t r u l y u n i v e r s a l , one that everyone has and secondly, i t must be of paramount importance such that i f v i o l a t e d - j u s t i c e i s then abused. Storch (1982) d e f i n e s r i g h t s as " j u s t i f i e d claims that persons or groups may make upon each other or s o c i e t y " (p. 26). This author a s s e r t s that the concept of r i g h t s i s a c t u a l l y a p r i n c i p l e , one of " c e n t r a l importance to e t h i c s and which spans the r e l a t e d but d i f f e r e n t d i s c i p l i n e s of e t h i c s and law" ( S t o r c h , 1984, p. 26). The nature of the r e l a t i o n s h i p between e t h i c s and law has been widely analyzed (Donaldson, 1986; Storch, 1982), and a s y n t h e s i s of the two i n r e l a t i o n to cur r e n t e t h i c a l 14 problems i s the s u b j e c t of many r e p o r t s by the Law Reform Commission of Canada. Storch (1982) explored the r e l a t i o n s h i p between law and e t h i c s . She e x p l a i n e d that the law i s sometimes more r i g o r o u s than e t h i c a l p r i n c i p l e s , while at other times i t may be congruent or s i l e n t with respect to these p r i n c i p l e s ( S t o r c h , 1982). The C o n s t i t u t i o n of Canada was amended to l e g i s l a t e the concept of human r i g h t s f o r Canadian s o c i e t y . The Canadian Charter of Rights and Freedoms (Governnment of Canada, 1981), guarantees fundamental freedoms i n c l u d i n g : (a) freedom of conscience and r e l i g i o n (b) freedom of thought, b e l i e f , o p i n i o n , and e x p r e s s i o n (c) freedom of p e a c e f u l assembly and (d) freedom of a s s o c i a t i o n . Furthermore, democratic, l e g a l , m i n o r i t y , language, and e q u a l i t y r i g h t s are l e g i s l a t e d i n Canadian s o c i e t y (Government of Canada, 1981). Given t h i s recent i n t e r p r e t a t i o n of r i g h t s and freedoms i n Canadian c o n s t i t u t i o n a l law, i t may be that the concept of human r i g h t s w i l l continue to evolve and bridge the r e l a t i o n s h i p between the f i e l d s of law and e t h i c s . Human r i g h t s i s s u e s have more s p e c i f i c i m p l i c a t i o n s f o r law and e t h i c s w i t h i n h e a l t h c a r e . The R e l a t i o n s h i p between E t h i c a l Theory and Health Care: From B i o e t h i c s to the " E t h i c s of Health Care" Recently, b i o e t h i c s has been r e - c o n c e p t u a l i z e d as the " e t h i c s of h e a l t h c a r e " to d e l i n e a t e those i s s u e s a s s o c i a t e d with a broader o r g a n i z a t i o n of p r o v i s i o n f o r c i t i z e n s ' 15 h e a l t h by a complex modern s t a t e " (Dunstan, 1987, p. 4; VanDeVeer and Regan, 1987). An e t h i c s of h e a l t h care i s based on a m u l t i d i s c i p l i n a r y approach to understanding the i s s u e s i n t h e i r r e l a t i o n to h e a l t h care and promotion as w e l l as to i l l n e s s p r e v e n t i o n and cure. Therefore these i s s u e s are not e x c l u s i v e l y w i t h i n the domain of t h e r a p e u t i c medicine ( D o x i a d i s , 1987, p. x i i ; Dunstan, 1987, p. 4). The i d e n t i f i c a t i o n of e t h i c a l i s s u e s s p e c i f i c to the area of h e a l t h promotion has most r e c e n t l y appeared i n the l i t e r a t u r e . In Canada, the p u b l i c a t i o n of two i n f l u e n t i a l p o l i c y papers i n h e a l t h care - the Lalonde r e p o r t i n 1974 and the more recent "Framework f o r Health Promotion" (Epp, 198 6) - has developed the p e r s p e c t i v e s of i l l n e s s p r e v e n t i o n and h e a l t h promotion. Doxiadis (1987) argues f o r the need to develop i n s i g h t i n t o those unique e t h i c a l dilemmas that occur when e f f o r t s are made to promote the h e a l t h of communities and may r e s u l t from d i f f e r e n c e s between t h e r a p e u t i c medicine and h e a l t h c a r e . For example, the c r i t e r i a f o r success or f a i l u r e are more e a s i l y d e f i n e d i n those i s s u e s r e l a t e d to the domain of t h e r a p e u t i c medicine. Issues r e l a t e d to h e a l t h promotion are not w e l l d e f i n e d ; they are r e l a t e d to many complex f a c t o r s which d i f f u s e the l e v e l of r e s p o n s i b i l i t y f o r decision-making ( D o x i a d i s , 1987). F u r t h e r , the r e s u l t s of d e c i s i o n s made i n the realm of h e a l t h promotion take a long time to emerge and may i n v o l v e the l i v e s of many; i n c l u d i n g those that f i n d i t 16 d i f f i c u l t to advocate f o r t h e i r r i g h t s . S p e c i f i c examples of e t h i c a l i s s u e s i n h e a l t h promotion are: value c o n f l i c t s i n s o c i a l p o l i c i e s , p a t e r n a l i s m i n h e a l t h education, c o n f l i c t s between personal and p u b l i c h e a l t h goals and the a l l o c a t i o n of h e a l t h care resources ( D o x i a d i s , 1987). The a p p l i c a t i o n of e t h i c a l theory to moral i s s u e s i n h e a l t h care i n v o l v e s f i r s t i d e n t i f y i n g the i s s u e s and then asking r e l e v a n t q u e s t i o n s . A s i t u a t i o n a l or case s p e c i f i c approach r e q u i r e s that the relevance of r u l e s be judged w i t h i n the unique context of i n d i v i d u a l s i t u a t i o n s (Veatch and Fry, 1987). For example, an int e r m e d i a t e l e v e l of r u l e e x i s t s w i t h i n h e a l t h care which may i n c l u d e g u i d e l i n e s or more r i g i d s p e c i f i c a t i o n s f o r procedures such as a b o r t i o n a p p l i c a t i o n s or t r a n s f e r r i n g c o n f i d e n t i a l i n f o r m a t i o n between h e a l t h care p r o f e s s i o n a l s . These i n t e r m e d i a t e r u l e may or may not be m o r a l l y c o r r e c t when analyzed i n r e l a t i o n to the f a c t s or background of a s p e c i f i c s i t u a t i o n and an appeal to e t h i c a l p r i n c i p l e s i s r e q u i r e d (Veatch and Fry, 1987). P h y s i c i a n s , nurses, and others experience e t h i c a l problems i n unique ways and t h e r e f o r e must r e f l e c t on the ba s i c p r i n c i p l e s of e t h i c s as they apply to the s i t u a t i o n s that are r e l e v a n t to the d i s c i p l i n e ( Veatch, 1981; Veatch and Fry, 1987). Nursing E t h i c s Nursing e t h i c s , a subsystem w i t h i n the l a r g e r 17 system of h e a l t h care e t h i c s (Chinn, 1986; Veatch, 1981; Veatch and Fry, 1987), has been d e f i n e d as a system of b e l i e f s about the moral v a l u e s , i d e a l s , v i r t u e s , o b l i g a t i o n s and p r i n c i p l e s i d e n t i f i e d as important by nurses (Lamb, 1981). I t both o r i g i n a t e s from and provides d i r e c t i o n f o r the r e s o l u t i o n of nurses' moral concerns. Furthermore, the f i e l d of nursing e t h i c s recognizes the importance of ap p l y i n g general e t h i c a l t h e o r i e s , p r i n c i p l e s , and standards to moral i s s u e s , problems, and dilemmas faced by nurses i n t h e i r d a i l y p r a c t i c e ( C u r t i n and. F l a h e r t y , 1982; Veatch and Fry, 1987). Within a c l i m a t e of change, nu r s i n g i s d i s t i n g u i s h e d by a predominant i n t e r p e r s o n a l c a r i n g e t h i c (C.N.A., 1980, 1985; Davis, 1986; G r i f f i n , 1983; Watson, 1987). Nursing l e a d e r s c a l l f o r the e v o l u t i o n of nursing e t h i c s to i n c l u d e advocacy f o r p a t i e n t r i g h t s as a fundamental r e s p o n s i b i l i t y e x i s t i n g w i t h i n the nur s i n g r o l e ( C u r t i n and F l a h e r t y , 1982; C.N.A., 1985; Gadow, 1982; Lamb, 1981; Stor c h , 1977, 1982). Nursing's predominant c a r i n g values and the c l o s e and continuous r e l a t i o n s h i p s with c l i e n t s i n f l u e n c e the uniqueness of nurses' experience of e t h i c a l problems and dilemmas ( C u r t i n and F l a h e r t y , 1982; Veatch and Fry, 1987; Murphy and Hunter, 1983; Stor c h , 1987). Furthermore, the complexity of the nursing r o l e i t s e l f and the m u l t i p l e , o f t e n c o n f l i c t i n g p r o f e s s i o n a l r e s p o n s i b i l i t i e s the nurse has i n r e l a t i o n s h i p s with c l i e n t s , a d m i n i s t r a t o r s , 18 p h y s i c i a n s and others are c i t e d as f a c t o r s which place nurses i n m o r a l l y problematic s i t u a t i o n s ( C u r t i n , 1982; Lamb, 1985; Smith and Davis, 1981; Sto r c h , 1987). C u r t i n (1982) i d e n t i f i e s "the most perv a s i v e e t h i c a l dilemma i n nurs i n g i s that nurses are not f r e e to p r a c t i c e n u r s i n g " (p. 85) . Within the e t h i c a l complexity of the n u r s e - c l i e n t r e l a t i o n s h i p , advocacy emerges as a s i g n i f i c a n t value to mediate p a t e r n a l i s t i c f o r c e s ( C u r t i n , 1979). Murphy (1983) c o n t r a s t s the p a t i e n t advocate model with those of the b u r e a u c r a t i c and p h y s i c i a n advocate models. The r o l e of p a t i e n t advocate i n v o l v e s the nurse i n " c r e a t i n g an environment that supports and enables the p a t i e n t to maintain h i s or her own autonomy and d i g n i t y as a person" (Murphy, 1983, p. 9). Gadow (1980) proposes the concept of e x i s t e n t i a l advocacy which "expresses the i d e a l that nurses a s s i s t i n d i v i d u a l s to a u t h e n t i c a l l y e x e r c i s e t h e i r freedom of s e l f d e t e r m i n a t i o n " . Recently, there has been some qu e s t i o n i n g of the scope of nursing's r e s p o n s i b i l i t y to advocate f o r f a m i l y , group, and community needs ( L i n d e l l , 1986; Anderson and McFarlane, 1988). While some qu e s t i o n whether the whole concept of advocacy i s i n f a c t compatible with nursing r o l e (Winslow, 1984; Bishop and Scudder, 1987), others ask whether nursing's codes of e t h i c s go f a r enough i n extending the advocacy r o l e to f a m i l i e s ( L i n d e l l , 1986). The same quest i o n may be asked about whether the advocacy 19 r o l e i n nursing i s a p p r o p r i a t e f o r broader human r i g h t s i s s u e s such as access to h e a l t h care w i t h i n communities. Codes of E t h i c s f o r Nursing P r a c t i c e Within the h i e r a r c h y of moral reasoning p r e v i o u s l y d e s c r i b e d , codes of p r o f e s s i o n a l e t h i c s represent a second l e v e l approach to the a p p l i c a t i o n of e t h i c a l theory - codes of e t h i c s are r u l e s ( S t o r c h , 1982, p. 20). A code of e t h i c s i s an e s s e n t i a l a t t r i b u t e of a p r o f e s s i o n and con t a i n s statements of values and b e l i e f s r e l a t e d to both r o l e m o r a l i t y and the law (Beauchamp and C h i l d r e s s , 1983; Stor c h , 1982) . Three p o t e n t i a l l i m i t a t i o n s of codes of e t h i c s have been i d e n t i f i e d (Beauchamp and C h i l d r e s s , 1983; Stor c h , 1982). F i r s t , the r u l e s s p e c i f i e d i n the codes o f t e n do not go f a r enough i n d i r e c t i n g e t h i c a l conduct i n complex c l i n i c a l s i t u a t i o n s . Rather they may be r e s t r i c t i v e and s e r i o u s l y d e f i c i e n t i f they are a p p l i e d without examining the uniqueness of the s i t u a t i o n and appealing to higher l e v e l r u l e s and p r i n c i p l e s . Beauchamp and C h i l d r e s s (1983) note that many p r o f e s s i o n a l codes of e t h i c s r e f e r to the i m p l i c a t i o n s of the broad p r i n c i p l e of beneficence, but do not go f a r enough i n s p e l l i n g out p r o f e s s i o n a l r e s p o n s i b i l i t i e s r e l a t e d to the p r i n c i p l e of autonomy or other r u l e s i n c l u d i n g v e r a c i t y . A second l i m i t a t i o n of codes i s that they s p e c i f y r i g h t s , r e s p o n s i b i l i t i e s , and standards from the p r o f e s s i o n a l p e r s p e c t i v e , and may not 20 adequately represent consumer needs and wishes (Beauchamp and C h i l d r e s s , 1983; Stor c h , 1982). T h i r d l y , codes of e t h i c s may remain s t a t i c and unresponsive to the dynamic changes i n the h e a l t h care system which r e s u l t i n the ongoing need f o r r e f l e c t i o n and r e - t h i n k i n g of e t h i c a l r e s p o n s i b i l i t i e s (Beauchamp and C h i l d r e s s , 1983; Stor c h , 1984). The ICN Code of E t h i c s . The Code of E t h i c s of the I n t e r n a t i o n a l C o u n c i l of Nurses (ICN, 1973) acknowledges the r e s p o n s i b i l i t y of nurses i n four areas i n c l u d i n g h e a l t h promotion, i l l n e s s p r e v e n t i o n , the r e s t o r a t i o n of h e a l t h , and the a l l e v i a t i o n of s u f f e r i n g . The code f u r t h e r recognizes that nurses provide n u r s i n g s e r v i c e s to i n d i v i d u a l s , f a m i l i e s , and c o m m u n i t i e s . E t h i c a l r e s p o n s i b i l i t i e s f o r nurses are d e l i n e a t e d i n r e l a t i o n t o : nurses and people, p r a c t i c e , s o c i e t y , co-workers, and the p r o f e s s i o n . The CNA Code of E t h i c s . The r e c e n t l y developed Code of E t h i c s of the Canadian Nurses A s s o c i a t i o n (CNA, 1985) recognizes the same areas of nursing r e s p o n s i b i l i t i e s as the ICN and adds the "ensuring of a p e a c e f u l death when l i f e can no longer be s u s t a i n e d " . This code attempts to " c l a r i f y those e t h i c a l p r i n c i p l e s that are d e f i n i t i v e of e t h i c a l n u r s i n g a c t i v i t y " which can then be used as a b a s i s f o r education and r e f l e c t i o n (CNA, 1985). Nursing values are the "broad i d e a l s of n u r s i n g " 21 while standards are the "more s p e c i f i c moral o b l i g a t i o n s that have t h e i r b a s i s i n n u r s i n g v a l u e s " . Values and standards are the elements of t h i s code which guide nurses i n i t s i n t e r p r e t a t i o n . The body of the code i d e n t i f i e s n u rsing values and standards i n four areas. These are the c l i e n t , the h e a l t h care team, the s o c i a l context of n ursing and the r e s p o n s i b i l i t i e s of the p r o f e s s i o n (CNA, 1985). Nursing o b l i g a t i o n s i n r e l a t i o n to the i n d i v i d u a l c l i e n t i n c l u d e the concepts of advocacy, informed consent, r e s p e c t , c o n f i d e n t i a l i t y , autonomy, v e r a c i t y , and the r e c o g n i t i o n of a c l i e n t ' s membership i n a c u l t u r a l group, f a m i l y , and community. Advocacy i s i d e n t i f i e d as a n u r s i n g value w i t h i n the CNA code. Related to t h i s value i s the standard that advocating f o r the i n t e r e s t s of the c l i e n t i n c l u d e s a s s i s t i n g t h e i r access to q u a l i t y h e a l t h c a r e . The E t h i c a l Dilemma Various c o n c e p t u a l i z a t i o n s of e t h i c a l problems v i s - a -v i s dilemmas have been presented i n the n u r s i n g l i t e r a t u r e (C.N.A., 1985; C u r t i n and F l a h e r t y , 1982; Davis and Aroskar, 1978; Murphy, 1978) and the d i s t i n c t i o n between the two i s not made c o n s i s t e n t l y . A review of the commonalities and d i f f e r e n c e s e x i s t i n g w i t h i n the d e f i n i t i o n s as proposed by v a r i o u s i n f l u e n t i a l authors i n d i c a t e s how the concept i s understood i n the f i e l d of n ursing e t h i c s . The Code of E t h i c s of the Canadian Nurses A s s o c i a t i o n (1985) d e s c r i b e s an e t h i c a l dilemma as a category of an 22 e t h i c a l problem which a r i s e s when e t h i c a l reasons both f o r and a g a i n s t a p a r t i c u l a r a c t i o n are prese n t . C u r t i n (1982) d e f i n e s an e t h i c a l problem more broadly than a dilemma and sees the l a t t e r as e x i s t i n g only when the choice to be made i s between e q u a l l y u n s a t i s f a c t o r y a l t e r n a t i v e s . This d i s t i n c t i o n between an e t h i c a l problem and a n o n - e t h i c a l problem i s most u s e f u l to understanding the unique c h a r a c t e r i s t i c s of moral s i t u a t i o n s . The d i s t i n c t i o n being that e t h i c a l problems do not f a l l w i t h i n any one or a l l of the s c i e n c e s . Furthermore, they are i n h e r e n t l y p e r p l e x i n g i n that a person i s unsure how much i n f o r m a t i o n i s needed and which value should be maximized. They w i l l r e s u l t i n an answer which w i l l have profound relevance f o r s e v e r a l areas of human concern ( C u r t i n , 1982, p. 39). Aroskar (1980) recognizes that an e t h i c a l dilemma i n v o l v e s a choice between e q u a l l y u n s a t i s f a c t o r y a l t e r n a t i v e s i n that e i t h e r course would r e s u l t i n an u n s a t i s f a c t o r y outcome. This author proposes that the e t h i c a l dilemma may be broken down i n t o the fundamental components of s i t u a t i o n a l f a c t s , decision-making q u e s t i o n s , and u n d e r l y i n g e t h i c a l t h e o r i e s . Smith and Davis (1980) a l s o i d e n t i f y the c o n f l i c t among r i g h t s , d u t i e s , and o b l i g a t i o n s inherent i n the e t h i c a l dilemma. Furthermore, Storch recognizes the e t h i c a l dilemma as one where the nurses' d u t i e s are i n c o n f l i c t with 23 reasons both f o r and a g a i n s t an a c t i o n , r e s u l t i n g i n the need f o r a decision-making framework ( S t o r c h , 1982). In summary, the e t h i c a l , dilemma i s d e f i n e d as a d i f f i c u l t choice between u n s a t i s f a c t o r y a l t e r n a t i v e s . I t evokes f e e l i n g s of c o n f l i c t , t e n s i o n , and questions such as: "What i s the r i g h t t h i n g to do?" and "What harm and b e n e f i t w i l l r e s u l t from t h i s choice or d e c i s i o n ? " (Aroskar, 1980; Davis and Aroskar, 1978; C u r t i n , 1978; 1982). The dilemma i s c h a r a c t e r i z e d by one or more types of e t h i c a l c o n f l i c t s . Futhermore, most authors recognize the combination of the decision-making process and e t h i c s as the b a s i s f o r r e s o l v i n g e t h i c a l dilemmas. Research In Nursing E t h i c s Research i n nu r s i n g e t h i c s has i n c l u d e d the f o l l o w i n g : 1. An a n a l y s i s of the h i s t o r i c a l e v o l u t i o n of nu r s i n g • e t h i c s i n Canada as a system of b e l i e f s (Lamb, 1981), and the r e l a t i o n s h i p of nu r s i n g e t h i c s to human r i g h t s i s s u e s ( S t o r c h , 1978). 2. An examination of decision-making from the p a t i e n t and f a m i l y p e r s p e c t i v e (Degner and Beaton, 1987; Gortner, Hudes, and Zyz a n s k i , 1984). 3. An examination of nurses' responses and moral reasoning when faced with e t h i c a l problems or dilemmas (Crisham, 1981; K e t e f i a n , 1981; Fenton, 1987; Lamb, 1985; Rodney, 1988; W i l k i n s o n , 1985). 4. Nurses' p e r c e p t i o n s of e t h i c a l problems, dilemmas, and decision-making ( A l l e n , 1972; Boyd, 1977; Davis, 1983; Gramelspacher et a l , 1986; Sietsma, 1987; Tate, 1977; Y o u e l l , 1986). For the purposes of t h i s l i t e r a t u r e review, the resear c h r e l a t e d to the nurses' p e r c e p t i o n s of the e t h i c a l 24 dilemma and decision-making i s most r e l e v a n t and t h e r e f o r e w i l l be d i s c u s s e d i n some d e t a i l . A b r i e f synopsis of the i n f l u e n t i a l works found i n the other r e s e a r c h c a t e g o r i e s w i l l be pro v i d e d . Nursing e t h i c s from a s o c i a l and h i s t o r i c a l p e r s p e c t i v e Master's theses completed by M. Lamb (1981) and Storch (1977) at the U n i v e r s i t y of A l b e r t a place Canadian n u r s i n g e t h i c s i n a s o c i a l and h i s t o r i c a l c o n t e x t . Both authors used a s c h o l a r l y a n a l y s i s of the l i t e r a t u r e to i d e n t i f y r e l e v a n t s o c i a l t r e n d s . Storch analyzed consumer r i g h t s i s s u e s i n h e a l t h care and r e l a t e d these to n u r s i n g . S p e c i f i c a l l y she i d e n t i f i e d n u rsing's a b i l i t y to advocate f o r those consumer r i g h t s i n the four areas i d e n t i f i e d by the Consumers A s s o c i a t i o n of Canada (1974). These four areas i n c l u d e the r i g h t to i n f o r m a t i o n , the r i g h t to r e s p e c t , the r i g h t to p a r t i c i p a t e and the r i g h t of equal access to h e a l t h care (Consumer A s s o c i a t i o n of Canada, 1974). This r e s e a r c h e r concluded that n u r s i n g has found i t d i f f i c u l t to a t t a i n i t s p o t e n t i a l a b i l i t y to advocate f o r human r i g h t s concerns due to an i n a b i l i t y to deal with problems inh e r e n t i n the p r o f e s s i o n i t s e l f . However, the importance of p a t i e n t advocacy as the r a i s o n d'etre of nurs i n g i t s e l f was suggested as nur s i n g must take r e s p o n s i b i l i t y f o r advocating f o r consumer r i g h t s i n h e a l t h care ( S t o r c h , 1977, p. 185). This r e s e a r c h has s i g n i f i c a n t 25 i m p l i c a t i o n s f o r the emergence of advocacy as a c e n t r a l concept i n nursing e t h i c s . Lamb (1981) analyzed Canadian nursing e t h i c s as an e v o l v i n g system of b e l i e f s during two decades - the 1920's and the 1970's. Using n u r s i n g l i t e r a t u r e as a primary data source, t h i s comparative a n a l y s i s d e p i c t e d changes i n both the concepts and context of nursing e t h i c s . R e l a t i v e to the changing concepts of n u r s i n g , Lamb (1981) d e s c r i b e d nursing e t h i c s i n the 20's as based p r i m a r i l y on an " e t h i c s of v i r t u e or c h a r a c t e r t r a i t s " . Nursing e t h i c s during the 70's were based on an e t h i c s of duty r e l a t e d to c u r r e n t concepts of r i g h t s , o b l i g a t i o n , and advocacy" (1981, p. 83). Of i n t e r e s t to c u r r e n t debates i n the p r o f e s s i o n over nursing's r e s p o n s i b i l i t y to advocate f o r the i n t e r e s t of groups and communities i s Lamb's c o n c l u s i o n that during both the 20's and the 70's c o n f l i c t between the good of i n d i v i d u a l s and the good of s o c i e t y as a whole was r e s o l v e d i n the favour of i n d i v i d u a l s (1981, p. 84). F i n a l l y , the "context of nursing e t h i c s was d e s c r i b e d as environmental f a c t o r s i n c l u d i n g changes i n nur s i n g r o l e s , the o r g a n i z a t i o n of the p r o f e s s i o n , the h e a l t h care system, and Canadian s o c i a l l i f e that seemed to i n f l u e n c e or be i n f l u e n c e d by the moral b e l i e f s of each decade" (Lamb, 1981, p. 92). E t h i c a l decision-making from the C l i e n t s ' P e r s p e c t i v e Gortner (1985) c i t e s a p a u c i t y of resea r c h i n t o the c l i e n t ' s p e r c e p t i o n of e t h i c a l d e c i s i o n s i n h e a l t h care 26 s i t u a t i o n s . One study examined e t h i c a l i n f l u e n c e s on f a m i l y decision-making r e g a r d i n g treatment f o r coronary a r t e r y disease and found that autonomy and beneficence were important to f a m i l y members (Gortner, Hudes, and Zy z a n s k i , 1984, pp. 319-24). Re c e n t l y , a f i v e - y e a r in-depth study on l i f e - d e a t h d e c i s i o n s from the p e r s p e c t i v e s of f a m i l y , p a t i e n t s , and h e a l t h p r o f e s s i o n a l s was completed (Degner and Beaton, 1987). The f i n d i n g s have i m p l i c a t i o n s f o r the v i t a l importance of i n c l u d i n g the consumer i n e t h i c a l decision-making. This i s c l e a r l y an important area f o r nurs i n g r e s e a r c h i n the f u t u r e ; Nurses' Responses to E t h i c a l Dilemmas Nurses' responses to e t h i c a l dilemmas are most o f t e n analyzed a c c o r d i n g to t h e o r i e s of moral reasoning or judgement. Moral judgement has been d e f i n e d as e v a l u a t i v e reasoning that r e q u i r e s the a p p l i c a t i o n of an i n d i v i d u a l ' s values about human welfare and s o c i a l j u s t i c e (Crisham, 1981, p. 105; Rawls, 1971). Research i n t o n u r s e s ' moral reasoning has been based on a c o g n i t i v e theory of moral development (Crisham, 1981; K e t e f i a n , 1981c). Although a thorough d i s c u s s i o n and c r i t i q u e of the use of cog n i t i v e - d e v e l o p m e n t a l theory to study nurses' moral responses i s beyond the scope of t h i s l i t e r a t u r e review, i t i s important to review the most i n f l u e n t i a l f i n d i n g s of nurse r e s e a r c h e r s working i n t h i s a r ea. 27 Of p a r t i c u l a r s i g n i f i c a n c e i s the f i n d i n g that education and previous experience with s i m i l a r dilemmas i n c r e a s e s the l e v e l of the n u r s e s ' moral responses (Crisham, 1981; K e t e f i a n , 1981c). K e t e f i a n (1981c) a l s o found education to be p o s i t i v e l y c o r r e l a t e d with l e v e l s of moral judgement among p r a c t i c i n g nurses and f u r t h e r r e l a t e d t h i s v a r i a b l e with one of r o l e c o n c e p t i o n . Furthermore, strong p r o f e s s i o n a l r o l e conceptions were r e l a t e d p o s i t i v e l y to both l e v e l s of education and moral reasoning ( K e t e f i a n , 1981c) . Recently, four master's theses were completed i n the area of n u r s e s ' moral responses (Fenton, 1987; R. Lamb, 1985; Rodney, 1987; W i l k i n s o n , 1985). Fenton (1987) and Rodney (1987) conducted i n t e r v i e w s with c r i t i c a l care nurses. They i d e n t i f i e d nurses' e t h i c a l p e r s p e c t i v e s on the i s s u e of p r o l o n g a t i o n of l i f e i n p a t i e n t s who were p e r c e i v e d as dying. R. Lamb (1985) i d e n t i f i e d nurses' p e r c e p t i o n s of the negative e f f e c t s of m u l t i p l e and c o n f l i c t i n g l o y a l t i e s e x i s t i n g w i t h i n v a r i o u s nursing p r a c t i c e s e t t i n g s and the l i m i t a t i o n s on nurses' a b i l i t i e s to uphold the value of p a t i e n t autonomy. W i l k i n s o n (1985) found the phenomenon of moral d i s t r e s s i n nurses to be s i g n i f i c a n t i n v a r i o u s ' c l i n i c a l s i t u a t i o n s i n v o l v i n g p r o l o n g i n g l i f e , performing unnecessary t e s t s and treatments, and t r u t h - t e l l i n g . A l l these s t u d i e s c o n t r i b u t e d to a developing understanding of the i n t e n s i t y of the n u r s e s ' experience with the moral 28 dimensions of nu r s i n g p r a c t i c e , and the need f o r c l i e n t advocacy i n a v a r i e t y of c l i n i c a l s e t t i n g s . Furthermore s e v e r a l c o n t e x t u a l f a c t o r s i n f l u e n c e d the occurrence of the dilemmas and r e s u l t e d i n the need to f i n d ways to support coping and decision-making i n a l l i n s t a n c e s . C o n s i d e r i n g the focus of t h i s study on decision-making i n response to e t h i c a l dilemmas, i t i s important to comment on the r e l a t i o n s h i p between the processes of moral reasoning, a c t i o n s , and decision-making. Crisham (1981; 1985) has concluded that the r e l a t i o n s h i p between moral reasoning and decision-making has not been s t u d i e d and i s not w e l l understood. Crisham f u r t h e r i m p l i e s that a l a c k of understanding of the r e l a t i o n s h i p between moral judgement and moral a c t i o n has r e s u l t e d , i n p a r t , from the l i m i t a t i o n s of using c o g n i t i v e - d e v e l o p m e n t a l moral t h e o r i e s as the predominant framework to guide t h i s i n q u i r y . Instead, she suggests the use of a v a r i e t y of methodological s t r a t e g i e s to observe the r e l a t i o n s h i p between moral judgement and a c t u a l n ursing i n t e r v e n t i o n s (Crisham, 1985, p. 42). Decision-Making In E t h i c a l Dilemmas; C o n c e p t u a l i z a t i o n and  Research This s e c t i o n i n c l u d e s a d i s c u s s i o n of rese a r c h i n t o n u r s e s ' i d e n t i f i c a t i o n of e t h i c a l dilemmas and the r e l a t i o n s h i p between the e t h i c a l dilemma and the decision-making process. 