Article summary and review essay
chbrg16
Week4ethical-issuearticle.pdf
Journal of Nursing Law, Volume 13, Number 3, 2009
68 • Copyright © 2009 Springer Publishing Company DOI: 10.1891/1073-7472.13.3.68
Ethical Issues in Nursing Practice
Mihyun Park, MSN, RN
Nurses play a role as advocates to assist patients and families struggling with complex information and difficult decisions. In particular, the fact that nurses encounter clinical situations that require ethical judgment highlights the need for nursing staff to gain knowledge and expertise in deliver- ing care in an ethical manner. In this study, through reviewing empirical studies of hospital-based nurses’ experiences, the author identified the ethical issues that nurses frequently face and the approaches that they have taken to solving them. The findings can serve to intensify the awareness of the ethical issues in both clinical and educational areas.
Keywords: ethical issues; nursing practice; education; hospitals
Advances in medical technology allow for bet-ter recovery for critically ill patients and dramatically extend the human life span. However, while advances bring benefits to patients and families, they simultaneously raise moral and ethical issues regarding respect for patient integrity and autonomy, soaring medical costs, quality care, and end-of-life decision making (Scanlon & Fleming, 1990; Wright, Cohen, & Caroselli, 1997). As the largest group of health care providers, nurses are frequently placed in unique positions to assist patients and families struggling with complex information and dif- ficult decisions (Briggs & Colvin, 2002). The fact that nurses encounter clinical situations that require ethi- cal judgment highlights the need for nursing staff to gain knowledge and expertise in delivering care in an ethical manner.
Reporting the lack of ethical confidence among newly graduated nurses, nursing ethics researchers have emphasizes the importance of having well- educated and well-qualified nurses who know how to find feasible solutions to ethical problems (Bunch, 2001; Woods, 2005). Although nursing schools have become more concerned with the ethical development of their students, researchers point out that education has not reflected reality and does not prepare newly qualifying nurses to deal effectively with a variety of ethical situations in the health care setting ( Woods, 2005). The traditional ethics education has tended to emphasize the acquisition of philosophical and
theoretical knowledge and has created a gap between theory and practice ( Woods, 2005). New approaches are needed for teaching nursing ethics pragmatically.
The nursing ethic as a dynamic standard for nurses’ professional moral behavior should address ethical issues confronted by nurses (Omery, Henneman, Bil- let, Luna-Raines, & Brown-Saltzman, 1995). Therefore, knowledge about specific nursing ethical issues found in the health care setting and understanding the impact of these issues on practice will be essential, pragmatic parts of nursing ethics education. That is, the ethical issues are subjects that should be dealt with in ethics education for nursing students before entering in nurs- ing practice. Thus, identifying what issues should be dealt with in classes is needed.
Researchers have tried to identify ethical issues that nurses confront in the clinical area since Vaughan’s (1935) study. The earliest study of ethical issues in nursing practice (Vaughan, 1935) identified 2,265 ethical issues based on the diaries of 95 nurses that recorded ethical issues. Since this study, many other studies have been focused on ethical issues that affect the profession of nursing and the everyday practice of individual nurses using qualitative methodolo- gies. In a review study, Christensen (2002) identified the ethical and legal issues that oncology nurses in hospitals face: (a) advance directives, ( b) do-not- resuscitate orders, (c) documentation and patient privacy, (d) informed consent, (e) medication errors, and (f ) pain management. A systematic analysis
Park • Ethical Issues in Nursing Practice • 69
study of nurses’ ethical conflicts identified each main ethical issue in a particular role or setting (Redman & Fry, 2000). Examples were (a) harm/good of life- prolonging aggressive therapies (intensive care unit); ( b) inadequacy of resources for care (administration); (c) undertreatment, consent, and refusal of treatment (oncology); (d) disagreement with quality of medical care (diabetes educators); and (e) protection of child’s rights (pediatric nurse practitioner). However, a sys- tematic review of ethical issues encountered by nurses in current practice is rarely found.
The purpose of this study is to review the empiri- cal studies of hospital-based nurses’ experiences with ethical issues to identify (a) the ethical issues nurses face and ( b) the approaches they have taken to solving them.
METHODS
This article reviewed quantitative studies of hospital- based nurses’ experiences with ethical issues. To be included in this review, a publication was to have reported the findings from a research project studying nurses’ experiences. The integrative review included the reports of primary research studies that were pub- lished in the English language from 1990 and 2007. This study began with a search of multiple library databases, including PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health (CINAHL), and ISI Web of Knowledge, to identify research related to ethical issues that nurses face. Key words used in the search process were “nursing ethics” and “issue” and/or “problem.” Additional literature was identified by reviewing the reference lists of journal articles identified during the literature review.
