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International Journal of Nursing Studies 47 (2010) 635–650
Review
Nurses’ ethical reasoning and behaviour: A literature review
Sabine Goethals a,*, Chris Gastmans b, Bernadette Dierckx de Casterlé c
a Catholic University College Ghent, Department of Nursing, Hospitaalstraat 23, 9100 Sint-Niklaas, Belgium b Centre for Biomedical Ethics and Law, Faculty of Medicine, Catholic University Leuven, Belgium c Centre of Health Services and Nursing Research, Catholic University Leuven, Belgium
A R T I C L E I N F O
Article history:
Received 16 July 2009
Received in revised form 4 November 2009
Accepted 18 December 2009
Keywords:
Ethical behaviour
Ethical decision making
Ethical reasoning
Ethics
Nursing
Literature review
A B S T R A C T
Background: Today’s healthcare system requires that nurses have strong medical–
technical competences and the ability to focus on the ethical dimension of care. For
nurses, coping with the ethical dimension of care in practise is very difficult. Often nurses
cannot act according to their own personal values and norms. This generates internal
moral distress, which has a negative impact on both nurses and patients.
Objectives: The objective of this review is a thorough analysis of the literature about
nurses’ ethical practise particularly with regard to their processes of ethical reasoning and
decision making and implementation of those decisions in practise.
Design: We conducted an extensive search of the electronic databases Medline, Embase,
Cinahl, and PsycInfo for papers published between January 1988 and September 2008. A
broad range of search keywords was used. The 39 selected articles had a quantitative,
qualitative, or mixed-method design.
Findings: Despite the conceptual difficulties that the literature on the ethical practise of
nurses suffers, in this review we understand nurses’ ethical practise a complex process of
reasoning, decision making, and implementation of the decision in practise. The process of
decision making is more than a pure cognitive process; it is influenced by personal and
contextual factors. The difficulties nurses encounter in their ethical conduct are linked to
their difficult work environment. As a result, nurses often capitulate to the decisions made
by others, which results in a conformist way of acting and less individually adapted care.
Conclusions: This review provides us with a more nuanced understanding of the way nurses
reason and act in ethically difficult situations than emerged previously. If we want to support
nurses in their ethical care and if we want to help them to change their conformist practises,
more research is needed. Especially needed are in-depth qualitative studies that explore the
experiences of nurses. Such studies could help us better understand not only how nurses
reason and behave in practise but also the relationship between these two processes.
� 2010 Elsevier Ltd. All rights reserved.
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What is already known about this topic?
� T
00
do
he ethical dimension of care is difficult to realise in the complex and stressful work environment that charac- terizes today’s nursing practise.
� Nurses are regularly confronted with ethical decisions
that others make and that are in conflict with their own
* Corresponding author. Tel.: +32 37808905; fax: +32 37663462.
E-mail address: [email protected] (S. Goethals).
20-7489/$ – see front matter � 2010 Elsevier Ltd. All rights reserved. i:10.1016/j.ijnurstu.2009.12.010
personal values and norms.
� N
urses who cannot sufficiently integrate their own values and norms into their daily practise may experi- ence moral distress. Moral distress results in less appropriate patient care and in nurses’ burnout.
What this paper adds
� T
his review provides a more nuanced understanding of the way nurses reason and act in ethically difficult situations.�
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650636
The process of decision making is more than a pure cognitive process; it is a difficult and complex process influenced by personal and contextual factors.
� The difficulties nurses encounter in their ethical practise
are linked to their difficult work environment.
1. Introduction
Today, nurses’ practise is characterized by a strong emphasis on high technological interventions and financial limitations, and is dominated by economic values (Dean, 1998; Spitzer, 1998; Milisen et al., 2006). Nurses are therefore confronted with complex care situations in which they are expected to autonomously make decisions in delivering good care to patients and to do so within the confines of strict deadlines. ‘Good care’ is oriented towards the promotion of the patient’s well-being in its entirety, i.e., considering patients’ physical as well as psychological, relational, social, moral, and spiritual well-being and so can be considered as a moral practise (Gastmans et al., 1998).
The ethical dimension of care cannot be restricted to specific ethical dilemmas in the context of the beginning and end of life. On the contrary, the ethical dimension of care is an essential part of nursing practise (Bishop and Scudder, 1990). Nurses make daily decisions that are ethically informed. Examples can be found in how they deal with intimacy and privacy (Mattiasson and Hemberg, 1998) and the use of physical restraints in their care for the elderly (Gastmans and Milisen, 2006). Acting responsibly in these and comparable situations requires not only medical/technical competency but also the ability to reflect critically about ethical dilemmas and the ability to surpass the mere implementation of previously defined rules (Bolmsjö et al., 2006).
Even though ethics is a constitutive element in current nursing education, research reveals that nurses face considerable difficulties when they have to implement the ethical dimensions of care in daily professional practise (Woods, 2005). Siebens et al. (2006) reported that nurses working in a complex work environment give priority to medical/technical interventions; establishing caring rela- tionships with their patients is of secondary importance. It is worrisome that nurses complain that it is impossible for them to practise according to their own ethical values or to voice ethical issues within the team. Furthermore, although nurses are regularly confronted with healthcare decisions that they perceive as morally wrong, they are expected to execute those decisions (Gutteriez, 2005). Nurses may feel that their self-image and integrity is threatened, if they have to comply with unwritten rules and routines and if they are unable to act according to their professional ideals because of practical circumstances (Sorlie et al., 2003; Torjuul and Sorlie, 2006). Regularly confronting such situations can lead to moral distress (Kälvemark et al., 2004; Gutteriez, 2005; Torjuul and Sorlie, 2006). According to Jameton (1984), nurses experience moral distress when they judge a particular decision to be ethically correct but are unable to execute it because of situational factors. Nurses most commonly respond to moral distress by being less involved with
patients and family members and by providing less personalized care (Gutteriez, 2005). As for nurses them- selves, moral distress may lead to decreased job satisfac- tion, increased staff turnover, health problems, and burnout, with nurses eventually leaving the profession (Gutteriez, 2005; Torjuul and Sorlie, 2006). Where Schluter et al. (2008) report a (developing) relationship between moral distress of nurses and the organization’s ethical climate, Pauly et al. (2009) confirm this relationship, which would be negatively correlated.
Given the significant consequences of moral distress for nurses as well as for patients, it is essential to identify and to fully understand what is currently known in literature about nurses’ ethical practise. This insight may help us provide guidance to nurses that can support them in the ethical dimension of care.
2. Review
2.1. Aim
The objective of this review was to thoroughly examine the literature about nurses’ ethical reasoning process and nurses’ ethical behaviour. Ethical practise includes the reasoning process, the associated decisions, and the actual implementation of the ethical decisions (Dierckx de Casterlé et al., 1997). Ethical reasoning involves the cognitive process of reasoning, which leads to moral decision making (Ketefian, 1989; Omery, 1989). We view ethical behaviour as putting an ethical decision into practise (Dierckx de Casterlé et al., 1997).
In this review, we specifically address the following research questions: (1) How do nurses reason when they are faced with an ethical decision? (2) How do nurses implement their ethical decisions in practise?
2.2. Review methodology
This review was conducted by following the guidelines of the United Kingdom Centre for Reviews and Dissemina- tion Guidelines on Systematic Reviews (Centre for Reviews and Dissemination, 2001). Articles were read, and relevant data were isolated, compared, and related. After consulta- tion with the other researchers (BD, CG), concepts and themes were identified (Dixon-Woods et al., 2006).