29 Research r e l a t e d to the e t h i c a l dilemma i n n u r s i n g . During the 1970's, nurses' p e r c e p t i o n s of e t h i c a l dilemmas i n t h e i r p r a c t i c e were surveyed. S e v e r a l of these surveys w i l l be d e s c r i b e d to develop the b a s i s f o r understanding how nurses d e f i n e e t h i c a l dilemmas i n t h e i r p r a c t i c e . A l l e n (1974) appealed to Canadian nurses f o r t h e i r d e s c r i p t i o n s of s i t u a t i o n s r e p r e s e n t i n g e t h i c a l problems. Working with a very low response rate of 22 from 100,000 members, A l l e n i d e n t i f i e d the predominant e t h i c a l theme as one "of i n c r e a s i n g d i f f i c u l t y responding to the i n d i v i d u a l p a t i e n t ' s needs due to c o n f l i c t with medicine, h o s p i t a l p o l i c y , the law, or r e l i g i o n " (p. 23). Tate (1977), r e s e a r c h i n g f o r the I n t e r n a t i o n a l C o u n c i l of Nurses, c o l l e c t e d examples of e t h i c a l problems from nurses i n t w e n t y - f i v e d i f f e r e n t c o u n t r i e s . This c o l l e c t i o n of e t h i c a l problems which "touched on a l l f a c e t s of the l i f e of a nurse as a p r o f e s s i o n a l person" was c o l l e c t e d a c c o r d i n g to the f o l l o w i n g fundamental c a t e g o r i e s i d e n t i f i e d by the ICN: respect f o r l i f e ; nurses and people; nurses and p r a c t i c e ; nurses and co-workers; and nurses and the p r o f e s s i o n (Tate, 1977). In a preface to the p u b l i c a t i o n of t h i s c o l l e c t i o n , the then E x e c u t i v e D i r e c t o r of the ICN noted: " I f there was a commonality throughout the m a t e r i a l ICN r e c e i v e d , i t was that the nurse seemed to f e e l the matter was her problem 30 alone. The nurse seldom d i s c u s s e d the i s s u e with n u r s i n g or medical c o l l e a g u e s " (Herwitz, 1977, p. v i ) . A d e s c r i p t i v e survey was conducted to examine nurs e s ' grasp of the concept of e t h i c a l dilemma and to o b t a i n data on the content of the e t h i c a l dilemmas faced by nurses (Davis, 1981). Davis (1981) had a f i f t y per-cent r e t u r n rate i n her study and found that the m a j o r i t y of the 210 members of a C a l i f o r n i a n ursing o r g a n i z a t i o n had a good understanding of the concept of the e t h i c a l dilemma. Two dilemmas occurred most f r e q u e n t l y : those i n v o l v i n g p r o l o n g a t i o n of l i f e and the unethical/incompetent a c t i v i t y of c o l l e a g u e s (Davis, 1981, p. 404). However, the exact nature of the c o n f l i c t or choice which e x i s t e d f o r these nurses i n the dilemmatic s i t u a t i o n was not s p e c i f i e d i n the pub l i s h e d r e p o r t . Davis (1981) concluded that ongoing dialogue i n e t h i c a l dilemmas and reasoning can enhance nurses' awareness and a s s i s t them to present a r a t i o n a l e t h i c a l stance. Perhaps the most systematic i n q u i r y i n t o the e t h i c a l c o n f l i c t u n d e r l y i n g the dilemmas was conducted by Crisham (1981). This r e s e a r c h e r i n t e r v i e w e d 130 v o l u n t e e r s t a f f nurses to i d e n t i f y 21 r e c u r r e n t n u r s i n g dilemmas which were grouped a c c o r d i n g to four u n d e r l y i n g e t h i c a l i s s u e s : 1. d e c i d i n g the r i g h t to know 2. determining the r i g h t to decide 3. d e f i n i n g and promoting the q u a l i t y of l i f e 4. m a i n t a i n i n g p r o f e s s i o n a l and i n s t i t u t i o n a l standards, and d i s t r i b u t i n g n u r s i n g resources (p. 106). 31 In t h i s study, "a dilemma was c l a s s i f i e d as a r e c u r r e n t moral dilemma i f a minimum of f i v e nurses d e s c r i b e d the same dilemma" (Crisham, 1981, p. 106). Of f u r t h e r i n t e r e s t i s Crisham's o b s e r v a t i o n that the nurses wanted the o p p o r t u n i t y to d i s c u s s a p a r t i c u l a r dilemma, many of which had occurred more than three years e a r l i e r and remained unresolved and troublesome i n the nurses' minds (Crisham, 1981, p. 106). These c a t e g o r i e s of moral dilemmas i n nur s i n g as i d e n t i f i e d by Crisham are s i m i l a r to those d e s c r i b e d i n a recent master's t h e s i s conducted with Canadian nurse a d m i n i s t r a t o r s ( Y o u e l l , 1986). T h i r t y - o n e s e n i o r and middle l e v e l nurse a d m i n i s t r a t o r s were i n t e r v i e w e d to determine t h e i r most common and d i f f i c u l t e t h i c a l problems. T h e i r most d i f f i c u l t problem was a s s o c i a t e d with the l e v e l of competence of the nur s i n g s t a f f (p. 30). The most common group of e t h i c a l problems r e l a t e d to the d i f f e r e n t i s s u e s a s s o c i a t e d with c l i n i c a l s p e c i a l i t i e s ; a b o r t i o n was an i s s u e r e l a t e d to the o b s t e t r i c s - g y n e c o l o g y s p e c i a l t y ( Y o u e l l , 1987, p. 29). The second and t h i r d most common e t h i c a l problems were l i s t e d as the d i a g n o s i s and treatment of p a t i e n t s beyond what they f e l t was a reasonable l i m i t and concerns about p a t i e n t ' s r i g h t s i n c l u d i n g informed consent and the p a t i e n t ' s r i g h t to i n f o r m a t i o n ( Y o u e l l , 1987, p. 29). In her i n t e r v i e w s with the nurses, Y o u e l l (1987) found they spoke of the "complexity of the e t h i c a l problems"; however "there was l i t t l e evidence of systematic r e f e r r a l to 32 e t h i c a l p r i n c i p l e s or o p t i o n s " (p. 29). This nurse re s e a r c h e r concluded that nurse a d m i n i s t r a t o r s would b e n e f i t from an a r r a y of resources such as c o n t i n u i n g education i n the use of e t h i c a l theory and o p p o r t u n i t i e s to c o n s u l t with nurse e t h i c i s t s , as w e l l as an o p p o r t u n i t y to share t h e i r experience with other nurse a d m i n i s t r a t o r s . Sietsma and Spradley (1987) found the most f r e q u e n t l y c i t e d category from among the pre-determined l i s t of p o t e n t i a l types of dilemmas f o r h o s p i t a l c h i e f nurse exe c u t i v e s was "the use of resources and q u a l i t y of care" (Sietsma and Spradley, 1987, p. 28). Some of the items on the q u e s t i o n n a i r e r e l a t e d to the resources the nurses used to r e s o l v e the dilemmas. These r e s e a r c h e r s a l s o noted that c o l l e g i a l support amongst nurse a d m i n i s t r a t o r s i s e s s e n t i a l f o r e f f e c t i v e decision-making (Sietsma and Spradley, 1987, p. 31). An i n t e r d i s c i p l i n a r y study was conducted to i n v e s t i g a t e the d i f f e r e n c e s i n the p e r c e p t i o n s of e t h i c a l problems between p h y s i c i a n s and nurses working i n an i n s t i t u t i o n a l s e t t i n g (Gramelspacher, Howell, and Young, 1986). This study was conducted by p h y s i c i a n s who i n t e r v i e w e d 26 nurses and 24 p h y s i c i a n s who worked i n acute-care u n i t s . Of s i g n i f i c a n c e was the d i s p a r i t y between the p e r c e p t i o n s of nurses and p h y s i c i a n s (Gramelspacher et a l . , 1986). Nurses perc e i v e d c o n f l i c t s with p h y s i c i a n s , whereas p h y s i c i a n s r a r e l y p e r c e i v e d c o n f l i c t with nurses. This f i n d i n g may 33 have i m p l i c a t i o n s f o r the problems inh e r e n t i n team decision-making i n s i t u a t i o n s i n v o l v i n g nurses and p h y s i c i a n s i n e t h i c a l dilemmas. In summary, most nu r s i n g r e s e a r c h i n t o nurses' i d e n t i f i c a t i o n of e t h i c a l dilemmas has been done with nurses working i n acute-care i n s t i t u t i o n s and has t h e r e f o r e c o n t r i b u t e d to understanding nursing dilemmas a s s o c i a t e d with the n u r s i n g r o l e i n t h i s s e t t i n g . However, excep t i n g Crisham's (1981) i d e n t i f i c a t i o n of the four e t h i c a l i s s u e s u n d e r l y i n g the dilemmas, the elements of choice and c o n f l i c t c h a r a c t e r i z i n g n u r s i n g dilemmas have not been r e p o r t e d . A d d i t i o n a l l y , most f i n d i n g s have r e s u l t e d from i n t e r v i e w s with small samples of nurses or surveys where r e t u r n r a t e s of w r i t t e n responses have been low. Decision-Making Models The elements of c o n f l i c t and choice inherent i n the e t h i c a l dilemma are best understood w i t h i n the context of the e t h i c a l decision-making p r o c e s s . E s s e n t i a l l y t h i s process combines elements of decision-making models which i n c l u d e s i d e n t i f y i n g the s i t u a t i o n a l components of the dilemma, e x p l o r i n g a l t e r n a t i v e s , c o n s i d e r i n g t h e i r consequences, choosing, and e v a l u a t i n g with e t h i c a l theory and concepts (Curtin,1987; Crisham, 1985; Thompson and Thompson, 1985). Three decision-making models developed by C u r t i n (1978), Crisham (1985), and J a n i s and Mann (1977) are 34 p a r t i c u l a r l y r e l e v a n t to the focus of t h i s study and w i l l now be d e s c r i b e d . The model f o r c r i t i c a l e t h i c a l a n a l y s i s as proposed by C u r t i n (1978, 1982) combines the decision-making process with e t h i c a l t h e o r i e s and p r i n c i p l e s . C u r t i n (1978) i n c l u d e s the f o l l o w i n g as e s s e n t i a l components of her model: background i n f o r m a t i o n , i d e n t i f i c a t i o n of the e t h i c a l components of the problem, i d e n t i f i c a t i o n of the e t h i c a l agents or a l l those i n v o l v e d i n decision-making, i d e n t i f i c a t i o n of o p t i o n s , a p p l i c a t i o n of e t h i c a l p r i n c i p l e s , and r e s o l u t i o n . The type of c o n f l i c t i n h e r e n t i n the s i t u a t i o n must be i d e n t i f i e d . For example, "Is i t a case of c o n f l i c t i n g r i g h t s ? Are d u t i e s c o n f l i c t i n g with outcomes?" ( C u r t i n , 1982, p. 60). P o t e n t i a l l y , t h i s model can a s s i s t the d e c i s i o n maker to i d e n t i f y the e t h i c a l components of the dilemma and the r i g h t s and values of those i n v o l v e d . The "MORAL" model was developed by Crisham through her work with groups of nurses who had asked f o r a model to help guide t h e i r decision-making i n s i t u a t i o n s i n v o l v i n g e t h i c a l dilemmas (Crisham, 1985, p. 28). Crisham d e s c r i b e s : The major purpose of the model i s to f a c i l i t a t e a t r a n s f o r m a t i o n i n the way nurses experience moral and e t h i c a l c o n f l i c t , from a dilemma to an o p p o r t u n i t y f o r committed a c t i o n . The model makes the decision-making process e x p l i c i t , f a c i l i t a t e s the d i s c o v e r y of the nurse's own i m p l i c i t moral and e t h i c a l r u l e s and p r i n c i p l e s , r e l a t e s the nurse's t h i n k i n g to moral and e t h i c a l t h e o r i e s i n philosophy and developmental 35 psychology, and l i n k s judgement, c h o i c e , and a c t i o n i n the n u r s i n g e xperience. The "MORAL" model i s s i m i l a r to C u r t i n ' s model f o r c r i t i c a l e t h i c a l a n a l y s i s i n that i t cont a i n s the decision-making elements of d e f i n i n g or "massaging the dilemma", o u t l i n i n g o p t i o n s , a p p l y i n g e t h i c a l theory, choosing, and a c t i n g on the c h o i c e . L i k e C u r t i n , Crisham recognizes the importance of d e f i n i n g the type of e t h i c a l c o n f l i c t . A unique f e a t u r e of the "MORAL" model i s the use of Levin's (1969) f o r c e f i e l d a n a l y s i s as a technique f o r i d e n t i f y i n g the f o r c e s that i n f l u e n c e the nurse's choice between the two incompatible a c t i o n s (1985, p. 29). "The f o r c e f i e l d a n a l y s i s technique serves to focus a t t e n t i o n on the horns of the dilemma and the f e a t u r e s of the s i t u a t i o n that are percei v e d to p u l l or push the nurse" (Crisham, 1985, p. 29). This a n a l y s i s p o t e n t i a l l y f a c i l i t a t e s r e s o u t i o n of the dilemma i n a more goal d i r e c t e d manner as the nurses are encouraged to i d e n t i f y and enhance the goal of r e s o l u t i o n as we l l as those f o r c e s which f r u s t r a t e and encourage the nurses . A model of d e c i s i o n a l c o n f l i c t developed by J a n i s and Mann (1977) d e s c r i b e s the s t r e s s e s and coping p a t t e r n s a s s o c i a t e d with v i t a l , a f f e c t laden i s s u e s g e n e r a l l y i n v o l v i n g "hot c o g n i t i o n s " (p. 45). C h a r a c t e r i s t i c of s i t u a t i o n s i n v o l v i n g "hot c o g n i t i o n s " or d e c i s i o n s i s the phenomenon of " d e c i s i o n a l c o n f l i c t which i s the simultaneous 36 opposing tendencies w i t h i n the i n d i v i d u a l to accept and r e j e c t a given course of a c t i o n " ( J a n i s and Mann, 1977, p. 46). J a n i s and Mann (1977) d e s c r i b e the unpleasant emotions a s s o c i a t e d with d e c i s i o n a l c o n f l i c t as i n c l u d i n g " h e s i t a t i o n , v a c i l l a t i o n , f e e l i n g s of u n c e r t a i n t y , and signs of acute emotional d i s t r e s s whenever the d e c i s i o n becomes the focus of a t t e n t i o n " (p. 49). According to t h i s model, the degree of p s y c h o l o g i c a l d i s t r e s s experienced when faced with a "hot" d e c i s i o n depends on the degree of the l o s s the decision-maker a n t i c i p a t e s w i l l be a s s o c i a t e d whatever choice i s made ( J a n i s and Mann, 1977, p. 49). These l o s s e s are u s u a l l y p e r c e i v e d i n r e l a t i o n to s e l f esteem, and s o c i a l r e l a t i o n s h i p s or standing ( J a n i s and Mann, 1977; 1982). These t h e o r i s t s d e s c r i b e f i v e coping p a t t e r n s of which "defensive avoidance" or escape from the c o n f l i c t and non-decisiveness as p o t e n t i a l l y l e a d i n g to the poorest q u a l i t y of d e c i s i o n s . ( J a n i s and Mann, 1977; 1982). Research i n decision-making. There has been mimimal resea r c h i n t o how nurses a c t u a l l y make d e c i s i o n s i n e t h i c a l dilemmas. Tanner (1987) has i d e n t i f i e d two d i f f e r e n t t h e o r e t i c a l p e r s p e c t i v e s that have guided r e s e a r c h i n t o c l i n i c a l judgement i n n u r s i n g . These are the r a t i o n a l i s t i c and phenomenological p e r s p e c t i v e s (Tanner, 1987). The r a t i o n a l i s t i c p e r s p e c t i v e i s based on the assumption that a c t i o n i s the r e s u l t of l o g i c a l processes and i t i s p o s s i b l e and d e s i r a b l e to break 37 the process down i n t o i t s elements (Tanner, 1987). Based on mathematical and i n f o r m a t i o n p r o c e s s i n g t h e o r i e s , t h i s p e r s p e c t i v e downplays the importance of emotion, and c o n t e x t u a l f a c t o r s such as h i s t o r y and c u l t u r e i n the a n a l y s i s of the process (Tanner, 1987). The phenomenological p e r s p e c t i v e , on the other hand, emphasizes the importance of using grounded theory methods to examine the presence of c o n t e x t u a l f a c t o r s which are e s s e n t i a l to understanding decision-making (Tanner, 1987). Because of the l a c k of experience with n u r s i n g r e s e a r c h i n t o n u r s e s ' decision-making, i t i s most l i k e l y premature to p r e d i c t that one or the other of these p e r s p e c t i v e s alone i s more s u i t a b l e to guide i n q u i r y i n t o e t h i c a l decision-making. The r e s e a r c h conducted by P h i l l i p s and Rempusheski (1985) i n t o decision-making processes used by community h e a l t h nurses and s o c i a l workers i n v o l v e d i n diagnosing and i n t e r v e n i n g i n e l d e r abuse and n e g l e c t i s unique to the f i e l d of i n q u i r y - that of decision-making i n e t h i c a l dilemmas. Although not i n i t i a l l y c o n c e p t u a l i z e d as a study i n the f i e l d of nursing e t h i c s , these r e s e a r c h e r s i n d u c t i v e l y d e s c r i b e d complex d e c i s i o n processes i n e t h i c a l l y dilemmatic s i t u a t i o n s . Because of i t s relevance to community h e a l t h n u r s i n g p r a c t i c e and the focus of t h i s t h e s i s , i t w i l l now be d i s c u s s e d i n some d e t a i l . In t h e i r r e s e a r c h based on constant comparative a n a l y s i s of i n t e r v i e w s with 16 nurses and 13 s o c i a l workers, 38 P h i l l i p s and Rempusheski (1985) appear to have achieved a s y n t h e s i s of the goals c h a r a c t e r i s t i c of both the r a t i o n a l i s t i c and phenomenological modes of i n q u i r y . In accordance with the r a t i o n a l i s t i c model, they were able to break the decision-making process down i n t o four stages. These stages d e l i n e a t e the c a t e g o r i e s / s u b c a t e g o r i e s that the h e a l t h care p r o v i d e r s assessed when f o r m u l a t i n g a d i a g n o s i s of e l d e r abuse. Fi v e p o t e n t i a l d e c i s i o n pathways are designated w i t h i n the model; the one taken by the c a r e - g i v e r depends on the complex i n t e r a c t i o n of the assessment with p e r s o n a l and p r o f e s s i o n a l values which may or may not lead to an i n t e r v e n t i o n d e c i s i o n ( P h i l l i p s and Rampusheski, 1985, p.135). A c o n s i d e r a b l e s t r e n g t h of t h i s model i s that i t i s n o n - l i n e a r and t h e r e f o r e captures the complexity of decision-making as i t i s observed or experienced i n a c t u a l p r a c t i c e . The re s e a r c h e r s d e s c r i b e : "feedback can occur among a l l stages, with h e a l t h care p r o v i d e r s c o n t i n u i n g to accumulate data and formulate o p i n i o n s even a f t e r a stage has been completed" ( P h i l l i p s and Rampusheski, 1985, p. 138). I n t e r e s t i n g l y , no d i f f e r e n c e s between the decision-making of nurses and s o c i a l workers were d e s c r i b e d i n t h i s study. P h i l l i p s and Rampusheski (1985) compared t h e i r model with the other d e c i s i o n models and found i t was most s i m i l a r to J a n i s and Mann's (1977) model f o r c o n f l i c t e d decision-making. S p e c i f i c a l l y , they suggest that the 39 concepts of "defensive avoidance" and " p o s t d e c i s i o n a l r e g r e t " were r e l e v a n t . Defensive avoidance was d e s c r i b e d i n r e l a t i o n to the h e a l t h care p r o v i d e r ' s d e c i s i o n not to make a d e c i s i o n when the a l t e r n a t i v e s were seen as too r i s k y , while p o s t - d e c i s i o n a l r e g r e t c o n s i s t s of ongoing f e e l i n g s i n c l u d i n g " f r u s t r a t i o n , anger, and h e l p l e s s n e s s " once a d e c i s i o n had been made ( P h i l l i p s and Rempusheski, 1985, p. 139). F i n a l l y , these r e s e a r c h e r s developed s i x hypotheses to e m p i r i c a l l y t e s t the stages of the model which could p o t e n t i a l l y provide s i g n i f i c a n t d i r e c t i o n f o r f u t u r e s t u d i e s . In view of the expansion of nur s i n g r o l e s i n community h e a l t h and the p o t e n t i a l value of resea r c h i n t o e t h i c a l c h o i c e s , c o n f l i c t s and d e c i s i o n s , i t would appear that f u r t h e r i n q u i r y i s needed to i d e n t i f y community h e a l t h n urses' p e r c e p t i o n s of the nature of the e t h i c a l dilemma and r e l e v a n t aspects of the decision-making process. The Nature of Community Health Nursing P r a c t i c e In order to understand the e t h i c a l i s s u e s i n community h e a l t h n u r s i n g , i t i s f i r s t necessary to explore the nature of the p r a c t i c e , and the cu r r e n t f o r c e s i n f l u e n c i n g t h i s nursing r o l e . Therefore t h i s s e c t i o n w i l l begin with a d e s c r i p t i o n of community h e a l t h n u r s i n g p r a c t i c e i n the past and as i t i s today. This d e s c r i p t i o n w i l l develop the b a s i s 40 f o r understanding the p o t e n t i a l e t h i c a l i s s u e s and dilemmas c o n f r o n t i n g community h e a l t h nurses and t h e i r c l i e n t s . Community h e a l t h nursing i s d i s t i n g u i s h e d by i t s broad focus of care f o r i n d i v i d u a l s , f a m i l i e s , and groups w i t h i n the context of v a r i o u s community s e t t i n g s (A.N.A., 1985; Anderson, 1983; Archer and Fleshman, 1976; C.P.H.A., 1983). The community (Goeppinger, 1984, p. 384) i s the context of concern f o r promoting the h e a l t h of those i n d i v i d u a l s , f a m i l i e s , and groups through educ a t i o n , primary p r e v e n t i o n , h e a l t h maintenance and promotion, and the i d e n t i f i c a t i o n and f o l l o w up of those at r i s k f o r lower l e v e l s of h e a l t h (C.P.H.A., 1983; C.P.H.A., 1986). Community h e a l t h nursing i n Canada has a long h i s t o r y beginning i n the e a r l y days of New France (Allemang, 1985, p. 4 ) . According to Allemang: This e a r l y model of community nu r s i n g developed at a time when two a l i e n c u l t u r e s met, medical s c i e n c e and technology were unknown, and t r a i n e d nurses d i d not e x i s t . I n t u i t i v e concepts of community nursing may be recognized i n the r e l a t i o n s h i p between the persons g i v i n g and r e c e i v i n g care, i n the a t t e n t i o n given to people without community supports, and i n the s t a r k p o l i t i c a l and f i n a n c i a l problems that had to be confronted (p. 4). The e a r l y f e a t u r e s of community h e a l t h n u r s i n g p r a c t i c e i n c l u d e d a s s i s t i n g the poor, c a r i n g f o r the i l l i n the home, housing and teaching newly immigrated f a m i l i e s , communicable disease c o n t r o l , and concern f o r the h e a l t h of Native Canadian p o p u l a t i o n s . Furthermore, the h i s t o r y of community h e a l t h n u r s i n g supports i t s long standing concern f o r the 41 e f f e c t of s o c i a l , p o l i t i c a l , and economic c o n d i t i o n s on the h e a l t h of pop u l a t i o n s (Donahue, 1985; Monteiro, 1985; R u f f i n g - R a h a l , 1986). Today, community h e a l t h n u r s i n g i s undergoing a pe r i o d of i n t e n s e change. Within the arena of m u l t i p l e emerging nursing p r a c t i c e s p e c i a l t i e s and h e a l t h care d i s c i p l i n e s , many f o r c e s appear to,be c h a l l e n g i n g the essence of community h e a l t h nursing as a unique and e s s e n t i a l mode of p r a c t i c e . Increased concern about e s c a l a t i n g h e a l t h care c o s t s has l i m i t e d the economic support f o r h e a l t h care i n general and h e a l t h promotion and pre v e n t i o n i n p a r t i c u l a r . Community h e a l t h nursing s e r v i c e s are not w e l l recognized or funded i n the h e a l t h care system of today. The d i v i s i o n of community h e a l t h n u r s i n g i n t o p r e v e n t i o n , home care, long term care, and other programs i n North America and Great B r i t a i n has been another s i g n i f i c a n t f o r c e . As V i r g i n i a Henderson d e s c r i b e d i n a recent i n t e r v i e w on her experience with community h e a l t h n u r s i n g : I think t h i s s e p a r a t i o n of care of the s i c k and pre v e n t i v e work gives a mindset, a p u b l i c image of the community nurse p r e s e n t l y that i s strange to me. I have been shocked at things my f r i e n d s have s a i d to me about the community or p u b l i c h e a l t h nurse, because when I was such a nurse, I thought we were g r e a t l y a p p r e c i a t e d . Our s e r v i c e s , compared to those of the present day, were l e s s h i g h l y developed t e c h n i c a l l y , but the f a c t that we assumed r e s p o n s i b i l i t y f o r the p h y s i c a l care of the p a t i e n t as w e l l as f o r the teaching and c o u n s e l l i n g dimensions of care, I b e l i e v e , made the p u b l i c h e a l t h nurse h i g h l y v a l u e d . (Henderson, 1984, p. 199) 42 Given the trend of i n c r e a s i n g home h e a l t h care f o r the i l l and the e l d e r l y , i t i s apparent that these f u n c t i o n a l program d i v i s i o n s e x i s t i n g i n the community h e a l t h nursing r o l e may th r e a t e n i t s s o c i a l u t i l i t y . The o r g a n i z a t i o n of the h e a l t h care system a c c o r d i n g to programs has threatened the community h e a l t h nurses' a b i l i t y to focus on f a m i l y h e a l t h and i t s r e l a t i o n s h i p to the community as a whole (Banning, 1987). Furthermore the recent p o l i t i c a l focus on " h e a l t h promotion" as a new and unique h e a l t h care p o l i c y (Epp, 1986) has s t i m u l a t e d the development of new programs and d i r e c t i o n s w i t h i n the