Examination of the published abstracts and studies resulted in a decrease of the number of studies included in the first sampling because studies that did not match the project criteria were excluded ( n = 25). This study was limited to hospital-based research and settings in the United States. Most studies in special clinic areas dealt with a more specific ethical issue or conflict situa- tion. Therefore, these articles were excluded. However, this review included the studies done in operating room areas and collected data from registered nurses in a local area because the studies dealt with more general ethical issues encountered by perioperative nurses or registered nurses with a large sample size. One article that collected data from directors of nursing in hos- pitals was included because the directors explained ethical issues not that they faced but that were faced by staff nurses. Therefore, through the second review, the
researcher excluded the articles that did not match the purpose of this project.
This review classified the ethical issues reported by each study into three categories of the Ethical Issues Scale (EIS): end-of-life treatment decisions, patient care issues, and human rights issues. Fry and Damrosch (1994) developed the EIS in a study of Maryland nurses. The EIS was validated with a sample of New England registered nurses currently in practice (Fry & Duffy, 2001). The scale described the full range of ethical issues experienced by nurses in current practice. The 32-item scale represented three conceptual categories of ethical issues: end-of-life treatments, patient care, and human rights (Fry & Duffy, 2001) (see Table 1). The end-of-life treatment category was defined as issues about death or the dying process and included 13 issues. The patient care category addressed issues about how patients receive or do not receive quality nursing or health care (14 items). The human rights category was defined as issues concerning the rights of nurse, patients, and family members (five items). The EIS pro- vides information about the full range of ethical issues of registered nurses in active practice experience. The reliability and validity of the EIS have been validated through a study with a large RN sample ( n = 2,090) and nurses with expertise in bioethics (Fry & Duffy, 2001).
RESULTS
Twenty-five studies were identified through the first review process, and 11 studies met the inclusion crite- ria. All studies used a descriptive research method with survey instruments. Articles reviewed were classified into two settings: hospital and operating room. One article collected data from registered nurses in Mary- land; this article was integrated to hospital setting data. The ethical issues reported in reviewed studies were divided into three categories (end-of-life treatment decisions, patient care issues, and human rights issues) in the EIS. This review described disturbing ethical issues that were encountered by nurses separated from the frequent ethical issues. This study identified the top five frequent ethical issues and disturbing ethical issues reported in each article and then integrated and analyzed these issues. Furthermore, this study identi- fied the approaches that nurses have taken to solve the ethical issues and the resources that nurses frequently used to get help and information.
Ethical Issues
As shown in Table 2, the most of frequent ethical issues faced by nurses related to patient care issues and human
70 • Journal of Nursing Law • Vol. 13, No. 3
TABLE 1. The Ethical Issues Scale
Component 1: End-of-life treatment decisions
Prolong dying process with inappropriate measures Treatment or nontreatment despite patient or family wishes Use or removal of life support including nutrition and hydration To resuscitate or not to resuscitate Treatment or nontreatment of very disabled infant, child, adult Not considering quality of patient’s life Acting against your own personal or religious views Acting against patient’s personal or religious values Determining when death occurs Organ transplantation, or organ or tissue procurement Over- or underuse of pain management Ordering too many or too few procedures, tests, etc. Participation or refusal to participate in euthanasia or assisted suicide
Component 2: Patient care issues
Staffing patterns that limit patient access to nursing care Child or spousal or elderly or patient abuse or neglect Allocation of resources (human, financial, equipment) Implementing managed care policies threatening quality of care Breaches of patient confidentiality or privacy (e.g., HIV status) Irresponsible or unethical or incompetent or impaired colleague Ignoring patient or family autonomy Patients or families uninformed or misinformed about treatment, prognosis, medical alternatives Rights of minors versus parental rights Discriminatory treatment of patients Unsafe equipment or environmental hazards Conflict in nurse or doctor relationship (or other professional relationship) Reporting unethical or illegal practice of health professional or health agency Implementing managed care policies threatening availability of care
Component 3: Human rights issues
Use or nonuse of physical or chemical restraints Issues involving advance directives Protecting patient rights and human dignity Informed consent to treatment Providing care with possible risk to RNs’ health (e.g., TB, HIV, violence)
Note. From “The development and the psychometric evaluation of the Ethical Issues Scale,” by Fry and Duffy, 2001, Journal of Nursing Scholarship, 33(3), p. 276.
rights issues rather than end-of life issues. The most frequent issues were founded in patient care issue cat- egory. Of patient care issues that nurses encountered, staffing patterns that limit patient access to nursing care ( n = 6) was the most frequent ethical issue. In addition, nurses frequently encountered patient care issues such as conflict in nurse or doctor relationship ( n = 4), alloca- tion of resources (human, financial, equipment) ( n = 4), patient confidentiality or privacy ( n = 4), and incom- petent or impaired colleague ( n = 4). In human rights issue category, the following three items were identi- fied as the most frequent ethical issues: (a) protecting patient rights and human dignity ( n = 5), (b) providing
care with possible risk to RNs’ health ( n = 5), and (c) informed consent to treatment ( n = 4).