2.3. Search strategy
We conducted an extensive search in the databases Medline, Embase, Cinahl, and PsycInfo for papers pub- lished between January 1988 and September 2008 on nurses’ ethical practise. This review follows the review of Ketefian (1989), who systematically searched the litera- ture from 1983 to 1987. The following keywords were used: ‘ethical reasoning’, ‘ethical decision making’, ‘moral reasoning’, ‘ethical practise’, ‘ethical action’, ‘ethical behavio(u)r’, ‘moral behavio(u)r’, ‘moral judgment’. Each of these terms was combined with the wildcard term ‘nurs*’ and ‘research’.
This resulted in 6889 results. Titles and abstracts were screened, and studies were included if they met the
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650 637
following criteria: (1) empirical research published in Dutch, French, English, and German; and (2) research that dealt with the ethical reasoning and/or ethical behaviour of nurses. Publications were excluded if (1) the article concerned only student nurses, and (2) the studies were reviews or (3) doctoral dissertations. Reference lists of all articles were examined for additional publications not previously identified (Centre for Reviews and Dissemina- tion, 2001). Manual search of bibliographies of relevant articles was done and ethics experts (BD, CG) suggested other pertinent articles. These procedures added no articles. Our search procedure resulted in 39 papers which we examined critically.
2.4. Search outcome
The search strategy yielded 39 appropriate publications that described 38 separate studies (Tables 1–3). The articles from Lützen and Nordin (1993b, 1994) were derived from the same study; therefore, we considered these articles together as representing one study. Thirteen studies used a quantitative design (Table 1); eighteen used a qualitative design (Table 2); and seven used a mixed method (Table 3). Ethical reasoning was studied in 24 studies, most of which were qualitative studies. Ethical behaviour was studied in ten studies, in which researchers used both quantitative and qualitative research designs. Four studies described both ethical reasoning and ethical behaviour processes (Carpenter, 1991; Vogel Smith, 1996; Dierckx de Casterlé et al., 1997, 2008). Only one study examined the relationship between ethical reasoning and the implementation of ethical decisions in practise (Dierckx de Casterlé et al., 1997).
The studies were conducted in ten different countries: USA (n = 14); Sweden (n = 9); Canada (n = 4); Australia (n = 2); and Belgium, Denmark, Greece, Korea, Mexico, and South Africa (n = 1 for each country). Three studies reported results from internationally conducted research (Davidson et al., 1990; Norberg et al., 1994; Dierckx de Casterlé et al., 2008).
Most research settings consisted of a combination of several acute and/or chronic settings. In 24 studies, the sample consisted of only nurses. The remaining studies consisted of nurses and/or nursing students and/or doctors and/or other healthcare workers. The combined research population consisted of about 4100 nurses, mainly women, between 20 and 65 years old, and with a nursing experience ranging from <1 year to 39 years.
2.5. Methodological features
The methodological features of the included studies are summarized in Tables 1–3. Barring one study (Kim et al., 2007), all quantitative studies implemented a descriptive, correlational or comparative design. In the quantitative studies, the sample sizes varied from 63 to 1592 nurses. Response rates, when mentioned, varied from 20% to 84% (Table 1). The sampling methods were very diverse: random sampling (Kuhse et al., 1997; Dodd et al., 2004); stratified random sampling (Erlen and Sereika, 1997); purpose sampling (Dierckx de Casterlé et al., 1997;
Penticuff and Walden, 2000); convenience sampling (Corley and Selig, 1994; Kyriacos, 1995; Raines, 2000); and randomized convenience sampling (Ham, 2004). In some studies, the sampling method was not mentioned (Garritson, 1988; Elder et al., 2003; Kim et al., 2007).
In the qualitative studies, the sample sizes varied from 9 to 169 nurses (Table 2). In half of these studies, nurses were purposefully selected using specific criteria, such as ‘experienced and good’ (Jansson and Norberg, 1989, 1992; Davidson et al., 1990; Aström et al., 1993, 1995; Norberg et al., 1994); ‘competent and reflective’ (Lützen and Nordin, 1993a, 1994); ‘recommended by peers and supervisors’ (Lützen and Nordin, 1993b); and ‘thoughtful about ethical questions’ (Oberle and Hughes, 2001).
In the mixed-method studies, the sample sizes varied from 20 to 149 nurses (Table 3). In the study of Norberg et al. (1994), nurses were also selected using the criterion ‘experienced and good’. In three other studies, the sampling method was convenience sampling (Chally, 1995; Mattiasson and Andersson, 1995; Monterosso et al., 2005).
Many of the studies lacked clear conceptualisation and operationalization of the terms ‘ethical reasoning’ and ‘ethical behaviour’, leading to the development and use of customised definitions. Some studies even failed to define the concepts of ‘ethical reasoning’ and ‘ethical behaviour’. Especially in studies that used quantitative and mixed methods, various theoretical frames and definitions were used to study ethical reasoning and ethical behaviour processes. Theories that were frequently referred to were the moral development theory by Kohlberg (1981), the four principles of biomedical ethics by Beauchamp and Childress (1979), the justice-care perspective by Gilligan (1982), and deontological and teleological approaches.
The use of established measurement instruments, like the Nursing Dilemma Test (Crisham, 1981) and the Judgment about Nursing Dilemmas (Ketefian, 1981) was very limited. Most researchers developed their own instruments to measure ethical reasoning and behaviour, using vignettes, dilemmas, and/or questionnaires that measured variables considered to be connected with ethical reasoning and/or ethical behaviour.
In some of the qualitative studies, nurses presented ethically difficult situations and then described how they subsequently handled these situations in practise (Erlen and Frost, 1991; Grundstein-Amado, 1992; Uden et al., 1992; Aström et al., 1993, 1995; Lützen and Nordin, 1993a,b, 1994; Chally, 1995; Oberle and Hughes, 2001; Rodney et al., 2002; Tsaloglidou et al., 2007). In sixteen qualitative studies, respondents were interviewed. Two studies used focus groups. Only two studies combined two methods to obtain data (Rodney et al., 2002; Tsaloglidou et al., 2007). Many of the studies used well-known metho- dological approaches like the grounded theory (n = 4), phenomenology (n = 4), constructivist methodology (n = 2), and narrative theory (n = 1).
2.6. Quality appraisal
One researcher (SG) assessed the included publications using the assessment sheets prepared and tested by
Table 1
Quantitative studies included in the literature review.
