THE DEVELOPMENT OF NURSING CASES FOR ETHICS RESEARCH: A METHODOLOGIC ENQUIRY
Louise R Sanchez-Sweatman
A thesis submitted in confonnity with the
requirements for the Degree of Master of Science
Graduate Department of Nursing Science University of Toronto
O Copyright by Louise R. Sanchez-Sweatman 1999
1+1
National Library ofCamda
Bibliothèque nationale du Canada
Acquisitions and Bibliographie Senrices
Acquisitions et services bibliographiques
395 Wdlington Street OtrawaON K 1 A W
395, nie Wellingtal O&awaON KlAON4 Canaeia
Canada
The author has granted a nonexclusive licence allowing the National Libra~yof Canada to reproduce, loan, distribute or sell copies of this thesis in microform, paper or electronic formats.
L'auteur a accordé une licence non exclusive permettant à la Bibiiothèque nationale du Canada de reproduire, prêter, distriiuer ou vendre des copies de cette thèse sous la forme de microfiche/film, de reproduction sur papier ou sur format électronique.
The author retains ownership of the copyright in this thesis. Neither the thesis nor substantid extracts 6om it may be printed or othewise reproduced without the author's permission.
L'auteur conserve la propriété du droit d'auteur qui protège cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation.
ABSTRACT The Development of Nursing Cases for Ethics Research: A Methodologic Enquiry
Louise R Sanchez-Sweatman
Master of Science, 1999 Graduate Department of Nursing Science University of Toronto Cases are frequenly used in education to teach concepts or skills and to evaiuate the extent of learning. However, the methodology for developing these cases is not clearly identified in the literature. This study was part of a larger research project that required a case-based instrument in order to deveiop and test a theory about how nurses make ethical decisions. The study describes the creation of four ethical cases, or scenarios, that codd be used to elicit judgement responses fiom nurses. Guidelines were developed, and, based on these guidelines and content analysis of experiences reported by fifty-five Canadian nurses,
environmentally valid cases for nursing ethics research were written. The results of tbis study contribute to methodologic knowledge about case development, case study research, education case development, and instrument development.
A
0WLEDGEMENTS
1 thank my family and fiends for their continuous support over the years it took to
compIete my degree and thesis. 1 wodd also iike to thank my cornmittee members: Gai1 Donner, PhD,my supervisor; Anne Moorhouse, PhD; and Hilary Lleweilyn-Thomas, P D . Dr. Donner provided steady input, keen interest, and strong enthusiasm throughout this project. Her many skills and extensive knowledge were invaluable, and 1 thank her for
s h a ~ them g with me. 1 thank Dr. Lleweiiyn-Thomas for her thoughtful criticisms of the structure and organization of the thesis; 1 very much appreciate her suggestions. Finaily, 1
thank Dr. Anne Moorhouse for initiating the research project to study nurses' ethical decision making and for permitting me to participate in her research project.
TABLE OF CONTENTS
..
ABSTRACT .................................................................................................................
u
ACKNOWLEDGEMENTS ..........................................................................................
ut
...
TABLE OF CONTENTS .............................................................................................iv LIST OF T E S ....................................................................................................... vi LIST OF FIGURES .....................................................................................................
vii
LIST OF APPENDICES ..............................................................................................
vu
CHAPTER 1: PROBLEM AND PURPOSE .................................................................
1
***
Background to the Research Problem ............................................................ 1 Pilot study .............................................................................................
2
Foiiow-up study ...................................................................................
5
Probtem Statement .........~............................~..................................................... 7 Literature Review .............................................................................................
7
Education Literature ............................................................................. 8 Surnmary of the education iiteratwe ......................................... 11
Judgement Theory Literature .......... .................................................... 12 Summary of the judgernent theory literature ............................... 15
Purpose ............................................................................................................
15
Definitions of Tenns ......................................................................................... 15
Guiding Framework ......................................................................................... 16 CHAPTER II: METHODS ..........................................................................................
22
Stage One: CoUecting the Practice Narratives .................................................. 22
iv
Stage Two: ûrganizing a d Analyzing the Practice Narratives.......... . . . ........e23 s. Stage Three: Writing the Cases .... ......................................................... 27
E
C o i d t i o ........................................................................................
27
Summary of Methods ......................................................................................... 28 CHAPTER
m: RESULTS AND DISCUSSION............................................................
30
Stage One: Coilectiog the Practice Narratives .................................................... 30 Stage Two: Organipng and Analyzing the Ptactice Narraîives ......................-....31
Stage Three: Writing the Cases ..........................................................................
38
Limitations .........................................................................................................
46
Implications ........................................................................................................ 47
Case Development ..................................................................................
47
Case Study Research ............................................................................. 47
Education Case Development ................................................................. 48 Instrument Development ......................................................................... 49
Implications for Future Research ............................................................. 49
Summary and Conclusions................................................................................... 50
REFERENCES ..............................................................................................................
53
LIST OF TABLES Table 1:
The Most Frequent Ethical Situations Identifieci by Nurses .......................32
Table 2:
Case C: Type and Frequency ofResponses th& Occutred in the Hospital
and the Identifidon Table 3 :
Number of the Practice N d v e s Used .................. 37
Case D:Type and Frequency ofResponses that Occwred in the Hospital
and the Identification Number of the Practice N d v e s Used ..................38 Table 4:
Ethicai Issue(s) Included in the Cases ........................................................ 39
Table 5 :
Ages and Chicai Areas ofthe Four Cases ..............................................40
Table 6:
Characters Appearing in the Four Cases: Role and Name .......................... 41
Table 7:
Moorhouse, Dow, et al. (1997) Theoretical Elernents Included in the Four Cases: Legal Aspects, institutional Policy and Professional Values ............ 42
LIST OF FIGURES Figure 1 :
Oveniew of Studies in Research Program ........,..........~~~~~~..~~...~.~ 6
Figure 2:
Bninswik's Lens Model ......................................................................
14
Figure 3 :
Template for the Practice Narraivees Chart ..........................................
23
Figure 4:
Template for the Ethical Issues Frquency Table ................................. 25
Figure 5:
Template for the Setting Chart ............................................................
Figure 6:
Five Steps to Develop Environmentaüy W d Ethical Case
vii
.................
26 29
LIST OF APPENDICES A. Letter of Invitation ................................................................................................. 58
...., B . Completed Practice Narratives Chart .....*................ . . ..................................... 61 C. Frequency Table of Ethical Issues ..............................................................................
72
D . Completed Setting Chart for CorrunUMty-Based Practice Narratives .......................... 79
E. Case A ......................................................................................................................
81
F. Case B .......................................................................................................................
83
G. CaseC ..................................................................................................................... 85
H. CaseD ......................................................................................................................
88
1. Practice Narratives Related to Probnging Life and Palliation ...................................... 90
J. One Nursing Home and Two Hospital Practice Narratives Used in Case B ................. 91
CHAPTER 1
PROBLEM AND PURPOSE Background to the Research Problem
Nursing practice is a moral enterprise (Johnstone, 1998) ûlled with ethical diiemrnas. Nurses' contact with patients continuaily places nurses in ethical situations. Furthermore, nurses have obligations to thernselves, their regdatory bodies, the institutions wherç they work. and oùier heaith care professionais that ofien engender ethical conflict Advances in technology, Iimited W t h care h d i n g , and the patients' rights movement have fùrther contributed to the complexity of ethicai situations in nursing care. The challenge for nurses is to provide ethicaüy sensitive health care in a moral, professional, and accountable manner.
Ethical nursing practice requires recognkhg, i d e n t w g , and analysing dilemmas to detennine what ought to be done, which, in turn, means that nurses m u t be active participants in decision making about ethical issues. Their decisions must meet the standards of ethical nursing practice as defined by nursing regdatory bodies and the profession's code of ethics. The teaching of ethics to nursing students is one method of preparing nurses to
recognize, identifi, analyse, and resdve ethical dilemmas. Although the teaching of ethics in nursing education has k e n expanding over the past two decades (Wehrwein, 1996)- little is known about the goals, teaching methods, or effectiveness of nursing ethics education
generally (Thompson, 1991) or specifically in Canada (Moorhouse, Caulfield, Donner, &
Thomas, 1993; Moorhouse, Caulfield, Donner, & Yeo, 1993; Moorhouse, Caulfield. Donner, & Thomas, 1996). in an attempt to rectifi. this gap in knowledge, Moorhouse et al.
2 ( 1996) conducted a Canada-wide pilot study of nursing ethics education; they embarked on
this pilot study with the assistance of a Strategic Grmt fiom the Social Sciences and
Humanities Research Counçil of Canada (SSHRC). Pilot Studv The purpose of the SSHRC pilot study was to develop methods to w e y and assess current Canadian educational prograrns in nming bioetbics (Moorhouse et al., 1996). The
goals of the pilot study were to (a) develop a study design and measurement strategies to survey and evaluate the bioethics education of nursing students, (b) carry out a survey of ethics education in nursuig programs at five undergraduate nursing schools in southern
Ontario, (c) describe the effectiveness of these programs in teaching nursing students to be ethical decision makers, and (d) make preliminary observations and recommendations about the teaching of etfiics to nursing students (Moorhouse et al., 1993).
The instruments used in the SSHRC pilot study included the Nursing Dilemma Test (NDT), which was developed by Crisham (1 980) and based on Kohlberg's theory of moral development (1 984). Kohlberg's theory (1984) is founded on the premise that moral reasoning is influenced by cognitive development. The theory comprises six stages of m o d
developrnent, which are grouped into three major levels: (a) the preconventional level, stages 1 and 2; (b) the conventional Ievel, stages 3 and 4; and (c) the postconventional level, stages
5 and 6. The preconventional level generally applies to children under the age of nine and
some adolescents. These individuals have Little understanding of societal rules and expectations. individuals at the conventional level include adolescents and most adults. These people are aware of societai expectations and conform to them because they are
3
society's d e s . The postconventional level applies to a minor* of individuals who have differentiated themselves fkom convention and who make judgements and decisions on the basis of principles rather than societal noms and expectations. Kohlberg's theory (1984) assumes that moral behaviour progresses through the levels and stages in a Linear and irreversible manner, with each stage representing more complex reasoning. For example, Stage 1 is identified as practical moral reasoaing, whereas Stage 6 is identified as justice-
based moral reasoning, where the individual uses an unbiased and cntical approach to ethical decision making (Kohlberg, 1984). To meet the goals of the SSHRC pilot study, three sets of respondents at three
univenity and two community coUege nursing schools in southem Ontario, Canada were asked to participate: deans (n = 9,faculty members (n = 67), and students (n = 92). The sites chosen taught ethics in a variety of ways ranging fiom informal ethics discussions to formal lectures. Deans were asked in muctured interviews m d pre-tested questionnaires to
report the goals of, and recommendations for, bioethics education at their schools. Faculty members were asked in pre-tested questionnaires about their educational preparation to teach bioethics, the educational goals of the bioethics component of the curriculum, and the bioethics content of the curriculum at their school. The students, al1 in their fuial year of study, were asked to respond to the NDT questionnaire, with supplemental questions about factors iduencing their decision making and their ethical values, attitudes, and knowledge.