When this review separated the setting into a gen- eral hospital versus operating room area, studies done in a general hospital setting identified other frequent ethical issues: dealing with an irresponsible or unethi- cal or incompetent or impaired colleague (Berger, Sev- erson, & Chvatal, 1991; Cook, Hoas, & Joyner, 2000), end-of-life care (Killen, 2002; Scanlon, 1990, 1994), and pain management (Omery et al., 1995; Scanlon, 1994). Nurses in hospitals reported that they experienced fre- quent ethical problems related to patient confidential- ity or privacy issues as well as staffing patterns issues.
T A
B L
E 2
. F
re q
u en
t E
th ic
a l
Is su
es
A rt
ic le
s Se
tt in
g E
n d -o
f- L
if e
T re
at m
en t
D ec
is io
n s
P at
ie n
t C
ar e
Is su
es H
u m
an R
ig h
ts I
ss u
es
B er
ge r
et a
l.
(1 99
1) A
h o sp
it al
( U
) P
ro lo
n gi
n g
li fe
w it
h
h er
o ic
m ea
su re
sa St
af fi
n g
p at
te rn
s,
in ap
p ro
p ri
at e
al lo
ca ti
o n
o f
re so
u rc
es ,
d ea
li n
g w
it h
si
tu at
io n
s w
h er
e p
at ie
n ts
a re
d is
cu ss
ed i
n ap
p ro
- p
ri at
el y ,
d ea
li n
g w
it h
c o ll
ea gu
es ’ i
rr es
p o n
si b le
ac
ti v it
y C
o o k e
t al
. (2
00 0)
H o sp
it al
s (R
) St
af fi
n g
p at
te rn
s, p
at ie
n t
fa m
il y r
eq u
es ti
n g
m o re
ag
gr es
si v e
tr ea
tm en
t o p
ti o n
s, a
p at
ie n
t h
as u
n cl
ar i-
fi ed
c o n
fu si
n g
o r
n o -c
o d e
o rd
er s,
c o ll
ea gu
es a
re
d is
cu ss
in g
p at
ie n
ts i
n ap
p ro
p ri
at el
y ,
d ea
li n
g w
it h
an
i n
co m
p et
en t
co ll
ea gu
e F
ry a
n d
D am
ro sc
h (
19 94
) R
N s
in M
ar y -
la n
d Q
u al
it y o
f p
at ie
n t
li fe
St af
fi n
g p
at te
rn s,
n u
rs e–
p h
y si
ci an
r el
at io
n sh
ip s
P ro
v id
in g
ca re
t h
at p
la ce
s th
e n
u rs
e at
r is
k a
Je n
k in
s et
a l.
(2
00 6)
O R
i n
a rm
y St
af fi
n g
p at
te rn
s, c
o n
fl ic
ts i
n t
h e
n u
rs e–
p h
y si
ci an
re
la ti
o n
sh ip
a P
ro v id
in g
ca re
w it
h r
is k
to s
el f,
p ro
te ct
in g
p at
ie n
t ri
gh ts
a n
d h
u m
an d
ig n
it y
K il
le n
e t
al .
(1 99
6) O
R St
af fi
n g
p at
te rn
s, n
u rs
e– p
h y si
ci an
r el
at io
n sh
ip P
ro v id
in g
ca re
w it
h r
is k t
o
se lf
,a i
n fo
rm ed
c o n
se n
t,
p at
ie n
t ad
v o ca
cy K
il le
n (
20 02
) O
R E
n d
-o f-
li fe
c ar
e,
ab o rt
io n
i ss
u es
Q
u al
it y o
f ca
re ,
tr u
th t
el li
n g,
a b u
se o
f ch
il d re
n /o
ld er
p eo
p le
, co
n fi
d en
ti al
it y ,
p ri
v ac
y
In fo
rm ed
c o n
se n
t, a
H IV
/ A
ID S
ca re
, cl
in ic
al s
af et
y
K in
g an
d
M is
k o v ic
( 19
96 )
O R
St af
fi n
g p
at te
rn s,
a al
lo ca
ti o n
o f
re so
u rc
es ,
p at
ie n
ts ’ a
u to
n o m
y /a
d v o ca
cy In
fo rm
ed c
o n
se n
t, o
cc u
- p
at io
n al
r is
k ,
p at
ie n
t se
lf -
d et
er m
in at
io n
a ct
O m
er y e
t al
. (1
99 5)
A h
o sp
it al
( U
) P
ai n
r el
ie f/
m an
ag em
en ta
D ea
li n
g w
it h
d if
fi cu
lt p
at ie
n ts
, p
at ie
n t–
p h
y si
ci an
– n
u rs
e re
la ti
o n
sh ip
, ca
re o
f n
o n
co m
p li
an t
p at
ie n
t,
co st
o f
ca re
t o t
h e
p at
ie n
t Sc
an lo
n (
19 90
) H
o sp
it al
s (U
) D
o n
o t
re su
sc it
at ea
d ea
th a
n d d
y in
g. P
ro fe
ss io
n al
p ra
ct ic
e is
su es
, A
ID S,
a ll
o ca
ti o n
o f
re so
u rc
es P
at ie
n ts
’ r ig
h ts
, A
ID S
Sc an
lo n
( 19
94 )
H o sp
it al
s in
50
s ta
te s
E n
d -o
f- li
fe c
ar e,
p
ai n
m an
ag em
en t
C o st
o f
co n
ta in
m en
t is
su e,
a co
n fi
d en
ti al
it y ,
in co
m p
et en
t, u
n et
h ic
al ,
o r
il le
ga l
p ra
ct ic
es o
f co
ll ea
gu es
Sc h
ro et
er (
19 99
) O
R
Im p
ai re
d p
ro v id
er /p
o te
n ti
al f
o r
u n
sa fe
p ra
ct ic
e,
m is
re p
re se
n ta
ti o n
b y c
ar e
p ro
v id
er ,
p ro
v id
er
ju d gm
en t/
co m
p et
en cy
C o n
se n
t/ ad
v o ca
cy ,a
d is
re sp
ec t
fo r
p at
ie n
t
N ot
e. U
= u
rb an
a re
a; R
= r
u ra
l ar
ea ;
R N
= r
eg is
te re
d n
u rs
es ;
O R
= o
p er
at in
g ro
o m
. a M
o st
f re
q u
en t
it em
i n
t h
e ar
ti cl
e.