system. I n c r e a s i n g l y , community h e a l t h nurses i n B r i t i s h Columbia are q u e s t i o n i n g these new d i r e c t i o n s as nur s i n g programs are cut to make way f o r new p r o j e c t s (Whyte, 1988). It seems the relevance and e f f e c t i v e n e s s of community h e a l t h nursing i n t h i s new i n i t i a t i v e i s being c h a l l e n g e d . An a d d i t i o n a l undercurrent i n community h e a l t h n u r s i n g i n v o l v e s the qu e s t i o n of who should be the primary c l i e n t of the nurse - the i n d i v i d u a l , the f a m i l y , the aggregate or the community as a whole? Some c h a r a c t e r i z e the community as a s e t t i n g f o r p r a c t i c e and p u b l i c h e a l t h n u r s i n g as a s p e c i a l t y area of p r a c t i c e where the nurse has e x p e r t i s e i n both p u b l i c h e a l t h and nur s i n g s c i e n c e and provides care to the community as a whole (Meyer and Delman, 1986). Recently, t h i s c o n t r o v e r s y surrounding the CHN's focus of care has r e s u l t e d i n the qu e s t i o n of how education f o r 43 community h e a l t h n u r s i n g should be i n c o r p o r a t e d i n t o undergraduate nursing c u r r i c u l a . There has been some concern that community h e a l t h n u r s i n g as a d i s t i n c t area of nurs i n g p r a c t i c e i s not adequately d e f i n e d i n n u r s i n g education (Young-Graham, 1987). And t h i s at a time when i n t e r n a t i o n a l h e a l t h l e a d e r s are c a l l i n g f o r i n c r e a s e d nursing involvement i n planning and developing primary h e a l t h care programs (Mussallem, 1985). I t appears there i s a need to r e - d e f i n e the community focus i n community h e a l t h nursing p r a c t i c e i n order to improve the q u a l i t y of care provided to po p u l a t i o n s and achieve world h e a l t h g o a l s . Toward t h i s end, Anderson and McFarlane (1988) s t a t e the community i s the primary c l i e n t of the community h e a l t h nurse. These authors f u r t h e r c l a r i f y the unique and i n t i m a t e r e l a t i o n s h i p between nursing the i n d i v i d u a l , f a m i l y , and community c l i e n t : "Even though care i s f r e q u e n t l y given to i n d i v i d u a l s , f a m i l i e s , and groups, the community h e a l t h nurse always c o n s i d e r s the impact and consequences of these cases upon the h e a l t h of the community (Anderson and McFarlane, 1988, p. 375; S c h u l t z , 1987). I t may be argued that the nurse through m u l t i p l e l e v e l c a r i n g i s i n a p r i v i l e g e d p o s i t i o n to understand the impact of the needs of i n d i v i d u a l s and f a m i l i e s on the h e a l t h of p o p u l a t i o n s . Advocacy, or speaking f o r the h e a l t h needs of po p u l a t i o n s should t h e r e f o r e be a b a s i c n u r s i n g I n t e r v e n t i o n used by the 4 4 community h e a l t h nurse. Through community advocacy, the nurse may express t h i s i n s i g h t i n t o the r e l a t i o n s h i p between i n d i v i d u a l , f a m i l y , and community h e a l t h i n order to i n f l u e n c e p o l i c y , and the development of r e l e v a n t programs that t r u l y promote h e a l t h and provide q u a l i t y care f o r the i l l . E t h i c a l Issues i n Community Health Nursing The q u e s t i o n a r i s e s as to the uniqueness of e t h i c a l i s s u e s i n community h e a l t h nursing p r a c t i c e : Are they d i f f e r e n t i n any way from those a s s o c i a t e d with other n u r s i n g r o l e s ? A review of the l i t e r a t u r e would suggest that community h e a l t h nurses encounter e t h i c a l dilemmas of a more s u b t l e , l e s s dramatic nature than those o c c u r r i n g i n i n s t i t u t i o n a l s e t t i n g s . Many of the i s s u e s may occur day to day and i n v o l v e c a r i n g f o r v u l n e r a b l e groups, r e s p e c t f o r autonomy by m a i n t a i n i n g c o n f i d e n t i a l i t y , and the a l l o c a t i o n of scarce community h e a l t h n u r s i n g resources among competing program demands. However, i t i s suggested that the d i f f e r e n c e i n s e t t i n g does not d i s t i n g u i s h the i s s u e s . Rather, i t i s the "wider context of concern" f o r groups and the h e a l t h of the community based on the nurses' experiences i n c a r i n g f o r i n d i v i d u a l , f a m i l y , and group c l i e n t s i n many s e t t i n g s (Aroskar, 1979). This wider context of concern may r e s u l t i n c o n f l i c t between o b l i g a t i o n to b e n e f i t the i n d i v i d u a l or f a m i l y c l i e n t and the o b l i g a t i o n to b e n e f i t the community as a 45 whole. The r e s o l u t i o n of t h i s l e v e l of c o n f l i c t i n v o l v e s an an appeal to the e t h i c a l p r i n c i p l e s of j u s t i c e and b eneficence (Aroskar, 1979; Fry, 1983, 1985). Furthermore community h e a l t h nurses experience the r e l a t i o n s h i p s between i n d i v i d u a l , f a m i l y , and community h e a l t h and must r e c o n c i l e the c o n f l i c t s between the d e o n t o l o g i c a l n u r s i n g e t h i c s and the u t i l i t a r i a n e t h i c of p u b l i c h e a l t h (Aroskar, 1979; Fry, 1979, 1985). I t i s p o s s i b l e the community h e a l t h nurses' experience of e t h i c a l c o n f l i c t may be i n f l u e n c e d by t h e i r autonomy i n decision-making as they p r a c t i c e nursing i n a l t e r n a t e s e t t i n g s which are o f t e n removed from the continuous presence of p h y s i c i a n s , s u p e r v i s o r s , and other h e a l t h care team members. S i m i l a r l y , these nurses are o f t e n c l o s e r to the c l i e n t s ' point of view as they see them i n homes, s c h o o l s , and other s e t t i n g s that are o u t s i d e the t r a d i t i o n a l h e a l t h care domain. Community h e a l t h n u r s e s ' p r o x i m i t y to c l i e n t s i n t h e i r n a t u r a l community s e t t i n g s may i n f l u e n c e t h e i r p e r c e p t i o n of the advocacy r o l e f o r c l i e n t needs. P o t e n t i a l l y , these nurses may recognize a primary o b l i g a t i o n to a s s i s t h i g h - r i s k or v u l n e r a b l e c l i e n t s to represent t h e i r own needs, and/or i n c r e a s e the system's responsiveness to t h e i r needs by a c t i n g on t h e i r behalf when they are too v u l n e r a b l e to a s s e r t t h e i r human r i g h t s . The nurses' awareness of the needs of these v u l n e r a b l e groups i s o f t e n enhanced by 46 experiences with i n d i v i d u a l s and f a m i l i e s on t h e i r c a s e l o a d s . This m u l t i - f a c e t e d focus on human needs un i q u e l y f a c i l i t a t e s the community h e a l t h nurse's a b i l i t y to recognize the " s o c i a l dimension of e t h i c s " (Aroskar, 1979), and to t a r g e t the system through advocacy and a c t i v i s t r o l e s . I n c r e a s i n g l y , e t h i c a l dilemmas i n community h e a l t h n u r s i n g p r a c t i c e w i l l r e f l e c t the d i f f i c u l t c hoices to be made i n the l a r g e r h e a l t h care arena - those i n v o l v i n g the a l l o c a t i o n of resources among the human p r i o r i t i e s of t r a n s p l a n t surgery and t e c h n o l o g i c a l advancements r e q u i r e d to save the l i v e s of some and the co s t s of p r o v i d i n g a b a s i c l e v e l of care to a l l . Community h e a l t h n u r s i n g p r a c t i c e r e f l e c t s a broad context of concern f o r the h e a l t h care of p o p u l a t i o n groups. R e s o l v i n g the l a r g e r e t h i c a l dilemmas a s s o c i a t e d with the a l l o c a t i o n of h e a l t h care resources r e q u i r e s a broad p e r s p e c t i v e on the i s s u e s . T h e r e f o r e , community h e a l t h nurses' p e r c e p t i o n s of e t h i c a l c o n f l i c t i s v a l u a b l e to developing the l a r g e r p i c t u r e r e q u i r e d to confront the d i f f i c u l t choices a s s o c i a t e d with these i s s u e s . To date, t h i s w r i t e r has been unable to l o c a t e any re p o r t s of re s e a r c h i n t o community h e a l t h nurses' p e r c e p t i o n s of e t h i c a l c h a l l e n g e s i n t h e i r p r a c t i c e . I t appears t h i s group has been under-represented i n e t h i c s r e s e a r c h . An i n t e r v i e w with M i l a Aroskar was f e a t u r e d i n a 47 recent e d i t i o n of an i n f l u e n t i a l p e r i o d i c a l which was devoted to the e x p l o r a t i o n of e t h i c s i n f a m i l y and community h e a l t h ( S c h u l t z and S c h u l t z , 1987). In i t , t h i s community h e a l t h n u r s e - e t h i c i s t r e p o r t s the p r e l i m i n a r y impressions of her r e s e a r c h i n t o e t h i c a l problems faced by community h e a l t h nurses i n Minnesota: These problems do not have the same drama of the l i f e - a n d - d e a t h s i t u a t i o n s as e x i s t i n acute care s e t t i n g s . Out i n the community, the nurse i s worrying about c h i l d abuse - about the p h y s i c a l , p s y c h o l o g i c , and s o c i o l o g i c aspects of the problem. The e t h i c a l aspects must be focused on as w e l l . ( S c h u l t z and S c h u l t z , 1987, p. 85). Summary This l i t e r a t u r e review began with an i n t r o d u c t i o n to the fundamental elements of e t h i c a l theory i n c l u d i n g the r e l a t i o n s h i p s between and among e t h i c s and morals; e t h i c s and law; t h e o r i e s , p r i n c i p l e s and val u e s ; and the e t h i c a l context of human r i g h t s . Using t h i s i n t r o d u c t i o n of e t h i c a l theory as the b a s i s f o r the ensuing d i s c u s s i o n of the f i e l d of b i o e t h i c s f a c i l i t a t e d the e x p l a n a t i o n of how e t h i c s may be a p p l i e d to moral concerns i n the broader h e a l t h care arena. Nursing e t h i c s was int r o d u c e d as a subsystem w i t h i n h e a l t h care e t h i c s . Predominant nursing values and codes of e t h i c s were d i s c u s s e d i n t h i s s e c t i o n . Various d e f i n i t i o n s of the e t h i c a l dilemma i n nur s i n g were compared and c o n t r a s t e d . 48 Four types of re s e a r c h i n t o n u r s i n g e t h i c s were c o n t r a s t e d . Most r e l e v a n t to t h i s study was the resea r c h i n t o n u r s e s ' p e r c e p t i o n s of e t h i c a l problems, dilemmas, and decision-making. Therefore decision-making models and resear c h i n t o t h e i r use was d i s c u s s e d i n some d e t a i l . Contemporary trend s , i s s u e s , and concerns a s s o c i a t e d with community h e a l t h n u r s i n g were d e s c r i b e d and the e t h i c a l dimensions a s s o c i a t e d with t h i s p r a c t i c e were e x p l o r e d . The need to r e s e a r c h the e t h i c a l dimensions of community h e a l t h n u r s i n g p r a c t i c e was evident w i t h i n t h i s d i s c u s s i o n and some i n d i c a t i o n of the beginning of t h i s endeavour concluded t h i s chapter . 49 CHAPTER THREE METHOD This chapter i n c l u d e s a d e s c r i p t i o n of the process undertaken to answer the re s e a r c h q u e s t i o n s . Because of the l a c k of previous r e s e a r c h i n t o the e t h i c a l dimensions of community h e a l t h n u r s i n g p r a c t i c e , a q u a l i t a t i v e , d e s c r i p t i v e design was used to explore the C.H.N.s' pe r c e p t i o n s of the content and context of e t h i c a l problems. S p e c i f i c a l l y , the design of the study was a d e s c r i p t i v e survey using an open-ended w r i t t e n data c o l l e c t i o n guide as the b a s i s f o r a q u a l i t a t i v e approach to data c o l l e c t i o n and a n a l y s i s . The approach c o n s i s t e d of the s e l e c t i o n of p a r t i c i p a n t s , the development of a data c o l l e c t i o n guide, and the processes of data c o l l e c t i o n and a n a l y s i s . A d d i t i o n a l l y , l i m i t a t i o n s i nherent i n the approach and the e t h i c a l c o n s i d e r a t i o n s observed during the course of the study are r e l e v a n t to the f o l l o w i n g d e s c r i p t i o n of the methodology. S e l e c t i o n of P a r t i c i p a n t s The use of a q u a l i t a t i v e approach does not r e q u i r e that c o n t r o l s be i n s t i t u t e d to ensure that the c h a r a c t e r i s t i c s of the sample are r e p r e s e n t a t i v e of the p o p u l a t i o n . Rather, t h i s approach i s a c c e p t i n g of purposive sampling, whereby 50 p a r t i c i p a n t s are s e l e c t e d or v o l u n t e e r on the b a s i s of t h e i r e xperience, i n t e r e s t i n , or knowledge of the area of r e s e a r c h ( D i e r s , 1979; F i e l d and Morse, 1985). Whereas t h i s type of sample s e l e c t i o n i s a form of b i a s i n q u a n t i t a t i v e r e s e a r c h , i t may be an asset i n exporatory s t u d i e s when those p a r t i c i p a n t s who are most i n v o l v e d or i n t e r e s t e d can begin to d e s c r i b e a p o o r l y understood phenomenon. A purposive sample of t h i r t y community h e a l t h nurses was obtained i n t h i s study. Two groups of community h e a l t h nurses were approached to request the members' p a r t i c i p a t i o n . The f i r s t group c o n s i s t e d of CHNs' who were employees i n the p r e v e n t i v e program of an urban Health Department. This group was s e l e c t e d because the nurse a d m i n i s t r a t o r had suggested that the nurses may be i n t e r e s t e d i n p a r t i c i p a t i n g i n nursing r e s e a r c h and consented to having the r e s e a r c h e r present the proposal and i n v i t e nurses to p a r t i c i p a t e on work time. The second group which c o n s i s t e d of a l l CHNs who were p r a c t i c i n g members of a p r o v i n c i a l Community Health Nurses' I n t e r e s t Group was s e l e c t e d f o r three reasons. F i r s t the r e s e a r c h e r had been a member of the group f o r some time and t h e r e f o r e had a good working r e l a t i o n s h i p with members. Secondly, the r e s e a r c h e r had observed that members of an i n t e r e s t group were concerned about and t h e r e f o r e more l i k e l y to acknowledge the e t h i c a l dimensions of t h e i r p r a c t i c e . T h i r d l y , members of the group i n c l u d e CHNs 51 p r a c t i c i n g i n many i s o l a t e d and r u r a l l o c a t i o n s i n the pr o v i n c e , thereby i n c r e a s i n g the range of experiences reported i n t h i s study. Development of the Data C o l l e c t i o n Guide C u r t i n ' s (1978) Model f o r C r i t i c a l E t h i c a l A n a l y s i s was the b a s i s f o r the development of the data c o l l e c t i o n guide (appendix B) . Within the guide, t.he nurses were r e f e r r e d to an i n t r o d u c t o r y d e f i n i t i o n of the e t h i c a l dilemma and asked to r e c a l l a c l i n i c a l s i t u a t i o n that had i n v o l v e d them In such a dilemma. This method of working with i n d i v i d u a l s i t u a t i o n s or i n c i d e n t s i s known as the C r i t i c a l I n c i d e n t Technique (Flanagan, 1954). According to Flanagan (1954) the c r i t i c a l i n c i d e n t i s one which has s p e c i a l s i g n i f i c a n c e f o r p a r t i c i p a n t s i n that i t has d i s t i n c t p o s i t i v e or negative e f f e c t s on the outcome of the a c t i v i t y . In t h i s study, the c r i t i c a l element of the s i t u a t i o n was the e t h i c a l dilemma. The C r i t i c a l I n c i d e n t Technique i s compatible with C u r t i n ' s model i n that i t r e q u i r e s that background i n f o r m a t i o n be c o l l e c t e d to develop the context of the i n c i d e n t . Therefore the subsequent questions i n c l u d e d w i t h i n the data c o l l e c t i o n guide were designed to guide the p a r t i c i p a n t s through the process of d e s c r i b i n g and a n a l y z i n g the c r i t i c a l e t h i c a l elements of the s i t u a t i o n s . S p e c i f i c a l l y the nurses were asked to d e s c r i b e r e t r o s p e c t i v e l y the circumstances, t h e i r r o l e , the p e r c e i v e d 52 c o n f l i c t , options c o n s i d e r e d , a c t i o n s taken, outcomes, f e e l i n g s , and s u p p o r t i v e or inadequate r e s o u r c e s . The guide was p i l o t t e s t e d with 5 CHNs. T h e i r responses i n d i c a t e d that a l l items on the data c o l l e c t i o n guide were comprehensible and r e l e v a n t i n that they y i e l d e d u s e f u l data. Furthermore, i t was c l e a r that these nurses were able to grasp the concept of the e t h i c a l dilemma and r e t r o s p e c t i v e l y analyze t h e i r e x p e r i e n c e s . The nurses suggested that the d e f i n i t i o n of the e t h i c a l dilemma w i t h i n the i n t r o d u c t i o n of the guide be expanded and c l a r i f i e d . T h e i r comments were most u s e f u l to the f i n a l refinement of the guide i n which the d e f i n i t i o n of the e t h i c a l dilemma was expanded to i n c l u d e a more s p e c i f i c r e f e r e n c e to the elements of c o n f l i c t and choice between c o n t r a d i c t o r y values or human r i g h t s . Data C o l l e c t i o n The data c o l l e c t i o n procedures f o r the two samples d i f f e r e d and w i l l be i n d i v i d u a l l y d e s c r i b e d . For the group i n the suburban h e a l t h department, the process began with the submission of the t h e s i s p roposal to the D i r e c t o r of the P r e v e n t i o n Program. A f t e r o b t a i n i n g a p p r o v a l , the resea r c h e r arranged to attend a r e g u l a r l y scheduled monthly nurs e s ' meeting. During that meeting on May 16, 1988, the d e f i n i t i o n of the e t h i c a l dilemma, and the r e s e a r c h o b j e c t i v e s were presented. F o l l o w i n g the p r e s e n t a t i o n , each 53 of the twenty-eight nurses r e c e i v e d a copy of the data c o l l e c t i o n guide and was i n v i t e d to p a r t i c i p a t e by w r i t i n g about a s i t u a t i o n which had i n v o l v e d them i n an e t h i c a l dilemma. The date f o r completion of the guide was n e g o t i a t e d with the nurses at that time f o r f i v e weeks l a t e r i n c o n s i d e r a t i o n of other demands on t h e i r time during May/June of 1988. The nurses were asked to r e t u r n t h e i r completed guides to the nurse manager's o f f i c e where they would be picked up by the r e s e a r c h e r . During the meeting, the nurses expressed some concern that the d e f i n i t i o n of the e t h i c a l dilemma was not d i r e c t i v e enough and requested s p e c i f i c c l i n i c a l examples. Most expressed an i n t e r e s t i n e t h i c a l i s s u e s . One week p r i o r to the r e t u r n date, the resea r c h e r contacted the nurse manager to i n q u i r e as to the number of responses. D i s a p p o i n t i n g l y , only 2 CHNs had responded and these had a l r e a d y been mailed to the r e s e a r c h e r . An e x t e n s i o n of the response p e r i o d d i d not improve the s i t u a t i o n as the nurses were a p p a r e n t l y too busy with other p r o j e c t s r e q u i r i n g e x t e n s i v e documentation and end of school year a c t i v i t i e s . In the end, only two nurses from t h i s group p a r t i c i p a t e d i n the r e s e a r c h . The data c o l l e c t i o n process was i n i t i a t e d with CHNIG members with an advertisment i n the bi-monthly n e w s l e t t e r which d e s c r i b e d the r e s e a r c h o b j e c t i v e s , the e t h i c a l dilemma, and appealed to the members to p a r t i c i p a t e given the l a c k of r e s e a r c h i n t o the e t h i c a l dimensions of t h e i r 54 n u r s i n g p r a c t i c e . Then data c o l l e c t i o n guides were mailed to 110 CHNIG members. T h e i r names and addresses were accessed with permission from the members' l i s t . A l l members who were a c t i v e l y p r a c t i c i n g community h e a l t h n u r s i n g were i n c l u d e d i n the i n i t i a l m a i l i n g and asked to r e t u r n the guides v i a the enclosed r e t u r n envelope to the r e s e a r c h e r ' s home address by a s p e c i f i c date four weeks l a t e r . Three weeks l a t e r , a reminder l e t t e r was mailed to a l l p a r t i c i p a n t s and the r e t u r n date f o r t h i s group was not extended. A l l of the CHNIG responses were returned w i t h i n a p e r i o d of 1 to 6 weeks f o l l o w i n g the i n i t i a l m a i l i n g . Two noteworthy o b s e r v a t i o n s were made w i t h i n the data c o l l e c t i o n p r o c e s s . F i r s t , the r e s e a r c h e r r e c e i v e d phone c a l l s from 11 nurses who expressed i n t e r e s t i n the r e s e a r c h t o p i c . E i g h t of these nurses f e l t they could not p a r t i c i p a t e i n w r i t i n g due to a l a c k of time, while 3 d i d p a r t i c i p a t e but wanted to c l a r i f y t h e i r d e f i n i t i o n of the dilemma with the r e s e a r c h e r . Of the 8 nurses who d i d not r e t u r n a w r i t t e n response, 5 d e s c r i b e d examples of dilemmas from t h e i r p r a c t i c e i n c l u d i n g p h y s i c i a n m a l p r a c t i c e , inadequate community h e a l t h s e r v i c e s , and the r e p o r t i n g of c h i l d abuse. I t may be that s i n c e most of the nurses c a l l e d from r u r a l , more i s o l a t e d regions of the p r o v i n c e , they had a need to have more personal contact and d i a l o g u e about these d i f f i c u l t s i t u a t i o n s than could be achieved through a 55 w r i t t e n response. These telephone responses were not i n c l u d e d i n the data. The second s u p r i s i n g o b s e r v a t i o n was the low response rate from the CHNs i n the suburban h e a l t h department. The r e s e a r c h e r had thought that p e r s o n a l contact and the o p p o r t u n i t y to e x p l a i n the study would encourage t h e i r p a r t i c i p a t i o n . However, t h i s was c e r t a i n l y not the case. S e v e r a l reasons are proposed. I t may be that nurses who belong to an i n t e r e s t group have a g r e a t e r commitment to p r o f e s s i o n a l p r a c t i c e i s s u e s ; t h i s has i m p l i c a t i o n s f o r the value of i n t e r e s t group c o n t r i b u t i o n s to f u t u r e n u r s i n g r e s e a r c h . I t may a l s o have been that the nurses from the low response group were too busy with other p r o j e c t s during the data c o l l e c t i o n p e r i o d ; t h i s was the e x p l a n a t i o n given by the nurses. F i n a l l y , i t may be that nurses working i n more i s o l a t e d regions of the province have a g r e a t e r need to share t h e i r experiences with dilemmas. Data A n a l y s i s The u n i t s of a n a l y s i s were the c l i n i c a l s i t u a t i o n s as d e s c r i b e d by the nurses i n c l u d i n g the circumstances surrounding the dilemmas and t h e i r responses to them. As d i r e c t e d by the C r i t i c a l I n c i d e n t Technique, the s i t u a t i o n s were analyzed a c c o r d i n g to the r e s e a r c h questions and e t h i c a l theory i n order to i d e n t i f y the c r i t i c a l elements of the e t h i c a l dilemmas. 