The purpose of the NDT is to measure the subject's abiiity to make ethical decisions by determinhg the appropriateness of their responses to ethical dilemmas. The NDT is a paper and pencil test in which subjects are presented with six dilemmas and are asked to
4
(a) choose, îkom three possible options, what they would do in the particular dilemma, where
at least one option is based on practicd considerations and a m h e r on principled thinking rationales; (b) rank the moral and practical considerations in order of importance; and (c) state the degree of their previous familiarïty with the dilemma- The answers to (a) and (b) are then rated on a scale based on Kohlberg's theory of moral developrnent. The theoretical ideal mean score is six for practicai considerations and 66 for principled thuiking (Crisham, 1980).
In the SSHRC pilot study, the overail mean scores for practical considerations and principled thinking were 16.3 and 53.7 respectively; these results implied that the nursïng students used practical and p ~ c i p l e dttiinku?g concurrently. This observation is incongruent with Kohlberg's (1984) work, which theorizes that those who apply principled thinking are not influenced by practical considerations, because principled thinkers have progressed beyond the practical levels. The results of the SSHRC pilot study, wherein students scored
high on both practicd and principled thinking, suggested that, for nurses, practicd issues are relevant in solving ethical dilemmas. Moorhouse and her colleagues (1 993) argued that this combination was reasonable, because nwsing is a practice discipline and nurses are required to make decisions that take iuto account practical implications. The investigators also found
that the ethical situations presented in the NDT did not reflect ethical dilemmas in nursing, that some were not dilemmas, and that others did not reflect the complex circumstances of nurses' working environments. Furthemore, the use of hypothetical dilemmas raised questions about the realism of the situations. Thus, Moorhouse et al. (1996) concluded that the NDT is limited in its ability to measure nurses' ethical decision making.
in view of these results, Kohlberg7stheory may be inappropnate for rneasuring
5
nurses' ethical decision making. His theory has been criticùed for its exclusive definition of good moral reasoning in t e m s of the principles of justice rather than also considering the particulars of situations or the opportunity to do good (Gilligan, 1982). Because, according to Gilligan (1982), this caring approach is more characteristic of women, and the nghts and d e s approach is more characteristic of men, Kohlberg's theory (1984) may be limited in scope, and the application of the NDT to women rnay produce invalid scores. Given that the nursing profession is composed primarily of women, it may be inappropriate to use the
NDT, with its b a i s in Kohlberg's theory, as a way to measure nurses' ethical decision making. Therefore, a theoreticai framework addressing the complex nature of nurses'
ethical decision making, as weii as an appropriate measurement tool are required. Follow-UDStudy Moorhouse et ai. (1996) concluded that, before undertaking a national survey to examine bioethics in Canadian nursing educational programs, they needed to better understand the processes of nurses' ethicai decision making, as weil as how to mesure and evaluate that process. A follow-up study was designed to achieve those goais. The purposes of this study, also îùnded by SSHRC, were to develop (a) a concepnial framework describing how nurses ought to make ethical decisions, and (b) an instrument to evaluate nurses' ethical
judgement. The first objective, developing the conceptual framework, was achieved by Moorhouse, Dow, Wall, and Donner (1 997). The second objective, developing an instrument to evaluate nurses' ethicai judgement, invotved preparing four ethical "cases,"
with associated multiplechoice questions and a stnictured interview. This study documents the development of these four ethicai cases. Figure 1 provides an oveMew of the studies.
7 Problem Statement In the dinical setting, nurses use their judgement in ethical dilemmas to decide what course of action to follow. Because the clinical judgement process is private, quasi-rational, and non-repeatable (Hammond, 1959, our bowledge of the processes of nurses' judgement and ethical decision making is limited. Given the inçreased complexity of the clinical
setting, it is necessary to understand how these decisions are reached, because reliance on intuition is insufficient to meet the demands of the health care setting. The goal of this study was to develop four environmentally vaiid cases, to be incorporated in an instrument that
could subsequently be used to better understand nurses' ethical decision making. The process of developing cases is not clearly described in the literanire. While cases have been used fkequently for educational and evaluative purposes, Little has been reported describing the process of developing cases that reflect the practice setting. in the area of cognitive psychology, particularly in judgement theory, models can be found to represent judgement formation and decision making. However, there is little in the literature about developing environmentaily valid cases to trigger judgement responses. Therefore, this study addressed the problem of developing environmentally valid ethical cases that can elicit judgement responses which then can be critiqued using an ethical decision making theory (see Defhitions of Tems, pages 15- 16). Literature Review This review surveyed two bodies of literature in case development, by s e a r c h g the (a) databases of CINAHL, Medline, and ERIC, and (b) University of Toronto and University
of Ottawa book catalogues, using key words such as instrument development, case
8
development, prototype, method, decision making, and judgement. The body of literature first reviewed was descriptive and empirical in nature: the education literature on case development. The teaching environment is well known for its use of cases to teach and evaluate students. Some education theories, such as problem-based learning, are solely reliant on the use of cases to teach students new ideas, behaviours, or
skilk For these reasons, it seemed logicai to review the teaching literaiure. The second focus of the literature review was theoretical: Brunswik's judgement theory (1952). Brunswick argued that judgement responses were a fiinction of b t h individual characteristics and the environment, which he represented in a "lens model" (explained on page 13). It seemed appropriate tu review Brunswick's model because this study was concerned with writing cases to elicit judgement responses based on environmentai cues (see Purpose, page 15; and Methods, pages 22-28). Education Literature The education literature revealed two starting points for the process of case development: one begins with a conceptual model or theory, and the other begins with realIife scenarios. This author found no literature that either described in detail or provided a cornparison of these starting points. Cases are fiequently used to either evaluate or to teach nursing and medical students (Aroskar, 1977). In the literature one study by Hébert, Meslin, Dunn, Byme,and Reid (1990) was found that developed an instrument using cases to evaluate the ability of medical students to recognize ethical issues. in that study, a group of individuals with various backgrounds and education developed five vignettes and a list of ethical issues associated
9 with each vignette; the purpose was to assess recognition of etbicd dilemmas, which is only
one aspect of ethical decision making- Theu study report did not identiQ how the vignettes were developed, other than stating that they had k e n Wfitten by a group of individuals, nor did their study evaluate the ethical decision making process.
With respect to the second use of cases, to teach, the aim is to develop critical
thinking, probIem-solving, and reflective skills @ailey, 1992; Lowenstein & Sowell. 1992: Parker, 1995). Thus, the case-based method of teaching has been used in nucsing ethics education (Dailey, 1992; Thompson, 1991) and problem-based learning (Glick & Armstrong, 1996; VanLeit, 1995). Cases are the focal point of problem-based Iearning, which is discussed more fùlly below. Problem-based leaming (PBL) is an instructional method using cases in small-group tutonals for teaching-leaming purposes- A conceptual model for the development of PBL paper cases has been created at McMaster University in Ontario, Canada (Mohide, Dnimmond-Young, Byme, Baumann, Avilla, & Tew, 1996). In this model, eight steps are outlined for problem development. For example, step three involves the development of the problem using a clinicai situation; however, procedural details are not provided. GIick and Armstrong (1996) described four requirements in developing cases for problem-based leaming. The cases must reflect tme-life stories, generate scientific understanding, rneet the educational course goals, and integrate into the curriculum. While the authors emphasized the importance of the use of cases in Iearning and the goals that the
cases must meet, they did not describe a systematic methodology for case development. Houts and Leaman (1983) indicated that, when developing teaching cases, the first
10
step was to select a problem based on actual experiences. in their view, cases should as much as possible represent reality. They believed that deletion of facts fkom the actual experience was permissible; however, the addition of externai facts to cases was inappropriate because this would destroy authenticity. They also provided guidelines on the organization and presentation of cases, such as details about the physician and community where the case transpire& Again, these anthors did not describe the steps in incorporating real-life clinicai situations in the development of cases. Erksine, Leenders, and MauEette-Leenders (198 1) explicitly stated that cases m u t be selected fiom real-life situations, otherwise the cases are merely fictionalized versions of
reality. They argue that cases must: (a) be acqukd fiom actuai experiences; (b) contain sufficient information for the reader to identifi with the situation; (c) be curent; and (d) accomplish the educational purpose for which they were intended. Al1 of these authors (Glick & Armstrong (1996); Houts & Leaman (1983); Erksine, Leenders, & Mauffette-Leenders (1981)) emphasized using real-life material and actual experiences as the starting point fiom which to develop cases. They focused on the educational goals and on the presentation of the cases. This literature, however, said little about how to use real-life scenarios and translate them into cases. There is another trend in the case-based method teaching literature. Dailey (1992) argued that the students' characteristics and the leamhg objectives should be defined before developing cases. With respect to case development, she suggested outiining a problem statement, case characters, pertinent facts, a logical chain of events, anaiysis, and diagnosis of the problem. Once the outline is completed, she proposed that cases should progress fiom
11
simple to complex problems in a chronologicai or logical order. The development of scenarios as described by Dailey (1992) focused on a formalistic marner of developing cases fiom an abstract position. That is, she did not suggest the selection of a real-life situation and then use o f that real-Me situation to develop cases, Her rationale was that to develop positive student aîtitudes toward learning, instruction must incorporate the needs of the learner and this mast be detemiued pnor to developing the actual case. Her perspective, therefore, is to draft an o u t h e and then develop a case using real-life facts. Barrows (1985) supported Dailey's (1 992) view of h
t determinhg
the problem and
then crafting cases to support the course content that the student is expected to learn. Again, little specificity is provided as to how to develop cases. Hafler (1991) combined and expanded Dailey's (1992) and Barrows's (1985) suggestions- Her perspective, like Dailey's (1992) was driven by curricula requuing paper cases to teach students various concepts. Rather than having the same person draft the concepts and cases, she proposed that faculty members identim the course goals and that writers be selected to draft the cases. These writers were fiee to develop the case however they pleased. Hafler (1991) aoted, nonetheless, that case writers found that the best cases were derived fiom real situations.
Summarv of the e d i i d o n li-.
This literature suggested two approaches
related to case development: in the first, cases must directly reflect a real problem. and therefore, cases are a reflection of actual events; and in the second, cases are written considering the theories or principles to be taught. These two approaches suggested two
12
different starting points for developing cases: red-life scenarios or theoretical concepts. Although two different starting points are identified, there are few guidelines for developing cases (Mohide et al., 1996)- There is clearIy a need for guidelines outlining the development of cases to ensure a systematic process of case construction.