72 • Journal of Nursing Law • Vol. 13, No. 3
TABLE 3. Rankings of Frequent Ethical Issues and Disturbing Ethical Issues
Frequent Ethical Issues in All Reviews (N)
Frequent Ethical Issues in Hospital Setting (N)
Frequent Ethical Issues in Operating Room (N)
Disturbing Ethical Issues (N)
Staffing patterns that limit patient access to nursing care
(6) Patient confiden- tiality or privacy
(4) Protecting patient rights and human dignity
(4) Prolong dying process with inappropriate measures
(4)
Protecting patient rights and human dignity
(5) Staffing patterns that limit patient access to nursing care
(3) Informed consent to treatment
(4) Child or spousal or elderly or patient abuse or neglect
(3)
Providing care with possible risk to RNs’ health
(5) Allocation of resources (human, finan- cial, equipment)
(3) Providing care with possible risk to RNs’ health
(3) Staffing patterns that limit patient access to nursing carea
(2)
Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)
(4) Irresponsible or unethical or incompetent or impaired col- league
(3) Staffing patterns that limit patient access to nursing care
(3) Acting against your own personal or reli- gious views
(2)
Allocation of resources (human, finan- cial, equipment)
(4) Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)
(2) Conflict in nurse or doctor relationship (or other profes- sional relationship)
(2) Irresponsible or uneth- ical or incompetent or impaired colleaguea
(2)
Informed consent to treatment
(4) Providing care with possible risk to RNs’ health
(2) Providing care with possible risk to RNs’ healtha
(2)
Irresponsible or unethical or incompetent or impaired col- league
(4) End-of-life deci- sion
(2) Treatment or nontreat- ment despite patient or family wishes
(2)
Patient confiden- tiality or privacy
(4) Pain manage- ment
(2)
aFrequent ethical issues included in the disturbing ethical issues.
In contrast, this review found that perioperative nurses experienced more frequent ethical issues related to protecting patient rights and human dignity issues and informed consent than other issues (see Table 3).
Five of the reviewed articles reported disturbing eth- ical issues separately from the frequent ethical issues faced by nurses. Although these ethical issues would not frequently happen in their practice areas, nurses reported to be disturbed a great deal or quite a bit when these occurred. As shown in Table 3, the disturb- ing issues related to patient care issues and end-of-life issues. The disturbing ethical issues were (a) prolonging the dying process with inappropriate measures ( n = 4), (b) child, spousal, elderly, or patient abuse or neglect ( n = 3); (c) staffing patterns that limit patient access to nursing care (Berger et al., 1991; Jenkins, Elliott, &
Harris, 2006); (d) acting against your own personal or religious views (Berger et al., 1991; Cook et al., 2000); (e) irresponsible, unethical, incompetent, or impaired colleague (Jenkins et al., 2006; Killen, Fry, & Damro- sch, 1996); (f) providing care with possible risk to RNs’ health (e.g., TB, HIV, violence) (Fry & Damrosch, 1994; Killen et al., 1996); and (g) treatment or nontreatment despite patient or family wishes (Berger et al., 1991; Cook et al., 2000) (see Table 4).