56 This process of content a n a l y s i s c o n s i s t e d of coding according to a conceptual framework (Babbie, 1986) which was the model f o r c r i t i c a l e t h i c a l a n a l y s i s . The r e s e a r c h e r reviewed the n u r s e s ' d e s c r i p t i o n s of the phases of e t h i c a l decision-making w i t h i n the context of the t o t a l response, and then coded the c e n t r a l theme(s) contained w i t h i n the phases. The i d e n t i f i c a t i o n of r e c u r r e n t themes l e d to the development of c a t e g o r i e s o f : c l i n i c a l s i t u a t i o n s , c o n f l i c t s i nherent i n the dilemmas, nu r s i n g responses, f o r c e s i n f l u e n c i n g the n u r s i n g responses, and advocacy as a f e a t u r e of the n u r s i n g r o l e . These c a t e g o r i e s were developed through the processes of i d e n t i f i c a t i o n , c o n f i r m a t i o n by e s t a b i s h i n g c r i t e r i a f o r t h e i r d i s t i n c t i v e n e s s and i n t e r - r e l a t e d n e s s , and t h e i r r e l a t i o n to e t h i c a l theory or models (Babbie 1986; Fox, 1982; P o l i t and Hungler, 1983). Therefore both i n d u c t i v e and deductive methods were used i n t h i s a n a l y s i s (Babbie, 1986). Fox (1983) d e s c r i b e s the f o l l o w i n g four a t t r i b u t e s of c a t e g o r i e s : homogeneity, i n c l u s i v e n e s s , u s e f u l n e s s , and mutual e x c l u s i v e n e s s (p. 410). In t h i s study the emergent c a t e g o r i e s were homogeneous i n t h e i r l e v e l of a b s t r a c t i o n , u s e f u l i n t h e i r d e p i c t i o n of meaningful f a c e t s of community h e a l t h n u r s i n g p r a c t i c e , and i n c l u s i v e i n that every response was c a t e g o r i z e d . However, the c a t e g o r i e s were not mutually e x c l u s i v e i n that some responses could be i n c l u d e d i n more than one category. For example, responses i n c l u d e d 57 i n the s i t u a t i o n a l category of c l i e n t s ' r i g h t s may a l s o be r e p r e s e n t a t i v e of the category of system i n t e r a c t i o n . T h i s i n a b i l i t y to achieve mutual e x c l u s i v i t y w i t h i n the c a t e g o r i e s i s due i n part to the l i m i t a t i o n s In the methodolology. L i m i t a t i o n s The v a l i d i t y and r e l i a b i l i t y of the f i n d i n g s were l i m i t e d i n some ways by the methodological approach. The v a l i d i t y of the f i n d i n g s may have been improved i f the data c o l l e c t i o n method had c o n s i s t e d of i n t e r v i e w s i n s t e a d of the w r i t t e n responses. During i n t e r v i e w s , a g r e a t e r s p e c i f i c i t y of the n u r s e s ' d e s c r i p t i o n s of t h e i r experience may have been f a c i l i t a t e d through i n t e r a c t i v e communication between researc h e r and respondent. This g r e a t e r s p e c i f i c i t y of data may have r e s u l t e d i n the i d e n t i f i c a t i o n of mutually e x c l u s i v e c a t e g o r i e s , a p r e v i o u s l y i d e n t i f i e d l i m i t a t i o n . In a d d i t i o n , the f e e l i n g s a s s o c i a t e d with the experience of the e t h i c a l dilemma may have been expressed more f u l l y during a personal i n t e r v i e w . C e r t a i n l y , those nurses who telephoned the r e s e a r c h e r and d i d not respond i n w r i t i n g may have been i n h i b i t e d by t h i s method. However, the c o n s t r u c t v a l i d i t y of the data c o l l e c t i o n guide was enhanced by the use of the model f o r c r i t i c a l e t h i c a l a n a l y s i s to guide the nurses' responses w i t h i n the data c o l l e c t i o n process. The r e l i a b i l i t y of the f i n d i n g s was i n f l u e n c e d by the s e l f - s e l e c t i o n of the sample group as w e l l as by the 58 r e s e a r c h e r ' s a b i l i t y t o d e l i m i t t h e i n f l u e n c e o f h e r own e x p e r i e n c e w i t h e t h i c a l d i l e m m a s w h i l e a n a l y z i n g t h e c o n t e x t a n d r e s p o n d i n g a c c u r a t e l y t o t h e s i t u a t i o n s d e s c r i b e d b y t h e p a r t i c i p a n t s . T h i s a b i l i t y was a i d e d t h r o u g h c o m m u n i c a t i o n w i t h t h e t h e s i s c o m m i t t e e a n d w o r k i n g w i t h t h e d a t a o v e r t i m e . F u r t h e r m o r e , s i n c e t h e n u r s e s who r e s p o n d e d a r e members o f a n i n t e r e s t g r o u p , one m u s t a s s u m e t h e e x i s t e n c e o f u n i q u e c h a r a c t e r i s t i c s a n d p e r s p e c t i v e s w h i c h p r e c l u d e t h e g e n e r a l i z a b i l i t y o f t h e i r e x p e r i e n c e s t o o t h e r c o m m u n i t y h e a l t h n u r s e s who a r e n o t m e m b e r s . E t h i c a l C o n s i d e r a t i o n s B e f o r e b e g i n n i n g t h e r e s e a r c h p r o c e s s , o f f i c i a l a p p r o v a l o f t h e s t u d y was r e c e i v e d f r o m t h e E t h i c s C o m m i t t e e o f t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , t h e E x e c u t i v e o f t h e C H N I G , a n d t h e n u r s i n g a d m i n i s t r a t i o n o f t h e h e a l t h d e p a r t m e n t . The p a r t i c i p a n t s w e r e i n f o r m e d o f t h e i r r i g h t t o w i t h d r a w f r o m t h e s t u d y a t a n y t i m e w i t h o u t p e n a l t y , a n d o f t h e i r r i g h t o f n o n - p a r t i c i p a t i o n . W i t h r e s p e c t f o r human r i g h t s t o c o n f i d e n t i a l i t y a n d p r i v a c y , t h e p a r t i c i p a n t s w e r e r e q u e s t e d t o a l t e r t h e i r d e s c r i p t i o n o f t h e s i t u a t i o n s so a s t o m a i n t a i n t h e a n o n y m i t y o f t h e c l i e n t s , h e a l t h c a r e t e a m m e m b e r s , o r a g e n c i e s i n v o l v e d . T h i s r e q u e s t was s p e c i f i e d o n t h e c o n s e n t f o r m a n d i n t h e d a t a c o l l e c t i o n g u i d e . F u r t h e r m o r e , t h e p a r t i c i p a n t s w e r e a s s u r e d t h a t t h e i r 59 i d e n t i t i e s would be not be rev e a l e d to anyone and t h i s o b l i g a t i o n was f u l f i l l e d throughout the course of the study. I t was not a n t i c i p a t e d that the nurses' p a r t i c i p a t i o n i n the study would place them at risk, i n any way. However, the n u r s e s ' s e n s i t i v i t y to the emotional nature of the s i t u a t i o n s i s r e c o g n i z e d . T h e r e f o r e , the r e s e a r c h e r i n d i c a t e d her ongoing a v a i l a b i l i t y f o r d i s c u s s i o n of the s i t u a t i o n ( s ) through telephone contact or a meeting. F i n a l l y , the c o n s i d e r a b l e time and e f f o r t r e q u i r e d to complete the q u e s t i o n n a i r e i s recognized and a p p r e c i a t e d . The i n v e s t i g a t o r acknowledges the r e s p o n s i b i l i t y to share f i n d i n g s i n order to r e a l i z e the s i g n i f i c a n c e of nurses' c o n t r i b u t i o n to understanding e t h i c a l problems i n community h e a l t h nursing p r a c t i c e . Summary The approach used to answer the resea r c h questions was de s c r i b e d i n t h i s chapter. This approach i n c l u d e d the s e l e c t i o n of p a r t i c i p a n t s , the development of the data c o l l e c t i o n guide, and the processes of data c o l l e c t i o n and content a n a l y s i s of the nurses' w r i t t e n d e s c r i p t i o n s . The l i m i t i n g e f f e c t s of some elements of design and method on r e l i a b i l i t y and v a l i d i t y were noted. F i n a l l y , the e t h i c a l c o n s i d e r a t i o n s which guided the conduct of the r e s e a r c h were e x p l a i n e d . The f i n d i n g s which r e s u l t e d from t h i s methodology are presented i n the f o l l o w i n g chapter. 60 CHAPTER FOUR FINDINGS T h i s c h a p t e r p r e s e n t s and d i s c u s s e s the f i n d i n g s w h i c h r e s u l t e d f r o m t h e c o n t e n t a n a l y s i s of the n u r s e s ' w r i t t e n d e s c r i p t i o n s o f t h e e t h i c a l dilemmas t h e y had e x p e r i e n c e d i n t h e i r community h e a l t h n u r s i n g p r a c t i c e . I n o r d e r to a c c o m p l i s h t h i s , t h e c h a p t e r w i l l be o r g a n i z e d i n t o two s e c t i o n s . F i r s t , the c h a r a c t e r i s t i c s of the n u r s e s who p a r t i c i p a t e d i n t h i s s t u d y a r e d e s c r i b e d . In the s e c o n d s e c t i o n t h e t y p e s o f e t h i c a l dilemmas and n u r s i n g r e s p o n s e s a r e p r e s e s n t e d w i t h i n the f o l l o w i n g t h r e e c a t e g o r i e s : 1. C l i e n t s ' R i g h t s 2. System I n t e r a c t i o n 3. N u r s e s ' R i g h t s These c a t e g o r i e s were d e v e l o p e d from t h e n u r s e s ' d e s c r i p t i o n s of t h e c i r c u m s t a n c e s s u r r o u n d i n g the e t h i c a l dilemmas t h e y r e p o r t e d . A d d i t i o n a l l y , f i v e CHNs r e s p o n d e d by r e p o r t i n g t h e y had had no e x p e r i e n c e w i t h e t h i c a l dilemmas i n t h e i r community h e a l t h n u r s i n g p r a c t i c e . P o s s i b l e e x p l a n a t i o n s f o r t h i s r e s p o n s e a r e p r o p o s e d i n c h a p t e r f i v e . C h a r a c t e r i s t i c s of t h e P a r t i c i p a n t s T h i r t y CHNs p a r t i c i p a t e d i n t h e s t u d y by m a i l i n g t h e i r c o m p l e t e d q u e s t i o n n a i r e to the i n v e s t i g a t o r ' s home. Response r a t e s f o r the two g r o u p s a r e p r e s e n t e d i n T a b l e 1. 61 TABLE I Response Rates T o t a l # T o t a l # Sample D i s t r i b u t e d Received Rate Urban Health Department 28 2 7% CHNIG 110 28 25% Both Groups 138 30 21% C h a r a c t e r i s t i c s of the p a r t i c i p a n t s i n c l u d i n g t h e i r l e v e l of education and years of general and community h e a l t h n u rsing experience are presented i n Tables 2 and 3., TABLE II Years of General and Community Health Nursing Experience Number of Nurses Range (years) General Community Health I- 5 1 5 6-10 7 15 I I - 15 7 3 16-20 8 6 21-25 5 1 26-30 2 0 T o t a l years Mean 462 15.4 294 .5 9.8 62 TABLE I I I Le v e l of Education Current E d u c a t i o n a l Status Number of CHNs R.N. & C e r t i f i c a t e i n P u b l i c Health Nursing 2 B.S.N. 22 Masters (Nursing and other) 6 The p a r t i c i p a n t s p r a c t i c e d i n urban, r u r a l , and mixed communities i n the lower mainland, the northern and i n t e r i o r l o c a t i o n s of the province and on Vancouver I s l a n d . Twenty nurses p r a c t i c e d i n urban communities, 8 i n r u r a l , and 2 i n combined urban and r u r a l d i s t r i c t s . The CHNs had been i n t h e i r c u r r e n t p o s i t i o n s f o r an average of 4 ye a r s . Twenty worked i n the p r e v e n t i v e community h e a l t h program and f u n c t i o n e d as g e n e r a l i s t s with combined caseloads of f a m i l i e s , s c h o o l s , communicable disease c o n t r o l and other p r o j e c t s . Seven of the nurses held management p o s i t i o n s and were r e s p o n s i b l e f o r community h e a l t h nursing programs. Three nurses held p o s i t i o n s i n s p e c i a l i z e d programs f o r s e n i o r s and youth. Types of E t h i c a l Dilemmas and Nursing Responses Within each of the three general c a t e g o r i e s of c l i e n t s ' r i g h t s , system i n t e r a c t i o n , and nurses' r i g h t s , the nature of the dilemmas was s p e c i f i c a l l y determined by d e s c r i b i n g 63 the circumstances and the focus of the c o n f l i c t . Furthermore, the nurse s ' d e s c r i p t i o n s of t h e i r f e e l i n g s and decision-making comprise the p r e s e n t a t i o n of t h e i r responses to the dilemmas. C l i e n t s ' Rights E t h i c a l dilemmas i n v o l v i n g the r i g h t s of c l i e n t s formed the l a r g e s t category of responses. These dilemmas occurred when the nurse was working with h i g h - r i s k parents, a d o l e s c e n t s , and a d u l t c l i e n t s with mental h e a l t h concerns. The circumstances and c o n f l i c t s w i l l now be i d e n t i f i e d i n r e l a t i o n to each of these c l i e n t groups. H i g h - r i s k p a r e n t i n g Within the context of the data, h i g h - r i s k p a r e n t i n g i s def i n e d as those s i t u a t i o n s where the h e a l t h of parents and t h e i r c h i l d r e n i s at r i s k due to maladaptation to one or more aspects of the p a r e n t a l r o l e which i n turn may be a t t r i b u t e d to a complex array of h e a l t h , s o c i a l , and economic f a c t o r s . In each of the s i t u a t i o n s , the nurses d e s c r i b e d t h e i r involvement with f a m i l i e s where c h i l d abuse or n e g l e c t was suspected or probable as i n d i c a t e d by the presence of r i s k f a c t o r s and i n d i c a t o r s . CHNs were f r o n t - l i n e i n r e c o g n i z i n g and determining the degree of r i s k and the need f o r r e f e r r a l and p r o t e c t i v e a c t i o n . T y p i c a l l y , others i n v o l v e d i n t h i s category i n c l u d e d the i n f a n t or c h i l d , one or both of the parents, members of the extended f a m i l y , other community h e a l t h nurse 64 c o l l e a g u e s , the community h e a l t h nurse a d m i n i s t r a t o r and most o f t e n the s o c i a l worker employed by the B.C. M i n i s t r y of S o c i a l S e r v i c e s and Housing (MSSH). I d e n t i f i e d as key p l a y e r s were other h e a l t h care team members - the f a m i l y p h y s i c i a n , medical s p e c i a l i s t s , t h e r a p i s t s and sexual abuse c o n s u l t a n t s . The degree to which the CHN i d e n t i f i e d the i n d i v i d u a l , m a t e r n a l - c h i l d dyad, or the f a m i l y as the c l i e n t v a r i e d or was d i f f i c u l t to determine from the data. This d i f f e r i n g p e r s p e c t i v e i s l i k e l y i n f l u e n c e d by s e v e r a l f a c t o r s i n c l u d i n g the nurses' t h e o r e t i c a l o r i e n t a t i o n , l e v e l of knowledge and s k i l l , v a l u e s , and the degree and a c u i t y of the p e r c e i v e d r i s k to the c h i l d w i t h i n the h i g h - r i s k f a m i l y s i t u a t i o n . Nature of the c o n f l i c t ( s ) . These c o n f l i c t s i n v o l v e d questions about how to i n t e r v e n e t h e r a p e u t i c a l l y i n h i g h - r i s k p a r e n t i n g s i t u a t i o n s and how to meet l e g a l and moral o b l i g a t i o n s i n r e p o r t i n g suspected or probable c h i l d abuse. Three c o n f l i c t s were c h a r a c t e r i s t i c of the h i g h - r i s k parenting s i t u a t i o n s . F i r s t , the predominant c o n f l i c t centered around the nurses' assessment of how to a s s i s t the f a m i l y while f u l f i l l i n g p r o f e s s i o n a l and l e g a l o b l i g a t i o n s . In the m a j o r i t y of s i t u a t i o n s , the nurses f e l t that the a c t i o n taken to meet the immediate p r o t e c t i o n needs of the c h i l d r e n would not decrease the r i s k s nor c o n t r i b u t e to the h e a l t h of 65 the f a m i l y . The nurses f e l t t h e i r l e g a l and moral duty to report signs of p o t e n t i a l c h i l d abuse or neg l e c t would r e s u l t i n the l o s s of t h e i r r e l a t i o n s h i p with the c l i e n t , and the r e s u l t i n g immediate i n t e r v e n t i o n by MSSH, the RCMP and others would decrease the c l i e n t s ' chances of s e c u r i n g the long term, comprehensive care they needed. On the other hand, by choosing not to report s u s p i c i o n s of c h i l d abuse, the nurses feared f o r the s a f e t y of the c h i l d and f e l t they were not meeting t h e i r p r o f e s s i o n a l , l e g a l , and moral o b l i g a t i o n s to p r o t e c t the c h i l d r e n . One nurse expressed her p e r c e p t i o n of t h i s c o n f l i c t and the l o s s r e s u l t i n g from her a c t i o n : L e g a l l y I had to re p o r t t h i s high r i s k s i t u a t i o n but i t r e s u l t e d i n t h i s f a m i l y being u n w i l l i n g to have f u r t h e r contact with me. They have r e c e i v e d s p o r a d i c help from other agencies (when i n c r i s i s ) but there has been no long-term help which I f e e l I could have p r o v i d e d . The nurses had i d e n t i f i e d that the act of r e p o r t i n g c h i l d abuse would r e s u l t i n a c r i s i s f o r a l l concerned, and there was no on-going support f o r the c l i e n t during the c r i s i s : The most d i f f i c u l t t h i n g i n t h i s s i t u a t i o n was r e p o r t i n g to the s o c i a l worker about the abuse as I knew that there would be no s e r v i c e s to support the mom at the time of the RCMP i n v e s t i g a t i n g and that was when she needed i t . . . I considered d e l a y i n g r e p o r t i n g u n t i l a l l support s e r v i c e s ( i . e . c o u n s e l l i n g ) were a v a i l a b l e but i f the f a t h e r was abusing k i d s then they needed help now. I f e l t trapped as l e g a l l y I had to r e p o r t but knew my c l i e n t would s u f f e r . 66 The second c o n f l i c t centered around the q u e s t i o n of approach to i n t e r v e n i n g with f a m i l i e s . The nurse seemed to be s t r u g g l i n g with the focus of care - should i t be the i n d i v i d u a l or the family? T h i s c o n f l i c t i n determing the focus of care r e s u l t e d i n questions such as: "How long could we work with the mother i n hopes of long range change v i s - a - v i s short term d r a s t i c i n t e r v e n t i o n on the c h i l d ' s b e h a l f ? " A t h i r d c o n f l i c t was inherent i n the nurse's s t r u g g l e to respect the c l i e n t s ' r i g h t s to c o n f i d e n t i a l i t y , and p a r t i c i p a t i o n i n treatment d e c i s i o n s , while s h a r i n g the necessary i n f o r m a t i o n with other members of the h e a l t h care team i n order to p r o t e c t the c h i l d or access needed s e r v i c e s f o r the f a m i l y . In most i n s t a n c e s , t h i s i n v o l v e d s h a r i n g s e n s i t i v e i n f o r m a t i o n about inadequate or p o t e n t i a l l y unsafe pa r e n t i n g p r a c t i c e s with the MSSH s o c i a l worker and the c l i e n t ' s p h y s i c i a n . One nurse s t a t e d : "I was f r o n t - l i n e i n r e c e i v i n g the i n i t i a l concerns of the mother, a s s e s s i n g the s i t u a t i o n and the needs of t h i s c h i l d and the mother, making a c o n c l u s i o n and a c t i n g on i t by way of r e f e r r a l s to a p p r o p r i a t e r e s o u r c e s " . The essence of the c o n f l i c t was f u r t h e r i d e n t i f i e d as: "how to maintain the c l i e n t ' s t r u s t and the c o n f i d e n t i a l i t y of her d i s c l o s u r e while r e c o g n i z i n g the need to inform the doctor of her symptoms without her consent" or "how to get to the root of the problem f o r the f a i l u r e - t o - t h r i v e i n f a n t by t r y i n g to get a p p r o p r i a t e 67 supports f o r the mother and get the p r o f e s s i o n a l s to work tog e t h e r " . Nurses' responses. Most nurses i d e n t i f i e d one or more of the f o l l o w i n g as a l t e r n a t i v e s i n the h i g h - r i s k p a r e n t i n g s i t u a t i o n s where c h i l d abuse was suspected: (a) to r e p o r t to MSSH immediately as per p o l i c y g u i d e l i n e s (b) to delay r e p o r t i n g u n t i l they were c e r t a i n that p h y s i c a l c h i l d abuse or n e g l e c t was o c c u r r i n g and/or u n t i l support systems were i n place and (c) to not r e p o r t and continue to monitor the s i t u a t i o n without the involvement of other p r o f e s s i o n a l s . In those s i t u a t i o n s where the p h y s i c a l s a f e t y of the c h i l d was not threatened, the nurses s t i l l s t r u g g l e d with the d e c i s i o n about whether to continue to work with those parents who were having severe d i f f i c u l t i e s a d j u s t i n g to the p a r e n t i n g r o l e . A d d i t i o n a l l y , some of the a l t e r n a t i v e s i d e n t i f i e d f o r working with "non-compliant" or "hard to change" f a m i l i e s r e v o l v e d around the "how t o ' s " of working with the f a m i l y . S p e c i f i c a l l y , the options i n c l u d e d when and how to i n v o l v e other p r o f e s s i o n a l s such as the f a m i l y p h y s i c i a n , and whether to focus on the c h i l d , parent, or the f a m i l y as the c l i e n t . In most i n s t a n c e s , the nurses d e s c r i b e d the outcomes of t h e i r dilemmas as u n s a t i s f a c t o r y . This was due to the l o s s of t h e i r own r e l a t i o n s h i p with the h i g h - r i s k c l i e n t without the assurance that the f a m i l y had r e c e i v e d a p p r o p r i a t e and 68 e f f e c t i v e a s s i s t a n c e from other p r o f e s s i o n a l s i n the system. They seemed to f e e l that the parents and c h i l d r e n would remain at r i s k f o r some time. A not uncommon sequela was for the f a m i l y to leave the geographic area once a c t i o n had been taken, thereby s l i p p i n g through the gaps i n the system. In some i n s t a n c e s , the nurses remained f e a r f u l that the c h i l d was s t i l l at r i s k d e s p i t e the a c t i o n they had taken In accordance with the c h i l d p r o t e c t i o n p o l i c y . The nurses expressed anger at the system, f r u s t r a t i o n with the l a c k of i n t e r - p r o f e s s i o n a l communication, and a sense of " h e l p l e s s n e s s " i n f e e l i n g they had no c o n t r o l over what happened to the c l i e n t once a c h i l d abuse r e p o r t had been made. Other f r u s t r a t i o n s i n c l u d e d f e e l i n g l i k e a "policeman" or " t r a i t o r " i n t r y i n g to get parents to do what i s r i g h t f o r t h e i r c h i l d r e n , and f e e l i n g a l a c k of "time, energy, and s k i l l s " to help them with t h e i r " personal problems". Even when they had taken p r o t e c t i v e a c t i o n , some nurses had c o n t i n u i n g concerns that the c h i l d may s t i l l be at r i s k . T h e i r f e e l i n g s about these s i t u a t i o n s may have been unresolved f o r some time. A p e r v a s i v e sadness was expressed i n one nurse's d e s c r i p t i o n of her experience with a s c h i z o p h r e n i c young mother who was on t r i a l to see i f she could manage the care of her i n f a n t : I f e l t a r e a l sense of doom that the Mom would l o s e the baby before I had even met them. This can make i t d i f f i c u l t to be encouraging and hopeful to the c l i e n t s . 69 The p a t i e n t very d e f i n i t e l y had a mental problem. One could a l s o t e l l that she loved her baby d e a r l y . The s o c i a l worker d i d want the Mom to have every chance to have her baby. I t was a l l so sad. C l e a r l y , these w r i t t e n responses were only the t i p of the i c e b e r g of the nurses emotional experience with these dilemmas. One nurse wrote: There are many other f a c t o r s a s s o c i a t e d with the case that I have not i n c l u d e d . I worked so hard at b u i l d i n g t r u s t so that she would open up ... which she d i d r e : the sexual abuse because i t was awful abuse by f a t h e r s and uncles and I had to r e l y on other p r o f e s s i o n a l s who did not care or were u n w i l l i n g to put i n equal energy thereby causing r e g r e s s i o n i n t h i s f a m i l y . In some i n s t a n c e s i t was apparent the dilemmas o f f e r e d the o p p o r t u n i t y f o r developing a g r e a t e r degree of i n s i g h t i n t o the n u r s e s ' personal and p r o f e s s i o n a l v a l u e s . One nurse commented that her negative f e e l i n g s about the s i t u a t i o n had r e s u l t e d i n her being more a s s e r t i v e and c o n f i d e n t i n e x p r e s s i n g her n u r s i n g e x p e r t i s e and understanding of the f a m i l y w i t h i n the community h e a l t h care system. However with h i g h - r i s k p a r e n t i n g dilemmas, only two nurses expressed r e l i e f that they had made the r i g h t d e c i s i o n because the c h i l d was safe and the f a m i l y was r e c e i v i n g c a r e . The a d u l t c l i e n t with mental h e a l t h concerns Two nurses d e s c r i b e d e t h i c a l dilemmas which occurred while they were c a r i n g f o r adul t c l i e n t s with mental h e a l t h concerns. In these s i t u a t i o n s the CHNs' were the primary contact f o r the c l i e n t who was at home. The nurses 70 responded to the concerns of f a m i l y members, assessed the c l i e n t ' s needs and determined the need f o r f u r t h e r i n t e r v e n t i o n i n c l u d i n g r e f e r r a l . Nature of the c o n f l i c t . These s i t u a t i o n s i n v o l v e d d e c i s i o n s about when and how to i n t e r v e n e . A s s o c i a t e d with these d e c i s i o n s were c o n s i d e r a t i o n s of the degree of r i s k to the c l i e n t and ot h e r s , the o b l i g a t i o n to maintain s a f e t y , and the c l i e n t s ' r i g h t s to c o n f i d e n t i a l i t y , and s e l f - d e t e r m i n a t i o n . The nurses i d e n t i f i e d the crux of the e t h i c a l dilemma as the c o n f l i c t between the c l i e n t s ' r i g h t s to d i e or l i v e at r i s k versus the f a m i l y , p r o f e s s i o n a l , and s o c i e t a l r e s p o n s i b i l i t y to p r o t e c t the a d u l t from harm. A c l e a r case of t h i s c o n f l i c t occurred when: The niece had requested an assessment as she f e l t her aunt was no longer able to manage alone i n her apartment due to memory impairment and paranoia. The c l i e n t was r e l u c t a n t to have a v i s i t and became s u s p i c i o u s . The c l i e n t was not i n agreement t o t a l l y to seeing me or complying with a care plan because she d i d not have i n s i g h t i n t o the problems i n d e n t i f i e d by the f a m i l y . Due to the c l i e n t ' s mental s t a t u s she could not understand the consequences of l i v i n g at r i s k . A f u r t h e r dimension of t h i s c o n f l i c t was a s s o c i a t e d with the f a m i l y ' s request f o r the CHN's involvement without consent of the i n d i v i d u a l c l i e n t who was deemed at r i s k . Other nurses a l s o experienced t h i s c o n f l i c t between i n d i v i d u a l and f a m i l y needs. F i n a l l y , the CHN found i t both necessary and d i f f i c u l t to i n v o l v e other h e a l t h care team members, while m a i n t a i n i n g 71 c o n f i d e n t i a l i t y , t r u s t , and p r o t e c t i n g the c l i e n t f r o m o v e r l y a g g r e s s i v e i n t e r v e n t i o n . N u r s e s ' r e s p o n s e s . The n u r s e s i d e n t i f i e d a l t e r n a t i v e a c t i o n s i n t h e s e dilemmas i n c l u d i n g i n t e r v e n i n g w i t h o u t the c l i e n t s ' c o n s e n t to e n s u r e the i m m e d i a t e s a f e t y of c l i e n t , s e l f , and o t h e r s ; i n v o l v i n g o t h e r h e a l t h c a r e team members i n t h e d e c i s i o n - m a k i n g i n a manner more r e s p e c t f u l of t h e c l i e n t ' s w i s h e s , or m o n i t o r i n g the s i t u a t i o n u n t i l t h e d e g r e e o f r i s k became c l e a r e r . The n u r s e s a c t e d t o i n v o l v e o t h e r h e a l t h p r o f e s s i o n a l s and f a m i l y members w i t h o u t f u l l c o n s e n t of t h e c l i e n t i n o r d e r to p r o t e c t the c l i e n t , the n u r s e , and o t h e r s who were p o t e n t i a l l y a t r i s k due to the c l i e n t ' s u n s t a b l e m e n t a l h e a l t h . The d e g r e e to w h i c h the CHN c o n t i n u e d to i n v o l v e the c l i e n t i n t r e a t m e n t d e c i s i o n s was u n c l e a r from t h e d a t a . However, i t was c l e a r the n u r s e s r e s p e c t e d t h e i r c l i e n t s ' f e a r s and w i s h e s and i n d i c a t e d t h e i r d e s i r e to i n f l u e n c e the s y s t e m to r e s p e c t t h e s e as f u l l y as p o s s i b l e . F o r example, one n u r s e worked w i t h the f a m i l y p h y s i c i a n who had known the c l i e n t f o r some t i m e i n o r d e r to f a c i l i t a t e an a p p r o p r i a t e r e f e r r a l to a s h o r t term a s s e s s m e n t u n i t i n a n o n - t h r e a t e n i n g manner. A n o t h e r CHN c l e a r l y s e p a r a t e d h e r r o l e and i n t e r v e n t i o n f r o m the RCMP i n v o l v e m e n t when n e g o t i a t i n g a p l a n of c a r e w i t h a p o t e n t i a l l y v i o l e n t c l i e n t 72 and was t h e r e f o r e able to maintain t h e r a p e u t i c contact over a longer p e r i o d of time. The most d i f f i c u l t aspect of t h i s dilemma was d e s c r i b e d as the "gray area" i n determining c l i e n t ' s competence to d e c i d e , t h e i r degree of r i s k , and the c l i e n t ' s r i g h t to remain at r i s k . F i n d i n g ways to work with the c l i e n t s was seen as o f t e n over s i m p l i f i e d : I t ' s too easy to say the c l i e n t s are non-compliant. I t h i n k we have to c o o p e r a t i v e l y and c r e a t i v e l y work to devise ways to achieve h e a l t h f o r a l l . F i n a l l y , f e a r f o r personal s a f e t y was expressed i n one i n s t a n c e due to the c l i e n t ' s anger and p o s s i b l e backlash r e s u l t i n g i n h i s / h e r l o s s of t r u s t i n the f a m i l y and the CHN. The adolescent c l i e n t Two CHNs reported dilemmas that occurred as a r e s u l t of t h e i r involvement with adolescents i n elementary and secondary s c h o o l s . Although the e t h i c a l c o n f l i c t s are s i m i l a r to those d e s c r i b e d i n previous c a t e g o r i e s , adolescence as a t r a n s i t i o n between c h i l d and a d u l t presents unique l e g a l and moral problems f o r the community h e a l t h nurse. Nature of the c o n f l i c t ( s ) . The adolescents were h i g h - r i s k i n that they were e x p e r i e n c i n g severe h e a l t h problems such as drug abuse, e