Judeement Theory 1. i t e r a m This literature review also focused on judgement theory because of the overail motivation to write cases that could be used to elicit judgement responses. Psychologicai research on judgement and decision making theory in the mid-twentieth century began to follow two trends based on two different views (Goldstein & Hogarth, 1997). One view, grounded in economic and probabilisric theories, is focused on how people make choices or decide on a course of action. The second is interested in how people integrate multiple ambiguous environmental cues to arrive at an understanding and judgement of a situation;
this view makes use of theories of judgement and perception (Goldstein & Hogarth, 1997). The fundamental questions both views are attempting to answer are the following: How do
people make decisions? How can we improve decision making? Hurnan beings Iive in complex environments with numerous direct and indirect variables influencing their ability to make judgements, and thus theu behavîour. The problem human beings face is to know this environment and to cope with these variables
which are only partly predictable (Hammond, Stewart, Brehmer & Steinmann, 1986). The limited predictability of these ambiguous and interdependent environmental variables creates causal arnbiguity (Tolman & Brunswik, 1935). Human beings use a variety of processes,
such as perception, instinct, memory, intellect, emotion, leaming, and thinking to manipulate
13
the variables to decreilse or eliminate this causal ambiguity. When this is not possible,
however, human beings must exercise their judgement (Hammond et al-, 1986). Judgement theories, therefore, strive to answer the question of how people integrate multiple,
probabilistic, and potenîidy conflicting environmental cues to arrive at a judgement. Egon Brunswik is considered a founder of judgement theory. His research focused
on the analogy betweenjudgement and perception. Brunswik insisted that the environment and the individual must be analyzed in order to l e m more about human judgement (Tolman & Bmswik, 1935). This means that two parallel and symmetrical concepts must be
addressed: the environmental and the individuai systems (Hammond et al., 1986). This symmetry is represented in a "lem model" (Brunmlck, 1952; Brunswik, 1955) (see Figure
2). On one side of the Lens the environment is represented, and on the other side the cues used by the individual to make a judgement are represented.
Variable
]
!
Cue Utilization
Environmental Validity
Cues
Figure 2: Brunswik's Lens Mode1
Summarv of t h e m e n t b o r y l i t e r a w - A great ded has k e n written in the psychophysics, measurement, decision making, and social psychologicd fields on judgement processes. Judgement processes, which can only be understood by inference, are used by nurses and other clinicians. Thus, judgement research methodology is concerned with eliciting responses under given conditions so that cornparisons of judgements c m be made between (a) different individuais responding to the same conditions or cues, and (b) the same individuals responding to different cues (Eiser, 1990). Purpose The purpose of this study was twofold: (a) to identify guidelines to develop environmentally valid ethical cases, and (b) based on these guidelines and using practice narratives reported by Canadian nurses, to write four environmentally vdid ethicai cases. Definitions of Tems The following definitions are provided to assist the reader. Cases - hypothetical stories about ethical situations and invoLving a nurse and other
characters such as patients and physicians, based on one or more practice narratives. Practice narratives - experientid stones that practising Canadian nurses recalled fkom
memory and reported in an ethics survey. Ethics survey - the method of data collection, carried out by the larger research team, that was used to collect self-reported ethical situations fiom nurses (see Figure 1).
Larger reseurch team
- the Moorhouse research team; of which this study is a part (see
Figure 1). EnvironmentaZZy valid cases - realistic nursing ethical stones which will elicit a judgement
response by the case reader.
Environmenrai cues - iafomation in the cases gathered fiom the practice narratives.
-
Ethical situations or stories situations involvhg either a confict between (a) a moral obligation and selfointerest, or (b) two opposiag moral obligations.
Guidelines - specific directives identified by the larger research tearn, or by this author prior to analyzing the survey data, or dwing analysis of the s w e y data, to guide the writîng of the cases.
Guiding Framework Since the purpose of this study was to develop environmentaiiy valid cases with cues to elicit responses fiom nurses, the cases had to be constructed to reflect ethical dilemmas that would require nurses to use their ethical knowledge, decision making, and judgement skills. Because the literature review generated no explicit method for developing such cases, this exploratory study was limited to the identification and description of guidelines necessary to write four environmentally valid cases. The process of i d e n t i m g the guidelines occurred throughout the study; some guidelines were identified by the larger research team, or by this author prior to, or concurrent with, the analysis of the survey data. Regardless of the time point at which they were identified, for purposes of clarity al1 nine guidelines (A to 1) are outlined below. Guideline A: The Cases Must be Situaed in NursU Practice Because the larger research study is interested in studying nurses' ethicd decision making. the cases had to involve nurses in nursing practice. Ethical situations ofien arise for
nurses because of the context in which nurses work. For exarnple, nurses fiequently have
17
responsibilities to their employers, to their professional bodies, and to themselves. Nurses also work in health teams with other health care professionds and volunteers- Furthemore, nurses are aEected by the health care system and the reduced resources of health care personnel and equipment. The relationships, pressures, obligations, and expectations brought to bear on nurses in the practice setting, therefore, had to be evident in the cases. Guideline R: The Cas-
Present Diment m a l Issues
For practical and strategic rasons, the cases each had to present different ethical issues. Practically, nurses encounter a multitude of ethical situations in their nursing routines; therefore, for the cases to be realistic they had to reflect a variety of nursing ethical situations. Strategically, cases with different ethical situations would eiicit a breadth of judgement responses and, therefore, increase the scope of analysis. Additionally, the larger research project's instrument will require the subjects to answer questions on four cases; their interest, therefore, would need to be sustained to maintain their motivation to complete the instrument's questions. To use sùnilar ethicai situations in each case would be
unattractive to the subjects, increasing the possibility of questions k i n g ignored or incompletely answered. Guideline C:The Se-
of the Cases Must be D i f f i
Nurses work in many settings: institutional (such as hospitais and nursing homes), clinics, patients' homes, and independent practice. The majority of nurses, however. work in hospitais (College of Nurses of Ontario, 1998); therefore, the ethical situations of the majority of cases had to occur in a hospitai. However, because nurses aiso work in patients'
homes and in other institutions,these settings also needed to be exhibited in the cases.
18
Guideline D: The C w M m Incbde Q p a c t m with a Varietv of
Nurses work with patients of al1 ages; thus, the four cases had to uiclude patients of al1 age groups to reflect this lifespan. Guideline E: The Cases C
o
-
..
of C b a l A r e s
Because nurses work in a variety of clinical areas (e-g. medical-surgical, obstetrical, psychiatry), the ethical situations in each case had to occur in diffèrent clinical contexts. A variety of clinical areas would be more representative of the situations in which nurses work
and, thus, more authentic.
Guideline F: The Cases MuInc-cters
of Vaxied Cul-
Ba-ounds
and of
Both Sexes Nurses care for male and female patients of different cultural, educational, social, and religious backgrounds. Nurses and other health care professionals also reflect both sexes and a variety of cultures. Thus, the characters in the four cases had to include male
and fernale nurses and patients of different cultures. Guideline G: The Cases Must Involve Freauentl~Encountered Ethical Situations Because the larger research study is to develop an instrument to evaluate nurses' ethical decision making in general and not just in specific ethical situations, the cases had to
include commonly encountered ethical issues. Guideline H: The Case Prese-
be -tr-
. .
Clear. a d &tlistiç
Because the four cases will constitute the prirnary measurement strategy to be used in the larger research study's instrument, the cases had to be bnef, clear, and engaging. The realism of the cases was to be fostered in part by following Guidelines A - G, and in part by
19
using the practice narratives (see Chapter II, Methods, pages 22-28). Cover the El-
of the Ihde-cai
..
Decisipn
Theorv The cases had to include the four elements of the Moorhouse, Dow, et al. (1997) theory of ethical decision making. This theory is explahed in pater detail below. The tenns contaùled in this theory are not de-
by the authors and, because this theory is not
central to this study, no attempt is made in this study to define them. For the sake of clarity, this author wili describe the theory using the words, such as "decision" or "elements", as used in the theory by the authors.
The Moorhouse, Dow, et al. (1997) theory of ethicd decision making for health care practitioners has four elements: pre-requisites, ethical reasoning, prudentid reasoning, and
Pre-requisites are the resources that nurses use when faced with an ethical problem requiring a decision. These resources include (a)education in ethics, which ought to
include instruction in legal issues, professional standards, and codes of ethics; (b) critical
thinking skills, or the knowledge and ability to identiQ and analyse problems; (c) nursing experience, including the establishment and maintenance of the therapeutic nurse-patient relationship, knowledge of institutionai policies, and knowledge of social and health policy; (d) values-clarification, or reflection on personal values and priorities; and (e) intellectuai
and moral v h e where nurses critically assess the situational moral requirements and
constraints, and recognize the moral factors to respond affectively.
The second element, ethical reasoning, is the process by which nurses reach a
decision about the ethicai problem by considering o d y ethical theones and principles. That is, the nurse critically analyses the problem and reaches a conclusion of what ought to be done based on ethical premises, without consideration of the practical consequences.
In the prudential reasoning element, the working environment (for example. institutional poficy), professional standards of practice, legal issues, the nurse's values, and the decision arising fiom ethical reasoning are considered- The result is that the prudential
decision may or may not coincide with the ethical decision. Shodd the decisions not coincide, the nurse must choose wtiich decision, ethical or prudential, to act upon. If the prudentid decision is favoured, then the nurse must evaluate the consequences of this decision &er she or he has acted upon it. The fourth eiement is evaluation which involves follow-up. Once the nurse has irnplemented the prudential decision, she or he may do nothing m e r , or the nurse may actively search for ways to resolve the constraints that required the nurse to undertake the
prudential decision rather than the ethical one. The Moorhouse, Dow, et al- (1997) theory is presented by its authors as an 3deai" theory of ethical decision making because, according to its authors, it represents how nurses "ought" to resolve ethical dilemmas. Thus, when nurses are presented with an ethicai dilemma in a case, for example, and are asked to respond and record their judgement, their response can be evaluated in terms of this theory.
. .
Summary of the mridelines. The nine guidelines identified above were intended to
ensure the preparation of environmentaliy valid cases that would trigger the kinds of
judgement responses that actually occur in real situations. These cases could then
subsequently be used without generating the problems that were encountered with the Nursing Dilemma Test that had been used in the SSHRC pilot study (see pages 2-5).
CHAPTER II METHODS This section outlines three methodologic stages; the fïrst was accomplished by the larger research team and the remaining two by this author. The f k t stage involved a survey to collect practice narratives, and the second and third stages, which formed the basis of this study, consisted of orgaxziang and analyzing the practice narratives with reference to the guiding framework (see Chapter 1, pages 16-21) and then writing the cases. Because the
t Stage One, al1 stages are described execution of Stages Two and Three was c o n ~ g e nupon below. Stage One: Collecting the Practice Narratives The larger research team had detennined that the cases had to be reaiistic, so data had
to be collected on the kinds of ethical situations that nurses have actually encountered. The larger research tearn, therefore, surveyed practishg Canadian nurses, asking them to describe, in writing, ethical situations in whiçh they had been involved or that they had observed in their clinical practice. Survey subjects were approached by means of a letter of request and poster (Appendix A), which were mailed to (a) al1 institutiond and nurse members of the Canadian Bioethics Society; (b) al1 faculty of, and those with a cross-appointment to, the Facuity of
Nursing, Universi5 of Toronto; (c) d l hospitals, and heads of nursing associated with the Joint Centre for Bioethics, University of Toronto; and (d) d l nurses who attended the nursing workhg lunch at the Canadian Bioethics Society annuai conference in Montreal in 1995. Approxirnately 300 packages were mailed. A notice inviting nurses to submit
23 practice narratives was also pubhshed in the October 1996 newsletter of the Ontario Nurses' Association. The subjects were asked (a) to r
d and describe an ethical situation, identifjhg the
type of setting (for example, hospitd or nursing home) and any bamers that hindered them
fiom acting ethically; (bj to avoid providing any data that rnight identifjr the institution, a
patient, a nurse, or other health care professionals; and (c) to send theu descriptions via regular mail to the principal investigator's attention. The survey responses were stripped of any identifjhg information by an undergraduate nursing student (see Ethical Considerations,
pages 27-28). Stage Two: Organizing and Analyzhg the Practice Narratives
The practice narratives were organized and analyzed in four steps: (a) development of a Practice Narratives Chart, (b) development of an Ethical Issues Frequency Table, (c) development of a Setting Chart, and (d) development of questions related to the setting. These steps are outlined below. S t e 1: ~ Deveio~mentof the Practice Narratives Chm
The Practice Narratives Chart (see Figure 3) was developed to structure the content
analysis of the practice narratives collected in the ethics survey.