The most of disturbing issues were not frequent ethical issues experienced by nurses. Disturbing issues often related to end-of-life issues: prolonging the dying process with inappropriate measures, acting against your own personal or religious views, and treatment or nontreatment despite patient or family wishes. Nurses reported being disturbed when patient abuse or neglect
Park • Ethical Issues in Nursing Practice • 73
TABLE 4. The Most Disturbing Ethical Issues
Articles Setting End-of-Life Treatment Decisions Patient Care Issues
Human Rights Issues
Berger et al. (1991) A hospital (U) Treatment despite patients’ objectives, prolonging life with heroic measures, acting against personal principles
Inadequate staffing patterns,a incidents of patients’ abuse
Cook et al. (2000) Hospitals (R) Acting against personal principles,a prolonging life with heroic measures
Patient family requesting more aggressive treat- ment options, cost- containment issues that threaten quality if care, treatment or nontreatment despite patient or family wishes
Fry and Damrosch (1994)
RNs in Maryland Prolonging life with extraordinary measures,a quality of patient life
Cost-containment issues that threaten quality of care, child/spousal / elderly/patient abuse or neglect
Providing care with risk to selfa
Jenkins et al. (2006)
OR in army Dealing with incom- petent or impaired colleagues,a conflicts in the nurse–physician relationship, staffing patterns, unsafe equipment and /or environment hazards
Killen et al. (1996) OR Prolonging life with extraordinary means,a treatment over family objectives
Irresponsible/incom- petent colleagues, patients and families who are uninformed or misinformed about treatment plans, prognosis, child/other abuse
Providing care with risk to self
Note. U = urban area; R = rural area; RN = registered nurses; OR = operating room. aMost frequent item in the article.
of patient care issues occurred. Furthermore, the review found that the staffing pattern and incompetent, impaired colleagues issues and providing care with pos- sible risk to RNs’ health were disturbing issues as well as frequent issues that were faced by nurses.
Approaches/Resources
This study also reviewed the approaches and resources that nurses have taken to solving ethical issues. Four
articles reported that most nurses used their own per- sonal values to solve ethical issues (Berger et al., 1991; Cook et al., 2000; Killen et al., 1996; Schroeter, 1999) (see Table 5). In addition, most nurses discussed ethical problems with nursing peers (Berger et al., 1991; Cook et al., 2000; Jenkins et al., 2006; Killen et al., 1996; Scanlon & Fleming, 1990). One study reported that 68% of respondents reported talking to a higher administra- tive authority (e.g., managers, supervisors, or directors)
T A
B L
E 5
. A
p p
ro a ch
es a
n d
R es
o u
rc es
f o
r E
th ic
a l
Is su
es
A rt
ic le
s Se
tt in
g Sa
m p
le Sa
m p
le S
iz e
(N )
M ea
su re
s A
p p
ro ac
h es
/R es
o u
rc es
E N
C o m
m en
ts
B er
ge r
et a
l. (
19 91
) A
h o sp
it al
i n
an
u rb
an a
re a
N u
rs es
52 A
q u
es ti
o n
n ai
re
(E th
ic al
I ss
u es
i n
N
u rs
in g
)
O w
n p
er so
n al
v al
u es
( 88
% )
N u
rs in
g co
ll ea
gu es
( 97
% )
(+ )
R ec
o m
m en
d at
io n
: n
u rs
in g
et h
ic s
ro u
n d s,
e d u
ca ti
o n
al
o p
p o rt
u n
it ie
s/ p
ro gr
am s,
a
sh ar
ed g
o v er
n an
ce m
o d el
C o o k e
t al
. (2
00 0)
21 h
o sp
it al
s in
r u
ra l
ar ea
N u
rs es
20 4
A 1
4- p
ag e
su rv
ey O
w n
p er
so n
al v
al u
es (
48 %
) N
u rs
in g
co ll
ea gu
es (
87 %
),
n u
rs in
g le
ad er
sh ip
( 77
.4 %
),
p h
y si
ci an
s (7
0% ),
c le
rg y
(7 %
)
(+ )
E d u
ca ti
o n
t o p
ic s:
p ro
fe s-
si o n
al r
es p
o n
si b il
it ie
s, i
n fo
r- m
at io
n o
n p
at ie
n t
ri gh
ts ,
p ri
v ac
y a
n d c
o n
fi d en
ti al
it y ,
in fo
rm at
io n
r eg
ar d in
g tr
u th
te
ll in
g F
ry a
n d
D am
ro sc
h (
19 94
) R
N s
in
M ar
y la
n d
N u
rs es
46 2
T h
e su
rv ey
in
st ru
m en
t N
u rs
in g
p ee
rs (
71 %
),
n u
rs in
g le
ad er
sh ip
( 51
% ),
p
h y si
ci an
s (5
6% ),
o th
er p
ro fe
ss io
n al
s (3
9% ),
et
h ic
s co
m m
it te
e (1
1% )
(+ )
E d u
ca ti
o n
t o p
ic s:
e m
p o w
er -
m en
t o f
n u
rs es
, co
n te
n t/
in te
rp re
ta ti
o n
o f
n u
rs es
’ et
h ic
al c
o d es
, ca
re o
f H
IV /
A ID
S p
at ie
n ts
, tr
ea tm
en t/
n o n
tr ea
tm en
t o f
th e
d y in
g an
d /o
r el
d er
ly ,
q u
al it
y o
f li
fe ,
u se
/r em
o v al
o f
li fe
su
p p
o rt
s y st
em s,
p ro
fe s-
si o n
al r
es p
o n
si b il
it ie
s,
ca re
o f
d an
ge ro
u s
an d /o
r o ff
en si
v e
p at
ie n
ts ,
et h
ic al
d ec
is io
n m
ak in
g, p
ai n
m an
- ag
em en
t, m
o ra
l d ev
el o p
- m
en t/
r ea
so n
in g
Je n
k in
s et
a l.