Author(s) Country Aim(s) of the study Design- sample Data collection Data analysis
Care setting Response rate (RR)
Garritson (1988) USA
29 psychiatric inpatient
units in private, county,
veterans administration
university hospitals
To investigate nurses’ ethical
decision-making patterns
Quantitative
177 registered nurses (RNs)
RR: 20–4%
Questionnaires presented to
nurses during staff meetings,
distributed to nurses’ mailboxes
Questionnaire included: staff
demographic characteristics,
case vignettes, nursing
philosophy statement
Frequency data
Bowker Test of
Symmetry
Corley and
Selig (1994)
USA
Federal teaching hospital
(850 beds)—all CCUs:
medical, surgical, coronary,
haemodialysis, emergency
admitting
To examine how often nurses
use principled thinking to
decide on actions in specific
ethical situations
Quantitative exploratory
91 RNs
RR: 82% (n = 75)
Questionnaire: Nursing
Dilemma Test (NDT)
(Crisham, 1981)
Six client care dilemmas
considering the following:
nurses’ principled thinking,
practical considerations,
and other issues considered
in making a decision
Frequency data
t-test
Pearson product
moment
correlation
Kyriacos (1995) South Africa
Convenience sample
of nurses following
an ethical workshop
To explore nurses’ stage of
thinking in moral judgment
development
109 nurses
RR: 63% (n = 69)
Questionnaire: completing
the questionnaire on a
one-day nursing ethics
workshop NDT (Crisham, 1981)
Six client care dilemmas—considering
nurses’ principled thinking
Frequency data
Dierckx de Casterlé
et al. (1997)
Belgium
14 Flemish schools
of nursing
University students
Expert nurses
To explore nursing students’
ethical behaviour in five
nursing dilemmas
Quantitative descriptive
correlational
2634 nursing students
(technical–professional)
176 university students
59 expert nurses
Questionnaire: Ethical Behaviour
Test (EBT) based on DIT (Rest, 1976)
and NDT (Crisham, 1981) developed
by Dierckx de Casterlé (1993)
Five stories depicting nurses in daily
ethical dilemmas were used to
assess the subjects’ perceptions
of the nursing dilemma and the way
in which they would reason and
act in that situation
Two-way analysis of
variance
Bonferroni method
Multivariate analysis
(MANOVA)
Erlen and
Sereika (1997)
USA
2 tertiary care
university-affiliated
hospitals
16 ICUs
To measure ethical decision
making and stress
To examine the relationship
of selected nurse characteristics
with aspects of ethical decision
making and stress
To examine the relationship
between ethical decision-making
and stress in ICU nurses
Quantitative descriptive
correlational
Stratified random
sample—proportional
allocation
80 nurses
RR: 78.8% (n = 63)
Questionnaires mailed to
interested nurses
NEDM-ICU: Nursing Ethical Decision
Making—ICU included: NEDM-ICU
part I, WPR: workplace restrictions,
RT: risk taking. NEDM-ICU part II,
NA: nurse autonomy, PR: patient
rights, RTR: rejection traditional
role, HPSI: Health Professional
Stress Inventory
30 general stressful
situations—identification of how
stressful nurses perceive a
particular situation
Pearson product
moment correlation
Student’s t-test
One-way analysis
of variance (ANOVA)
Tukey’s pairwise
multiple comparison
Mann–Whitney U test
Spearman’s rank order
correlation
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s 4
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6 3
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Kuhse et al. (1997) USA
Victorian and New
South Wales Medical
Boards
Australian Nursing
Federation
To discover whether gender or
occupation affected the approach
(partialist or impartialist) that
participants took in response to
various moral dilemmas
Quantitative descriptive
correlational
Random sample
400 doctors from Victoria,
200 doctors and 400 nurses
form New South Wales
RR: 30.5% (n = 122 nurses)
Questionnaire mailed to a
randomly selected sample
of nurses and doctors
Questionnaire included:
4 moral dilemmas involving
combinations of (healthcare)
professional, non-professional,
life-threatening, and
non-life-threatening situations
Lambda measures
Penticuff and
Walden (2000)
USA
4 obstetrics units
and 4 neonatal
ICU from 5 major
hospitals
To explore the relative contributions
of practical environment
characteristics and nurses’ personal
and professional characteristics
on the willingness of perinatal nurses
to be involved in activities used to
resolve clinical ethical dilemmas
Quantitative descriptive
correlational
Purpose sample
200 nurses
RR: 64% (n = 127)
Questionnaires: personal invitation
to nurses—nurses who agreed
received questionnaires
Questionnaire included:
Demographic Data Sheet, PVQ:
Perinatal Value Questionnaire,
NEIS: Nursing Ethical Involvement
Scale
Multiple
regression analysis
Raines (2000) USA
Oncology nurses
To determine the relationship
between moral reasoning,
coping style, and ethics stress
Quantitative descriptive
correlational—survey
Convenience sample
795 nurses
RR: 29% (n = 229)
Questionnaires to oncology nurses
members of Oncology Nursing
Society (nationwide), a professional
nursing organization
Questionnaire included:
Demographic Data Sheet, MRQ:
Moral Reasoning Questionnaire,
WCI: ways of coping inventory, ESS:
Ethical Stress Scale, EIS: Ethics
Inventory Instrument
Descriptive statistics
Multiple regression
analysis
Analysis of variance
(ANOVA)
Elder et al. (2003) Australia-Queensland
Hospital environment
To explore differences in the
ethical attitudes of medical
students and nurses
Quantitative descriptive
Voluntary participation
125 medical students
67 nurses
Questionnaire was completed by
nurses during a seminar
Questionnaire containing 23 vignettes
followed by four alternative responses
t-test
Analysis of variance
(ANOVA)
Dodd et al. (2004) USA, New York
3 urban hospitals
A non-profit hospital
(903 beds)
A university hospital
(600 beds)
A rehabilitation hospital
(396 beds)
To explore the extent to
which nurses engage in
ethical activism and
ethical assertiveness
Quantitative descriptive
correlational
Random sample
165 nurses from 3 hospitals
RR from 3 hospitals: 26–41%
Postal self-administered 72-item
questionnaire
Ethical activism
Ethical assertiveness
Analysis of variance
(ANOVA)
Bonferroni post
hoc analysis
t-test
Multiple regression
analysis
Ham (2004) USA
4 Midwestern states
To study the effects of
environmental influences
and previous ethical
decision-making experiences
on nurses’ moral reasoning
Quantitative descriptive
Randomized convenience
sample
200 nursing students
500 RN
RR RN: 24% (n = 120)
Questionnaire mailed to randomly
selected nurses in the four-state area
NDT (Crisham, 1981)
Six client care dilemmas—considering
nurses principled thinking and
practical considerations
Pearson product
moment correlation
One-way analysis
of variance
Kim et al. (2007) Korea
Hospital environment
To examine changes in
nursing students’ moral
judgment after becoming
qualified nurses
Quantitative descriptive
100 nursing students
80 nurses
Questionnaire JAND: Judgment about
Nursing Dilemma (Ketefian, 1981)
modified to a Korean population
(Kim, 1999)
Idealistic—realistic decision making
Paired t-test
Independent t-test
Analysis of variance
(ANOVA)
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S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650640
Hawker et al. (2002). This screening method enabled us to evaluate the quality of both quantitative and qualitative studies. We analysed the 38 studies on a number of aspects, including method and analysis, ethical issues, quality and strength of evidence, and their relevance to the research question. With this system, it was possible to calculate a summed score (9 = very poor; 36 = good), reflecting the methodological strength of the studies. The minimum score was 19/36 and the maximum score was 33/36. In addition, the articles were assessed on the criteria of validity, reliability (for the quantitative studies), and the criteria of trustworthiness (for the qualitative studies) (Polit and Beck, 2008).
The shortcomings of the quantitative studies mostly were related to issues of confidentiality, sensitivity, and consent. Most of the quantitative studies discussed the reliability and validity of the instruments only to a limited extent. The authors of these studies most often limited themselves to a description of the development of the instruments and to a report of internal consistency scores. An obvious shortcoming of most of the qualitative studies was a rather limited description of the samples, the methods of data collection, and data analysis. Little attention was spent on reflexivity and possible bias; however, most authors did use a number of methods to enhance the trustworthiness of their studies. All inter- views were audiotaped and transcribed. Most used one method for data collection, while Rodney et al. (2002) used focus groups and open-ended questions. Tsaloglidou et al. (2007) applied interviews and participant observation techniques to collect data. Several researchers used investigator triangulation for their analyses (Jansson and Norberg, 1989, 1992; Carpenter, 1991; Erlen and Frost, 1991; Grundstein-Amado, 1992; Uden et al., 1992; Aström et al., 1993; Norberg and Uden, 1995; Vogel Smith, 1996; Varcoe et al., 2004; Monterosso et al., 2005). In addition, member-checking and the audit trail under the form of field notes, logs, and theoretical memos were used (Lützen and Nordin, 1994; Oberle and Hughes, 2001; Rodney et al., 2002; Tsaloglidou et al., 2007). Only two studies men- tioned that saturation was reached (Carpenter, 1991; Uden et al., 1992).