a t i n g d i s o r d e r s , and d e p r e s s i o n . T h e i r f a m i l i e s were 73 unaware of the extent of t h e i r problems. The CHN was then confronted with the choice of informing parents and other p r o f e s s i o n a l s of the c l i e n t ' s problems, or choosing to maintain c o n f i d e n t i a l i t y and provide only those s e r v i c e s and c o u n s e l l i n g that the adolescent accepted. The nurses pe r c e i v e d that e i t h e r choice could p o t e n t i a l l y r e s u l t i n more harm than b e n e f i t to the a d o l e s c e n t . I f they i n v o l v e d the f a m i l y without the consent of the a d o l e s c e n t , they r i s k e d l o s i n g a t r u s t i n g r e l a t i o n s h i p with a high-needs c l i e n t . They feared t h i s i n t e r v e n t i o n may r e s u l t i n more harm than good f o r the adolescent as they may r e s i s t other forms of a s s i s t a n c e i n the f u t u r e . A l t e r n a t i v e l y , not informing parents or others was a l s o p e r c e i v e d to be r i s k y as s i g n i f i c a n t others may not be aware of the s e v e r i t y of the a d o l e s c e n t ' s problems. T h e r e f o r e , i n these s i t u a t i o n s the nurse may be i n a l e g a l l y and e t h i c a l l y tenuous p o s i t i o n f o r not i n v o l v i n g the f a m i l y i n the h e a l t h care of a minor. In one nurse's words "the c o n f l i c t was to maintain c o n f i d e n t i a l i t y or allow dangerous behaviour to continue without p o s s i b l e r e c o u r s e " . A d d i t i o n a l l y , the nurse's p r o f e s s i o n a l competence may be at r i s k . At r i s k i f she exceeds the l e g a l boundaries of her employment c o n t r a c t i n meeting the dependency needs of the adolescent c l i e n t i n the absence of a s u p p o r t i v e parent or quardian. For example, one nurse t r a n s p o r t e d a c l i e n t to an appointment with a p s y c h i a t r i s t - a p r a c t i c e that i s 74 a g a i n s t agency p o l i c y . The nurse had f e l t t h i s i n t e r v e n t i o n was necessary i n order to encourage the adolescent to o b t a i n the treatment she badly needed. At the same time she was concerned about j e o p a r d i z i n g her employment c o n t r a c t : It was most d i f f i c u l t to be aware of a p o l i c y and n e g l e c t to observe i t . In t h i s case the c l i e n t ' s w e l l being was more important to me. There i s f e a r you may be d i s c o v e r e d p r o v i d i n g t h i s much needed s e r v i c e . I t i s f r u s t r a t i n g - t h i s i s an ongoing problem. Even though you encourage independence i n c l i e n t s and expect them to meet t h e i r own needs i n t h i s area, o f t e n i t i s unsafe, or impossible f o r them to do so. Nurses' responses. The nurses i d e n t i f i e d the consequences of t h e i r i n t e r v e n t i o n s with the a d o l e s c e n t s . The main a l t e r n a t i v e was to i n v o l v e f a m i l y , school c o u n s e l l o r s , or other h e a l t h care team members. For those adolescents who were a c t i v e l y i n v o l v e d with drug abuse, and i n one case t r a f f i c k i n g , the nurse i n v o l v e d other p r o f e s s i o n a l s and f a m i l y . The nurses pe r c e i v e d the outcome of t h e i r i n t e r v e n t i o n as inadequate. The adolescents and t h e i r f a m i l i e s d i d not get the treatment and follow-up they needed w i t h i n the system. However, i n one s i t u a t i o n the nurse maintained a long-term r e l a t i o n s h i p with her adolescent c l i e n t and found that her c l i e n t ' s t r a n s i t i o n to p s y c h i a t r i c therapy was more s u c c e s s f u l due to her continuous support through the r e f e r r a l p rocess. The nurses' involvement with the h i g h - r i s k a d o l e s c e n t s evoked f e e l i n g s of f r u s t r a t i o n , anger, and of being a t r a i t o r or spy. They a l s o f e l t they were b e t r a y i n g a t r u s t 75 when c o n t a c t i n g f a m i l i e s w i t h o u t the a d o l e s c e n t ' s c o n s e n t . One CHN e x p r e s s e d h e r an g e r toward s o c i e t a l c o n d i t i o n s f o r her a d o l e s c e n t c l i e n t ' s i n v o l v e m e n t i n d r u g use and t r a f f i c k i n g . System I n t e r a c t i o n E t h i c a l dilemmas a s s o c i a t e d w i t h t h e c a t e g o r y of s y s t e m i n t e r a c t i o n were d e s c r i b e d by CHNs i n p r a c t i c e and a d m i n i s t r a t i v e p o s i t i o n s . These dilemmas o c c u r r e d i n two t y p e s of s i t u a t i o n s : t h o s e i n v o l v i n g the n u r s e s ' i n t e r a c t i o n w i t h i n t h e h e a l t h c a r e team, and s e c o n d l y , t h e i r r o l e i n i n t e r p r e t i n g a g e n c y p o l i c i e s and a l l o c a t i n g n u r s i n g and o t h e r h e a l t h c a r e r e s o u r c e s . The c o n f l i c t s and the n u r s i n g r e s p o n s e s w i l l be d e s c r i b e d f o r b o t h t y p e s o f s i t u a t i o n s . I n t e r a c t i n g w i t h i n the h e a l t h c a r e team  N a t u r e of the c o n f l i c t ( s ) . The p r i m a r y c o n f l i c t c e n t e r e d a r o u n d t h e q u e s t i o n of how t h e c o n f i d e n t i a l i t y of c l i e n t i n f o r m a t i o n c o u l d be m a i n t a i n e d w h i l e r e c o g n i z i n g t h e o b l i g a t i o n to s h a r e i n f o r m a t i o n w i t h members o f t h e h e a l t h c a r e or s c h o o l - b a s e d teams. F o r example, a s c h o o l n u r s e l e a r n e d t h a t o t h e r members of the s c h o o l - b a s e d team were not p r o t e c t i n g t h e c o n f i d e n t i a l i t y of s e n s i t i v e i n f o r m a t i o n about a c h i l d ' s h e a l t h and s o c i a l s i t u a t i o n . T h i s n u r s e s t r u g g l e d w i t h c h o o s i n g t o a d v o c a t e f o r t h e c l i e n t s ' r i g h t s to 76 c o n f i d e n t i a l i t y and thereby t h r e a t e n i n g the q u a l i t y of her r e l a t i o n s h i p with an a l r e a d y fragmented team. Another s i t u a t i o n i n v o l v e d the misuse of a nurse's c o n f i d e n t i a l w r i t t e n assessment of a pre s c h o o l c h i l d by a MSSH s o c i a l worker and lawyers i n t h e i r e f f o r t s to i n f l u e n c e a custody s u i t . In these s i t u a t i o n s , the nurse's r e s p o n s i b i l i t y to p r o t e c t the c l i e n t ' s r i g h t to c o n f i d e n t i a l i t y c o n f l i c t e d with her r e l a t i o n s h i p with the MSSH s o c i a l worker or the school-based team. The decision-making centered around how to develop and maintain working r e l a t i o n s h i p s with h e a l t h care team members while advocating f o r the c l i e n t s ' r i g h t s to c o n f i d e n t i a l i t y and p r i v a c y . These s i t u a t i o n s threatened r e l a t i o n s h i p s that were deemed e s s e n t i a l to the q u a l i t y of \ care f o r the present and f u t u r e c l i e n t s . Another dimension of the c o n f l i c t i nherent i n h e a l t h care team r e l a t i o n s h i p s was r e f l e c t e d i n a s i t u a t i o n i n v o l v i n g q u e s t i o n a b l e medical p r a c t i c e . The s i t u a t i o n arose when a p h y s i c i a n was p r o v i d i n g c h i l d care to a f a m i l y which was a l s o a c l i e n t of the CHN's. The c o n f l i c t centered around how the CHN could take a c t i o n to p r o t e c t the c l i e n t from unsafe i n t e r v e n t i o n s p r e s c r i b e d by the p h y s i c i a n . The nurse s t r u g g l e d with the qu e s t i o n of how to approach the p h y s i c i a n ' s incompetence. Should she confront the p h y s i c i a n d i r e c t l y or a s s i s t the c l i e n t to recognize the problem and seek a l t e r n a t e medical care? In choosing to address the problem with the c l i e n t alone, the nurse was 77 p r o v i d i n g i n f o r m a t i o n on i n f a n t h e a l t h care and medical treatment which was c o n t r a d i c t o r y to that of the p h y s i c i a n ' s . Although t h i s a c t i o n may have b e n e f i t e d the c l i e n t at the time, i t would not p r o t e c t those c l i e n t s who may contact the p h y s i c i a n i n the f u t u r e . On the other hand by c o n f r o n t i n g the p h y s i c i a n ' s incompetence d i r e c t l y the nurse r i s k e d d i s r u p t i n g an e s s e n t i a l working r e l a t i o n s h i p w i t h i n a small community. She a l s o was without the e s s e n t i a l support of s u p e r v i s o r s f o r responding to the d i f f i c u l t i s s u e of p h y s i c i a n m a l p r a c t i c e . Nurses' responses. The a l t e r n a t i v e s i d e n t i f i e d by the nurses f o r the r e s o l u t i o n of the c o n f l i c t between h e a l t h care team r e l a t i o n s h i p s and c l i e n t s ' r i g h t s i n c l u d e d : to d i s c u s s the dilemma with one or more members of the h e a l t h care team; to avoid d i s c u s s i n g the matter with the h e a l t h care team member and encourage the c l i e n t to a s s e r t t h e i r human r i g h t s w i t h i n the system or to i n v o l v e s u p e r v i s o r s to take a c t i o n on the c l i e n t s ' b e h a l f . In these s i t u a t i o n s , the nurses c l e a r l y valued t h e i r c l i e n t s ' r i g h t s to p r i v a c y , c o n f i d e n t i a l i t y , and access to s a f e , competent c a r e . Also honesty and e f f e c t i v e communication w i t h i n h e a l t h care team r e l a t i o n s h i p s were ap p a r e n t l y v a l u e d . The nurses expressed concern f o r t h e i r c l i e n t s ' r i g h t s to c o n f i d e n t i a l i t y and p r i v a c y by c o n f r o n t i n g the h e a l t h 78 care team with the i s s u e of needing to p r o t e c t c l i e n t c o n f i d e n t i a l i t y . This r e s u l t e d i n p r o t e c t i n g the c l i e n t ' s r i g h t i n one in s t a n c e and i n c r e a s i n g awareness of the value of c o n f i d e n t i a l i t y w i t h i n the team i n another. One nurse chose not to confront the p h y s i c i a n with her concerns about the s a f e t y of the medical i n t e r v e n t i o n . This r e s u l t e d i n a l e s s e f f e c t i v e outcome as the c l i e n t continued to r e c e i v e incompetent care and the nurse was reprimanded by her su p e r v i s o r f o r conducting her r e l a t i o n s h i p with the p h y s i c i a n i n an u n p r o f e s s i o n a l manner because she had presented c o n t r a d i c t o r y advice to the c l i e n t . Some of the nurses d e s c r i b e d a growing s t r e n g t h to work e f f e c t i v e l y with the h e a l t h care team as a r e s u l t of t h e i r experience with these dilemmas. However, ongoing f e e l i n g s of f r u s t r a t i o n with the l a c k of concern f o r c l i e n t s ' r i g h t s to c o n f i d e n t i a l i t y and p r i v a c y were a l s o expressed. I n t e r p r e t i n g p o l i c y and the a l l o c a t i o n of nur s i n g and h e a l t h  care resources Nature of the c o n f l i c t ( s ) . Among the many e t h i c a l c o n f l i c t s encountered by community h e a l t h nurses i n middle management p o s i t i o n s , the most p e r v a s i v e i s the s t r u g g l e to provide q u a l i t y care to the i n d i v i d u a l or f a m i l y c l i e n t , while m a i n t a i n i n g a l e v e l of s e r v i c e s f o r the aggregate or community as a whole. Inherent i n t h i s s t r u g g l e i s the c o n f l i c t between p r o v i d i n g a b a s i c standard of s e r v i c e to groups of c l i e n t s and the 79 p r o v i s i o n of s e r v i c e s to those c l i e n t s who do not respond to group i n t e r v e n t i o n s . The community h e a l t h nurse a d m i n i s t r a t o r who i s i n d i r e c t contact with s e r v i c e d e l i v e r y and p o l i c y makers sees "both s i d e s of the c o i n " and i n some in s t a n c e s must decide to reduce nu r s i n g s e r v i c e s provided to h i g h - r i s k i n d i v i d u a l c l i e n t s i n order to implement program d i r e c t i v e s aimed at the aggregate or community as a whole: The nurses and I walk a f i n e l i n e i n ad m i t t i n g q u i e t l y , s e l e c t i v e l y that we can not do a l l programmes, that new d i r e c t i v e s are " n i c e " i f s t a f f and t r a i n i n g and support m a t e r i a l are a v a i l a b l e to do them. A s s o c i a t e d with d e c i s i o n s about how to a l l o c a t e r e s o u r c e s , are those r e l a t e d to a d v i s i n g s t a f f about t h e i r r o l e and i n t e r v e n t i o n s with c l i e n t s and how to r e s o l v e e t h i c a l c o n f l i c t s i n v o l v i n g groups of c l i e n t s . These d e c i s i o n s i n v o l v e the de t e r m i n a t i o n of the scope and l i m i t s of community h e a l t h n u r s i n g r e s p o n s i b i l i t y , and which nur s i n g values should be emphasized. I t was a l s o expressed that many f e e l i n g s and questions a r i s e from the d i f f i c u l t d e c i s i o n to withdraw nursing s e r v i c e s from h i g h - r i s k f a m i l i e s : I wonder about people who have l i m i t e d a b i l i t y to cope. Is i t the r i g h t of s o c i e t y to allow these people to get i n t o s i t u a t i o n s that are very p a i n f u l and perhaps d i s a s t r o u s ? Do we have a r e s p o n s i b l i t y to p r o t e c t them from such s i t u a t i o n s ? I f we do, where Is the beginning and end of such r e s p o n s i b l i l i t y ? 80 Nurses' responses. A myriad of choices confront the community h e a l t h nurse l e a d e r . The main a l t e r n a t i v e s i d e n t i f i e d by the community h e a l t h nursing a d m i n i s t r a t o r s were to comply t o t a l l y and u n q u e s t i o n i n g l y with p o l i c y d i r e c t i v e s , while i g n o r i n g the needs of i n d i v i d u a l s , f a m i l i e s , or groups i d e n t i f i e d by the nurses; or to qu e s t i o n p o l i c y d i r e c t i v e s that do not seem e f f e c t i v e while c o n t i n u i n g to a l l o c a t e n u r s i n g resources to provide s e r v i c e s to h i g h - r i s k f a m i l i e s . Within these a l t e r n a t i v e s i s the a d d i t i o n a l q u e s t i o n of whether to confront p o l i c y makers and government with l o c a l community needs that are not met by new programs. Furthermore, to what degree do the a d m i n i s t r a t o r s a l l o c a t e n u r s i n g resources f o r the f o l l o w up of those f a m i l i e s that are not v i s i b l y responding to i n t e r v e n t i o n and may be more c l e a r l y w i t h i n the j u r i s d i c t i o n of another community agency such as MSSH? The nurses value honesty i n responding to t h e i r n u r s i n g s t a f f and communities about the true a v a i l a b i l i t y and e f f e c t i v e n e s s of r e s o u r c e s . A d d i t i o n a l l y , they valued the e f f e c t i v e a l l o c a t i o n of nursing resources i n t o programs that w i l l make a d i f f e r e n c e to the h e a l t h of i n d i v i d u a l s , f a m i l i e s , and communities. Concern f o r CHN's support needs and t h e i r r i g h t to be informed and i n v o l v e d i n decision-making were expressed. 81 Nurses' Rights This category was represented by s i t u a t i o n s where the main focus was the n u r s e s ' r i g h t to act a c c o r d i n g to t h e i r p ersonal and p r o f e s s i o n a l v a l u e s . In these s i t u a t i o n s , the nurses f e l t t h e i r r i g h t to act a c c o r d i n g to t h e i r values was threatened by a c o n f l i c t between p r o f e s s i o n a l values and p ersonal needs and/or by agency p o l i c y or t h e i r terms of employment. Nature of the c o n f l i c t ( s ) The predominant c o n f l i c t was p e r c e i v e d to e x i s t between the n u r s e s ' p r o f e s s i o n a l values and r e s p o n s i b i l t i e s and those r e l a t e d d i r e c t l y to t h e i r terms of employment and/or t h e i r p e r s o n a l l i v e s . For example, one CHN d e s c r i b e d a s i t u a t i o n where her need to access q u a l i t y c h i l d care f o r her own c h i l d r e n r e s u l t e d i n her use of an u n l i c e n s e d f a m i l y daycare f a c i l i t y . This f u l f i l l m e n t of a personal need was a c o n t r a d i c t i o n to her p r o f e s s i o n a l commitment to promoting q u a l i t y l i c e n s e d daycare i n the community and t h e r e f o r e r e s u l t e d i n e t h i c a l c o n f l i c t f o r t h i s nurse: The s i t u a t i o n occurred as a r e s u l t of c o n f l i c t between a p e r s o n a l need and a w e l l i n d o c t r i n a t e d p r o f e s s i o n a l r e s p o n s i b i l i t y ... a d e s i r e to f i n d s a f e , s t a b l e , p o s i t i v e care f o r my c h i l d r e n , an awareness of the need to promote l i c e n s e d daycare, concern and a strong b e l i e f i n l i c e n s i n g f a c i l i t i e s , and awareness of myself as a r o l e model f o r s t a f f and community... 82 Another s i t u a t i o n r e s u l t e d i n a c o n f l i c t between the nurse's p r o f e s s i o n a l values and those of her employer. This CHN d e s c r i b e d a r e l u c t a n c e to f u l f i l l an employment o b l i g a t i o n which d i r e c t e d her to i n f l u e n c e an i n d i v i d u a l ' s decision-making by p r e s e n t i n g only one side of an i s s u e . This a c t i o n , i f taken, threatened t h i s nurse's a b i l i t y to act a c c o r d i n g to her personal and p r o f e s s i o n a l value which was to present a l l i n f o r m a t i o n necessary f o r informed decision-making. The nurse expressed the r i s k s a s s o c i a t e d with the c o n f l i c t : I could do as I was t o l d and r i s k l o s i n g my job arid r i s k my personal and p r o f e s s i o n a l c r e d i b i l i t y or a l t e r my personal and p r o f e s s i o n a l values or expose my employer and refuse to take the assignment or asked to be r e - a s s i g n e d . A c o n f l i c t between a nurse's p r o f e s s i o n a l values and h e a l t h care system p o l i c y arose when a h i g h - r i s k p r e n a t a l c l i e n t d i s c l o s e d f i n a n c i a l earnings beyond what i s allowed f o r MSSH c l i e n t s r e c e i v i n g income a s s i s t a n c e . This CHN p e r c e i v e d a c o n f l i c t between her o l i g a t i o n to r e p o r t the i l l e g a l earnings as a v i o l a t i o n of p o l i c y and her p r o f e s s i o n a l o b l i g a t i o n to maintain c o n f i d e n t i a l i t y , t r u s t , and support the development of the r e l a t i o n s h i p with a high-needs c l i e n t . Although t h i s nurse chose not to inform on the c l i e n t i n favor of her s u p p o r t i v e r e l a t i o n s h i p with her c l i e n t , she and others r e f e r r e d to honesty as a fundamental pe r s o n a l v a l u e : 83 I am an honest person and f e e l I am i g n o r i n g a s i t u a t i o n of t h e f t . However, I a l s o f e e l that those c l i e n t s on s o c i a l a s s i s t a n c e should be allowed to earn f a r more than i s p r e s e n t l y a c c e p t a b l e . Honesty, as a fundamental value guided another nurse's d e c i s i o n to inform a group of parents that t h e i r c h i l d r e n had r e c e i v e d the wrong dosages of vaccine during a r o u t i n e immunization c l i n i c at the s c h o o l . The pros and cons of choosing to admit the e r r o r were i d e n t i f i e d and the a c t i o n to inform was s e l e c t e d d e s p i t e the l a c k of evident adverse r e a c t i o n s and the concern that "CHN's would l o s e face i n the community" . Nurses' responses In most i n s t a n c e s , the nurses chose to act ac c o r d i n g to t h e i r 1 p r o f e s s i o n a l and personal values as opposed to agency p o l i c y or a c c o r d i n g to standards imposed by the employer. The nurses p e r c e i v e d these c o n f l i c t s as wrenching and r i s k y as they feared l o s s of t h e i r employment or of t h e i r p e r s o n a l and/or p r o f e s s i o n a l c r e d i b i l i t y . A l l nurses expressed s a t i s f a c t i o n with t h e i r d e c i s i o n to act ac c o r d i n g to t h e i r values and uphold p r o f e s s i o n a l standards r e l a t e d to honesty and respect f o r i n d i v i d u a l autonomy. However, per s o n a l s t r e n g t h and p r o f e s s i o n a l experience were c i t e d as e s s e n t i a l r e q u i s i t e s f o r coping s u c c e s s f u l l y with t h i s type of c o n f l i c t : These are not abnormal s i t u a t i o n s but r a t h e r are o c c u r r i n g more f r e q u e n t l y . I t does, however, take a c o n f i d e n t , experienced nurse to be able to s o r t them out and handle them without a s s i s t a n c e . In a d d i t i o n , I 84 think, i t a l s o takes a person who i s w i l l i n g and able to r i s k l o s i n g employment to do t h i s without union or p r o f e s s i o n a l p r o t e c t i o n . Summary The f i n d i n g s presented i n t h i s chapter c o n s i s t of a summary of r e l e v a n t c h a r a c t e r i s t i c s of the p a r t i c i p a n t s and the CHNs' w r i t t e n d e s c r i p t i o n s of c l i n i c a l s i t u a t i o n s which i n v o l v e d e t h i c a l dilemmas. The CHNs who p a r t i c i p a t e d i n t h i s study were able to d e s c r i b e the c o n f l i c t s -inherent i n the s i t u a t i o n s and t h e i r responses i n c l u d i n g f e e l i n g s , and some f a c e t s of decision-making. Through a process of content a n a l y s i s , the dilemmas were c a t e g o r i z e d a c c o r d i n g to t h e i r primary focus i n order to r e l a t e them to dimensions of community h e a l t h n u r s i n g p r a c t i c e . Three c a t e g o r i e s of dilemmas were i d e n t i f i e d : c l i e n t s ' r i g h t s , system i n t e r a c t i o n , and nurses' r i g h t s . Within these c a t e g o r i e s , the dilemmas were c h a r a c t e r i z e d by one or more e t h i c a l c o n f l i c t s . Within the category of c l i e n t r i g h t s , e t h i c a l c o n f l i c t s r e l a t e d to working with h i g h - r i s k parents, a d u l t c l i e n t s with mental h e a l t h concerns, and adolescent c l i e n t s were f u r t h e r i d e n t i f i e d . This was the l a r g e s t response category i n t h i s study. E t h i c a l c o n f l i c t s r e l a t e d to the category of system i n t e r a c t i o n c o n s i s t e d of two types of s i t u a t i o n s - those i n v o l v i n g h e a l t h care team r e l a t i o n s h i p s and the a l l o c a t i o n of community h e a l t h r e s o u r c e s . T h i s category of dilemma 85 i n c l u d e d responses of CHNs i n both p r a c t i c e and l e a d e r s h i p p o s i t i o n s . The e t h i c a l c o n f l i c t s u n d e r l y i n g the two types of s i t u a t i o n s were i d e n t i f i e d . The t h i r d category was comprised of dilemmas r e l a t i n g to the r i g h t s of nurses. Here, pe r s o n a l and p r o f e s s i o n a l r i g h t s and values were seen to be i n c o n f l i c t . The a n a l y s i s of these e t h i c a l c o n f l i c t s and n u r s i n g responses i s presented i n the f o l l o w i n g chapter. 86 CHAPTER FIVE DISCUSSION OF ETHICAL THEMES, FORCES, AND NURSING RESPONSES The purpose of t h i s chapter i s to analyze and d i s c u s s p e r t i n e n t themes u n d e r l y i n g the e t h i c a l c o n f l i c t s presented i n chapter f o u r . The c o n f l i c t s are analyzed i n three ways. F i r s t , the most r e l e v a n t u n d e r l y i n g components of e t h i c a l theory evident i n the d e s c r i b e d dilemmas are i d e n t i f i e d . Secondly, the key f o r c e s which seemed to i n f l u e n c e the occurrence of the dilemmas are presented. T h i r d l y , the nurses' d e s c r i p t i o n s of t h e i r r o l e i n responding to the dilemmas w i l l be analyzed. In a f i n a l s e c t i o n of t h i s chapter, the response of those nurses who reported e x p e r i e n c i n g no e t h i c a l dilemmas are d i s c u s s e d . D i s c u s s i o n of E t h i c a l Themes According to C u r t i n (1978) the a p p l i c a t i o n of e t h i c a l p r i n c i p l e s or a p p l i e d normative e t h i c a l a n a l y s i s to c l i n i c a l s i t u a t i o n s can help do the f o l l o w i n g : 1) c l a r i f y the meaning and a p p l i c a t i o n of the general p r i n c i p l e s ; 2) c l a r i f y f o r the i n d i v i d u a l s i n v o l v e d the reasons f o r which a p a r t i c u l a r d e c i s i o n i s made; and 3) help f u t u r e decision-making i n s i m i l a r s i t u a t i o n s (p. 17). L i t e r a t u r e presented i n chapter two i s r e - i n t r o d u c e d to h i g h l i g h t t h i s a n a l y s i s . 87 E t h i c a l themes a s s o c i a t e d with c l i e n t s ' r i g h t s  H i g h - r i s k p a r e n t i n g . E t h i c a l c o n f l i c t i n h i g h - r i s k p a r e n t i n g s i t u a t i o n s i n v o l v e s the p r i n c i p l e of b e n e f i c e n c e . Frankena (1973) d e s c r i b e s four parts of the p r i n c i p l e of b e n e f i c e n c e : a) a v o i d i n g causing e v i l or harm b) p r e v e n t i o n of e v i l or harm c) removing e v i l or p o t e n t i a l f o r harm and d) doing good or promoting good (p. 47). Based on t h i s e l a b o r a t i o n of the components of the p r i n c i p l e , i t appears that the nurses are caught i n a s t r u g g l e between the second and f o u r t h p a r t s of b e n e f i c e n c e . On the one hand they are s t r i v i n g to prevent harm to the c h i l d r e n through t h e i r e f f o r t s to i n t e r v e n e a c c o r d i n g to c u r r e n t c h i l d abuse p o l i c y . On the other hand they are expressing concern f o r the long term h e a l t h of the parents, c h i l d and f a m i l y u n i t i n that they p e r c e i v e t h e i r i n t e r v e n t i o n s may r e s u l t i n g r e a t e r harm i f the c h i l d and parents do not r e c e i v e the a p p r o p r i a t e c a r e . Frankena (1972) notes there i s some precedence e x i s t i n g w i t h i n the four d u t i e s i n that "a" would take precedence over "b", "b" over "c", and "c" over "d", i n degrees of moral o b l i g a t i o n . According to t h i s d i s c u s s i o n of the p r i n c i p l e , i t appears that the nurses' duty to p r o t e c t the c h i l d r e n precedes t h e i r duty to promote the long term h e a l t h of the f a m i l y i n terms of moral o b l i g a t i o n . 