(2
00 6)
A rm
y i
n
U n
it ed
S ta
te s
C R
N A
s A
N C
= 7
4;
D A
C =
2 2
M o d if
ie d E
th ic
al
Is su
e Sc
al e
(E IS
) A
n i
n fo
rm al
a p
p ro
ac h
N u
rs in
g p
ee r
(8 4.
5% ),
n
u rs
in g
le ad
er sh
ip (
54 .6
% ),
et
h ic
s co
m m
it te
e (5
.2 %
)
(+ )
E d u
ca ti
o n
t o p
ic s:
e th
ic s
o f
tr ia
ge ,
co n
d u
ct o
f th
e h
ea lt
h
ca re
p ro
v id
er a
s a
p ri
so n
er
o f
w ar
, th
e ro
le o
f n
u rs
es a
s ad
v o ca
te s,
e th
ic al
d ec
is io
n
m ak
in g,
q u
al it
y o
f li
fe K
il le
n e
t al
. (1
99 6)
O R
/r ec
o v er
y
ro o m
P O
R N
s 37
3 P
re -E
IS N
u rs
es ’ p
er so
n al
c o d es
o f
et h
ic s
N u
rs in
g p
ee rs
( 73
% ),
n
u rs
in g
le ad
er sh
ip (
57 .7
% ),
p
h y si
ci an
s (5
0% ),
o th
er p
ro fe
ss io
n al
( 30
.8 %
),
fa m
il y o
r fr
ie n
d s
(3 0.
8)
(+ )
E d u
ca ti
o n
t o p
ic s:
p at
ie n
t’ s
ri gh
t to
i n
fo rm
at io
n ,
tr ea
t- m
en t
o f
th e
d y in
g an
d t
h e
el d er
ly ,
tr ea
tm en
t o f
th e
d ef
o rm
ed a
n d h
an d ic
ap p
ed ,
p ai
n m
an ag
em en
t, p
at ie
n t’ s
ri gh
t to
d em
an d o
r re
fu se
tr
ea tm
en t
K il
le n
( 20
02 )
T h
e m
em b er
s o f
th e
A O
R N
P O
R N
s 21
4 A
c ro
ss -s
ec ti
o n
al
su rv
ey E
th ic
al p
ri n
ci p
le s:
a u
to n
- o m
y (
33 .8
% ),
n o n
m a-
le fi
ce n
ce (
42 .9
% ),
f id
el it
y
(9 .8
% )
N A
R ec
o m
m en
d at
io n
: ad
m in
is -
tr at
iv e
su p
p o rt
K in
g an
d M
is k o v ic
(1
99 6)
T h
e m
em b er
s o f
th e
A O
R N
i n
B
al ti
m o re
P O
R N
s 21
7 E
th ic
al I
ss u
es :
A
Su rv
ey o
f P
er io
p -
er at
iv e
N u
rs e
N A
(+ )
R ec
o m
m en
d at
io n
: ed
u ca
- ti
o n
a b o u
t th
e A
m er
ic an
N
u rs
es A
ss o ci
at io
n c
o d e
o f
et h
ic s
O m
er y e
t al
. (1
99 5)
A m
ed ic
al
ce n
te r
in a
n
u rb
an a
re a
N u
rs es
79 4
T h
e E
th ic
al I
ss u
e an
d R
es o u
rc es
Su
rv ey
N A
N A
N A
Sc an
lo n
( 19
90 )
In st
it u
ti o n
s in
an
u rb
an a
re a
D ir
ec -
to rs
o f
n u
rs in
g
71 A
q u
es ti
o n
n ai
re F
o rm
at s
ad d re
ss in
g et
h ic
al
is su
es i
n n
u rs
in g:
n u
rs in
g m
ee ti
n g
(6 6%
), i
n -s
er v ic
e ed
u ca
ti o n
( 18
% ),
h o sp
it al
co
m m
it te
es (
9% ),
i n
d iv
id u
- al
d is
cu ss
io n
/c o n
su lt
at io
n
(9 %
), h
o sp
it al
e th
ic s
co m
m it
te e
(9 %
)
(+ )
U se
d e
th ic
s ed
u ca
ti o n
m
et h
o d s
in h
o sp
it al
s:
o ri
en ta
ti o n
p ro
gr am
( 35
% ),
co
n ti
n u
in g
ed u
ca ti
o n
p
ro gr
am s
(4 2%
)
Sc an
lo n
(1 99
4) R
N s
in
50 s
ta te
s (h
o sp
it al
s)
N u
rs es
93
4 A
w ri
tt en
s u
rv ey
L it
er at
u re
( 44
% ),
et
h ic
s co
m m
it te
es (
42 %
),
co n
ti n
u in
g ed
u ca
ti o n
(3
9% )
(+ )
N A
Sc h
ro et
er (
19 99
) P
O R
N s
in
so u
th ea
st er
n
W is
co n
si n
P O
R N
s 40
A d
es cr
ip ti
v e
se lf
-r ep
o rt
q u
es -
ti o n
n ai
re ,
a sc
en ar
io -b
as ed
su
rv ey
P er
so n
al v
al u
es ,
w o rk
ex
p er
ie n
ce s,
n u
rs in
g co
d e
o f
et h
ic s,
p ro
fe ss
io n
al
ed u
ca ti
o n
A h
ig h
er a
d m
in is
tr at
iv e
au th
o ri
ty (
68 %
), d
ir ec
t co
n fr
o n
ta ti
o n
( 21
% )
N A
N A
N ot
e. E
N =
e d u
ca ti
o n
n ee
d ;
(+ )
= e
xp re
ss ed
e d u
ca ti
o n
n ee
d ;
C R
N A
s =
c er
ti fi
ed R
N a
n es
th et
is ts
; A
N C
= A
rm y
N u
rs e
C o rp
s; D
A C
= D
ep ar
tm en
t o f
th e
A rm
y
C iv
il ia
n ;
O R
= o
p er
at in
g ro
o m
; P
O R
N s
= p
er io
p er
at iv
e R
N s;
A O
R N
= A
ss o ci
at io
n o
f P
er io
p er
at iv
e R
N s;
N A
= n
o t
ap p
li ca
b le
.