3. Findings
The ethical practise of nurses is a complex process that combines the processes of ethical reasoning and ethical behaviour (Vogel Smith, 1996; Dierckx de Casterlé et al., 1997, 2008). The study of Vogel Smith (1996) labelled the inter-related processes of ethical reasoning and ethical conduct ‘deliberation’ and ‘integration’, respectively. Deliberation or the process of reasoning by nurses involves the consideration of the different factors that affect ethical decision making. Integration concerns the implementation of nurses’ decisions in clinical practise. Personal and contextual factors play an essential role in both processes. Examples of personal factors are nurses’ values, convic- tions, experiences, knowledge, and skills. Contextual factors include opinions and expectations of other nurses, doctors, and family. They also include rules and routines, and procedures and guidelines that are specific to wards in
Table 2
Qualitative studies included in the literature review.
Author(s) Country Aim(s) of the study Sample Data collection Data analysis
Jansson and
Norberg (1989)
Sweden
Oncological, medical,
surgical clinics
To elucidate ethical reasoning of
experienced nurses concerning the
feeding of terminally ill cancer
patients
20 RN ‘good and experienced’ Structured interviews Qualitative analysis
Coding scheme
Independent coding
Davidson et al. (1990) Canada, USA, Switzerland,
Finland,
Sweden, Australia, China,
Israel
Variety of acute care centres
To compare the ethical reasoning
of nurses associated with the
feeding of terminally ill elderly
cancer patients
169 nurses in 8 countries
‘good and experienced’
Structured interviews Qualitative analysis
Coding scheme
Carpenter (1991) USA
5 private agencies or hospitals
6 work settings affiliated
with the Roman Catholic church
9 agencies publicly owned
To examine the ethical
decision-making processes of
psychiatric nurses in clinical
practise
20 RNs who had worked
at least 1 year in a
psychiatric setting
Open-ended interviews Qualitative analysis
Thematic analysis
Erlen and Frost (1991) USA
Medical–surgical
Critical care setting
Psychiatric Hospital
To examine how nurses’
experiences influence ethical
decisions related to
patient care management
Convenience sample
25 nurses
In-depth interviews using
perceptions of nursing
ethics interview schedule
Content analysis
Independent coding
Grundstein-Amado
(1992)
Canada
Nurses
Acute-care setting
Long-term care setting
Doctors
Family practise
Internal medicine
Long-term care
To assess differences in the
ethical decision-making of nurses
and doctors
9 nurses
9 doctors
In-depth, semi-structured
interviews
Qualitative analysis
Jansson and
Norberg (1992)
Sweden
Nursing home
Psychogeriatric clinic
Somatic long-term clinic
To elucidate ethical reasoning of
experienced nurses working in
dementia care
20 nurses
8 head nurses
12 staff nurses ‘experienced
and good’
Structured interviews Qualitative analysis
Coding scheme
Independent coding
Uden et al. (1992) Sweden
Department of internal medicine
in an oncology university hospital
To examine the ethical reasoning in
nurses and physicians
Convenience sample
23 nurses
9 physicians
Interviews: narrations
of any ethically
problematic care
situation experienced
Qualitative analysis
Independent coding
Narrative theory
Lützen and
Nordin (1993a)
Sweden
Various psychiatric settings
To conceptualise the experiential
aspect of moral decision-making
Purpose sample
14 nurses
(>5 years experience)
‘recommended by peers
and supervisors’
In-depth interviews Qualitative analysis
Grounded theory
(Glaser and Strauss, 1967;
Corbin and Strauss, 1990)
Contextual research
approach
Ethnograph for first and
second levels of analysis
Lützen and
Nordin (1993b)
Sweden
Hospital setting
Community clinic
To study the moral decision-making
experiences of nurses working in a
psychiatric nursing setting
14 nurses
(>5 years experience)
‘competent and reflective’
In-depth interviews Qualitative analysis
Grounded theory
(Glaser and Strauss, 1967;
Corbin and Strauss, 1990)
Contextual research
approach
Ethnograph for first and
second levels of analysis
S .
G o
e th
a ls
e t
a l./
In te
rn a
tio n
a l
Jo u
rn a
l o
f N
u rsin
g S tu
d ie
s 4
7 (2
0 1
0 )
6 3
5 –
6 5
0 6
4 1
Table 2 (Continued )
Author(s) Country Aim(s) of the study Sample Data collection Data analysis
Sherblom et al.
(1993)
USA
3 hospitals in a large
metropolitan area
To describe nurses’ ethical concerns 31 female staff nurses Interviews Qualitative analysis
Responsive reader method
Lützen and
Nordin (1994)
Sweden
Hospital setting
Community clinic
To study the moral decision-making
experiences of nurses in psychiatric
practise
14 nurses
(>5 years experience)
‘competent and reflective’
Interviews Qualitative analysis
Grounded theory
(Glaser and Strauss, 1967;
Corbin and Strauss, 1990)
Contextual research
approach
Ethnograph for first and
second levels of analysis
Aström et al. (1993) Sweden
Hospital setting
Oncological, medical
and surgical
clinics in Northern Sweden
To examine the experiences of nurses
in ethically difficult situations
To define the expression ‘It depends
on the situation at hand’
18 nurses: 14 staff nurses
and 4 ward nurses
Interviews Qualitative analysis
Phenomenology—
Hermeneutic
Aström et al. (1995) Sweden
Oncological, medical,
and surgical
clinics specialized in
cancer care
To explore how nurses manage
ethically difficult care situations
14 staff nurses, 4 head nurses
RR: 90% ‘experienced in
the care of cancer patients’
Interviews Qualitative analysis
Structural analysis
Phenomenology—
Hermeneutic
Viens (1995) Mexico
A variety of primary care
settings in a large city in the
western United States
To describe and analyse the
process of moral reasoning
10 nurse practitioners Interviews Qualitative analysis
Phenomenology
Vogel Smith (1996) USA
Medical–surgical, paediatrics,
obstetrics,
and psychiatric units, and
various IC settings in one hospital
To examine the experience of staff
nurses in ethical decision-making
Random sample
19 nurses
Interviews Phenomenology
Ethnograph program
Giorgi’s method
(Giorgi et al., 1975)
Oberle and
Hughes (2001)
Canada
Adult medical–surgical units in one
large hospital
To examine similarities and differences
in the ethical reasoning of doctors
and nurses
Nominated sample
14 staff nurses ‘‘thoughtful
about ethical questions’,
7 doctors
Unstructured
interviews
Qualitative analysis
Grounded theory
(Corbin and Strauss, 1990)
Thematic analysis
Rodney et al. (2002) Canada
Mid-sized metropolitan area
with one health region
Large metropolitan area with
several health regions
Settings: maternity, paediatrics,
medicine, surgery, critical care,
emergency, operating room,
oncology, psychiatry, rehabilitation,
long-term care, home care,
and community care
To examine the complexity of nurses’
ethical decision-making
Theoretical sampling 19 focus
groups: 3 groups
advanced-practise
nurses, 12 groups practising
nurses, 4 groups nursing
students, 87 participants
Focus groups
Open-ended trigger
questions
Constructivist methodology
(Lincoln and Guba, 1985)
Varcoe et al. (2004) Canada
19 practise settings
10 different organizations
To study the enactment of ethical
practise in nursing
87 nurses, 41 nurses mid-sized
metropolitan area, 46 nurses
larger metropolitan area
Focus groups Qualitative analysis
Interpretive constructivist
paradigm
Tsaloglidou
et al. (2007)
Greece
9-bed clinical nutrition unit—large
teaching hospital in UK
To determine nurses’ ethical
decision-making role in artificial
nutritional support
12 RN
2 consultants, 1 dietician
Participant observation
Semi-structured
interviews
Qualitative analysis
Content analysis
S .