88 Autonomy, or s e l f - d e t e r m i n a t o n i n matters of care treatment and f a m i l y l i f e are fundamental to the promotion of h e a l t h i n h i g h - r i s k p a r e n t i n g s i t u a t i o n s . The pa r e n t s ' r i g h t to autonomy, or s e l f - d e t e r m i n a t i o n i n matters concerning t h e i r c a r e , treatment, and involvement with t h e i r c h i l d r e n i s compelling i n these s i t u a t i o n s , as s o c i e t y i s p a t e r n a l i s t i c i n i t s e f f o r t s to p r o t e c t c h i l d r e n . According to s o c i e t a l values,, p a r e n t s ' r i g h t s to autonomy are l i m i t e d by t h e i r i n a b i l i t y to meet t h e i r r o l e o b l i g a t i o n s . These p a r e n t a l r o l e o b l i g a t i o n s are determined by the c h i l d ' s r i g h t s as dependent f a m i l y members to have t h e i r needs met. Furthermore, i t may be noted that the pa r e n t s ' autonomy and the i n t e g r i t y of the f a m i l y u n i t i s f u r t h e r l i m i t e d by the percei v e d u n a v a i l a b i l i t y of treatment or care options w i t h i n the c u r r e n t h e a l t h and s o c i a l s e r v i c e s system. F i n a l l y , the human r i g h t to access e f f e c t i v e h e a l t h care and s o c i a l s e r v i c e s r e l a t e s to the e t h i c a l p r i n c i p l e of j u s t i c e , or the f a i r d i s t r i b u t i o n of b e n e f i t s , and burdens i n s o c i e t y based on an e g a l i t a r i a n c r i t e r i o n (Frankena, 1973). Rawls (1971) f u r t h e r acknowledges d i s t r i b u t i v e j u s t i c e which acknowledges as the o b l i g a t i o n to provide a s s i s t a n c e to those at gr e a t e r r i s k of e x p e r i e n c i n g g r e a t e r burdens and a c c e s s i n g fewer b e n e f i t s . Within the cu r r e n t system, i t i s apparent that h i g h - r i s k f a m i l i e s may not have access to those s e r v i c e s which may be e f f e c t i v e i n h e l p i n g 89 them with t h e i r problems and a s s i s t i n g them to develop as parents. Adult c l i e n t s with mental h e a l t h concerns. These dilemmas a l s o i n v o l v e d c o n f l i c t between the p r i n c i p l e s of autonomy and be n e f i c e n c e . The nurses' commitment to promote autonomy on the one hand and p r o t e c t c l i e n t s from harm on the other seemed in c o m p a t i b l e . In these i n s t a n c e s , c l i e n t autonomy i n c l u d e d the r i g h t to accept and refuse h e a l t h care d e s p i t e the assessment of s i g n i f i c a n t r i s k f a c t o r s , or p o t e n t i a l f o r harm by h e a l t h p r o f e s s i o n a l s and f a m i l y members. Therefore the c l i e n t ' s r i g h t to l i v e at r i s k or determine the a c c e p t a b i l i t y of h i s / h e r own q u a l i t y of l i f e was fundamental to the qu e s t i o n of h i s / h e r autonomy. The nurse's moral o b l i g a t i o n to respect human autonomy i s s t a t e d i n the CNA (1985) Code of E t h i c s : I l l n e s s or other f a c t o r s may compromise the c l i e n t ' s c a p a c i t y f o r s e l f - d i r e c t i o n . Nurses have a c o n t i n u i n g o b l i g a t i o n to value autonomy i n such c l i e n t s , f o r example, by c r e a t i v e l y p r o v i d i n g them with o p p o r t u n i t i e s f o r c h o i c e s , w i t h i n t h e i r c a p a b i l i t i e s , thereby a i d i n g them to maintain or re g a i n some degree of autonomy, (p. 5) This s e c t i o n of the code suggests that the nurse's assessment of c l i e n t ' s c a p a b i l i t i e s f o r s e l f - d e t e r m i n a t i o n w i l l i n f l u e n c e the degree to which autonomy can be res p e c t e d . Furthermore, the Code does not a n t i c i p a t e the s t r u g g l e between the p r i n c i p l e s of autonomy and be n e f i c e n c e . 90 Therefore each s i t u a t i o n must be r e s o l v e d on the b a s i s of the nurse's assessment of c l i e n t c a p a b i l i t i e s and wishes, the values of the care p r o v i d e r s , and moral judgements about l e v e l s of competency and human r i g h t s to s e l f d e t e r m i n a t i o n i n matters concerning t h e i r q u a l i t y of l i f e . A d o l e s c e n t s . The e t h i c a l c o n f l i c t s inherent i n the primary h e a l t h care of the adolescent c l i e n t are i n f l u e n c e d by the l e g a l s t a t u s of the adolescent r i g h t s v i s - a - v i s a d u l t r i g h t s . Adolescent autonomy i n c l u d e d the r i g h t to p r i v a c y and to make d e c i s i o n s about a c c e p t i n g and a c c e s s i n g h e a l t h and s o c i a l s e r v i c e s . L e g a l l y , the adolescent has not been granted f u l l r i g h t s to s e l f - d e t e r m i n a t i o n and decision-making i n matters concerning t h e i r h e a l t h and w e l l - b e i n g . Developmentally, they may need g r e a t e r or l e s s e r degrees of a s s i s t a n c e from nurses, f a m i l i e s and others i n v o l v e d i n t h e i r care depending on t h e i r v u l n e r a b i l i t y . The adolescents i n v o l v e d i n these s i t u a t i o n s were h i g h - r i s k and r e q u i r e d p r o t e c t i o n from harm and a s s i s t a n c e i n matters of t h e i r h e a l t h and s o c i a l w e l l - b e i n g . Therefore the nurse was once again s t r u g g l i n g to prevent harm and promote h e a l t h , while determining and acknowledging the a d o l e s c e n t ' s r i g h t to autonomy i n a l e g a l system which does not d i s t i n g u i s h adolescent r i g h t s from those of younger c h i l d r e n or the l e g a l s t a t u s of adulthood. 91 S e v e r a l questions a r i s e from the i s s u e of adolescent r i g h t s to make d e c i s i o n s about t h e i r care: Who should make d e c i s i o n s f o r the adolescent who does not have a c a r i n g , concerned, or a v a i l a b l e parent or guardian? Or what happens when the adolescent doesn't want the parent involved? Furthermore, what l e g a l p r o t e c t i o n i s a v a i l a b l e f o r the h e a l t h p r o f e s s i o n a l who provides needed s e r v i c e s f o r adolescents i n youth c l i n i c s and other h e a l t h care s e t t i n g s without p a r e n t a l consent or knowledge? These e t h i c a l and l e g a l questions are complex and unresol v e d . The c u r r e n t CNA Code of E t h i c s does not r e f e r to the c o n f l i c t s surrounding adolescent r i g h t s and nur s i n g r e s p o n s i b i l i t i e s . E t h i c a l themes a s s o c i a t e d with system i n t e r a c t i o n Dilemmas Inherent i n the CHNs' involvement with the h e a l t h care team a r i s e from c o n f l i c t s between the primary p r i n c i p l e s of autonomy and ben e f i c e n c e . The c l i e n t ' s autonomy may be j e o p a r d i z e d by communication between team members i n the i n t e r e s t s of promoting the best p o s s i b l e care. In other words, the nurses are i n a p o s i t i o n to share i n f o r m a t i o n about c l i e n t s with h e a l t h care team members i n order to provide a q u a l i t y of care through a coo r d i n a t e d team approach. However, as a r e s u l t of these e f f o r t s to work c o o p e r a t i v e l y with other p r o f e s s i o n a l s , the c l i e n t s ' r i g h t s to p r i v a c y , which i s r e l a t e d to t h e i r autonomy or personhood may be j e o p a r d i z e d . The nurse s t r u g g l e s to 92 balance the person's r i g h t to q u a l i t y care and h i s / h e r r i g h t to p r i v a c y and c o n f i d e n t i a l i t y through determining the approach to working with the h e a l t h care team. The CNA Code of E t h i c s (1985) recognizes that the e t h i c a l dimensions of the nurses' r e l a t i o n s h i p s with the h e a l t h care team are based on the value that "care should represent a c o o p e r a t i v e e f f o r t drawing upon the e x p e r t i s e of n u r s i n g and other h e a l t h p r o f e s s i o n s " (p. 11). The code f u r t h e r s p e c i f i e s the nurse's o b l i g a t i o n to act i f she suspects other h e a l t h care team members of incompetent or u n e t h i c a l conduct. On the other hand the code s p e c i f i e s that r e l a t i o n s h i p s i n the h e a l t h care team should not be d i s r u p t e d u n n e c e s s a r i l y and that c o n f l i c t s be r e s o l v e d through d i r e c t d i s c u s s i o n . Herein l i e s the dilemma the approach to which must be s i t u a t i o n a l l y determined. Furthermore, s t r a t e g i e s should be supported by employers and p r o f e s s i o n a l a s s o c i a t i o n s , as p r o t e c t i o n f o r the nurse i s a l s o a dimension of these dilemmas. J u s t i c e , the f a i r d i s t r i b u t i o n of harms and b e n e f i t s i n s o c i e t y (Rawls, 1971; Frankena, 1973), i s the e t h i c a l p r i n c i p l e most r e l e v a n t to the c o n f l i c t s i nherent i n a l l o c a t i n g n ursing r e s o u r c e s . Through the enactment of the p r i n c i p l e of u n i v e r s a l i t y , Canadian s o c i e t y has acknowledged h e a l t h care as a b e n e f i t a v a i l a b l e to a l l . Due to the l i m i t s of h e a l t h care r e s o u r c e s , the problems of a l l o c a t i o n w i l l continue to present our most intense 93 c h a l l e n g e s ( F r y , 1986; Lynch, 1985; Noble, 1985). Operating from a u t i l i t a r i a n p e r s p e c t i v e , policy-makers, p o l i t i c i a n s , and a d m i n i s t r a t o r s s t r i v e to provide more t e c h n o l o g i c a l l y advanced and c o s t l y l e v e l s of h e a l t h care f o r g r e a t e r numbers of people with i n c r e a s i n g l y fewer r e s o u r c e s . From a d e o n t o l o g i c a l p e r s p e c t i v e , however, those c l o s e s t to s e r v i c e d e l i v e r y are concerned about the q u a l i t y of care, the means of s e r v i c e d e l i v e r y . In other words, the u t i l i t a r i a n p e r s p e c t i v e i s concerned about reaching g r e a t e r numbers through cost e f f e c t i v e group and community s t r a t e g i e s , thereby p r o v i d i n g the higher access f o r g r e a t e r numbers. The d e o n t o l o g i c a l p e r s p e c t i v e i s concerned with the relevance of programs to i n d i v i d u a l s and f a m i l i e s . The s e n i o r community h e a l t h nurse i s aware of the importance of p r o v i d i n g h e a l t h care to a l l , and i s a l s o concerned that e f f o r t s be made to provide s e r v i c e s to those who need i t most, the h i g h - r i s k p o p u l a t i o n . Those at g r e a t e s t r i s k are o f t e n the most unable to ask f o r the s e r v i c e s they need. T h e r e f o r e , they may not have equal access i n a system founded on u t i l i t a r i a n philosophy alone. In r e c o g n i z i n g the importance of s e r v i c e d e l i v e r y to those at g r e a t e s t r i s k , these nurses may a l s o be r e c o g n i z i n g the r e l a t i o n s h i p between p r o v i d i n g q u a l i t y care at the i n d i v i d u a l and f a m i l y l e v e l as a v i t a l component of enhancing the h e a l t h of the community as a whole. In t h i s way the d e o n t o l o g i c a l and u t i l i t a r i a n p e r s p e c t i v e s on access 94 to h e a l t h care may be viewed as p o t e n t i a l l y complementary, r a t h e r than e n t i r e l y o p p o s i t i o n a l . However, as a r t i c u l a t e d by Aroskar (1979) and Fry (1985), t h i s s t r u g g l e i s seen as one of concern for both the i n d i v i d u a l and aggregate w e l l - b e i n g i n our s o c i e t y . The a l l o c a t i o n of n u r s i n g resources to c a r i n g f o r the h i g h - r i s k c l i e n t s i n v o l v e s the d e t e r m i n a t i o n of the l i m i t and scope of n u r s i n g r e s p o n s i b i l i t y . Often CHNs determine the l e v e l of s e r v i c e based on day to day caseload management d e c i s i o n s without access to c o n s u l t a t i o n with c o l l e a g u e s or s e n i o r nurses. This r e s u l t s i n d a i l y moral dilemmas which i n v o l v e choices about how to a l l o c a t e t h e i r n ursing e x p e r t i s e w i t h i n c o n f l i c t i n g caseload demands. The nurse must answer such questions as: "Should t h i s f a m i l y r e c e i v e another v i s i t ? " or " W i l l another f a m i l y b e n e f i t more i n the long run from my nursing care?" and "What i s the r i s k to t h i s c l i e n t i f I do not continue to monitor t h e i r h e a l t h care?" E t h i c a l themes a s s o c i a t e d with nurses' r i g h t s The c e n t r a l theme i n t h i s category i s the nurse's i n d i v i d u a l and c o l l e c t i v e r i g h t s to autonomy. I t i s of v i t a l s i g n i f i c a n c e that the degree to which the nurse has p e r s o n a l and p r o f e s s i o n a l autonomy i n f l u e n c e s the degree to which the standards and values of the p r o f e s s i o n are upheld. Nurses' autonomy i n c l u d e s the a b i l i t y to act according to p e r s o n a l and p r o f e s s i o n a l values and as w e l l as the r i g h t to 95 those resources which enable them to meet t h e i r personal and fa m i l y needs, as these i n f l u e n c e t h e i r c a p a c i t y to care f o r ot h e r s . C u r t i n (1982) d i s t i n g u i s h e s b a s i c human r i g h t s from earned p r o f e s s i o n a l r i g h t s . Such p r o f e s s i o n a l r i g h t s i n c l u d e "the r i g h t to p r a c t i c e n u r s i n g i n accord with p r o f e s s i o n a l l y d e f i n e d standards", "the r i g h t to in t e r v e n e when necessary to p r o t e c t p a t i e n t s , c l i e n t s , or the p u b l i c " , and "the r i g h t to t e s t i f y a u t h o r i t a t i v e l y to the community about the h e a l t h care needs of people" (p. 129). This e s s e n t i a l r e l a t i o n s h i p between personal and p r o f e s s i o n a l r i g h t s has been recognized ( C u r t i n , 1982; CNA, 1985) and i s becoming more c r i t i c a l as the q u a l i t y of nurses' working c o n d i t i o n s i s i n c r e a s i n g l y i n f l u e n c i n g nurses entry i n t o and commitment to the p r o f e s s i o n and t h e i r a b i l i t y to uphold moral values i n c a r i n g f o r others ( A t t r i d g e and C a l l a h a n , 1987; Baumgart, 1988). C o n f l i c t between nurses' personal needs and r i g h t s and t h e i r p r o f e s s i o n a l r e s p o n s i b i l i t i e s i s a component of many e t h i c a l dilemmas f a c i n g nurses. M u l t i p l e , c o n f l i c t i n g r o l e o b l i g a t i o n s f o r nurses have been i d e n t i f i e d as l i m i t i n g n urses' autonomy ( C u r t i n and F l a h e r t y , 1982; Lamb, 1985). U n t i l r e c e n t l y , t h i s c o n f l i c t has been poorly recognized and a r t i c u l a t e d . According to the Canadian Nurses Code of E t h i c s : Nurses too possess l e g a l and moral r i g h t s , as persons and as nurses. I t i s beyond the scope of t h i s Code to address the pers o n a l r i g h t s of nurses. To the extent 96 that c o n d i t i o n s of employment are e s s e n t i a l to the establishment of e t h i c a l n u r s i n g , however, t h i s Code must deal with that i s s u e , (p. 3) There are an i n c r e a s i n g number of f o r c e s i n nurses' working l i v e s which i n f l u e n c e t h e i r r i g h t to act according to p e r s o n a l and p r o f e s s i o n a l standards. T h e r e f o r e , acknowledgement of these dilemmas and i d e n t i f y i n g means of p r o t e c t i n g and supporting nurses' e x p r e s s i o n of t h e i r p r o f e s s i o n a l r i g h t s would strengthen t h i s s e c t i o n of the Code of E t h i c s . Forces I n f l u e n c i n g the Dilemmas Crisham (1985) suggests that a f o r c e - f i e l d a n a l y s i s based on Lewin's (1969) f i e l d theory "allows us to focus a t t e n t i o n of the horns of the dilemma and the f e a t u r e s of the s i t u a t i o n that are p e r c e i v e d to p u l l or push the nurse From the nurses' d e s c r i p t i o n s , i t was apparent that some fo r c e s w i t h i n the h e a l t h care and s o c i a l system, the n u r s e - c l i e n t r e l a t i o n s h i p , and the nurses' working and personal l i v e s c o n t r i b u t e d to t h e i r experience of c o n f l i c t while other f o r c e s supported the nurses i n t h e i r e f f o r t s t r e s o l v e the c o n f l i c t a c c o r d i n g to t h e i r values and p r i n c i p l e s . For the purpose of t h i s d i s c u s s i o n , Lewin's d e f i n i t i o n of r e s t r a i n i n g and d r i v i n g f o r c e s w i l l be used order to d i s t i n g u i s h these two types. 97 R e s t r a i n i n g f o r c e s R e s t r a i n i n g f o r c e s are those that c o n t r i b u t e d to the nurses' experiences of c o n f l i c t by I n t e r f e r i n g with r e s o l u t i o n i n ways and means deemed e t h i c a l by the p l a y e r s i n the s i t u a t i o n s . S o c i e t a l values and p u b l i c p o l i c y . Health and s o c i a l s e r v i c e s p o l i c y i s a major f o r c e i n f l u e n c i n g h e a l t h care d e l i v e r y and nursing p r a c t i c e . Recently, the s i g n i f i c a n c e of the r e l a t i o n s h i p between s o c i a l values and p o l i c y development and the need to develop means of f a c i l i t a t i n g p u b l i c input i n t o h e a l t h and s o c i a l p o l i c y development has been recognized (Hines, Bayley, and S e v e r o n i , 1987; McPher son, 1987). In t h i s study, i t was c l e a r that i s s u e s such as the a v a i l a b i l i t y of community h e a l t h r e s o u r c e s , and the d i r e c t i o n of care f o r h i g h - r i s k c l i e n t s was i n f l u e n c e d by both the presence and absence of r e l e v a n t p o l i c i e s . Issues r e l a t e d to c h i l d p r o t e c t i o n most c l e a r l y represent how p o l i c y acts as a f o r c e i n the e t h i c a l c o n f l i c t s d e s c r i b e d by the nurses and w i l l now be presented as a s i g n i f i c a n t case i n p o i n t . The nurse's r o l e i n r e c o g n i z i n g and r e p o r t i n g suspected c h i l d abuse was i n f l u e n c e d by c h i l d abuse p o l i c y and s o c i e t a l values which support a p a t e r n a l i s t i c approach to i n t e r v e n i n g i n c h i l d abuse. The I n t e r - M i n i s t r y C h i l d Abuse P o l i c y f o r the 98 Province of B r i t i s h Columbia ( M i n i s t r y of Human Resources, 1988) d e f i n e s the r o l e of the community h e a l t h nurse as the f o l l o w i n g : The p u b l i c h e a l t h nurse, through v i s i t s to s c h o o l s , c h i l d care f a c i l i t i e s and homes, may be the f i r s t person o u t s i d e the f a m i l y to observe or be t o l d of i n d i c a t i o n s of c h i l d abuse or n e g l e c t . Where i n d i c a t o r s of abuse are r e a d i l y apparent and i d e n t i f i a b l e the d e c i s i o n to r e p o r t i s c l e a r cut and the a p p r o p r i a t e procedure should be f o l l o w e d . However the r e a l i t y f o r p u b l i c h e a l t h nurses i s t h a t - o f t e n i n d i c a t o r s of abuse are not r e a d i l y apparent and n e g l e c t i s the p r e s e n t i n g concern. It may be d i f f i c u l t f o r the p u b l i c h e a l t h nurse to determine whether the l e v e l of care c o n s t i t u t e s a t h r e a t to the s a f e t y or w e l l being of the c h i l d (p. 58). Furthermore, t h i s r e c e n t l y r e v i s e d p o l i c y d e s c r i b e s the p r e v i o u s l y unacknowledged f a c e t of the community h e a l t h nurse's r o l e i n monitoring h i g h - r i s k s i t u a t i o n s : Where the s a f e t y or w e l l being of the c h i l d i s not p r e s e n t l y endangered but the l e v e l of care i s marginal, ongoing monitoring the c h i l d and f a m i l y i s r e q u i r e d . Part of the monitoring process should, w i t h i n the c o n f i n e s of c o n f i d e n t i a l i t y , i n c l u d e c o n s u l t a t i o n with the immediate s u p e r v i s o r , the M i n i s t r y of S o c i a l S e r v i c e s and Housing s o c i a l worker, and other p r o f e s s i o n a l s working with the f a m i l y i f a p p r o p r i a t e . C o n s u l t a t i o n with other p r o f e s s i o n a l s should i n v o l v e the s p e c i f i c assignment of any follow-up r e q u i r e d , thus a v o i d i n g the r i s k of one agency mistakenly assuming the other i s monitoring when i n f a c t i t i s not. (p. 59) However, t h i s p o l i c y does not address the d i f f i c u l t y the nurses or other p r o f e s s i o n a l s may have i n o b t a i n i n g c o n s u l t a t i o n or other a s s i s t a n c e f o r f a m i l i e s without "blowing the w h i s t l e " and d i s r u p t i n g the r e l a t i o n s h i p that provides p r e v e n t i v e i n t e r v e n t i o n s such as support, guidance, 99 c o u n s e l l i n g , and ed u c a t i o n . The absence of p o l i c y to d i r e c t r e s o l u t i o n of the c o n f l i c t imposed by the grey areas of suspected c h i l d abuse was a s i g n i f i c a n t i s s u e c o n t r i b u t i n g the nurses' dilemma i n working with h i g h - r i s k p arents. At l e a s t one author has recognized the i n c r e a s e d a n x i e t y f o r p r o f e s s i o n a l s and the need f o r c o n s u l t a t i o n and d i r e c t i o n i n s i t u a t i o n s where c h i l d abuse i s suspected or unprovable ( H a r r i s , 1985, p. 138). S i g n i f i c a n t l y , H a r r i s notes that "parenting 'bad enough' to warrant i n t e r v e n t i o n by the State i s a l e s s d i f f i c u l t concept" than i s the attempt to d e f i n e 'good enough p a r e n t i n g ' , r e s u l t i n g i n the dilemmas surrounding r e p o r t i n g : To avoid t h i s dilemma i t seems e s s e n t i a l that p r a c t i t i o n e r s should s a t i s f y themselves before c o n t r i b u t i n g to a case conference or other i n q u i r y i n t o c h i l d abuse that there are reasonable grounds f o r supposing that a c h i l d or other c h i l d r e n may be at r i s k and should assure themselves that the parents or guardians of the c h i l d know that the i n q u i r y i s tak i n g place and why. (p. 138) According to H a r r i s (1985), the e t h i c a l r e s p o n s i b i l i t i e s of the p r o f e s s i o n a l are c l e a r . However c u r r e n t p o l i c y i n B r i t i s h Columbia does not s p e c i f y how p r o f e s s i o n a l s may f u l f i l l these moral o b l i g a t i o n s i n t h e i r work with h i g h - r i s k parents while complying with the l e g a l o b l i g a t i o n s d i r e c t e d by the M i n i s t r y of Human Resources and the C h i l d and Family S e r v i c e s A ct. In support of the nurses' d e s c r i p t i o n s of the l a c k of sup p o r t i v e treatment s e r v i c e s a v a i l a b l e to r e l i e v e s t r e s s i n 100 h i g h - r i s k f a m i l i e s are recent s i t u a t i o n s d e s c r i b e d i n the p r e s s . On June 3, 1988 the Vancouver Sun reported that the S o c i a l S e r v i c e s M i n i s t r y was a l l o c a t i n g funds f o r the h i r i n g of 80 " f a m i l y advancement workers". These f a m i l y advancement workers were to be h i r e d to counsel f a m i l i e s having t r o u b l e budgeting or l o o k i n g a f t e r t h e i r c h i l d r e n a f t e r being i d e n t i f i e d "through s c h o o l s , the p u b l i c h e a l t h nurse and other community agencies". In the same a r t i c l e concerns about the l a c k of e d u c a t i o n a l p r e p a r a t i o n of the new category of worker were expressed. More r e c e n t l y , on two separate occasions the Sun headlined the c a l l f o r an i n t e r m i n i s t e r i a l i n v e s t i g a t i o n of p o l i c e and s o c i a l workers i n c h i l d sexual abuse complaints sparked by s i t u a t i o n s where the outcomes i n v o l v e d the deaths of f a m i l y members. These more v i s i b l e c r i t i c i s m s of the system have r e s u l t e d from the absence of a c o o r d i n a t e d , t h e r a p e u t i c response to a l l e g a t i o n s of sexual abuse w i t h i n f a m i l i e s . F r e q u e n t l y , i n these s i t u a t i o n s where the tragedy of abuse becomes more v i s i b l e i n the media, i t i s the f r o n t l i n e h e a l t h p r o f e s s i o n a l who i s scapegoated. In r e a l i t y i t i s the d i f f i c u l t i e s that p r o f e s s i o n a l s have i n p r o v i d i n g a c o o r d i n a t e d i n t e r d i s c i p l i n a r y approach to i n t e r v e n i n g i n these most d i f f i c u l t s i t u a t i o n s . From t h i s s p e c i f i c d i s c u s s i o n of c h i l d abuse p o l i c y as a major f o r c e i n f l u e n c i n g the e t h i c a l c o n f l i c t s emerges two broader r e a l i z a t i o n s of the e f f e c t s of p o l i c y on the 101 development of h e a l t h and s o c i a l s e r v i c e s . F i r s t i t i s apparent that s e r v i c e s f o r primary p r e v e n t i o n are d e f i c i e n t w i t h i n the cu r r e n t h e a l t h and s o c i a l s e r v i c e s system. This i s due to cuts i n these community based s e r v i c e s to h i g h - r i s k f a m i l i e s that occurred as a r e s u l t of the 1983 economic r e s t r a i n t program which i n c l u d e d the e l i m i n a t i o n of s o c i a l workers, f a m i l y support workers, and the c h i l d abuse team ( C a l l a g h a n , 1984). Furthermore, an a n a l y s i s of the policy-making process l e a d i n g to the enactment of the cur r e n t C h i l d and Family S e r v i c e s Act of 1980 i n d i c a t e s that many of the recommendations of Royal Commission stage were not i n c l u d e d i n the l e g i s l a t i o n ( C a llaghan and Wharf, 1982) r e s u l t i n g i n many of the inadequacies observed by CHNs i n t h i s study. The f o l l o w i n g , observed by one p o l i c y a n a l y s t supports the e x i s t e n c e of t h i s i n t e r r e l a t i o n s h i p : Undoubtably there are reasons why the present government chose not to i n c l u d e a range of pre v e n t i v e f a m i l y and c h i l d r e n ' s s e r v i c e s i n the new l e g i s l a t i o n . This permits i t to avoid a commitment to p r o v i d i n g such s e r v i c e s on an on-going b a s i s . It a l s o a f f o r d s the M i n i s t r y of Human Resources [ c u r r e n t l y MSSH] complete d i s c r e t i o n as to the nature and scope of s e r v i c e s to be developed and d e l i v e r e d . In the w r i t e r ' s o p i n i o n t h i s f a i l s to recognize members of the general p u b l i c as partne r s i n e f f o r t s to strengthen f a m i l y l i f e and r e l i e v e f a m i l y d i s t r e s s . I t a l s o has the e f f e c t of reducing p u b l i c v i s i b i l i t y of s o c i a l s e r v i c e s and rendering such s e r v i c e s as are provided v u l n e r a b l e to cut-backs i n government funding. One i s fo r c e d to conclude, t h e r e f o r e , that notwithstanding i t s t i t l e , the new Family and C h i l d S e r v i c e s Act f a i l s to break new ground i n the p r o v i s i o n of s e r v i c e s to f a m i l i e s and c h i l d r e n . (MacDonald, 1982, p. 38). 