LDENTIFICATION
SEITLNG
PERSON
FACTS
ISSUES
COMMENTS
Setting of the ethical situation
Main character
Summary of
Ethical issues
Other relevant points
NUMBER Identification of the practice narrative
-
ethicai
situation
m r e 3. Template for the Practice Narratives Chart.
24
Number. The practice narratives were identified by nurnber in the order that this author received them fiom the principal investigator of the larger research project. Setting. Given GuideLine C (see page 17), which stated that the cases had to reflect
the numerous settings in which nurses work, data on the setting of the ethical situation were required.
x developed h m this process, Person. Because the cases, that were eventually to l had to trigger judgements from nurses, the practice narratives of interest were those of nurses
and not other heaith care professionals. Thus, information about each practice narrative's
main character or the person involved in the ethical situation was required. Facts. The salient facts for each practice narrative were summarîzed to allow this author to recall its content. Issues. The practice narratives were collected to provide material that could be used in the preparation of reaiistic ethical cases. There was no guarantee, however, that the survey respondents actually had described ethical situations, so the narratives were analyzed
for their etbical content. Criteria that were used for this analysis were ethical principles (for example, justice and beneficence), and ethical values as refiected in nursing codes of ethics. Cornmen@ A final column was included in the Practice Narratives Chart for points raised in the practice narratives that were untelated to the other columns. Once the Practice Narratives Chart had been developed, the content of the narratives
analyzed, and the results recorded in the Practice Narratives Chart (see Appendix B), the thesis supervisor reviewed the narratives to validate the content analysis.
S t e II: ~ Deveionment of the Ethical Issues Freauencv Table Guideline G (see page 18) required that the cases involve a commoniy occurring ethical situation. The Practice Narratives Chart did not assist in c l a s s ~ the g type of
ethical situation or in detennining the îkquency of the situations encountered by the nurses surveyed; it only provided a structure to i d e n t e and record the setting, person, facts. and
issues of e ~ c h narrative. A method to debeate the type and frequency of the etbical situations was necessary and, therefore, a fiequency table was created (see Figure 4)-
1 ISSUE Type of ethical issue.
1 NUMBER OF OCCURRENCES Identification, using the "Issues" column of the Practice Narratives Chart, of every practice narrative that contained the type of ethical issue.
1 TOTAL NUMBER Frequency count for each type of ethical issue.
Figure 4. Template for the Ethical Issues Frequency Table The purpose of the fiequency table was to (a) list al1 of the types of ethical issues identified in the practice narratives (for example, euthanasia and withdrawal of treatment), and (b) record the fkequencies of occurrence of each type. This table was completed using
the qualitative information compiled under the "Issues" column of the Practice Narratives Chart; every occurrence of each issue was noted with a check mark in the table and then a
total frequency count was computed (see Appendix C). Step In: Developrnent of the Senineçhaa
Guideline C (see page 17) mandated that the ethical problem of each case had to occur in a unique setting, different fiom the setting of every other problem, and Guideline H
1
26 (see pages 18- 19) required that the cases be realistic. Therefore, it was essential to determine which practice narratives occwred in which settings. This could be done by, for example, identiwg al1 the practice narratives in which the reported ethical problem had occurred in a hospital. Although the Practice Narratives Chart provided a summary of the various attributes of the narratives, it did not group al1 the narratives that occurred in the same setting. To do this, a four-attribute Setting Chart (see Figure 5) was developed.
IDENTIFICATION NUMBER Identification number of the practice narrative (taken fkom the Identification column of the Practice Narratives Chart).
l
ISSUE
USE?
Type of ethical issue (taken from the Issues column of the Practice Narratives Chart).
Decision as to whether Reasons why the to use the ethical issue ethical issue should in a case (Yes or No). or should not be used in a case.
REASONS
Figure 5. Template for the Setting Chart Identification numbec. Because the "Setting" column of the Practice Narratives Chart had identified the setting in which ai1 the practice narratives had occurred, al1 the
practice narratives whose ethical dilemma had occurred in the same setting were identified and this information was copied to the first column of the Setting Chart.
Issue. The information in the "Issue" column of the Practice Narratives Chart was copied to the second column of the Setting Chart.
Use?. In this column this author specified whether the practice narrative should be used in a case.
27
Re-.
in this coliimn this author recorded the reasons for the decision about
whether or not to use information fiom the practice narrative in the development of the cases.
Al1 of the practice narratives for a given setting were reviewed, and the information was recorded in the Setting Chart (see Appendix D). Stetl TV: Develo~mentof Ouestions Related to the S e m
Once the practice narratives for each setting (for example, al1 those occurring in a hospital or a nursing home) had been identified with the Setting Chart, a series of questions was posed to M e r analyze the data. These questions emerged fiom a review of the
guidelines and the content analysis of the practice narratives (see Results and Discussion, pages 34-35) .
Stage Three: Writing the Cases Writing the cases involved adhering to the guidelines and using the results of the
content analysis of the survey data. A systematic consideration of the guidelines was used to write four fictional cases.
Ethical Considerations The larger research project had received ethics approval fiom the Office of Research Services, University of Toronto. Because this study was a part of the larger research project, it was not necessary to receive M e r ethics approval.
Stage One of the Methods (see pages 22-28), or the survey letter of request and
poster, asked that the subjects respond anonymously and that no person or institution be identified. To ensure anonymity of the elicited responses, a nursing undergraduate student
28
photocopied the responses and deleted any i d e n t w g information. The original descriptions were returned to the principal investigator for safekeeping and kept in a locked filing cabinet in her office- Despite these precautions, three practice narratives contauied identimg data and thus were eliminated fiom the sample. One of those narratives was deleted when this author attended a seminar and it became obvious that the speaker was
presenting the incident she had described in her survey response. Two other practice narratives were discarded as they identified the institution wherein the ethical situation had occurred. Summary of Methods
In summary, after the larger research team conducted a survey eiiciting ethical situations fiom practising nurses, these survey data were organized and analyzed in a five
step process by this author (see Figure 6). These steps descnbed the development of various charts and tables to assist with the content analysis of the practice narratives. Once the
survey data were andyzed and organized, the cases were written.
4 tice N a r r a t i v 2 à ; i . ; \
\"
C
al Issues Frequency
4
, n '
1
Setting C
1
i
i
I ! a
l. DISCUSSION The purpose of this study was to identifj. guidelines for developing environmentally vaiid ethical cases, and, on the basis of these guidelines and using practice narratives reported by Canadian nurses, to write four environmentaily valid ethical cases (Cases A. B. C, and D) (sec Appendices E, F, G, and H). As discussed in the Methods chapter, there were
three procedurd stages. Although oniy Stages Two and Three formed the basis of this thesis, al1 three stages will be discussed, because al1 are integral to the study. Stage One: Collecting the Practice Narratives The larger research team determhed that the judgement processes used by nurses in ethical decision making were unknown; they suggested developing an instrument to help determine how nurses make ethical decisions (see Background, pages 1-6). Because the team's measurement strategy cailed for four reaiistic ethical cases, they needed knowledge of the ethical situations that practising nurses encounter; thus, a survey to elicit those situations
was conducted.
The fifiy-eight subjects who responded to the survey provided a total of 83 practice narratives. Three of these were discarded because they contained identieng materiai. The result was a collection of 80 practice narratives that related nurses' own experiences or their observations. Collecting a large number of practice narratives provided a broad and current picture of nurses' ethical environments.
Stage Two: Organizing and Aoalyzing the Practice Narratives
S t e ~1: Practice Narratives C b The s w e y data were organized in a Practice Narratives Chart (see Appendîx B), which was a straightforward process. The three narrative attributes of primary interest, identified in the letter sent to the survey subjects and from the guidelines, were "Place" (for example, hospital or nursing home), ''Person" (for example, registered nurse), and "Issues"-
The letter to the survey subjects made clear that each narrative had to involve a practising
nurse who had encountered or observed an ethicai situation. An additional three column headings were used to organize the 80 narratives: identification number, facts. and comments. S t e IT: ~ Ethical Issues Fre-cv
Ta&
The Ethical Issues Frequency Table was formatted to provide a visuai representation of the types and fiequencies of the ethical situations encountered by the nurses who responded to the survey. There were 40 ethicai issues (see Appendix C), and the issues that occurred most fiequently are presented in Table 1.
Table 1 The Most F r e a u . ~ t i o m e bvdN
m
TOTAL FREQUENCY
ISSUE Death and dyhg
13
Tnith-telling
12
Consent
11
Confidentiality
11
Prolonging life (cardiopdmonary resuscitation)
8
Withdrawing treatment
8
Violating patient autonorny
7
Pain management
6
Reporting a colleague
6
--
-
These issues are similar to those identified in previous studies. In a survey of 205 nurses, Davis (198 1) found that prolonging life, violating patient autonomy, withholding treatment, and unethical or incompetent activity by colleagues were the most fiequently encountered ethical issues. Berger, Seversen, and Chvatal (1991) f o n d that the five most frequently encountered ethical issues were inadequate staffing patterns, prolonging life, inappropriate resource allocation, inappropriate discussion of patients, and irresponsible activity of colleagues.
33 Occasionally, it was difficult to label the ethical issues because the subjects' written descriptions were vague, bnef, or complex. For example, in one narrative the author could not determine whether the ethical dilemma was euthanasia or assisted suicide. in some narratives the subjects had written only one or two sentences and, therefore, the issues couid
not easily be distinguished. Finaiiy, in some narratives many issues were raised and differentiating among them was arduous. For these reasons, the review by the thesis supervisor was essential and the resulting hi& level of concordance provided validation for the organization of the material in the Practice Narratives Chart.