G o
e th
a ls
e t
a l./
In te
rn a
tio n
a l
Jo u
rn a
l o
f N
u rsin
g S tu
d ie
s 4
7 (2
0 1
0 )
6 3
5 –
6 5
0 6
4 2
Table 3
Mixed-method studies included in the literature review.
Author(s) Country Aim(s) of the study Design—sample Data collection Data analysis
Care setting Response rate
Martin (1989) USA, Texas
Neonatal intensive
care units (NICU)
5 large urban hospitals
in the Southwest
To determine nurses’ involvement
in treatment decisions and factors
influencing their participation in
the decision-making process
83 RNs NEDMS: Nursing Ethical
Decision Making Scale
Semi-structured interviews
Frequency data
Qualitative analysis
Ethnograph for analysis
Norberg
et al. (1994)
Sweden, USA, Australia,
Canada, China, Finland,
Israel
Nurses from institutions
providing high-quality care
To compare the ethical reasoning
of nurses in the feeding of a
severely demented patient who
seems to refuse food, this in a
variety of cultures
Structured interviews
Ranking of the ethical
principles
Coding scheme
Chi-square test
Chally (1995) USA
31-bed level III NICU Midwest
Two 10-bed adult ICU Midwest
To compare and contrast the
perspective used by nurses working
in neonatal and adult ICUs when
making moral decisions
Convenience sample
26 NICU nurses
25 adult ICU nurses
Semi-structured interviews
12 open-ended
interview questions
Identification of Care
and Justice Taxonomy
Demographic variables
and perspective
Interpretive method of analysis
Chi-square test
Norberg and
Uden (1995)
Sweden
Geriatric and surgical care unit
one large hospital
To determine whether gender and
different healthcare settings affect
the content and form of moral
reasoning
30 physicians
38 RNs
40 enrolled nurses (EN’s)
Interviews
Comparison between
physicians, RNs, and
enrolled nurses concerning
form and content of their
moral reasoning
Phenomenology—hermeneutic
Chi-square test
Mattiasson and
Andersson (1995)
Sweden
13 nursing homes in the county
of Stockholm
To explore ethical awareness:
autonomous vs. heteronomous
The following were assessed:
nurses’ personal opinion of the case,
unit’s anticipated decision regarding
the case, responses analysed from
the perspective of bioethical principles
Convenience sample
41 nurses
46 assistant nurses
83 nurse’ aides
17 other staff
Self-report questionnaire:
Hypothetical vignette
about restraint
Percentage per ethical
principle for personal
opinion and unit’s
anticipated opinion
Distribution of ethical
awareness
Content analysis
Frequency data
Holm et al. (1996) Denmark
5 internal medicine departments
To assess the ethical reasoning content
of nurses and physicians in terms of
style and time used by participants
21 physicians
20 nurses
7 Focus groups for
content analysis
Discussion style used
Discussion time used
Content analysis
Sign test
Fisher’s exact test
Mann–Whitney U test
Monterosso
et al. (2005)
Australia
2 NICUs of the sole perinatal
tertiary referral
centre of Western Australia
To explore to what extent nurses are
involved in complex clinical and
ethical decision-making
Nurses’ understanding of patient
advocacy in NICUs
Categories of infants causing most
concern in NICUs
Convenience sample
200 nurses
RR: 30% (n = 61)
Nurses were invited to
participate Questionnaire
contains: DCSN: Decisions
in Caring for Sick Newborn
Infants Questionnaire
Demographic characteristics
Patient advocacy
Nurses’ involvement in clinical
and ethical decision making
Open-ended questions
Descriptive statistics
Thematic analysis
S .
G o
e th
a ls
e t
a l./
In te
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tio n
a l
Jo u
rn a
l o
f N
u rsin
g S tu
d ie
s 4
7 (2
0 1
0 )
6 3
5 –
6 5
0 6
4 3
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650644
which nurses work. Most of the studies analysed for this review support aspects of the findings of Vogel Smith (1996); therefore, we used their study as a guideline for structuring and integrating the different research results in this review.
3.1. Ethical reasoning
Many of the studies endorsed the complexity of the reasoning process. From their ethical awareness, nurses observe, analyse, and judge a given problem in a specific care context. Nurses consider many factors that guide them in their eventual ethical decision making (Vogel Smith, 1996; Lützen and Nordin, 1993a; Carpenter, 1991; Viens, 1995; Rodney et al., 2002; Grundstein-Amado, 1992). They weigh various alternatives, make choices, and make decisions (Grundstein-Amado, 1992; Lützen and Nordin, 1993a; Mattiasson and Andersson, 1995; Viens, 1995; Vogel Smith, 1996). To justify their decisions, they rely on medical knowledge, personal values and experi- ences, and the consequences of their possible choices (Grundstein-Amado, 1992). As a result, the ethical reason- ing process is embedded within the specific context and is determined by nurses within the context of the nurse– patient relationship. Here, given the important contextual embeddedness of nurses’ ethical reasoning and decision making, it cannot be reduced to its cognitive dimension. Ethical reasoning is studied from various perspectives. Grundstein-Amado (1992) and Holm et al. (1996) demon- strated that nurses reason using different theories and fundamental moral principles. They use deontological and teleological theories or a combination of both. Research into the ethical principles on which nurses ground their analysis shows that they apply various ethical principles, such as the principles of biomedical ethics, with a preference for beneficence and respect for autonomy (Garritson, 1988; Jansson and Norberg, 1989, 1992; Davidson et al., 1990; Norberg et al., 1994; Mattiasson and Andersson, 1995). They orient themselves from the perspective of the ethics of care or from the ethics of justice (Sherblom et al., 1993; Chally, 1995; Norberg and Uden, 1995; Kuhse et al., 1997). However, some authors emphasized that the principles and perspectives that are applied do not exclude each other, but that nurses integrate both care and justice perspectives in their decision-making processes (Sherblom et al., 1993; Chally, 1995). Both studies by Dierckx de Casterlé et al. (1997, 2008) indicated that nurses, when one applies the moral development stages from Kohlberg (1981), attribute more weight to conventional arguments (third and even fourth stage) than to post-conventional arguments (fifth and sixth stage).
