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UBC Theses and Dissertations

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


The purpose of the study was to describe the types of ethical dilemmas experienced by community health nurses and their responses to them. Specifically, the research questions directed the identification of those clinical situations which contained the dilemmas, the inherent ethical conflicts, the nurses' responses to them, and the forces influencing their occurrence. Due to the exploratory nature of the study, a descriptive survey was selected as the research method. The Critical Incident Technique (Flanagan, 1954) and the Model for Critical Ethical Analysis (Curtin, 1978) were the basis for the development of the data collection guide. The CHNs who received copies of the guide were asked to describe in writing the practice situations which had contained dilemmas and their responses to them. Thirty CHNs practicing in communities throughout B.C participated by completing and returning their responses to the guides. Their written responses indicated they were able to identify common practice situations which had contained ethical dilemmas. Furthermore, these nurses were able to identify the conflicts which had existed for them, their feelings, and their experiences with the decision-making process. Content analyses of the nurses' responses resulted in three categories of dilemmas - clients' rights, system interaction, and nurses' rights. Within these categories, the dilemmas are characterized by one or more ethical conflicts which resulted in difficult choices for the nurses. During data analysis, the situations were further analyzed to identify underlying ethical themes and influential forces. The ethical themes underlying the nurses' dilemmas fundamentally involved conflicts between the principles of autonomy, beneficence and justice. Additionally, human rights and value conflicts are relevant in situations where the nurses are caring for high-risk client groups; interacting with the health care team; and asserting their own rights as employees, professional nurses, and citizens. Key restraining and driving forces influenced the CHNs' experience with the dilemmas. Restraining forces included policy, and a lack of interdisciplinary collaboration. Driving forces included supportive nursing leadership, consultants from other disciplines, nursing knowledge and skill, the nurse-client relationship and most importantly the nurses' interaction with colleagues. These CHNs saw their role as one of an advocate for their clients. Although the ethical dilemmas described by this sample of CHNs are not notably different from those experienced by nurses in other settings, the way in which these nurses experience them is influenced by unique features of their role. These unique features result from the CHN's position in the health care system. The CHN is often a primary contact for clients, and therefore often assumes a role in initiating and coordinating referrals to social workers, physicians, and others. Furthermore the independent nature of community health nursing practice increases their needs for collaboration with others who are often removed from their setting of practice. Finally, because this group of nurses see clients in their natural community settings, they have an awareness of community health conditions which are determinants of health. Based on these findings, implications for community health nursing practice, nursing education, and nursing research are proposed.

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