76 • Journal of Nursing Law • Vol. 13, No. 3
(Schroeter, 1999). A small percentage of responding nurses had experience consulting with ethics commit- tee (Fry & Damrosch, 1994; Jenkins et al., 2006; Scan- lon & Fleming, 1990) (see Table 4). However, one study reported ethics committees as one of main resources that nurses consider available when facing an ethical problem (Scanlon, 1994).
Moreover, most of studies (n = 8) reported nurses’ educational need related to nursing ethics. In four stud- ies, the nurses indicated the need for the following edu- cation topics: (a) professional responsibility, (b) patient rights, (c) ethical code/principles, (d) treatment/non- treatment of the dying, (e) patient advocacy, (f) ethical decision making, and so on (see Table 4).
DISCUSSION
Most of ethical issues mentioned in the reviewed articles can be classified into three categories in the EIS: end-of-life issues, patient care issues, and human rights issues. Frequent ethical issues faced by nurses related mainly to patient care issues and human rights issues, whereas the disturbing issues frequently related to end-of-life issues. The most frequent issues are staff- ing patterns, protecting patient rights and human dig- nity, providing care with possible risk to RNs’ health, conflict in the nurse or doctor relationship, and alloca- tion of resources. The disturbing ethical issues include prolonging the dying process, child or elderly abuse (neglect), staffing patterns, acting against your own personal, and impaired colleagues.
Nurses in daily practice face various ethical issues. In particular, as technology becomes more compli- cated and medical care resources become more limited, the concern over “staffing patterns” or “allocation of resources” is centered frequently on nurses, reflecting the industry-wide trend of balancing cost and quality (Killen et al., 1996). The issues are also ranked among the most disturbing issues; that is, it is not a rare event that nurses are directly involved in these most disturb- ing issues. Thus, nurses may need special support to ethically respond to the issues that are particularly dis- turbing to them.
Nurses in hospitals reported that they experienced frequent ethical problems related to patient confiden- tiality or privacy. In contrast, perioperative nurses more frequently encountered ethical issues related to protecting patient rights and the human dignity issue and informed consent than other issues. The frequency of ethical issues may differ depending on the nurses’ specialty areas. Redman and Fry (2000) reported that the main ethical conflict was experienced differently
by nurses in a particular role or setting. The findings indicate that ethical decision-making resources need to be made available to nurses in a specialty area in view of their higher-frequency issues.
In terms of how the nurses handle their ethical issues and what resources help nurses handle these issues, most of studies show that nurses deal with ethical issues on the basis of their own values and receive guid- ance from nursing peers rather than from ethics com- mittees. The fact that nurses use their personal values most frequently to clarify ethical issues draws atten- tion to necessity of nurturing qualified nurses in ethi- cal decision making through education. Furthermore, most of the nurses in the reviewed studies recognized the necessity of ethics education related to the ethical issues that they face. Therefore, nursing education should develop pragmatic ethics programs based on the ethical issues and the needs of nurses. In particular, the frequent ethical issue should be discussed in the ethics curriculum of undergraduate programs for developing skills in recognizing and analyzing the issues.
The code of ethics of the American Nurses Asso- ciation (ANA, 2001) deals with moral accountability as a nursing professional based on ethical principles. According to study findings, nurses have not recog- nized the code of ethics as their reference when ethical issues are encountered. However, nurses simultane- ously expressed education needs regarding professional ethical responsibility and ethic codes. Ethics educators in nursing programs need to explain the ANA’s code of ethics as well as ethical principles. The code of ethics will provide a guide for nurses when facing an ethical dilemma.