Many of the studies that investigated ethical reasoning described the personal relationship between nurses and their patients. This caring relationship forms the context for the ethical assessment (Martin, 1989; Uden et al., 1992; Grundstein-Amado, 1992; Lützen and Nordin, 1993b, 1994; Chally, 1995; Viens, 1995; Vogel Smith, 1996; Oberle and Hughes, 2001; Rodney et al., 2002, Varcoe et al., 2004; Tsaloglidou et al., 2007). Driven by the ideal of care and with the aim of ‘doing good’ for the patient, nurses take
the patient’s life history, feelings, wishes, intentions, and integrity into account (Jansson and Norberg, 1989; Grundstein-Amado, 1992; Lützen and Nordin, 1993b, 1994; Rodney et al., 2002). This finding is supported by various studies that indicated that a nurse’s ethical decision emerges as a result of the patient’s need for specific care, which is also influenced by the nurse’s relationship with the patient’s family and the team within the context of treatment and care (Jansson and Norberg, 1989, 1992; Davidson et al., 1990; Aström et al., 1993; Norberg et al., 1994; Viens, 1995; Vogel Smith, 1996; Rodney et al., 2002; Varcoe et al., 2004).
As ethical reasoning is embedded in the personal relationship between a patient and a nurse, the patient’s and nurse’s personal qualities influence the ethical decision-making process. Nurses are strongly driven by values (Grundstein-Amado, 1992; Viens, 1995; Vogel Smith, 1996; Dierckx de Casterlé et al., 1997; Penticuff and Walden, 2000; Raines, 2000; Rodney et al., 2002; Varcoe et al., 2004; Monterosso et al., 2005): convictions, religion, education, and upbringing (Jansson and Norberg, 1992; Vogel Smith, 1996). In addition, nurses are inspired by their intuitions and feelings as they undertake ethical reflection (Lützen and Nordin, 1993a; Aström et al., 1995); and by their personal and professional experiences (Jansson and Norberg, 1989, 1992; Uden et al., 1992; Grundstein-Amado, 1992; Viens, 1995; Vogel Smith, 1996; Erlen and Sereika, 1997; Varcoe et al., 2004; Monterosso et al., 2005).
Some studies indicated that ethical reasoning is supported by medical and nursing knowledge and skills (Grundstein-Amado, 1992; Lützen and Nordin, 1993a; Vogel Smith, 1996; Varcoe et al., 2004; Tsaloglidou et al., 2007). Nurses’ ethical reasoning was also influenced by their collaboration with the patients’ family as well as with colleagues, doctors of the ward, and the institution (Jansson and Norberg, 1989, 1992).
Nurses find it very important to share their ethical dilemmas with other nurses, to receive support, and to share their decisions with their colleagues (Uden et al., 1992; Aström et al., 1993; Raines, 2000). However, because nurses seek to adhere to the majority view of the nursing staff, they often put their own opinions aside (Jansson and Norberg, 1989, 1992; Davidson et al., 1990; Norberg et al., 1994). Different studies stated that nurses changed their decisions following a medical order (Jansson and Norberg, 1989, 1992; Davidson et al., 1990; Norberg et al., 1994). These situations can interfere with, influence, and change the development of nurses’ conclusions (Uden et al., 1992; Grundstein- Amado, 1992; Aström et al., 1993; Lützen and Nordin, 1994; Oberle and Hughes, 2001; Rodney et al., 2002).
On the other hand, some elements facilitated ethical decision making: education, guidelines, standards, sup- portive colleagues (Rodney et al., 2002); and years of experience at the same job (Erlen and Sereika, 1997). Other factors hindered decision making: dominance within the medical profession, a stressful work environment with complex patient situations, insufficient resources, time, and workload pressure (Oberle and Hughes, 2001; Rodney et al., 2002). Corley and Selig (1994), Kyriacos (1995), and Ham (2004) confirmed some of these impediments,
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650 645
reporting that experienced nurses in their ethical reason- ing give more importance to practical considerations, like time and means, and less weight to ethical principles.
The studies of Rodney et al. (2002) and Varcoe et al. (2004) reported that nurses find a middle ground between their values and those of their colleagues and institution. These values often conflict with each other. Consequently, the decision-making process of nurses is not always straightforward and is characterized by a personal and professional struggle to realise what is good for the patient. Hereby nurses experience tension between their personal values, professional ideals, and the expectations of others (Lützen and Nordin, 1993a). Nurses experience an internal conflict when their personal values and professional responsibilities do not harmonize. This conflict can be manifested as tension between the ‘morally correct’ decision and the ‘legally correct’ decision (Lützen and Nordin, 1993b). How nurses cope with this tension may differ greatly. Rodney et al. (2002) reported that nurses looked for alternative solutions, like a wait-and-see approach or leaving the decision to others. The studies of Dierckx de Casterlé et al. (1997, 2008) reported that, in difficult situations, conventional arguments (Kohlberg’s third and even fourth stages), mostly influenced nurses’ decisions, indicating that their decisions were mostly influenced by professional norms, laws, and rules. Thus, nurses forsake their values and principles in order to adapt to the opinions and expectations of others.
There are also, however, nurses who place their values above professional expectations (Viens, 1995; Dierckx de Casterlé et al., 1997, 2008; Raines, 2000; Corley and Selig, 1994; Ham, 2004). In the studies of Raines (2000) and Corley and Selig (1994), 42.8% and 63% of nurses, respectively, took this approach. Moreover, the studies of Dierckx de Casterlé et al. (1997, 2008) observed that expert nurses, whose capacity for ethical acting in nursing dilemmas was estimated to be high, placed their values above professional expectations. Indeed, the reasoning of these nurses was not guided by the expectations of others or by the customs of their environment but was guided by their desire to provide the best patient care.
3.2. Ethical behaviour
The ethical behaviour of nurses is a strong relational and contextual process in which personal and contextual aspects play an important role (Vogel Smith, 1996; Varcoe et al., 2004). In order for nurses to implement their decision in practise, it is important they are allowed to act as patient advocates. Additionally, consultation and a good relation- ship between the involved actors are essential for the process of integration. Having authority and power also contributes substantially to the implementation of ethical decisions in practise (Vogel Smith, 1996).
Various studies, however, indicated that a gap exists between the ‘ideal’ ethical decision and the ‘real’ ethical behaviour (Sherblom et al., 1993; Raines, 2000; Kim et al., 2007). Some authors illustrated how nurses have difficul- ties in implementing their decisions in practise (Uden et al., 1992; Oberle and Hughes, 2001; Varcoe et al., 2004; Dierckx de Casterlé et al., 1997, 2008). Many of the studies
showed that contextual factors often limited nurses’ abilities to implement their decision in practise or to act according to their values and norms (Dierckx de Casterlé et al., 1997, 2008; Varcoe et al., 2004; Oberle and Hughes, 2001; Rodney et al., 2002; Uden et al., 1992; Erlen and Frost, 1991; Erlen and Sereika, 1997; Raines, 2000; Kim et al., 2007; Penticuff and Walden, 2000; Sherblom et al., 1993). Dierckx de Casterlé et al. (1997, 2008) reported that the chance that nurses actually implement their decisions becomes smaller when they are confronted with difficult contextual circumstances. In such situations, nurses often do not apply their decisions in practise but rather conform to existing practises and group ethics.