The ethical issues fiequently cited by the sweyed nurses formed the basis of tbree of the four cases. Thus, Case A (see Appendix E) is about patient autonomy, Case B (see Appendix F) is about withdrawal of treatment, and Case C (see Appendix G) is about truthtelling, pain management, and prolongation of life. Using these issues for the cases is further supported by the results of Davis (1 98 1) and Berger, Seversen, and Chvaal (199 1) because there is a similmïty in al1 three surveys as to the ethical issues that nurses report as encountering in nursing practice. Case D (see Appendix H) did not conform to the guidelines used for cases A, Br and C. It was based on stafEng and workload issues, because the larger research team believed
that these issues are of increasing concem to nurses. This reasoning was supported by Berger, Seversen, and Chvatal (199 l), who found that inadequate m
g was a fiequent
ethicai issue encountered by nurses. However, because Case D is based on minimal information fkom the practice narratives obtained fiom the survey, its realism is
questionable. The Iimited number of practice narratives on resource issues resulted fiom the
34
weaknesses of the non-random survey design. Thus, the results included only self-reported data fiom nurses who were motivated to respond to the letter or poster. Selfkeporting could
bias the results because the subjects might have underestimateil or exaggerated aspects of the incident they described. In addition, it was impossible to independently v e r Q the ethical situation or to determine the temporal relation of the episode; thus, it was possible that the ethical event had occurred many years ago, which would decrease its realisrn. S t e ïIï: ~ The -Se Once the survey information was organized, the practice narratives that had occurred in the same setting (for example, those that had taken place in hospitals) had to be reviewed
together. This was done using a Setting Chart, which provided an organizational fiamework to analyze the narratives according to the setting in which they had arisen. In this study, the practice narratives based in patients' homes were reviewed f k t because they were few in number. Organizing the practice narratives by setting was a simple task, because this information had already k e n identified in the Practice Narratives Chart. Determining which practice narratives to employ in the cases was aiso straightforward, because this involved the application of the guidelines. Ste~ IV: Ouestions Related to the S e t t i u
Once the practice narratives that took place in patients' homes were identified, they were analyzed in more detail by posing pivotal questions. The first question was whether the ethical dilemma might occur in a different setting fiom the one in which it originally occuned.
35 This question was posed in order to determine if the setting raised ethical issues that, for example, could only, or would be more likely to, occur in the community rather than in a hospital or other institution. The rationale for this question was based on the assumption that the ethical dilemmas that nurses encounter m e r fiom one setting to auother. Therefore, the cases would be more realistic if the setting of the case remained the same as in the practice narrative. The second question was whether the ethical course of action was obvious. if the answer to this question indicated that the ethicd course of action was clearly apparent, then it was assurned that most nurses would recognize the appropriate action to take. These
practice narratives were disregarded, because they would be insufficiently complex to assist
in the wrîting of cases that would stimulate judgement responses. As a result of this analysis, Case A was based prirnarily on one practice narrative and incorporated considerable material from the original survey namtive, including the ethical issues and background of the situation- Cases B and C used material fiom a number of narratives, and Case D was based on the ethicd dilemma descnbed in one survey response and incorporated no materiai fiom other practice narratives. The differences in source material are discussed more fully below. tv Case. Twelve survey responses described situations that
occurred in the community. Five responses were discarded because the ethical situation
could have occurred in a hospital; thus, the situations they described were not exclusively community-based. Several other responses were abandoned for various reasons; for example, the response did not provide enough detail or was poorly written, or the nature of
36 the ethical situation was unclear. The result was that one survey response (see Appendix B,
narrative 53a), describing a complex situation that had taken place in the community, was used for the community-based case. Case R: Nurs-
Home The ethicai situation of Case B was to occur in a non-
hospital institution, such as a nursing home. Only m e survey narrative (see Appendix B, narrative 37) descnbed a situation in a nursing home; it d d t with an elderly person who was dying and raised issues of prolonging life through heroic measures. Because of the need to maintain consistency of setting between the narrative and the case, the issue of
cardiopulrnonary resuscitation (CPR) became the focus of the ethicd dilemma in Case B. Thirteen narratives dealt with issues of death and dying, and eight dealt with CPR (see Appendix I).
The eight practice narratives involving CPR were reviewed again to gather any m e r material that could assist in writing the nursing-home case. Two practice narratives
were found (see Appendix B,narratives 15 and 5 1). One of these described an elderly terminally il1 person who was given CPR, and another involved an institutional policy on donot-resuscitate (DNR)orders. Case B therefore used information fiom the nursing home narrative (narrative 37) and one hospital narrative (narrative 15) (see Appendix 0. Case C: Hospital C w .Truth-tellkg, pain management, and withdrawal of treatment were chosen as the ethical issues for Case C because they were fiequently raised in the survey responses (see Table 1, page 3 1). Twelve survey responses described situations involving ûuth-telling, six described pain management, and eight described withdrawal of treatment. Two tmth-telling survey responses (4,24b), one pain management response (8),
37 and two withdrawal-of-treatment responses (24% 32) were used in writing Case C. Data fiom six other practice narratives were also usedTable 2.
and the Identification N-r
of &e Practice Nanatives Used.
TYPE AND FREQUENCY IDENTIFICATION NUMBER OF THE OF RESPONSES PRACTICE NARRATIVES USED
Pain management - 6
8,1t, 44,48a, 48b
Case D: Hospital C a s e The second hospital case had to include an ethical situation that was fiequently raised in the survey responses but that had not been covered in cases A,
B, and C. The issues in the fiequency table with more than four check-marks were reviewed (see Appendix C). These were reporting a colleague, patient safety, consent, confidentiality. violating patient autonomy, and substitute decision making. The fiequency of survey responses was as follows: six described the reporting of a
colleague, 1 1 described patient safety, 11 described consent, and 11 were related to confidentiality. Because the main characer in Case C was a child (see Table 5) and his parents acted as substitute decision makers, and because guideline B specified that the issues in each case needed to be varieci, responses related to substitute decision makers were not used.
38
The analysis indicated that no single narrative embraced the issws of coiieague reporting, patient safety, consent, and confidentiality. Furthemore, a case including al1 four
of these issues would be unrealistic iuid thus would elicit an inaccuratejudgement response.
Table 3. Case D: T-ypeand F r e m-c-y of eR and the Identificationmber of the Practice N-tives
Used.
TYPE AND FREQUENCY IDENTIFICATION NUMBER OF THE OF RESPONSES
PRACTiCE NARRATIVES USED
Report a colleague - 6 Patient safety - 11 Consent - 1 1 Stage Three: Writing the Cases
The case writing required creative thinking and adherence to the guidelines outlined earlier (see pages 16-2 1).
. .
. .
~ l i c a o of n theGuideline A required that the cases be situated in nursing practice. This requirement acted as a reminder that the cases were king written for nurses about ethical decision making in nursing. The requirement was met by paying attention to guidelines C-G and 1. Given guideline A's overarching bction, it probably was
unnecessary to speciQ it as a guideline.
39
Guidelines B and G required that the cases include different and frequently
encountered ethical issues; the Frequency Table (see Appendix C and Table 1) assisted in identimg these issues.
Table 4.
Ethical Issuels) -ed
in the C a s e
CASE
ETHICAL ISSUE(S)
A
Violating patient autonomy
B
Withdrawal of treatment
C
Truth-teiling, pain management, and prolonging life
D
Resource ailocation
Guideline C specified that the case settings had to be different fiom one another. The larger research team had determined that two cases shouid be based in hospital settings
(Cases C and D), one in a patient's home (Case A), and one in a nursing home (Case B) (see Table 5).
Guideline D required that a variety of ages be used and Guideline E mandated that a variety of clinical areas be used in the cases (see Table 5).
Table 5.
..
Ages and C h c a l Areas
aFour C
m
CASE
AGE
CLiMCAL AREAS
A
middle age
mental health
B
86 years
chroaic care
c
16 years
acute care
D
not applicable
medical surgical
Guideline F required that the cases refer to both sexes and a variety of cultural backgrounds. This was achieved by using both sexes and different ethno-culturai names for the case characters (see Table 6). The main nurse characters in the cases were not given
cames and were referred to as "you". This was done because the ultimate purpose of this project was to develop cases for an instrument that would require nurses to respond to
questions. It was hoped that the use of the personal pronoun "you" would allow nurse subjects to identi@ with the main character and would thus foster a more salient judgement
process.
Table 6 , Characters A
. .
c &N
~
a
e
ROLE
CASE
PATIENT
PHYSICIAN
OTHER
Enrico
Not applicable
Angela
sister
Mrs. Marion Fraser
Rodriguez
Ji. Nicole Matthew
patient's cousin patient's niece patient's nephew
Jason
Chu
Maria Clara Duncan
night nurse night nurse
Not applicable
Not applicable
Sonja Ramu
part-tirne nurse unit manager
Guideline H required that the cases be short and written in an uifomal and clear rnanner. Therefore, each case was no longer than two pages, and included dialogue between the characters to create a casual informal atmosphere between the main character and the
nurse. Guideline 1 dictated that the cases include the four elements of the Moorhouse, Dow, et al. (1997) ethicai decision making theoty (see Table 7). The prudentid reasoning element
(see page 20) required that the legd aspects, institutionai policies, and values from nursing professional ethicai codes be included in the cases.
Table 7.
Moorhouse. Dow et al. (1 997) m r e t i c d Institutionai Policv and Prof-
Included in fbe Cases: Ide@ Aswcts.
Values
THEORETICAL ELEMENTS
CASE
LEGAL ASPECT
INSTITUTIONAL POLICY
PROFESSIONAL VALUES
child neglect
not applicable
-confidentiality -choice -autonomy
consent
-institutional policy on CPR
-dignity -choice -heaith and weH-king
cornpetence
-institutionai policy on consuking patients before withdrawal of treatment
-dignity -autonomy -choice
not applicable
not applicable
-fairness -accountability -advocate for d e , competent settings
Because deveEopment of the Moorhouse, Dow, et al. (1907) theory was driven by a need to describe how nurses ïntegrate multiple, conflicting environmental cues to understand or judge an ethical situation, their theory describes the process of untanghg the causal
ambiguity of the complex environment in which nurses work. Given the purpose of the
Iarger research study - to develop an instrument to measure how nurses make ethical
43
decisions -it was necessary to create cases with causal ambiguity requiring a judgement response, Writirg the cases, A similar process was foiiowed in writing each of the four cases.
Before wrïting began, the survey practice narratives used in the cases were re-read. The tirst paragraph of each case introduced the nurse and the setting. This usually involved a description of the nurse's background, or the workplace. The goal was to create an atmosphere, attract the reader's attention, and be realistic-
The cases were reviewed by the larger research team and their cornments were taken into account in re-drafting the cases. This process for writing the cases was applied successfully for Cases A, B, and C, but not Case D. The application of the guidelines in the initial development of Case D
resulted in a case that was unredistic, disjointed and that contahed too many ethical issues; thus, the case was discarded because it did not meet the guideline of realism. Because of the
research team's concern that the resource issue be included in a case, the practice narratives were reviewed to find those that dedt with resources issues; only one was found. Case D. therefore, was based solely on one survey narrative and was embellished with the author's and the research tearn's experiences.
. -
U s l n e : ~ d e b sto wnte cas=
One of the methods cited in the case-teaching
literature to ensure case reaiism, is to write the case on the basis of one's own experiences. However, this "personalized* approach reflects only one person's experiences, which rnay not be common to others. Moreover, these personal experiences might have happened long ago; therefore, although they rnight once have been fiequent occurrences, they may now be
44
irrelevant. To avoid these problems, the larger research team conducted a suncey to collect multiple ethicai situations fiom many nurses.