102 Secondly, p o l i c i e s which d i r e c t i n t e r - m i n i s t e r i a l communication between h e a l t h and s o c i a l s e r v i c e s appear to be l a c k i n g . A s s o c i a t e d with t h i s i s the absence of e f f e c t i v e l y c o o r d i n a t e d h e a l t h care teams at the l o c a l community l e v e l . In the m a j o r i t y of the s i t u a t i o n s d e s c r i b e d by the CHNs, the p r o f e s s i o n a l s c l e a r l y were unable to work together f o r the b e n e f i t of the c l i e n t due to poor communication, d i s p a r a t e goals and/or a l a c k of c o o r d i n a t i o n between p r i v a t e p h y s i c i a n s or t h e r a p i s t s , s p e c i a l i z e d h o s p i t a l s e r v i c e s , community h e a l t h s e r v i c e s , s o c i a l s e r v i c e s and the school system. In summary, then i t i s c l e a r that these p o l i c y i s s u e s are determinants of the e t h i c a l c o n f l i c t s experienced by the nurses. I n t e r d i s c i p l i n a r y r e l a t i o n s h i p s . F i e l d (1988) has d e f i n e d " i n t e r d i s c i p l i n a r y care as the concept of p r o f e s s i o n a l s working together In a h e a l t h care team, the goal of which i s to maximize f a m i l y h e a l t h " (p. 198). Toward t h i s end, s u c c e s s f u l team-work r e q u i r e s frequent i n t e r a c t i o n , d e f i n e d l e a d e r s h i p which changes with the focus of care, and c l e a r l y d e f i n e d tasks that are accepted and developed by the team members ( F i e l d , 1988, p. 198). In t h i s study, the absence of team-work was represented i n a l l c a t e g o r i e s of dilemmas i n that i t c o n t i n u a l l y f r u s t r a t e d the nurses' attempts to advocate f o r t h e i r c l i e n t s ' r i g h t s and community needs. Most s t r i k i n g i s the f e e l i n g that h e a l t h care team members did not share a 103 common e t h i c or l e v e l of concern f o r c o n f i d e n t i a l i t y , p r i v a c y , and the r i g h t to access competent s e r v i c e s . F i e l d ' s (1988) o b s e r v a t i o n s support t h i s f i n d i n g as she comments that c h i l d and f a m i l y h e a l t h care s e r v i c e s i n Canada are m u l t i d i s c i p l i n a r y as opposed to i n t e r d i s c i p l i n a r y i n that team r e l a t i o n s h i p s l a c k the e s s e n t i a l element of c o l l a b o r a t i o n and c i t e s improved l i n k a g e s between both h e a l t h and s o c i a l s e r v i c e s and p u b l i c and p r i v a t e s e v i c e s as c r i t i c a l i s s u e s . Of f u r t h e r relevance to t h i s d i s c u s s i o n of i n t e r d i s c i p l i n a r y r e l a t i o n s h i p s as a f o r c e shaping the dilemmas i s the p o s i t i o n and nature of the CHN's r o l e w i t h i n the h e a l t h care system. I t may be that CHNs' needs f o r c o l l a b o r a t i o n are even g r e a t e r as they care f o r c l i e n t s i n homes, s c h o o l s , or other community l o c a t i o n s which are removed from the o f f i c e s of those p r o f e s s i o n a l s who may a l s o be i n v o l v e d with t h e i r c a r e . Furthermore, f u l f i l l m e n t of the advocacy goals expressed i n the nurses' d e s c r i p t i o n s of t h e i r r o l e and responses r e q u i r e s c o l l a b o r a t i v e i n t e r d i s c i p l i n a r y r e l a t i o n s h i p s . D r i v i n g Forces S e v e r a l f o r c e s were perc e i v e d to be su p p o r t i v e of the nurses' e t h i c a l responses i n the dilemmas they d e s c r i b e d . These supports took the form of nursing l e a d e r s h i p , a v a i l a b i l i t y of h e l p f u l resources i n c l u d i n g c o n s u l t a n t s and educatio n , nursing s k i l l and knowledge, the q u a l i t y of the 104 n u r s e - c l i e n t r e l a t i o n s h i p , and most i m p o r t a n t l y the o p p o r t u n i t y to i n t e r a c t with other CHNs. Nursing l e a d e r s h i p . The nurses p e r c e i v e d that the support of a competent and f l e x i b l e s e n i o r nurse was most important to t h e i r h andling of the s i t u a t i o n s i n v o l v i n g e t h i c a l dilemmas. The s e n i o r nurse or nursing s u p e r v i s o r was f r e q u e n t l y c o n s u l t e d and most o f t e n p e r c e i v e d as s u p p o r t i v e . In one s i t u a t i o n , the s e n i o r nurse was able to f l e x i b l y i n t e r p r e t c h i l d abuse p o l i c y by communicating with a s u p e r v i s o r i n the s o c i a l s e r v i c e s m i n i s t r y . This communication r e s u l t e d i n a more f a v o r a b l e outcome f o r the f a m i l y as a whole, and the c h i l d r e n were p r o t e c t e d without taking a c t i o n that the f a m i l y had openly opposed. However, one nurse p e r c e i v e d the s e n i o r nurse to be not as h e l p f u l when she negated the s i g n i f i c a n c e of that nurse's r e l a t i o n s h i p with her c l i e n t by remarking that " i t i s no longer your problem" once the suspected c h i l d abuse had been r e p o r t e d . Resources. The nurses i d e n t i f i e d the o p p o r t u n i t y to c o n s u l t with o u t s i d e resources i n c l u d i n g : the C o l l e g e of P h y s i c i a n s and Surgeons, RNABC, Health Department lawyers, and s o c i a l workers, as s u p p o r t i v e of t h e i r responses to dilemmas i n v o l v i n g the h e a l t h care team. One nurse commented that ongoing access to the c o n s u l t a n t s e r v i c e s of a medical e t h i c i s t was needed. Others a l l u d e d to the need f o r 105 p r o t e c t i o n of nurses by nursing unions and p r o f e s s i o n a l a s s o c i a t i o n s . Nursing knowledge and s k i l l s . CHNs c i t e d experience, a s s e r t i v e n e s s , and knowledge of the p o l i t i c a l process as e s s e n t i a l to the development of t h e i r a b i l i t i e s to r e s o l v e e t h i c a l dilemmas. A d d i t i o n a l l y , ways and means of i n t e r v e n i n g with h i g h - r i s k c l i e n t s was i d e n t i f i e d as an important s k i l l which needs to be developed. The nurses s p e c i f i c a l l y i d e n t i f i e d the need f o r advanced assessment s k i l l s , and the a v a i l a b i l i t y of o b j e c t i v e t o o l s to a s s i s t them i n t h e i r work with h i g h - r i s k c l i e n t s . The n u r s e - c l i e n t r e l a t i o n s h i p . Among the f o r c e s shaping dilemmas was the nurses' c l o s e r e l a t i o n s h i p with the c l i e n t and i n t i m a t e knowledge of the f a m i l y s i t u a t i o n which e x i s t e d i n the m a j o r i t y of the s i t u a t i o n s . This l e v e l of understanding and knowledge of t h e i r c l i e n t s c o n t r i b u t e d to the nurses' r e c o g n i t i o n of the e t h i c a l dilemma and the need f o r advocacy. I n t e r a c t i o n with c o l l e a g u e s . S i g n i f i c a n t l y , support through i n t e r a c t i o n with c o l l e a g u e s was the most widely c i t e d as almost a l l p a r t i c i p a n t s noted some degree of i n f o r m a l c o n s u l t a t i o n with t h e i r c o l l e a g u e s . In a l l i n s t a n c e s , t h i s support occurred i n f o r m a l l y r a t h e r than as a r e g u l a r , a v a i l a b l e part of t h e i r working l i v e s . A recent r e s e a r c h p r o j e c t to explore the 106 c h a r a c t e r i s t i c s of a q u a l i t y working l i f e environment f o r nurses found that the support of amiable, e n t h u s i a s t i c , competent c o l l e a g u e s was a h i g h l y rated determinant ( A t t r i d g e and C a l l a h a n , 1987). This f i n d i n g was repeated when CHNs p a r t i c i p a t e d i n a workshop which c o n s i s t e d of the use of the same re s e a r c h method. A d d i t i o n a l l y , i t was apparent from the s e n i o r nurses' d e s c r i p t i o n s that they too needed support from t h e i r a d m i n i s t r a t i v e c o l l e a g u e s given that t h e i r experience with e t h i c a l dilemmas r e q u i r e d them to provide advice and c o n s u l t a t i o n to CHNs. However, they are o f t e n more g e o g r a p h i c a l l y i s o l a t e d from t h e i r n ursing peers i n l e a d e r s h i p p o s i t i o n s who may be l o c a t e d i n another o f f i c e or •community. Once again, there was no mention of s t r u c t u r e d support a c t i v i t i e s or forums f o r these nurses to a i r t h e i r experience with e t h i c a l dilemmas. A n a l y s i s of the Nursing Role S i g n i f i c a n t l y , CHNs' experiences with e t h i c a l dilemmas r e s u l t e d i n t h e i r i d e n t i f i c a t i o n of the o p p o r t u n i t i e s to advocate f o r t h e i r c l i e n t s ' r i g h t s and f o r community h e a l t h . Therefore the concept of advocacy i s pe r c e i v e d as a c e n t r a l and u n i f y i n g concept f o r the a n a l y s i s of the nursing r o l e i n t h i s study. From the l i t e r a t u r e v a r i o u s d e f i n i t i o n s help c l a r i f y the meaning of the advocacy r o l e i n n u r s i n g . Facets of the advocacy r o l e were both i m p l i c i t and e x p l i c i t 107 i n the nurses' d e s c r i p t i o n s . These w i l l now be d e s c r i b e d and r e l a t e d to the cu r r e n t l i t e r a t u r e . In h a l f of the s i t u a t i o n s the nurse seemed aware of the need f o r advocacy on behalf of the h i g h - r i s k I n d i v i d u a l or fa m i l y w i t h i n the h e a l t h and s o c i a l s e r v i c e s system. In these i n s t a n c e s the nurses expressed the d e s i r e to n e g o t i a t e the h e a l t h and s o c i a l s e r v i c e s system f o r the c l i e n t i n order to improve t h e i r chances of r e c e i v i n g care and follow-up that was r e s p e c t f u l of t h e i r human r i g h t s . Advocacy i n c l u d e d " t a l k i n g to the s o c i a l - w o r k e r and mental h e a l t h worker about the f a m i l y ' s needs and concerns" i n order to i n c r e a s e t h e i r s e n s i t i v i t y to the s i t u a t i o n s , s e c u r i n g a d d i t i o n a l s e r v i c e s such as homemaking, or p r o v i d i n g a d d i t i o n a l s e r v i c e s beyond what was designated by agency p o l i c y i n c l u d i n g t r a n s p o r t a t i o n or ma i n t a i n i n g contact with c l i e n t s f o r longer periods of time. The nurses i n t h i s study valued t h e i r c l i e n t s r i g h t s to p r i v a c y , c o n f i d e n t i a l i t y , and s e l f - d e t e r m i n a t i o n i n matters concerning t h e i r c a r e . T h i s was evidenced by t h e i r responses to dilemmas i n v o l v i n g h e a l t h care team i n t e r a c t i o n s . In team meetings, they r i s k e d d i s a p p r o v a l from t h e i r i n t e r d i s c i p l i n a r y c o l l e a g u e s by c o n f r o n t i n g the mishandling of s e n s i t i v e c l i e n t i n f o r m a t i o n and advocating f o r c l i e n t r i g h t s to c o n f i d e n t i a l i t y i n the l e g a l system. Senior CHNs' expressed t h e i r advocacy r o l e most c l e a r l y i n r e l a t i o n to the s t a f f CHNs f o r whom they were 108 r e s p o n s i b l e . S p e c i f i c a l l y , t h i s group supported the s t a f f CHN i n the det e r m i n a t i o n of the l i m i t s and scope of nursing r e s p o n s i b i l i t y with h i g h - r i s k f a m i l i e s and f a c i l i t a t e d the nurses' access to i n f o r m a t i o n and t h e i r input i n t o d e c i s i o n s about programs and resource a l l o c a t i o n . An a n a l y s i s of the ex p r e s s i o n of advocacy as a predominant n u r s i n g value and r o l e i n t h i s study i n d i c a t e s that most CHNs advocated f o r t h e i r c l i e n t s by r e p r e s e n t i n g t h e i r c l i e n t s ' r i g h t s to s e l f - d e t e r m i n a t i o n , a c c e s s i n g i n f o r m a t i o n and support, and p r o v i d i n g p r i v a c y . This was most o f t e n accomplished by speaking or a c t i n g on t h e i r c l i e n t s ' behalf as opposed to encouraging them to act on t h e i r own or assuming an a c t i v i s t r o l e . This may be due to the h i g h - r i s k c h a r a c t e r i s t i c s of these c l i e n t s and to the percei v e d v u l n e r a b i l i t y of these c l i e n t s . T h e i r v u l n e r a b i l i t y a d v e r s e l y a f f e c t e d t h e i r c a p a c i t y to act on t h e i r own behalf was r e l a t e d to the e x i s t e n c e of a power d i f f e r e n t i a l between the c l i e n t and the h e a l t h and s o c i a l s e r v i c e s system. T h e r e f o r e , the form of advocacy expressed i n t h i s study most c l o s e l y r e l a t e s to the concept developed by Gadow (1980) which " i s based upon the p r i n c i p l e that freedom of s e l f - d e t e r m i n a t i o n i s the most fundamental and va l u a b l e human r i g h t , and t h e r e f o r e i s a g r e a t e r good than any which h e a l t h care can pr o v i d e " (p. 45). Furthermore, "the i d e a l which ' e x i s t e n t i a l advocacy' expresses i s t h i s : that i n d i v i d u a l s be a s s i s t e d by nursing to a u t h e n t i c a l l y 109 e x e r c i s e t h e i r freedom of s e l f - d e t e r m i n a t i o n " (Gadow, 1980, p. 45). In t h i s study, the CHNs' o v e r r i d i n g concerns f o r c l i e n t s ' r i g h t s and t h e i r a b i l i t i e s to advocate f o r these was i n f l u e n c e d by t h e i r c l o s e r e l a t i o n s h i p s with and knowledge of the c l i e n t s ' needs, as w e l l as t h e i r p o s i t i o n i n the h e a l t h care system. As a f i n a l point i n t h i s a n a l y s i s of the advocacy r o l e , i t has been argued that community h e a l t h nurses are i n the p o s i t i o n to advocate c l i e n t s ' r i g h t s by assuming an a c t i v i s t r o l e and i n f l u e n c i n g the c o n d i t i o n s that a f f e c t h e a l t h , and/or by empowering v u l n e r a b l e c l i e n t s to represent t h e i r own r i g h t s (Dreher, 1982; Epp, 1987; Goeppinger, 1988; Mussallem, 1985). The o b s e r v a t i o n that t h i s was not an i n t e r v e n t i o n i d e n t i f i e d by the respondents (with two e x c eptions) may r e l a t e i n part to the h i g h - r i s k c h a r a c t e r i s t i c s of the c l i e n t s . However, i t may a l s o be that CHNs' are not as aware of community development s t r a t e g i e s f o r h i g h - r i s k groups. I t may a l s o be p o s s i b l e that the nurses' p e r c e p t i o n s of t h e i r v u l n e r a b i l i t y w i t h i n the system may preclude t h e i r e x p r e s s i o n of t h i s form of advocacy. No E t h i c a l Dilemmas I t was an unexpected f i n d i n g that 5 of the 30 p a r t i c i p a n t s reported e x p e r i e n c i n g no e t h i c a l dilemmas. 110 These nurses had s l i g h t l y more years of community h e a l t h nursing experience than the t o t a l sample (mean = 11.5 years versus 9.8 y e a r s ) . In view of the broad d e f i n i t i o n of the e t h i c a l dilemma presented to the p a r t i c i p a n t s , and nursing's i n t e n s e and continuous a s s o c i a t i o n with humane i s s u e s i t seems r e a l i s t i c to assume that a l l nurses would be f a c i n g e t h i c a l dilemmas. Although i t i s impossible to determine the f a c t o r s i n f l u e n c i n g t h i s somewhat d i s t u r b i n g response on the b a s i s of these l i m i t e d data, three p o t e n t i a l e x p l a n a t i o n s w i l l be hypothesized. One of the nurses had been i n her c u r r e n t p o s i t i o n f o r only a three month perio d and s t a t e d she could f o r s e e the occurrence of e t h i c a l dilemmas i n the f u t u r e . The f i r s t e x p l a n a t i o n , then may be that t h i s nurse may not have been s e n s i t i z e d to the e t h i c a l dilemmas i n c l i n i c a l p r a c t i c e due to the newness of the s e t t i n g . However, f o r others who had been i n t h e i r p o s tions f o r at l e a s t two years and much longer, one must look f o r other e x p l a n a t i o n s . A second e x p l a n a t i o n may be that nurses who have not had recent n u r s i n g education are u n f a m i l i a r with the concept of the e t h i c a l dilemma and/or may view i t i s an unusual occurrence of a more sensational, nature r a t h e r than a p o t e n t i a l l y common experience. The t h i r d and most alarming e x p l a n a t i o n may be that nurses who work i n a I l l s e t t i n g f o r many y e a r s may become d e s e n s i t i z e d to the e x p e r i e n c e of e t h i c a l dilemmas i n t h e i r n u r s i n g p r a c t i c e . The o n l y c o n c l u s i o n t h a t may be r e a l i s t i c a l l y drawn i s t h a t t h i s f i n d i n g w a r r a n t s f u r t h e r s t u d y to i d e n t i f y t h o s e f a c t o r s w h i c h may i n f l u e n c e a CHNs' a b i l i t y o r t e n d e n c y to p e r c e i v e t h e e t h i c a l dilemmas i n t h e i r p r a c t i c e . Summary The a n a l y s i s p r e s e n t e d i n t h i s c h a p t e r i n d i c a t e s t h a t the dilemmas a s s o c i a t e d w i t h each o f the c a t e g o r i e s a r e complex i n t h a t t h e y i n v o l v e m u l t i p l e c o n f l i c t s . T h ese c o n f l i c t s were d i s c u s s e d i n r e l a t i o n to t h e most r e l e v a n t e t h i c a l themes, f o r c e s and e l e m e n t s of the n u r s i n g r o l e . The e t h i c a l themes most f u n d a m e n t a l l y i n v o l v e d c o n f l i c t between the p r i n c i p l e s of autonomy and b e n e f i c e n c e . A d d i t i o n a l themes i n c l u d e d human r i g h t s and v a l u e c o n f l i c t s . Key r e s t r a i n i n g and d r i v i n g f o r c e s I n f l u e n c i n g the n u r s e s ' e x p e r i e n c e w i t h the dilemma were i d e n t i f i e d . R e s t r a i n i n g f o r c e s i n c l u d e d s o c i a l v a l u e s ; p o l i c y ; a l a c k of s e r v i c e s f o r the p r i m a r y p r e v e n t i o n of h i g h - r i s k p a r e n t i n g p r a c t i c e s , and t r e a t m e n t of t h o s e i n need o f l o n g - t e r m t h e r a p y ; and d i f f i c u l t i e s i n m a i n t a i n i n g an i n t e r d i s c i p l i n a r y a p p r o a c h a t the community l e v e l . D r i v i n g f o r c e s i n c l u d e d n u r s i n g l e a d e r s h i p , h e l p f u l r e s o u r c e s i n c l u d i n g c o n s u l t a n t s , n u r s i n g knowledge and s k i l l , t he 112 n u r s e - c l i e n t r e l a t i o n s h i p , and most importantly,- nurses' i n t e r a c t i o n with t h e i r c o l l e a g u e s . Advocacy was i d e n t i f i e d as a key f e a t u r e of the nu r s i n g r o l e as the nurses were concerned about and took a c t i o n to promote t h e i r c l i e n t s ' r i g h t s i n the h e a l t h and s o c i a l s e r v i c e s system. Facets of the advocacy r o l e expressed i n t h i s study were c o n t r a s t e d with the c u r r e n t l i t e r a t u r e . F i n a l l y , some t e n t a t i v e e x p l a n a t i o n s were proposed f o r the f i n d i n g that f i v e nurses reported they had not experienced e t h i c a l dilemmas i n t h e i r p r a c t i c e . A need f o r resear c h i n t o t h i s matter was i d e n t i f i e d . The c o n c l u s i o n s a r i s i n g from t h i s a n a l y s i s , as w e l l as i m p l i c a t i o n s f o r nursing p r a c t i c e , education, and r e s e a r c h are presented i n the f i n a l chapter of t h i s t h e s i s . 113 CHAPTER SIX SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR NURSING This chapter begins with a summary of the rese a r c h process d e s c r i b e d w i t h i n t h i s t h e s i s . Then, the c o n c l u s i o n s a r i s i n g from the a n a l y s i s of the f i n d i n g s are presented. F i n a l l y the i m p l i c a t i o n s f o r nursing p r a c t i c e , e d u c a t i o n , and r e s e a r c h are i d e n t i f i e d . Summary The rese a r c h problem f o r t h i s study was s e l e c t e d because of the r e s e a r c h e r ' s own experience with e t h i c a l dilemmas i n community h e a l t h nursing p r a c t i c e and concern that these dilemmas were not d i s c u s s e d i n the nursing r e s e a r c h l i t e r a t u r e . Thus, the purpose of the study was to begin to d e s c r i b e the types of e t h i c a l dilemmas experienced by community h e a l t h nurses. I t was broadly intended that the f i n d i n g s of the study would c o n t r i b u t e to a developing awareness of the e t h i c s a s s o c i a t e d with the community h e a l t h nursing r o l e . C u r t i n ' s (1978) Model f o r C r i t i c a l E t h i c a l A n a l y s i s was the conceptual framework which provided d i r e c t i o n f o r the methodological approach and a n a l y s i s of the f i n d i n g s . This model combines the decision-making process with elements of e t h i c a l theory to guide the i d e n t i f i c a t i o n of e t h i c a l dilemmas and the i n t e r p r e t a t i o n of n u r s i n g responses to 114 them. A l i t e r a t u r e review i n c l u d e d works r e l a t e d to e t h i c a l theory, h e a l t h care and nursing e t h i c s , and resea r c h i n nurs i n g e t h i c s to provide the backdrop f o r t h i s study. Furthermore, contemporary i s s u e s i n community h e a l t h nursing were reviewed to develop the context and support the need f o r r e s e a r c h i n t h i s a r ea. In view of the e x p l o r a t o r y nature of t h i s study, a d e s c r i p t i v e survey was the s e l e c t e d r e s e a r c h method. The survey was conducted with a n o n - p r o b a b i l i t y , purposive sample of community h e a l t h nurses. The C r i t i c a l I n c i d e n t Technique (Flanagan, 1954) was i n c o r p o r a t e d i n t o the design, and together with the Model f o r C r i t i c a l E t h i c a l A n a l y s i s ( C u r t i n , 1978) formed the b a s i s f o r the development of the data c o l l e c t i o n guide. The CHNs who r e c e i v e d mailed copies of the guide were asked to d e s c r i b e i n w r i t i n g the circumstances of those p r a c t i c e s i t u a t i o n s c o n t a i n i n g e t h i c a l dilemmas and t h e i r responses to them. T h i r t y CHNs p a r t i c i p a t e d i n the study during a 6 week data c o l l e c t i o n p e r i o d . C u r i o u s l y , 5 of the CHNs reported that they were unable to i d e n t i f y any e t h i c a l dilemmas i n t h e i r p r a c t i c e ; three p o t e n t i a l e x p l a n a t i o n s f o r t h i s unexpected f i n d i n g were proposed. The CHNs were able to i d e n t i f y p r a c t i c e s i t u a t i o n s c o n t a i n i n g e t h i c a l dilemmas and the s p e c i f i c c o n f l i c t s i n herent i n the dilemmas. Furthermore, the nurses d e s c r i b e d t h e i r v a l u e s , f e e l i n g s and responses a c c o r d i n g to phases of 115 the decision-making process. Through a process of content a n a l y s i s , the s i t u a t i o n s were c a t e g o r i z e d a c c o r d i n g to t h e i r primary f o c u s . The three main c a t e g o r i e s - c l i e n t s ' r i g h t s , system i n t e r a c t i o n , and nurse s ' r i g h t s - r e l a t e the s i t u a t i o n s to dimensions of community h e a l t h n u r s i n g p r a c t i c e . During data a n a l y s i s , the s i t u a t i o n s were f u r t h e r analyzed to i d e n t i f y e t h i c a l themes and the nurses' responses to them. In t h i s study, the most compelling f e a t u r e of e t h i c a l c o n f l i c t s i n c l i e n t s ' r i g h t s a r i s e s w i t h i n the CHNs' r e l a t i o n s h i p s with h i g h - r i s k c l i e n t s who are e x p e r i e n c i n g some degree of v u l n e r a b i l i t y w i t h i n the h e a l t h care system. Most of the s i t u a t i o n s i n v o l v e d CHNs' work with h i g h - r i s k parents and i n v o l v e d d i f f i c u l t choices about how to int e r v e n e when c h i l d abuse or neg l e c t was suspected or probable. Within the category of system i n t e r a c t i o n , e t h i c a l c o n f l i c t s r e l a t e to the a l l o c a t i o n of nursing r e s o u r c e s , and the f u n c t i o n i n g of the h e a l t h care team. F i n a l l y , the e t h i c a l c o n f l i c t s r e l a t e d to nurses' r i g h t s Involve the l i m i t a t i o n s on nursing autonomy imposed by m u l t i p l e , and o f t e n c o n t r a d i c t o r y o b i g a t i o n s a r i s i n g w i t h i n the CHNs' personal and p r o f e s s i o n a l l i v e s . The dilemmas i n v o l v e d c o n f l i c t s between the p r i n c i p l e s of autonomy, be n e f i c e n c e , and j u s t i c e . A d d i t i o n a l l y , value c o n f l i c t s c h a r a c t e r i z e these dilemmas i n c l u d i n g c o n f i d e n t i a l i t y , honesty, and the d e l i v e r y of q u a l i t y 116 community h e a l t h care to p o p u l a t i o n s . In some i n s t a n c e s the nurses' values are seen to be i n c o n f l i c t with those of t h e i r c l i e n t s , employer, or other h e a l t h care team members. A f o r c e f i e l d a n a l y s i s of the dilemmas as suggested by Crisham (1985) r e v e a l e d key r e s t r a i n i n g and d r i v i n g f o r c e s which i n f l u e n c e d the nurse s ' e x p e r i e n c e s . For example, a key r e s t r a i n i n g f o r c e was the r e l a t i o n s h i p between p o l i c y and the occurrence of e t h i c a l dilemmas i n d a i l y p r a c t i c e . A d d i t i o n a l l y , the absence of c o o r d i n a t e d , i n t e r d i s c i p l i n a r y team-work was a r e s t r a i n i n g f o r c e which c o n t r i b u t e d to both the occurrence of the dilemma and seemingly i n t e r f e r e d with the nurses' r e s o l u t i o n - t h i s was a l s o r e l a t e d to p o l i c y . D r i v i n g f o r c e s which enhanced the nurses' a b i l i t i e s to cope with the e t h i c a l dilemmas i n c l u d e d the support of a f l e x i b l e s e n i o r nurse; c o n s u l t a t i o n with n u r s i n g a s s o c i a t i o n s , h e a l t h department lawyers, and s o c i a l s e r v i c e s ; and the nurses' knowledge, s k i l l s i n working with h i g h - r i s k c l i e n t s , and t r u s t i n g r e l a t i o n s h i p s with t h e i r c l i e n t s . F i n a l l y , the nurses unaminously c i t e d t h e i r r e l i a n c e on the support of t h e i r c o l l e a g u e s i n community h e a l t h nursing during t h e i r experience with p r a c t i c e dilemmas. This support occurred predominantly through a process of i n f o r m a l c o n s u l t a t i o n with peers as opposed to a r e g u l a r f e a t u r e of t h e i r working l i v e s . Advocacy emerged as a u n i f y i n g value i n the community h e a l t h nursing r o l e . When compared with the concept of 117 advocacy d e s c r i b e d i n cu r r e n t l i t e r a t u r e , the CHNs i d e n t i f i e d i n t e r v e n t i o n s r e l a t e d to speaking or a c t i n g f o r the c l i e n t as opposed to encouraging c l i e n t s to act or t a r g e t i n g the system through community a c t i v i s m . S e v e r a l c o n c l u s i o n s about the e t h i c a l dimensions of community h e a l t h n u r s i n g p r a c t i c e emerge from the a n a l y s i s of the f i n d i n g s i n t h i s study. These c o n c l u s i o n s i n turn give r i s e to i m p l i c a t i o n s f o r p r a c t i c e , r e s e a r c h , and education i n community h e a l t h n u r s i n g . Conclusions The f o l l o w i n g c o n c l u s i o n s are based on the a n a l y s i s of the f i n d i n g s reported i n t h i s study: 1. The community h e a l t h nurses who p a r t i c i p a t e d i n t h i s study were able to i d e n t i f y s i g n i f i c a n t e t h i c a l dilemmas i n t h e i r p r a c t i c e and to r e s t r o s p e c t i v e l y analyze t h e i r e x p e r i e n c e s . The nurses reported i n w r i t i n g t h e i r f e e l i n g s and how they made d e c i s i o n s when faced with d i f f i c u l t c h o i c e s . 