Various studies showed that nurses are only indirectly, occasionally, or not at all involved in the ethical decision- making process (Martin, 1989; Monterosso et al., 2005; Tsaloglidou et al., 2007). As a result, they often do not feel personally responsible for their decisions, rather they feel that their role as patient advocates becomes lost (Martin, 1989; Uden et al., 1992; Monterosso et al., 2005). Nurses also experienced hierarchical relationships and traditional structures of power in the work environment as obstruc- tions, preventing them from acting ethically. Poor coopera- tion with doctors, not being able to discuss their ethical concerns, and a feeling of being ignored and not being respected in their professional abilities all created barriers that hindered nurses from acting on behalf of a patient’s best interest (Martin, 1989; Erlen and Frost, 1991; Chally, 1995; Tsaloglidou et al., 2007; Varcoe et al., 2004). These circumstances gave nurses the impression that they had little or no power to influence outcomes or the resolution of ethical dilemmas (Erlen and Frost, 1991; Penticuff and Walden, 2000). This often results in a reduced willingness to take action when ethical dilemmas arise. Nurses who are personally concerned about ethical dimensions and who focus primarily on the morally relevant aspects of each patient’s situation are more likely to be involved in dilemma resolution activities (Penticuff and Walden, 2000).
Varcoe et al. (2004) reported that nurses often find themselves lodged between the patient and the physician. Contrasting values and expectations often lead to tensions and conflicts in the provision of care, to which nurses respond in different ways. They do not react immediately in conflict situations but weigh the pros and cons. Various elements are taken into account, including the personality of the nurse, his or her position vis-à-vis the other actors, the importance of the situation, implicit and explicit customs of the institution, and the risk of negative repercussions. Carpenter (1991) stated that nurses could react in three different ways: They could directly address the person with whom they are in conflict; they could act indirectly; or they could do nothing. An example of reacting indirectly is discussing the conflict with a colleague, the head nurse, nursing staff, a social worker, or a physician (Martin, 1989; Raines, 2000; Penticuff and Walden, 2000).
Some nurses, however, do succeed in going against deep-rooted routines, taking risks in order to act according to their own values and norms (Lützen and Nordin, 1993b; Viens, 1995). According to the results of Dierckx de Casterlé et al. (1997, 2008), expert nurses have a higher
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650646
chance of effectively implementing their ethical decisions in practise. They rely mostly on post-conventional argu- ments (Kohlberg’s fifth and sixth stage) to implement their decisions. Martin (1989), Aström et al. (1995) and Varcoe et al. (2004) reported that knowledge, experience, risk taking, boldness, and strong problem-solving capabilities contribute to the fact that nurses eventually will act when confronted with ethical problems. Besides personal factors, contextual factors can also contribute to an active intervention when ethical problems occur. Being involved in ethical decision making, achieving a mandate in ethics deliberations, and being able to positively collaborate with physicians seem to prompt nurses to strive for the patient’s best interest (Dodd et al., 2004).
Carpenter (1991), Erlen and Sereika (1997), and Raines (2000) reported that difficult circumstances, rather than ethical problems, hinder nurses from acting as they would like and are the most important cause of moral distress. Several authors concluded that these situations lead to feelings of powerlessness, frustration, anger, dissatisfac- tion, and exhaustion (Martin, 1989; Carpenter, 1991; Erlen and Frost, 1991; Uden et al., 1992; Erlen and Sereika, 1997; Penticuff and Walden, 2000; Raines, 2000; Oberle and Hughes, 2001; Rodney et al., 2002; Varcoe et al., 2004). Sometimes these situations cause burnout or even cause nurses to leave the nursing profession altogether (Car- penter, 1991; Oberle and Hughes, 2001).
Only one study (Dierckx de Casterlé et al., 1997) examined the relationship between ethical reasoning and the implementation of ethical decisions in practise. This study reported a small but positive and significant relationship between ethical reasoning and ethical beha- viour (r = .18; p < 0.0001), indicating that the chance that nurses implement an ethical decision in practise tends to increase as their ability to make ethical deliberations increases.
4. Discussion
4.1. Conceptual and methodological issues
Most of the studies reviewed by Ketefian (1989) were based on Kohlberg’s theory on moral development and on the quantitative paradigm. The international character of this review as well as our inclusion of qualitative, quantitative, and mixed-method studies allows us to present a fairly balanced picture of how nurses actually reason and behave ethically. This review, which analysed a large number of qualitative studies and is mainly based on the experiences of nurses themselves, provides insight into the processes underlying nurses’ ethical reasoning. In the quantitative studies, many different frameworks were used and only a few studies relied on Kohlberg’s Moral Development Theory. Because of the legitimate critiques of his neglect of other elements such as context and emotion the study of Dierckx de Casterlé et al. (1997) added a caring perspective as well as some personal and situational variables in the application of the rigid, abstract justice- oriented theory of Kohlberg.
Ethical behaviour is examined in a far more limited and almost indirect way, focusing on contextual factors related
to ethical behaviour that either enhance or inhibit this behaviour. This finding illustrates the difficulty of actually measuring ethical behaviour. Only one study (Dierckx de Casterlé et al., 1997) alluded to the link between the reasoning and behaviour processes. This limited outcome makes it difficult to understand the relationship between ethical reasoning and ethical behaviour.
When interpreting the results of this review, research- ers need to consider some methodological shortcomings. The use of various theoretical frameworks, concepts, and definitions, and the unclear conceptualisation of the concepts ‘ethical reasoning’ and ‘ethical behaviour’ lead to highly fragmented research material that is difficult to compare and integrate. A large variation in sample sizes and response rates, possible non-responder bias, and validation of the instruments restricted to small popula- tions can limit the representativeness of results. Moreover, by selecting mainly ethically competent nurses, many qualitative studies may have presented an unrealistically favourable or optimistic picture of nurses’ ethical practises. Also, several studies were conducted in diverse research- ing settings. Although this can be viewed positively as reflecting different nursing cultures and positions in care settings, a large diversity of research settings also makes it even more difficult to clearly understand the ethical practises of nurses.
4.2. Substantive findings
On the basis of our concern for the difficulties nurses face as they endeavour to apply their ethical dimension of care, we wanted to address in this review how nurses reason and how they implement ethical decisions in practise’.
Nurses’ ethical practise is a difficult and complex process, in which an intricate web of personal and contextual factors plays an important role in the reasoning and behaviour processes. Most of the studies we analysed, from their own perspective, provided us with insight into the complexity of ethical practise and the difficulties that nurses face when they are involved in ethical reasoning and/or ethical behaviour.
The ethical reasoning process is complicated mainly by the numerous factors that influence the ethical decision- making process. As a starting point, nurses first consider their own ethical stance. However, they must eventually consider the values and expectations of patients, patients’ families, and others, in addition to the rules and routines of their ward and institution. Due to these influencing factors, nurses experience various difficulties that hamper their personal decision-making process. Indeed, numerous factors can hinder nurses from applying their ethically desirable decisions to clinical practise: stressful work environment, limited time and resources, lack of partici- pation in the ethical decision-making process, confronta- tion with opposing values and norms, and willingness to conform to the expectations of others. As a result, nurses are more likely to conform to the decisions of others.
Especially the difficult working conditions prevent nurses from acting ethically. The impact of the context on nurses ethical practise is not only supported by studies
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650 647
that rely on Kohlberg’s moral development theory. In a lot of qualitative studies in this review, collecting nurses’ narratives, indicate that the context is not only a crucial but also a problematic factor in their ethical practise. Using Kohlberg’s cognitive approach, one could suggest that nurses apply only a limited form of ethical reasoning, in which they often stick to the conventional level when faced with complex issues.