This survey provided a collection of personalized experiences, thus, increasing the number of practice narratives to analyze. Such an approach is more appropriate to creating environmentally valid cases than using one's own personal experiences, which would be restricted to the a
d expeïiences of the case author. Thetefore, cases written using a
"personalized" approach wodd be constrained by the behaviour, attitude, and personality of
the individual writing the case; assuming that individual character traits influence one's interaction with situations one encounters in the environment. Thus, while the "personaiized" approach has been wideiy described in the literature, it has uiherent limitations. For these reasons, this study used a survey approach for the writing of Cases A,
B, and C. The literature has also suggested a second method of writing cases: to determine, and then incorporate into a case, the p ~ c i p l efact, , theory, or attitude that is to be evaluated
or taught. This approach was used in the fmt attempt to write Case D. Using the frequency chart, Case D included issues of reporting a colleague, patient safety, consent,
confidentiality, and violating patient autonomy; the result was an unredistic case because it involved al1 these issues. While these problems may have been overcome by limiting the number of issues to include in the case, the "principled" approach may not yield a realistic case. An unredistic case is likely to occur if the case author includes cornplex issues or too
many issues (or principtes, facts, theones, or attitudes). The approach used in this study was neither a personalized approach nor a principled
45
approach. It was an approach using guidelines. The guidelines incorporated the personal experiences of 53 individuals and included principles to be evaluated; thus, k i n g a combination of an expanded version of the personaiized and principled approaches. The results of this study, therefore, suggest a third approach to writing cases: a "guided" approach. While the guidelines generated for this study were specific to writing nursing
ethics cases, it may be that such an approach can be used to write cases for other disciplines. The guidelines developed in this study were generated by the goal to be achieved: the writing of four ethical cases. Thus, the guidelines that the four cases contain different issues.
settings and clinical areas, and that the characters have a variety of ages. cultural backgrounds, and be of different sexes, would apply as guidelines for any case, assurning that the purpose of the cases is to evaluate or teach a breadth of topics or issues, rather than different facets of the same issue. If the latter were the case, then the cases ought to contain the same issue, with only one of the variables of setting, clinical area, and character traits
being varied. The guideline that the cases had to be situated in nursing practice refen to the population that the cases were k i n g written for. This guideline could easily be adapted to stand for the general guideline that the case must be situated in an environment familiar to the target population. The guideline that the cases must involve fiequentiy encountered
ethical situations, could be generalized to state that the cases must include fiequentiy encountered situations of the environment in which the population is located. For example, if the cases were being wrïtten for business students, then the guideline would be that the cases must include fiequently encountered situations encountered by those working in business. The guideline that the cases be presented in an ~ o r r n a lshort, , and clear manner
46
would apply to the writing of any case. Thus, it is suggested that the guidelines of this study
can be adapted and generalized beyond the nursing ethics context. This should be explored and examined in future research in the area of case writing. Limitations The generalizabilityof this study is constrained by its descriptive methodology.The s w e y design involved a non-random collection of ethicd practice narratives contributed by
nurses with the initiative and interest in sharing their experiences. Thus, the indetennùiate nature of the validity and reliability of the survey data prohibits application of the results beyond the scope of this study. Another researcher using the same s w e y practice narratives
and the same guidelines may not create the same cases. Brunswik (1955) stressed the importance of studying naîural envkonments as weil as behaviour that is situated in the natural environment. A M e r limitation of this study,
therefore, is that by having synthesized and manipulated various cues fiom different survey
practice narratives, a real environment was not a c t d l y described in the cases. To maintain the natural interconnections, one could argue that a single narrative should have been used to generate each case. Applying this reasoning, Case A would reflect the most natural
environment of nurses, because it was prirnarily based on one practice narrative. In contrast, altering the interrelationships between the environmental cues may result in the individual rnisperceiving the stimuli, and, therefore, the judgement that the individual would form in the real situation would be inaccurately captured. Thus, because Case D used minimal cues
fiom the survey practice narratives, or nanual environment, it may be non-representative, and, therefore, any judgements elicited by Case D may not accurately reflect nurses' actual
ethical decision making, and therefore, would not be envkonmentally vdid. Another limitation of this study is that the Moorhouse, Dow, et al. (1997) theory of
ethical decision making has not been criticalfy reviewed. While this did not affect the steps in developing cases, its applicability to ethical decision making is not known at this tirne.
ImpIications Although the study implications are constrained by its limitations, this study makes a contribution to four areas: (a) case development, (b) case study research, (c) education case development, and (d) instrument development.
Case Develo~menl There is poor conceptuaiization in the literature of the process of nurses' ethicai decision making because of inadequate instrumentation. This study directiy contributes to a process of developing cases to elicit judgement responses which, in tum, c m be anaiyzed to understand nurses' ethîcai decision making. This study, therefore, is an initial step in developing a tool to better understand nurses' ethical decision making.
-
The guidelines and steps used in this study can also be used to develop cases to
m e r understand decision making by nurses and other professionals in areas other than
ethics.
Case study research is a research method that involves in-depth analysis and
systernatic evaiuation of the circumstances, dynamics, and complexity of a single unit of study such as a person, family, or community (Burns & Grove, 1993). Case study research is often used to study complex social settings, for generating hypotheses, and for exploratory
research. Researchers interested in the phenomenological perspective use case study research to intensively explore and understand the phenomenon of interest (Bowling, 1997). There was nothing found in existing literature, however, that described how the case. in case
study research, is determined to be representative of the phenomenon to be studied. The method employed in this study could be used to locate the case (or cases) for such case study research, For example, case study researchers codd survey the population they wished to study, develop an organizationai structure to organize the data, and determine the guidelines required to wrïte their case or cases. Using this method, researchers would be
assisted in choosing a case that would reflect the reality of the research phenomenon they wished to study in detail. Case study research involves the intensive examination of one or a few cases and, thus, the resdts may not be generalizable. To validate the results, other research methods, such as surveys, are often subsequently employed (Bowling, 1997). Because the method used in this study suggests incorporaihg a survey to guide in the choosing of a case, the problem of validation associated with case study research is decreased.
Education Case DeveloThe literature review revealed that cases often are used for evaluative and pedagogical purposes, and that the content is based on the professional experience of the case author. Writing cases based on professional experience is efficient because it does not entail gathering data fiom outside sources. To expect educators to conduct a survey and undertake the steps suggested in this study to develop cases for examination or tutorial purposes is impractical, given the time constraints facing educators. Also, the purpose of
49
this study was to develop cases to trigger judgment responses. This purpose is different fiom the goal of teaching, which is to change behaviour, attitudes, or the knowledge of students. Thus, procedurally and substantively, the r d t s of this study have limited application for wrïting specific cases for one time use. However, for curriculum development, where cases would be used repeatedy, the results of this study may assis in case development for educational purposes.
Instrument Develo-
Validity of an instrument is concerned with the extent to which the instrument reflects the abstract constnict being examined (i3urns & Grove, 1993). Because the purpose of the larger research study was to measure ethical decision making, environrnentally valid
cases that could tngger valid judgement responses had to be developed. The seps of this study described a systematic process of developing environmentally valid cases. The results
of this study could, therefore, be appiied in instrument development that use cases as their
measurement strategy. Implications for Future Research
Based on this study, the following recommendations for fùture research can be made: 1. The study steps could be replicated to develop cases for use in ethical decision
making for other non-nursing populations, such as physicians. 2. The study steps could be replicated to develop cases for use in other decision making processes, such as ciinical decision making.
3. The M e r development of the instrument (to be used in the larger research project), such as the construction of questions for each of the four cases, could be wrïtten.
50
Also, once the instrument is completed, it could be administered to evaluate nurses' ethical decision making. Summary and Conclusions
This study was part of a larger research project, the purpose of which was to develop an instrument, using four realistic ethical cases, that could increase our knowledge about nurses' ethical decision making. The first step for the larger research team, therefore, was to gain insight into the ethicai situations that nurses encounter. This was accomplished by a survey which yielded 58 ethical practice narratives fiom practising nurses; three were
discarded, leaving a total of 55 praçtice narratives. The purpose of this thesis study was to use the 55 survey practice narratives to develop four realistic ethical cases that could elicit judgement responses which could, in tum, be assessed in terms of patterns in ethicd decision making. Two areas of the literature
were reviewed. The first was the teaching literature that described the use of cases in teaching and evaluating students; this literature, however, said Little about constnicting
realistic cases. The second was the judgement and decision making literature, with particular attention to Brunswik' s (1952) parallel constnict lem mode1. Brunswik
emphasized the importance of knowing the individual's environment. in this study, the individual's environment was ascertained through surveying practising nurses.
in order to use the survey results to write the cases, guidelines were developed. Some guidelines were developed a priori, in order to systematicaily organize and analyze the survey data, other guidelines were developed contemporaneously while writing the cases, and still other guidelines were developed by the larger research team. The result is a
51
collection of nine guidelines for the development of cases that could be used to elicit judgement responses. The guidelines required that the cases (a) be situated in nursing practice, (b) present different ethical issues, (c) have different settings, (d) include characters with a variety of ages, (e) cover an assortment of c l i n i d areas, (f) include a variety of
culturai backgrounds and both sexes, (g) involve fiequentiy encountered or rare ethical issues?(h) be presented concisely, clearly, and realistically, and O cover the elements of the
ethical decision making theory. Once the guidelines were established, the practice narratives were organized into a Practice Narratives Chart and a frequency table. A Setting Chart was also developed to anaiyze particular practice narratives. Once these steps were accomplished, the cases were
wriîîen-
in the past, judgement experiments have k e n conducted that are problematic because the situations presented were nonrepresentative of the phenomenon being studied (Harnmond et al. 1986). Accordmgly, there has been a reassertion of the Brunswikian principle that investigators must be concerned with the individual's environment (Hammond et ai. 1986). The emphasis on environmentai validity is particularly important in the health
care setting because the ethical, legal, social, institutional, and economic variables involved are increasingly complex and interrelated. This complexity emphasizes the need to create
research tools capable of generating data which c m guide the eventuai development of interventions to foster appropriate ethicai judgements.
In summary, this study fills a void in the literature by describing a systematic approach to developing environmentally valid cases. This approach includes carrying out a
52
survey, developing a system of organizing the survey results to assist in the wrïting of the cases, and developing guidelines to write the cases. The cases are anticipated to elicit
judgement responses that c m be evaluated using an ethical decision making theory. These judgernent responses can then be evaluated and extend our knowiedge of nurses' ethical decision making; this is necessary given the advances in medical technology, increased patient consumerism, and iimited heaith care fun& which have created an environment of
increasing etbical complexity. Knowing how nurses make ethical decisions will assist in
developing appropriate educational programs which can Mprove nurses' ethical decision making which in turn may improve patient health care.
REFERENCES
Aroskar, M.A. (1977). Ethics in the nursing curriculum. Nus-(4), 260-264Barrows, H. S. (1985). How to desigl, a ~roblem-basedcurriculum for
a
precl inical years. New York: Springer Publishing Co.
Berger, M. C., Seversen, A., & Chvatal, R (1 991). Ethical issues in nursing. W Re-(4),
W
5 14-521.
Bloom, A. H. (1986). Psychological Uigredients of hi&-level mord thinking. A critique of the Kohlberg-Gilligan paradigrn.
JO&
for m o r y of Socid Behaviour. t 6,890
103Bowiing, Ann. (1997). Research methods in health: Inve-th
. .
md health
services. Philadelphia: Open University Press.
Brunswick, E. (1952). The co-
framework of DW-
Chicago:
University of Chicago Press.