2. The s i t u a t i o n s c o n t a i n i n g e t h i c a l dilemmas f o r CHNs are p o t e n t i a l l y everyday occurrences, as opposed to being rare or s e n s a t i o n a l . 3. The e t h i c a l dilemmas d e s c r i b e d i n t h i s study present o p p o r t u n i t i e s f o r c l i e n t advocacy - p a r t i c u l a r l y with h i g h - r i s k c l i e n t s who are v u l n e r a b l e w i t h i n the h e a l t h and s o c i a l s e r v i c e s system. The c l i e n t s ' v u l n e r a b i l i t i e s 118 r e l a t e d to t h e i r d i f f i c u l t i e s i n a c c e s s i n g a p p r o p r i a t e h e a l t h and s o c i a l s e r v i c e s and the t h r e a t s to t h e i r b a s i c human r i g h t s e x i s t i n g w i t h i n the system. CHNs most o f t e n advocated f o r t h e i r c l i e n t s ' r i g h t s to p r i v a c y , s e l f - d e t e r m i n a t i o n and q u a l i t y care by speaking on t h e i r b ehalf i n order to i n c r e a s e the s e n s i t i v i t y to these. 4. The e t h i c a l c o n f l i c t s u n d e r l y i n g the dilemmas experienced by CHNs are s i m i l a r to those experienced by nurses i n other r o l e s and s e t t i n g s . For example CHNs a l s o experience the c o n f l i c t s reported by Crisham (1985) i n c l u d i n g determining the c l i e n t s ' r i g h t s to know and decide, m a i n t a i n i n g p r o f e s s i o n a l standards and a l l o c a t i n g n u rsing r e s o u r c e s , and promoting a q u a l i t y of l i f e . 5. Although the e t h i c a l c o n f l i c t s faced by the CHNs i n t h i s study are not unique i n themselves, the way i n which the CHNs experience the c o n f l i c t s may d i f f e r from nurses i n other r o l e s and s e t t i n g s . I f t r u e , t h i s uniqueness i n the way CHNs experience e t h i c a l c o n f l i c t corresponds to unique f e a t u r e s of the CHN r o l e . For example, the CHN i s o f t e n a primary contact f o r c l i e n t s needing h e a l t h and s o c i a l s e r v i c e s . As a r e s u l t of being a primary contact f o r c l i e n t s , the CHN may assume a r o l e i n r e f e r r i n g and c o o r d i n a t i n g the c l i e n t s ' access to the s e r v i c e s . Seemingly, many of the dilemmas reported i n t h i s study were i n f l u e n c e d by the primary p o s i t i o n of the CHN r o l e w i t h i n the system. The CHN o f t e n p e r c e i v e s c o n f l i c t s between the 119 needs and values of i n d i v i d u a l , f a m i l y , and aggregate c l i e n t s ; and i n r e l a t i o n s h i p s with h e a l t h care team members; employers, and t h e i r own f a m i l i e s . 6. The p o s i t i o n of the CHN r o l e w i t h i n the system may be d e s c r i b e d as p a r a d o x i c a l . From the data, i t appears that although the nurses may be f r o n t - l i n e i n i d e n t i f y i n g and responding to the needs and v u l n e r a b i l i t i e s of h i g h - r i s k c l i e n t s , they are most o f t e n unable to develop and maintain those i n t e r d i s c i p l i n a r y r e l a t i o n s h i p s which are r e q u i r e d to access q u a l i t y s e r v i c e s f o r t h e i r c l i e n t s . The absence of c o l l a b o r a t i v e r e l a t i o n s h i p s between community h e a l t h and s o c i a l s e r v i c e s was most evident i n the s i t u a t i o n s d e s c r i b e d by the nurses. 7. This a n a l y s i s of the CHNs' experiences with the e t h i c a l dilemmas revealed p a t t e r n s i n the d e l i v e r y of care which i n f l u e n c e d the occurrence of the e t h i c a l c o n f l i c t s . These patt e r n s h i g h l i g h t the s i g n i f i c a n t i n f l u e n c e of broader s o c i a l f o r c e s e x t e r n a l to the i n d i v i d u a l s i t u a t i o n . For example there i s a r e l a t i o n s h i p between p o l i c y i s s u e s at the system l e v e l and e t h i c a l c o n f l i c t s at the l e v e l of c a r e - g i v i n g . 8. Attempts to r e s o l v e the e t h i c a l dilemmas contained w i t h i n the m a j o r i t y of these s i t u a t i o n s were f r u s t r a t e d by the i n f l u e n c e of e x t e r n a l f o r c e s e x i s t i n g at the system l e v e l . S t r a t e g i e s f o r c o n t r i b u t i n g to developing p o l i c y and improving the o r g a n i z a t i o n and the means of d e l i v e r i n g care 120 are important to the r e s o l u t i o n of e t h i c a l dilemmas i n community h e a l t h n u r s i n g p r a c t i c e . 9. A l l of the CHNs i n t h i s study found t h e i r experiences with e t h i c a l c o n f l i c t to be d i f f i c u l t . F e e l i n g s re p o r t e d i n c l u d e d anger, g u i l t , f r u s t r a t i o n and f e a r . Some nurses p e r c e i v e d c h a l l e n g e and the o p p o r t u n i t y to gain s t r e n g t h w i t h i n t h e i r e x perience. 10. The nurses i d e n t i f i e d s i g n i f i c a n t needs f o r support during t h e i r experiences with these dilemmas. Most s t r i k i n g was t h e i r unanimous i d e n t i f i c a t i o n of the need f o r s h a r i n g t h e i r experiences with t h e i r c o l l e a g u e s . A d d i t i o n a l l y , t h i s a n a l y s i s i n d i c a t e s the importance of p r o t e c t i o n and support f o r nurses at the o r g a n i z a t i o n a l l e v e l . I m p l i c a t i o n s f o r Nursing P r a c t i c e The f i n d i n g s of t h i s study generate some i m p l i c a t i o n s f o r coping with e t h i c a l dilemmas i n community h e a l t h n u r s i n g p r a c t i c e . These i m p l i c a t i o n s are of two types. The f i r s t type i n c l u d e s s t r a t e g i e s f o r i n d i v i d u a l nurses coping with s i t u a t i o n s c o n t a i n i n g e t h i c a l dilemmas i n t h e i r d a i l y p r a c t i c e . The second type i d e n t i f i e s the need to develop s t r a t e g i e s which r e q u i r e l o o k i n g beyond the i n d i v i d u a l s i t u a t i o n at the f o r c e s o p e r a t i n g w i t h i n the system as a whole. F i r s t , these data i n d i c a t e that the CHNs r e q u i r e ongoing c o n s u l t a t i o n and support during t h e i r experience with 121 e t h i c a l dilemmas. T h e r e f o r e , i t i s important that support f o r nurses be provided i n the work s e t t i n g . Supportive c o n s u l t a t i o n may be provided through r e g u l a r i n t e r d i s c i p l i n a r y c l i e n t - c e n t e r e d conferences which i n c l u d e s the i d e n t i f i c a t i o n of the e t h i c a l c o n f l i c t s e x i s t i n g i n the s i t u a t i o n s brought forward by the p r a c t i t i o n e r s . During conferences, nurses and others may be supported by the awareness that others share t h e i r experiences and may be a s s i s t e d by sharing s t r a t e g i e s f o r i n v o l v i n g c l i e n t s as f u l l y as p o s s i b l e i n d e c i s i o n s about t h e i r c a r e . While sh a r i n g t h e i r e x p e r iences, CHNs may observe common themes and p a t t e r n s w i t h i n the dilemmas. This p e r s p e c t i v e on the " p a t t e r n s " may i n d i c a t e the need f o r i n t e r v e n t i o n beyond that which the i n d i v i d u a l nurse can provide and thereby reduce some of the personal g u i l t f e e l i n g s that are a s s o c i a t e d with " u n r e s o l v a b l e " dilemmas. It i s important f o r se n i o r nurses to c o n s u l t with CHNs about t h e i r p r a c t i c e dilemmas and provide f l e x i b l e and c a r i n g l e a d e r s h i p which recognizes the s i g n i f i c a n c e of the nurses ' r e l a t i o n s h i p s with t h e i r c l i e n t s . A d d i t i o n a l l y there i s a need to develop more e f f e c t i v e means of communication between CHNs and other p r o f e s s i o n a l s i n c l u d i n g MSSH s o c i a l workers and p h y s i c i a n s . Ways and means of developing c o l l a b o r a t i v e working r e l a t i o n s h i p s could be explored w i t h i n the h e a l t h u n i t s . An improvement i n i n t e r d i s c i p l i n a r y r e l a t i o n s h i p s w i t h i n communities may 122 f a c i l i t a t e a team approach to meeting c l i e n t needs while observing t h e i r human r i g h t s . A team approach to working with h i g h - r i s k c l i e n t s i s c r u c i a l to the p r e s e r v a t i o n of a c a r i n g , t r u s t i n g c l i e n t - c e n t e r e d r e l a t i o n s h i p s while r e c o g n i z i n g t h e i r s a f e t y needs through monitoring and p r o t e c t i v e i n t e r v e n t i o n s . An i n c r e a s e i n c l i e n t involvement i n d e c i s i o n s about t h e i r care on an i n d i v i d u a l l e v e l as w e l l as a community h e a l t h planning l e v e l would i n c r e a s e system responsiveness to the needs of h i g h - r i s k c l i e n t s . Although there i s a trend toward i n c r e a s i n g consumer involvement i n community pla n n i n g , care must be taken to i n c l u d e those who are at r i s k as w e l l as those who have resources and energy to be Involved i n t h i s p r o c e s s . I t may be that CHNs and s o c i a l workers who work c l o s e l y with v u l n e r a b l e c l i e n t groups are best able to f a c i l i t a t e t h e i r involvement i n the community development process. This community development f u n c t i o n could be d e f i n e d w i t h i n the CHNs' working r o l e . A d d i t i o n a l l y time and education could be provided f o r nurses to develop these community development and advocacy s k i l l s . F i n a l l y , CHNs i n p r a c t i c e and management p o s i t i o n s need to i d e n t i f y and c o n s i d e r the more g l o b a l i m p l i c a t i o n s of the p a t t e r n s seen i n t h e i r cumulative experiences with dilemmas. As these data i n d i c a t e i t may be most important f o r nurses to f i n d ways to improve the o r g a n i z a t i o n and d e l i v e r y of h e a l t h and s o c i a l s e r v i c e s . This r e q u i r e s l o o k i n g beyond the 123 i n d i v i d u a l c l i e n t s i t u a t i o n s to i d e n t i f y the f o r c e s that c o n t r i b u t e to t h e i r occurrence. This system l e v e l approach to managing e t h i c a l dilemmas r e q u i r e s that CHNs co n s i d e r ways of advocating f o r v u l n e r a b l e c l i e n t groups by changing the c o n d i t i o n s which determine h e a l t h and f i n d i n g ways to strengthen the c l i e n t s ' a b i l i t i e s to a s s e r t t h e i r r i g h t s and access q u a l i t y s e r v i c e s . Moreover, i t Is important to f i n d ways of enhancing nurses' autonomy and t h e i r a b i l i t i e s to act a c cording to t h e i r p ersonal and p r o f e s s i o n a l v a l u e s . I m p l i c a t i o n s f o r Nursing Education The education of f u t u r e community h e a l t h nurses r e q u i r e s c o n s i d e r a t i o n of the knowledge, s k i l l , and i n s i g h t needed i n order to cope with the e t h i c a l complexity of t h e i r work. I t i s fundamentally important f o r nurses to understand e t h i c a l theory and to a c q u i r e s k i l l s i n l o g i c a l reasoning provided through courses i n p h i l o s o p h y . Students should be encouraged to apply t h e i r knowledge of e t h i c s w i t h i n each c l i n i c a l s e t t i n g . In the c l i n i c a l p ost-conference or seminar students may be encouraged to I d e n t i f y the everyday occurrences of e t h i c a l dilemmas and develop t h e i r i n s i g h t s and s t r a t e g i e s f o r managing e t h i c a l c o n f l i c t . I n t e r d i s c i p l i n a r y courses would provide an e x c e l l e n t o p p o r t u n i t y f o r nurses and others to develop t h e i r awareness of the e t h i c a l p e r s p e c t i v e s of the v a r i o u s p r o f e s s i o n a l 124 groups working i n the h e a l t h and s o c i a l s e r v i c e s . C l i e n t - c e n t e r e d d i s c u s s i o n s i n seminars could i n c r e a s e s t u d e n t s ' awareness of how t h e i r i n t e r d i s c i p l i n a r y c o l l e a g u e s view and respond to e t h i c a l c o n f l i c t . P a r t i c i p a t i o n i n these seminars could develop s t u d e n t s ' a b i l i t i e s to work as e f f e c t i v e team members f o r the common goal of c l i e n t h e a l t h . I d e n t i f i c a t i o n of ways of i n c r e a s i n g c l i e n t autonomy w i t h i n the system of care would a l s o be an important goal of student i n t e r a c t i o n . A s s e r t i v e n e s s education i s c r i t i c a l f o r the development of "the nursing s t u d e n t s ' a b i l i t i e s to a s s e r t t h e i r own r i g h t s and advocate f o r t h e i r c l i e n t s i n an i n c r e a s i n g l y complex and c o m p e t i t i v e system of care. E d u c a t i o n a l s t r a t e g i e s f o r developing s t u d e n t s ' confidence and t h e i r a b i l i t i e s to c o l l a b o r a t e with others could be i n t e g r a t e d throughout the b a s i c nursing program. F i n a l l y , b a s i c courses i n community h e a l t h nursing theory and p r a c t i c e should focus on the needs of p o p u l a t i o n groups w i t h i n communities. C l i n i c a l courses should i n c l u d e the o p p o r t u n i t i e s to apply s t r a t e g i e s f o r making programs more responsive to the needs of p o p u l a t i o n groups and develop s k i l l s i n advocating f o r v u l n e r a b l e c l i e n t s . Therefore community h e a l t h nursing theory and p r a c t i c e should be based on the concepts of community needs assessment and development, advocacy, i n t e r d i s c i p l i n a r y approaches, p o l i c y , and program p l a n n i n g . 125 I m p l i c a t i o n s f o r Nursing Research This study has provided only a beginning understanding of the types of e t h i c a l dilemmas faced by one group of CHNs. Furthe r i n v e s t i g a t i o n of a more systematic nature could c o n t r i b u t e to our knowl.edge of those dilemmas which occur most f r e q u e n t l y , r e s u l t i n the g r e a t e s t degree of e t h i c a l c o n f l i c t , and are of the h i g h e s t p r i o r i t y f o r r e s o l u t i o n . This i n s i g h t could be f u r t h e r developed through a survey based on the Delphi Technique. Interviews to f u l l y explore the q u a l i t a t i v e elements of the CHNs' experiences with e t h i c a l c o n f l i c t could complement t h i s approach. E t h i c a l c o n f l i c t a s s o c i a t e d with h i g h - r i s k p a r e n t i n g and monitoring the grey areas of suspected or probable c h i l d abuse was most pr e v a l e n t i n t h i s study. I t seems t h i s area r e s u l t s i n s i g n i f i c a n t anguish f o r nurses, parents, c h i l d r e n and s o c i a l workers. T h e r e f o r e , f u r t h e r r e s e a r c h should be done on the r o l e s and r e l a t i o n s h i p s of s o c i a l workers and nurses i n t h e i r work with h i g h - r i s k f a m i l i e s . The grounded theory methods used by P h i l l i p s and Rempusheshki (1985) to study the decision-making processes of s o c i a l workers and CHNs i n s i t u a t i o n s i n v o l v i n g e l d e r abuse would be r e l e v a n t to f u r t h e r r e s e a r c h i n t o the dynamics of c h i l d abuse. P o l i c y and i t s e f f e c t s on e t h i c a l dilemmas In p r a c t i c e i s a area f o r f u t u r e r e s e a r c h . E t h i c a l analyses of p o l i c i e s which i n f l u e n c e the h e a l t h of communities could be i n v e s t i g a t e d through the a p p l i c a t i o n of the r e s e a r c h 126 process. This p o l i c y a n a l y s i s could i d e n t i f y the r e l a t i o n s h i p between p o l i c y and p r a c t i c e dilemmas. This i n t e g r a t i o n of e t h i c a l theory and policy-making i s needed to provide h e a l t h care based on j u s t i c e , autonomy and humanistic community v a l u e s . F i n a l l y , the need f o r r e s e a r c h i n community h e a l t h n u r s i n g p r a c t i c e i s i m p l i c a t e d i n the f i n d i n g s of t h i s study. In p a r t i c u l a r , r e s e a r c h i s needed to i d e n t i f y s u c c e s s f u l n u r s i n g i n t e r v e n t i o n s with h i g h - r i s k c l i e n t s and to d i s c o v e r new s t r a t e g i e s f o r nurses to s e n s i t i v e l y and m o r a l l y care f o r them. Research i s the v e h i c l e f o r q u e s t i o n i n g the o l d and adopting new s t r a t e g i e s . In so doing, i t br i n g s us c l o s e r to a c h i e v i n g h e a l t h f o r a l l . Concluding Remarks O p p o r t u n i t i e s to r e f l e c t and dialogue on the m o r a l l y s e n s i t i v e areas of p r a c t i c e are needed by nurses i n a l l s e t t i n g s and r o l e s . I t i s only through q u e s t i o n i n g the experiences with dilemmas and problems of e t h i c s that we t r u l y p e r c e i v e the c h a l l e n g e s of n u r s i n g . As Crisham (1985) suggests, the u l t i m a t e c h a l l e n g e provided by e t h i c a l dilemmas i s to r e - d i s c o v e r and r e - c r e a t e commitments i n nur s i n g . 127 REFERENCES Allemang, M. (1985). The development of community h e a l t h nursing i n Canada. In M. Stewart, J . Innes, S. S e a r l , C. S m i l l i e ( E d s . ) , Community Health Nursing i n Canada (pp. 3-29). Toronto: Gage. 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Unpublished master's t h e s i s ,  U n i v e r s i t y of M i s s o u r i , Kansas C i t y . Winslow, G. (1984). From l o y a l t y to advocacy: A new metaphor f o r n u r s i n g . The Hastings Center Report, June, 32-40. Y o u e l l , L. (1986). A q u e s t i o n of balance. The Canadian  Nurse, March, 26-33. Young-Graham, K. (1987). Curriculum Mania. P u b l i c Health Nursing, 4(3), 133-4. 135 Appendix A: L e t t e r of Information May 16, 1988 Dear Colleague: E t h i c a l i s s u e s i n community h e a l t h n u r s i n g p r a c t i c e are not w e l l understood. Although s i t u a t i o n s r e s u l t i n g i n e t h i c a l dilemmas f o r nurses i n i n s t i t u t i o n a l s e t t i n g s have been researched and d i s c u s s e d i n the l i t e r a t u r e , there has been much l e s s awareness of the e t h i c a l dimensions of our p r a c t i c e i n the community. T h e r e f o r e , r e s e a r c h i s needed to begin to i d e n t i f y the community h e a l t h nurse's p e r s p e c t i v e s on the e t h i c a l components of our p r a c t i c e . As a p r a c t i c i n g community h e a l t h nurse you have a v a l u a b l e p e r s p e c t i v e on the f u n c t i o n i n g of the h e a l t h care system and unique i n s i g h t i n t o e t h i c a l i s s u e s . For my Master's t h e s i s , I have chosen to study the c l i n i c a l s i t u a t i o n s that present e t h i c a l dilemmas f o r C.H.N.'s. As d i s c u s s e d i n the Spring n e w s l e t t e r of the Community Health Nurses' I n t e r e s t Group., I am asking a l l members to a s s i s t me i n t h i s endeavour. By choosing to d e s c r i b e your experie nee with an e t h i c a l dilemma, you w i l l be developing our understanding of the d i f f i c u l t s i t u a t i o n s faced by nurses and c l i e n t s . In so doing, we may l e a r n more about how to provide support f o r t h e i r r e s o l u t i o n . I f you choose to p a r t i c i p a t e i n t h i s study, I suggest that you read through the f o l l o w i n g d e s c r i p t i o n of the e t h i c a l dilemma and q u e s t i o n s . Then, i t may be h e l p f u l to thin k about them f o r a few days before s e l e c t i n g a s i t u a t i o n to d e s c r i b e . Approximately one hour of your time i s r e q u i r e d to answer the q u e s t i o n s . P a r t i c i p a t i o n o r n o n - p a r t i c i p a t i o n i n t h i s s t u d y w i l l n o t a f f e c t y o u r j o b s t a t u s , n o r y o u r r e l a t i o n s h i p v i t h y o u r p r o f e s s i o n a l o r g a n i z a t i o n i n a n y w a y . A l l d a t a w i l l b e k e p t s t r i c t l y c o n f i d e n t i a l a n d i d e n t i t i e s o f p a r t i c i p a n t s w i l l n o t b e r e l e a s e d t o a n y o n e . Please m a i l your response i n c l u d i n g the signed consent form i n the envelope addressed to my home by J u n e 1 5 , 1 9 8 8 . I would be happy to d i s c u s s the study with you at any time. You may telephone me at my home ( c o l l e c t ) i f you have questions or s u g g e s t i o n s . A more d e t a i l e d p r o j e c t i n f o r m a t i o n l e t t e r i s a l s o e n c l o s e d . The f i n d i n g s w i l l be presented to p a r t i c i p a n t s . Thank-you f o r your time and and concern f o r t h i s important area of our p r a c t i c e . I look forward to hearing from you. S i n c e r e l y Susan M. Duncan 136 A p p e n d i x B: Data C o l l e c t i o n G u ide CODE I. Demographic Data: Date: Number of years of experience as an nurse: Number of years of experience as a C.H.N.: Nursing Education (specify type of program(s), and date(s) of graduation): Employment Setting: ( s p e c i f y U r b a n / R u r a l ; H e a l t h U n i t or o t h e r s e t t i n g ) Current Assignment (specify school, p e r i n a t a l , long term care, administration, other areas of p r a c t i c e ) : Length of time i n current assignment: i 137 D e f i n i t i o n of an e t h i c a l dilemma: An e t h i c a l dilemma i n v o l v e s moral concerns about how the needs of c l i e n t s may be met while r e s p e c t i n g t h e i r human r i g h t s and those moral values considered to be most important. Examples of moral values i n c l u d e autonomy or the r i g h t to s e l f d e t e r m i n a t i o n , p r e v e n t i o n of harm, promotion of good or the c a p a c i t y to b e n e f i t o t h e r s , c o n f i d e n t i a l i t y , access to safe and e f f e c t i v e h e a l t h care, p r i v a c y , and o t h e r s . In s i t u a t i o n s i n v o l v i n g e t h i c a l dilemmas, i t i s o f t e n d i f f i c u l t to determine which valu e , or human r i g h t i s most important. The choice between a l t e r n a t i v e s may be d i f f i c u l t and u n c e r t a i n . The d e c i s i o n maker(s) grapple with the q u e s t i o n : "What i s the right t h i n g to do?" You are asked to d e s c r i b e your experience with a c l i n i c a l s i t u a t i o n that has i n v o l v e d an e t h i c a l dilemma f o r you i n your n u r s i n g p r a c t i c e . Your d e s c r i p t i o n of t h i s s i t u a t i o n w i l l be guided by t h i s d e f i n i t i o n of an e t h i c a l dilemma and the f o l l o w i n g q u e s t i o n s . I t may be h e l p f u l to r e f e r back to the d e f i n i t i o n from time to time as you work through the questions . 138 Note: It i s most important to maintain c o n f i d e n t i a l i t y for a l l persons involved i n the si t u a t i o n * Please avoid including names of persons, i d e n t i f y i n g circumstances, or other information that may resu l t i n the i d e n t i f i c a t i o n of those involved. A. Do you encounter e t h i c a l dilemmas i n your nursing p r a c t i c e ? : YES NO B. Please begin by d e s c r i b i n g where the s i t u a t i o n occurred and how you came to be involved? C. What happened? (describe the circumstances) 139 D. Who was i n v o l v e d ? : (please a l t e r names and other i d e n t i f y i n g i n f o r m a t i o n to maintain c o n f i d e n t i a l i t y ) : E. What was your r o l e i n the s i t u a t i o n ? : 140 F. What was the c o n f l i c t or choice that e x i s t e d f o r you i n t h i s s i t u a t i o n ? : G. What were the o p t i considered? (please d e s c r i b e probable consequences of each o n s or p o s s i b l e a c t i o n s you what you intended as the a l t e r n a t i v e you c o n s i d e r e d ) : 141 H. Although e t h i c a l dilemmas are not always r e s o l v e d i n the c l i n i c a l s e t t i n g , please d e s c r i b e what i n your mind was the best d e c i s i o n , and any a c t i o n s that were taken: I. What was the outcome of the s i t u a t i o n ( i f known): 142 J . I t i s important to begin to i d e n t i f y those resources that support nurses i n coping with s i t u a t i o n s i n v o l v i n g e t h i c a l dilemmas. Please i d e n t i f y those r e s o u r c e s that were h e l p f u l to you and comment on whether or not you f e l t you had adequate support: been K. Are there any h e l p f u l to you?: other r e s o u r c e ( s ) that may have 143 L. What was most d i f f i c u l t about t h i s s i t u a t i o n f o r you? : M. Please d e s c r i b e any other f e e l i n g s you have or have had about t h i s s i t u a t i o n : 144 Consent For Follow-Dp (optional): I t may be h e l p f u l f o r me to contact you at some point during the data a n a l y s i s phase of the study i n order to c l a r i f y some aspect of your response to the q u e s t i o n n a i r e . I f you consent to be contacted by me i n w r i t i n g , or by phone, please s i g n below. (Note: i t i s p o s s i b l e to f u l l y p a r t i c i p a t e i n the study without consenting to t h i s request f o r f u r t h e r c o n t a c t . ) I Hereby consent to being contacted by the i n v e s t i g a t o r f o r the purpose of c l a r i f y i n g some aspect of my response to t h i s q u e s t i o n n a i r e during the pe r i o d May 15-August 30, 1988. I am aware that f u l l c o n f i d e n t i a l i t y w i l l be maintained during any follow-up contact and that only the i n v e s t i g a t o r w i l l know my I d e n t i t y . Date Participant Please i n d i c a t e how you p r e f e r to be contacted and s p e c i f y phone number and/or address. 

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