Due to their central position in patient care, nurses seem to be the obvious persons to act as central figures in the ethical decision-making process. Several studies in this review show, however, that nurses are involved very little, if at all, in this process, making it difficult for them to fulfil their role as patient advocates (Martin, 1989; Uden et al., 1992; Monterosso et al., 2005). Results from the study of Milisen et al. (2006) corroborate these findings, stating that 49% of nurses do not perceive themselves as having a pivotal position in care. These findings are disappointing. Because of their unique advocacy position in care, nurses are privy to crucial patient information that can contribute to a more person-oriented care. In this context, Peter et al. (2004) pointed to the lack of clarity about the responsi- bilities delegated to nurses. Because of their accessible position in the care system and because they are driven by their feelings of responsibility towards patients, nurses often take over additional responsibilities from other care workers. As a result, nurses are faced with more responsibilities than they can reasonably handle with the time and resources available. Such situations cause nurses to feel like ‘task-oriented technicians’ rather than the ‘caring professionals’ they would like to be. These findings help us to understand why nurses, in the context of ethical practise, experience an unbridgeable gap between what they would like to do and what they only can do in practise.
The qualitative studies we reviewed especially demon- strate that nurses want to behave in a patient’s best interest, while many of these studies highlight the difficulties nurses face when they want to reason and behave in the patient’s best interest. Nurses are inclined to follow their intuitions and feelings, whereby ‘care’ and ‘doing good for the patient’ are the main motifs motivating their behaviour.
The multi-facetted meaning of the concept ‘nursing care’, as sketched by Gastmans et al. (1998), provides insight into the motifs driving nurses’ actions. We consider ‘good care’ to be both a praxis and a moral endeavour, in which attitudes and activities are the essential inalienable components of nursing practise. This presupposes a caring relationship between nurses and patients expressed in a caring behaviour which is both technical accomplished and virtuous. The development of a caring relationship with the patient, which is in most cases reciprocal, is essential for nurses’ ethical practice (Gastmans et al., 1998). A reciprocal relationship positively affects the mental well-being of nurses and results in feelings of satisfaction and person growth, and leads to renewal (Finfgeld-Connett, 2007). To which extent can nurses give meaning to and experience satisfaction in their job given the difficult circumstances in which they work? The results of this review, which show how difficult working condi-
tions prevent nurses from acting ethically, are supported by a large body of international literature demonstrating that difficult working conditions do indeed have an impact on nurses and patient care (Aiken et al., 2001; Peter et al., 2004; Gutteriez, 2005; Nordam et al., 2005; Milisen et al., 2006; Torjuul and Sorlie, 2006; Pendry, 2007). This suggestion is particularly unfortunate when nurses feel so unhappy with their job situation that they are compelled to leave the profession, even though many patients need their good bedside care (Peter et al., 2004; Gutteriez, 2005; Milisen et al., 2006).
However, Vogel Smith (1996) also showed that good cooperation with physicians is also important. Yet several studies examined in this review showed that nurses experience poor cooperation with physicians. This finding is consistent with the findings of Siebens et al. (2006) in which 43.3% of nurses reported a lack of teamwork between physicians and nurses. Larson (1999) concluded that lack of collaboration, coordination, and shared decision making between physicians and nurses leads to an unfavourable work environment and has a negative impact on patient care.
Despite the numerous factors that affect nurses’ ethical reasoning and behaviour, our review revealed that some nurses do succeed in overcoming the conformist way of reasoning and acting. These nurses critically evaluate the provided care, which is often based on rules and routines, in light of the specific needs of the patient. Dierckx de Casterlé et al. (1997, 2008) found this to be true for expert nurses, who are readily recognised for their ability to act ethically. Other studies in this review suggest strongly that personal factors like knowledge, experience, boldness, readiness to take risks, and strong problem-solving skills contribute to a post-conventional way of reasoning and behaving (Martin, 1989; Aström et al., 1995; Varcoe et al., 2004). Further research into personal factors that contribute to a post-conventional way of reasoning and behaving is recommended. This knowledge could be used to identify role models of good care. Role models are important with regard to students but may be equally important for nurses who continually search, in a critical and reflective way, for attitudes and actions that can contribute to more person-oriented care.
5. Implications for nursing education, the nursing profession, and nursing research
Today’s healthcare system demands more from nurses than the ability to apply the right knowledge, skills, and attitudes. It also demands that nurses have the ability to reflect on what they do and the ability to critically evaluate the provided care from an ethical perspective in order to meet the personal care needs of patients. This review shows that knowledge, good problem-solving skills, good collaboration with other care providers, and consultation with other professionals involved contribute positively to the ethical practise of nurses. Therefore, one challenge for nursing education, professional settings, and nursing
S. Goethals et al. / International Journal of Nursing Studies 47 (2010) 635–650648
research is to develop strategies that support nurses in developing these qualities.
The first step for nursing students is acquiring knowledge and developing skills that will enable them to critically reflect on the essence of good care. The second step is enabling students to participate in ethical decision-making scenarios. Nursing students should be encouraged to develop professional ethical awareness and personal vision of what good care means, and to discuss potential concerns and conflicts (Doane et al., 2004; Vanlaere and Gastmans, 2007). This can be achieved by introducing the students to biomedical ethics principles, different moral theories, and ethical decision-making procedures. While specialized theoretical knowledge is essential, solely having such knowledge is insufficient for helping nurses to cope with the complex ethical challenges of present-day nursing practise. Indeed, theoretical knowledge must be implemen- ted in conjunction with critical ethical reflection on what good care is, and both must be applied in actual nursing practise. This implies that nursing students should be capable of operating in a values-supportive context, in which they are challenged and encouraged to learn and to continuously improve their practise (Vanlaere and Gast- mans, 2007; Grady et al., 2008).
Nursing management centered on providing reasonable care that involves nurses can, in part, stimulate a context supported by values. A leadership style that increases the involvement of nurses is called transformational leader- ship (De Geest et al., 2003). In this specific leadership style, managers apply a clear vision, treat employees as individuals by trusting and respecting them, set compre- hensible goals, and anticipate pro-actively how to respond to a continuously changing environment. Implementing this leadership style results in better work environments for nurses and better patient outcomes, as confirmed by the study of Dierckx de Casterlé et al. (2008) on the effects of the transformational leadership style on nursing teams and patient care. They reported that nurses who feel supported, appreciated, and acknowledged in their job and nurses who have clear-cut patient and collegial respon- sibilities grow professionally and personally in their role as caregivers. Thus, implementation of the transformational leadership style can contribute to the realisation of qualitatively superior nursing care and the retention of satisfied nurses in the field.
In conclusion, this review has provided new insights into the ethical practise of nurses. The wide range of qualitative studies examined in this review has espe- cially broadened our knowledge of how nurses reason and behave ethically. Yet, there are still many issues requiring further investigation. Ethical behaviour is researched to a limited extent, mostly indirectly and with a plethora of methods. How exactly nurses act remains unclear. We identified a number of personal and contextual factors that play a role in the eventual ethical practise of nurses; however, which factors are important and what roles these factors play requires clarification. Our review included numerous qualitative studies that shed light onto the complex process of nurses’ ethical practise. Additional qualitative research is necessary if we are to understand more fully the complex reality of
ethical practises and the difficulties nurses face. A better understanding of how nurses reason and behave ethically and a better understanding of the relationship between both processes can help all individuals con- cerned to support nurses in the ethical aspects of their assignment.
Conflict of interest
None declared.
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- Nurses’ ethical reasoning and behaviour: A literature review
- Introduction
- Review
- Aim
- Review methodology
- Search strategy
- Search outcome
- Methodological features
- Quality appraisal
- Findings
- Ethical reasoning
- Ethical behaviour
- Discussion
- Conceptual and methodological issues
- Substantive findings
- Implications for nursing education, the nursing profession, and nursing research
- Conflict of interest
- References