Brunswick, E. (1 955). Representative design and probabilistic theory. Psvchological193-217.
Burns, N., & Grove, S. K. (1993) & critiaue and-u
.. .
research: Conduct.
(2nd ed.). New York: W .B. Saunders.
College of Nurses of Ontario. (1998). College of Nurses Web Page. Retrieved October 10, 1998 fiom the World Wide Web: http://www.cno.org/upload/Sitanb3.htm.
Cnsham, P. (1 980). Meas-g
moral judgment in nursing dilemmas,
Research. 30(2), 104- 110. Dailey, M. (1992). Developing case studies. Nurse Edwtor. 17(3), 8- 2 1.
Davis, A. J. (1981). Ethical dilemmas in nursing: A survey. Westem J o r n of Nursine Research. 3(4), 397-407. Eiser, R J. (1990).
. .
-
Buckingham: Open University Press.
Erksine, J. A., Leenders, M. R, & Madette-Leenders, L. A. (198 1).
with
cases. London, Canada: Research and publication division, school of business
administration, University of Western Ontario. Gilligan, C- (1982).
a different voice. Cambridge: Harvard University Press.
Glick, T. H., & Armstrong, E. (1 996). Crafting cases for probkrn-based learning: expenence in a neuroscience course. Medical Educabn. 30.24-30. Goldstein, W. M., & Hogarth, R. M. (1997). Judgrnent and decision research: Some historical context. In W. M. Goldstein & R M. Hogarth (Eds.)? Pesearch on -iudpent and decision makiw: C u r ~ n t sconnections. . and controversies @p. 3-65). Cambridge: Cambridge University Press.
Hafler, J. (1991). Case-writing: Case writers' perspectives. In D. Boud & G . Feletti (Eds.), The c
m of problem based le-
@p. 150-158). London: Kogan Page Ltd.
Hammond, K. R. (1 955). Probabilistic fiinctioning and the clinical method. Psvcholoszical Review- 62,254-262. Harnrnond, K. R., Hursch, C., & Todd, F. (1964). Analyzing the components of clinical inference.
Review. 71,438-456.
55
Hammond, K. R., Stewart, T.R,,Brehmer, B., & Steinmann, D. 0. (1986). Social
.
judgment theory. in H. R Arkes & K. R. Hammond (Eds.), d-
*
declsion maki&
An i n t e r d i s c w readet (pp. 56-76). Cambridge: Cambridge University Press.
Hébert, P., Meslin, E. M . ~ u n n E , . V., Byrne, N., & Reid, S. R. (1990). Evaluating ethical sensitivity in medical students: Using vignettes as an instrument. Journal of Medical Ethics. 16, 141-145,
Houts, P. S., & Leaman, T. L. (1983). Çase su t-
psvchol@cal
-
*
medical care: S o c i d
London: Pennsylvania State University
Press.
Johnstone, M. (1998). Dete-d
* .
professional misconduct in nursing:A r
respondu w to -es
board of Victo*
Melbourne:
Royal Melbourne hstitute of Technology.
Kohlberg, L. (19%). The cognitive developmental approach to moral education. In D. Puerpel & K. Ruan (Eds.), Moral eduçâtion: It cornes with the temtory @p. 176-195). Berkeley, CA: McCutcheson.
Kohlberg, L. (1984). m
s on moral develoment. Volume iI. The psycholow of
..
moral develo~ment:The nature & vald~tyof mral -.
New York: Harper & Row-
Lowenstein, A. J., & Sowell, R (1992). Clinical case studies: a strategy for teaching leadership and management. Nurse Educator. 17(5), 15-18.
Mohide, E-A., Dnunmond-Young, M., Byrne, C., Baumann, A., Avilla, E., & Tew,
M. ( 1996).
-mes.
DeveloDinP for
le-
. in bacc&ureate nursing *
Unpublished manuscript, McMaster University at Hamilton.
Moorhouse, A., Caulfield, P., D o ~ e rG., , & Y ~ o M. , (1993). Development of a theoretical h e w o r k and instruments to examhe ethicai decision making in nursing practice. Social Sciences and Humanities Research Council of Canada strategic grant proposalMoorhouse, A., Caulfield, P., Donner, G., & Thomas, J. (1993). A pilot study of bioethics education of nursing students, =red
N m June/July, 16-19.
Moorhouse, A., Caulfield, P., Donner, G., & Thomas, J. (1996). A pilot study of bioethics education of nursing students: Finai productivity report. Social Sciences and Humanities Research Council of Canada grant. Moorhouse, A., Dow,L., Wall, P., & Donner, G. (1997). m a k i n ~about bioethicai ~ r o b l for ~ sm t h c
..
the~prof ideal decisipn
w (sic). Unpublished manuscript,
University of Toronto at Toronto. Moorhouse, A., Wall, P., & Donner, G. (1997). &dot studv of bioethics nursing education. Unpublished manuscript, University of Toronto at Toronto. Parker, M. (1995). Autonomy, problem-based leamhg, and the teaching of medical ethics. Jounial of M e d a E
m 21(S), 305-3 10.
Thompson, D. L. (199 1). Ethical case analysis using a hospital bill. Nurse Educator, &(4), July/August, 20-23.
Tolman, E. C.,& Brunswik, E. (1935). The organism and the causal texture of the environment. Psvchologi-
43-77
VanLeit, B. (1995). Using the case method to develop ctinical reasoning skills in problem-based leaming. A
, J o u d of O c c w T h w v . 49(4), 349-3 53.
57
Wehrwein, T. (1 996). Developing an ethical basis for student-teacher interaction. Journal of Professional N u r s U ( S ) , 297-302.
Append i x A
.
Faculty of Nursing Univers'$y of Toronto
58
Dear 1 am a member of the Canadian Biocthics Society-studying ethical issues and concems for nurses. 1 an wirinp 10 ask for assistahv fiom niernbers of the Canadian Society for ~ i o e t h i c s who are directors of bi&ics dcrgartinents. chairpersons of clinical ethics and coii~mitteesand rnembrrs who have access to nurses aorking in rheir institution or agency.
These concerns. issues or dileilunas could a r i in ~ any setting and concem micro. meso and macro issues: at the bedside. in the communiiy, in education and raearch, involve
management. policies. rnuiqernent and labour issues. H o w can you help? 1 hëve enclosed a letter explaining the study and explaining how to respond. I hope you p s s on the request t o nuaing colleagues, employecs or students. 1 have dwi enclosed tlyers thac o u codd p s t o r circulate in p u r institution or agency. If you are a nurse, 1 hope )-ou will respocd.
Plcase norc chat responwr shou:d bc anon\-inoiis. If you have any questions. do not hesitate to cal1 me.
Yours [ru!!-.
.Arme Mooriiouse. RN. .Assista~cProrissor
PkD.
Description of an Ethical Situation Guideiïïes: 1. The situation involves a registered nurse deding with an ethical conccm or issue. 2- nie situation is a true one. You were a participant or obsewer. 3- State where the ethicd situation owurred: for example, hospital, wmmunity or hospice4. me sitution can be relaied to patient carc, administration. research andlor health policy. 5. Tell us ifyou thought that you had the oppomnity to be învolved ui responding to the isue, and tell us about what barrien if any stopped you Eom doing what you thought was ethical. 5- YOUa n submit more than one situation. 6.Be brief. You may h d it quicker to use point fonn in your response. Remember: Do not identify yoursclf, any other perron. the location. the institution or agcnq.
Thank ?ou for your assistance.
PLEASE CIRCULATE AND POST REGISTERED NURSES: WHAT ETHICAL ISSUES HAVE YOU EXPERIENCED? '
We are a team of registered nurses ttyhg to leam more about what are the current ethical issues in nursing practice, today. We want to leam from nurses about the ethical situations and problems chat concern them.
For more information, contact:
'
Anne Moorhouse, Faculty of Nursing, University of Toronto,
5 0 St. George Street, Toronto M5S 3H4. Telephone: 4 16-978-495 3 email:
[email protected] Fax:- 4 16-9 78-8222
Other team members are: Gail Donner, Faculty of Nursing, University of Toronto Patricia Wall, School of Nursing, McMaster University.
Appendix B Completed Practice Narratives Chart PLACE
FACTS
ISSUE
Client oEered car, jewehy to volunteer (retired RN) -RN declined -but took an antique do11 -voiunteer wants car
Gifl giving by client and receiving by volunteer
[
COMMENTS RN supervising volunteer institutional policy not to .accept gift > $50.00
Not a registered
nurse Hospital
Client asking for something to end misery RN not tell MD family wanting to sue Husband wanting to commit suicide RN knows that H ended W's life RN tells MD & SW RN does not teU H she spoke with MD & sw
Voluntary euthanasia requested by client Pain mgt Professional relationship w MD Terminating life -seif and others Professionai relationship -not t e l MD that F might sue Confidentiality Autonomy Respect Beneficence
1 Client and
--
Hospital
-
Tm&-telling Profession relnot follow order Patient safety Tx not given
Historically staff can refbse to assist in an abortion - due to cutbacks this option not available
Abortion Violation of personal values & mords Moral distress Professional integrïty Resource allocation
Lack of information
--
Hosp
Dignity Residents doing Respect procedures on the Consent dead Head Nurse discusses Autonomy with MDs
Hosp
Hosp
Terminally il1 patient: Order to give a rned Rn knows nothing about -tries to get info. -no support from colleagues -no policy -new dnig to hosp. -sbe does not give med & does not tell client or family
Staff
C's han& tied when remove tube feedings
Physical restn.int use Faise imprisoament Respect Dignity Consent Autonomy Patient safety
s-g
Cutbacks
RN observing Treating corpses as instruments to learn on
Hosp
Staff ? Other staff
Hosp
Hospital staff teiiing C & F that the care C is getting in nearby long t e m care facilities is not good
Professional conflict Tnith teiiing
Staff observe abuse of a resident - refuse to report
C.abuse by professionai Maleficence Refiised to whistie biow
--
-
Client wheelchair bound - should be lifted w lift - C r e h s staff womed about safety
Beneficence Autonomy Patient safety Staff d e t y
Hosp
RN and grad on duty - cardiac arrest - grad tells RN she caiinot give meds in ER -HN had not told RN, that grad is unregistered
Professional communication Patient safety Resource allocation
Hosp
Child booked for dental work w/out parent's consent done al1 the time
Consent Cornpetence Minor Common practice
Hosp
Staff
-
institutional bashing?
Hosp
Femaie with poor Teenage = 17 yrs prognosis team Truth telling suggests DNR Respecting wishes parents refiise - child of SDM had appointed parents as SDM parents wili not d1ow team to teli C she is going to die
-
-
--
Fear of what implications are if C is hurt
-
RN + other staff
-
--
-
LegaI Protect F-Team tension
.