During the process of review in this study, the reviewer did not include several articles related to specialty areas because they did not deal with ethical issues in terms of frequency. This study may not have identified all relevant studies. Furthermore, this review has limitations related to information about nurses’ eth- ical issues in other special areas, except the operating room. Therefore, the author recommends further study related to frequent ethical issues that nurses face in a particular role or setting. Future study can help nurses understand ethical issues in special areas and allows developing ethics education focused on specific issues in a particular nursing practice. Furthermore, new ethical issues in nursing are emerging with changes in our society. This study shows ethical issues frequently repeating in nursing in the past two decades and may not include some current issues. Therefore, nursing educators and researchers continuously need to update the ethical issues into nursing education.
Park • Ethical Issues in Nursing Practice • 77
The ethical issues measured by frequency provide information about the specific ethical issues of nurses in active practice experience. Therefore, the informa- tion can serve to intensify awareness of the issues in clinical areas as well as education areas. Gilbert (1982) pointed out the identification of ethical issues as one of critical content areas in ethics education. The findings in this article can be used to design and improve eth- ics education programs for nursing students as well as practice nurses as pragmatic evidence.
REFERENCES American Nurses Association. (2001). Code of ethics for nurses
with interpretive statements. Silver Spring, MD: American Nurses Publishing.
Berger, M. C., Seversen, A., & Chvatal, R. (1991). Ethical issues in nursing. Western Journal of Nursing Research, 13 (4), 514–521.
Briggs, L., & Colvin, E. (2002). The nurse’s role in end-of-life decision-making for patients and families. Geriatric Nurs- ing, 23 (6), 302–310.
Bunch, E. H. (2001). Hidden and emerging drama in a Norwe- gian critical care unit: Ethical dilemmas in the context of ambiguity. Nursing Ethics, 8 (1), 57–67.
Christensen, A. (2002). Legal and ethical issues confronting oncology nursing. Seminars in Oncology Nursing, 18(2), 86–98.
Cook, A. F., Hoas, H., & Joyner, J. C. (2000). Ethics and the rural nurse: A research study of problems, values, and needs. Journal of Nursing Law, 7 (1), 41–53.
Fry, S. T., & Damrosch, S. (1994). Ethics and human rights issues in nursing practice: A survey of Maryland nurses. Maryland Nurse, 13 (7), 11–12.
Fry, S. T., & Duffy, M. E. (2001). The development and the psychometric evaluation of the Ethical Issues Scale. Jour- nal of Nursing Scholarship, 33(3), 273–277.
Gilbert, C. (1982). The what and how of ethics education. Top- ics in Clinical Nursing, 4, 49–56.
Jenkins, C. L., Elliott, A. R., & Harris, J. R. (2006). Identifying ethical issues of the Department of the Army Civilian and
Army Nurse Corps certified registered nurse anesthetists. Military Medicine, 171 (8), 762–769.
Killen, A. R. (2002). Stories from the operating room: Moral dilemmas for nurses. Nursing Ethics, 9 (4), 405–415.
Killen, A. R., Fry, S. T., & Damrosch, S. (1996). Ethics and human rights issues in perioperative nurses: A subsample of Maryland nurses. Seminars in Perioperative Nursing, 5 (2), 77–83.
King, C. A., & Miskovic, J. M. (1996). Ethical issues: A survey of perioperative nurses. Seminars in Perioperative Nursing, 5 (2), 84–91.
Omery, A., Henneman, E., Billet, B., Luna-Raines, M., & Brown-Saltzman, K. (1995). Ethical issues in hospital-based nursing practice. The Journal of Cardiovascular Nursing, 9 (3), 43–53.
Redman, B. K., & Fry, S. T. (2000). Nurses’ ethical conflicts: what is really known about them? Nursing Ethics, 7(4), 360–366.
Scanlon, C. (1994, November–December). Ethics survey looks at nurses experiences. The American Nurses , 22.
Scanlon, C., & Fleming, C. (1990). Confronting ethical issues: A nursing survey. Nursing Management, 21 (5), 63–65.
Schroeter, K. (1999). Ethical perception and resulting action in perioperative nurses. AORN Journal, 69 (5), 991–1002.
Vaughan, R. H. (1935). The actual incidence of moral problems in nursing: A preliminary study in empirical ethics (Studies in Nursing Education, Vol. II, Fasc. 2). Washington, DC: Catholic University of America.
Woods, M. (2005). Nursing ethics education: Are we really delivering the good(s)? Nursing Ethics, 12 (1), 5–18.
Wright, F., Cohen, S., & Caroselli, C. (1997). Diverse deci- sions: How culture affects ethical decision making. Critical Care Nursing Clinics of North America, 9 (1), 63–74 .
Biographical Data. Mihyun Park, MSN, RN, is a doctoral stu- dent at the University of North Carolina, Chapel Hill, North Carolina. She is also a Catholic Sister in Sisters of Our Lady of Perpetual Help (SOLPH), South Korea.
Correspondence regarding this article should be directed to Mihyun Park, MSN, RN, University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: [email protected]
Copyright of Journal of Nursing Law is the property of Springer Publishing Company, Inc. and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.