Hosp ICU
Elderiy dying agressively treated discussed CPR w F -agreed to DNR w nurse - MD mived and made C a fidl code w/out talking w nurse C died despite CPR
Cornpetence DNR Futility Consent Prof, conflict w
Baby dying - parents agreed to let baby die but did not want to be present RN said baby should be held by a staff given bolus morphine w parents knowledge accused by some staff
Minor Beneficence Respect Dignity Euthanasia vs. palliative care Prof.conflict
-
-
-
RN SUPM-
sor
Staff 'tvalking" C off elevator to room -restrained not certified
-
- -
Hospital
L~4Pwe Religious belief Professional respect Nurses not involved in care
MD Death & dying Communication
-
Hosp
Elderly
-
Prof. conflict over whether certifiable Physicai restraint False imprisonment Respect Digaity Consent Autonorny Patient safety The law -
15 yr has arrest resuscitated - poor prognosis team discusses w F withdrawing tx - F distressed when C starts to die ask RN to do sometfiing gets increased order of morphine dies after 4 hours
-
-
-
-
Minor Withdrawal of tx Pain management Euthanasia vs palliative care Futiliîy k a t h & dying
Psychiatry -if attempt to Ieave becomes certifiable
-
Hosp
Consent form says wiii keep info confidentid - C teils researcher about seeing S exchanged btw. patients and staff - C agrees to bring it forward to administration rneaSuTes put in place to monitor - -
Confidentiality Consent Accepting S fkom patients Fear of rizprisal
Research Conflict resolution
-
Hosp
Replacing Rns w less qualified staff Closing beds
Unsafe care sef3 Professionai issues Not really a -unable to whistle specific event or situation blow -fear of layoff -1ack of respect of nurses Resource allocation
Hosp
[CU- elderly - MD stopped giving morphine b/c of potential respiratory failure -RN able to persuade medical team to change their rnind - gave morphine order - pt. died
Pain mgt vs. fear of respiratory failure Suffering Professional conflict w Mds Dignity Respect Palliative m e
Cornfort Caring Nurse doesn' t chriS. if euthanasia or not dramatic telling
New reproductive technology Resource allocation Values
Not really an ethical issue
-
- -
Hospital
Friend having twins fertiliîy drugs -colleague makes insensitive comment
Hospital
Hospital
Patient is verbally abusive to staff -alcohol -wheelcbair bound -amputee -staff have charged patient with harassrnent -staff& community agencies refiise to care for him Staff not cornfortable
with DNR order cal1 code Hospital
-
-
R e m to care for Patient 'Won-cornpliance" Resource ailocation Use of punishment - removing WC battery Staff d e t y Abuse
D m Respect Dignity Autonomy
Putting abortion & heroin user on a paeds unit
Resource allocation Respect Dignity Patient safety
Numbers of P on acute floors with casual, inexperienced
Patient safety Resource allocation
Management Not much detail
-
Hospital
staff
-1ittle training/orient -
-
Hospital
Hospital
89 yr old terminally il1 - CPR given in ER aggressive tx
-
Death & dying DNR/CPR Quality of life Paüiative care Equity, justice
OR rooms booked - emergency arrives no staff
Resource allocation Quality of care
Fear of law suit
Inadequacy of care Staffmg Workload Pt, advocate
Hospital
Public abuses nurses in ER -administration not supportive - RN feels has no rights
Abusive Ps Professional conflict --
Hospital
87 yr, terminaily ili, w DNR order F wants more done
-
-
Not really an incident
-
Palliative care Quality of life/death
DNR Codict w F Equity, justice Resource allocation -
-
-
Hospital
RN abuses OH Whistle-blowing colieagues covering P Quality of care care comptomised Drug abuse Incapacity Legal Regulatory
Hospital
13 yr oId w anorexia wodd eat w threat of NG tube parents want threat of NG at home
-
-
Hospital
-
--
Minor Threat force feeding Cornpetence Parent - child rd.
-
-
Car accident - F not want ventiiator removed despite brain dead - mother feared boyfiïend would commit suicide - SW involved did not speak w chaplain who had been involved
-
Communication Professional conflict -between team and between nurses Removal of Iife support Respect Autonomy Death & dying
Compassion Ethical decisionmaking requied
Hospital
Patient unaware of prognosis & severity of cancer - Wife knew but didn't wan busband to know RN mcomfortable spoke with colleagues
Truth teiling Respect Family wishes Respect Autonomy
Male with HTV - did not want M e prolonged - SDM said do everyîhing
SDM Respecthg wishes Mds a h i d of Iaw suit Advance directives Futiiity Withdrawal of tx Suffering Dignity Consent
-
-
Hospital
Terminally iil son insisting on hydratioi - RN opposed - W was SDM
SDM Palliative care Futility Withholding of tx Death & dying Conflict w F
Hospital
Family members asking that P not be toid s/he is dying
Truth telhg Disclosure Death & dying Family vs. P Palliative care Family vs. staff
-
Hospital
--
17 yr transplant candidate not know boy's wishes - staff divided on transplanl
-
Family vs. staff Organ donation Transplantation Inter-professional codict Hann Futility Consent
SDM religion Ethics committee
Colteague working out scope of practice; gives money to patient
Professional conduct Whistle blowing
Education No repercussions tolerated
Regulatory Hospital
Patient not infonned of risks of surgery painfitl treatment - no support fiom
Consent Professional conflict Patemalism
management -
--
Wife on Me-support - Withdrawai of Husband aEraid this treatment was killing wife - RN Communication provided support technology removed
Hospital
-
School
student
Student had problems mental, familial Instnictor womed about P d e t y - told to leave program
-
Safety
School
student and
Tension between faculty - impact on students
Interpersonal confiict
Education
Hemodialysis patient compIaining about nurses - threatening re. CNO, licenses decided to try a contract - mgt said no
Violence Abuse of staff Dialysis Duty to treat Professional tension Right to health care
Ethics cornmittee
12 yr wants vaccine parents do not
Consent Family vs. patient Minor C~~dentiaiity
faculty
Hospital
RN
Wife tenninaîiy iU at home - husband makes al1 decisions husband refüsing wife to have pain meds; making her wak when weak; force feeding - when alone wife wants meds - when husband confronted became abusive
Pain management Family vs. Patient SDM Abuse Family vs. staff Duty to treat Autonomy
-
Tenninally il1 - Pt. wants DNR - Family insist on CPR Husband uncertain
Pt. wishes Family vs. Pt.
Mother is nonresponsive and dying - daughter wants to stop treatment staff of mixed views daughter has power of attorney
Withdrawal of tx SDrnOA Staff codicted Cornpetence
Introduce clean instrument into sterile environment costly equipment
Patient d e t y
-
DNR Death & dying Palliative care
--
Hospital
-
Hospital
-
Told by colleague that a staff person had documented a home visit when in fact she had not done so - reported to management
Costs
Professional accountability Documentation Falsification Dishonesty Regdatory Obligation to report
Religion Ethics committee
PHN
Hospital
15 femaie babysitting Assault Minor assault by male Confidentiality stranger? wanted emergency Patient d e i y contraceptive pill did not want to involve police - PHN called CAS and police wlout names
-
-
-
Psych patient suicida1 - brought to ER on respirator MD wants to insert feed tube - family do not remained on respira. tube not inserted staff uncornfortable
Withdrawal of treatment MD vs. Family k a t h & dying Palliative care
Nursing Home
End stage Alzheimer's -family want CPR + transfer to hospital if necessary - RN feels doing for family & not patient
DNR
Hospital
92 yr - not terminal or life-threatening stopped eating starving to die expressed wish to die to RN MD called a code when found unresponsive
-
-
-
-
Hospitai
MD suggested to RN to increase meds wlout telling patient RN refûsed
Fuiility Withholding of tx Advocacy Family vs. staff Abuse SDM Autonomy Law Death & dying Patient wishes Dignity Abuse? Staff vs. staff
Consent Staffvs. staff
Violent death Feelings of betrayal by RN
-
Hospital
-
-
16 yr MVA brain damage over t yr on
-
unit - famiiy wanting aggressive treatment
- family brought
Resource allocation Lack of facility Futility Family vs. staff
lawyer to conferences -
-
Community
HIV passes through
condom - fear patient wiU stop using
Education
Not clinical
Education Values Religion
Not clinical
Education Societal, refigious values
Not clinical
condom
Community
Student ref'used to participate in ALDS education moral grounds
-
-
Community
-
Students not taught bhth control
--
Community
Dying children whether to let die or have surgery - RN had no tools to assist -
Hospital
Death & dying Prolonging life Quality of life Education
--
Single morn decided to pursue new reproducitve technologies pregnant with triplets - decided to put up for adoption 1 baby wanting the remaining 2 to be refered to as "twïns'' staff felt had to lie
Financial issues Family issues Adoption New reproductive technologies Tnith-telling
-
Hospital
H W delivered twins - Disclosure
-
father unaware twias receiving meds to HIV - father not living with mother
Truth-telling Law
Ethical decision making -not really a specific situation
Hospital
-
Patient in pain palliative care staff lack of knowledge no advocacy for patient RN checked P files after no longer employed - HR deptdid nothing - s t a f f left
-
-
Hospital
-
-
Pain management Palliative care Advocacy Death & dying Confidentiality Regdatory
-
Student f d e d a course - late in assignment another instructor in a different institution made arrangements for student to take her course did and passed
-
Where is ethics?
Management
-
Education Compassion
Not clinical
-
-
P has living will does not want CPR CPR given
-
Living will SDM CPR/DNR
P not told tmth because F does not want P to know
Truth-telling Family vs. P
P told vaguely about risks and benefits of
Consent
s'w==Y
P given false hope re. diagnosis Hospital
End stage COPD RN asking for increase pain rned -
Pain management
Fear of creating an addict
Truth-tehg Patient in septic shock - died Law autopsy: NG tube in wrong place - f d y never told - lawyer contacted staff saying not to speak with family
-
Student
Hospital
Hospital
Student
Student witnesses med error no harm done - tell anybody?
Truth-teiling Whistle blowing
MD orders normal safine vs. morphine
Pain management Placebo Drug addiction Truth-telling
AIDS diagnosis - tell family?
Disclosure consent Confïdentiality
Student notices another student is intoxicated on clinical
Incapacity Whistle blowing Patient safety
Drug abuse
RN had baby with damage - DNR MD wanting to provide tx - RN called palliative care consult - MD
Palliative care DNR Technology vs. nature Suffering MD vs. P
Personal essay on RN's experience relates to conflict resolution
-
-
~ ~ g r y
Hosp
Baby boni - intubated dways be dependent on respirator - infection given palliative care - Iives
-
-
Withholding of tx Pailiative care Minor , Futility , Staff vs. staff
DELETE
Wriiten in French
Hospitai
Brain injured patients
- policy: DNR on al1 patients before transfered to long term care facility
DNR Quality of life Policy Staffvs. staff Autonomy Digniîy Resowce allocation DELETEIdenmg Idormation
-
DELETE Identifj6ng Information
-
DELETE Identifying Information Patient living with 12 dogs in basement squalor - misses appointrnents - not wanting to move RN called City re potential £ire hazard w/out telling patient
"Noncornpliance" Poverty Patient safety Truth-telhg Patient selfdetennination
Psychotic patient driver's ticense removed still drives short distances financial incornpetence
Competency SDM when psychotic Patient and societal safety Autonomy
RN refuses to assist with abortion - little support fiom management
Moral and religion Professional rights vs. duties
-
Hospitai
?
RN
Conceiving a baby for bone marrow transplant for sibling
Family dynarnics
?
RN
Baby dying - staff suggest withdrawal of treatment - mom unable to decide
Death & dyuig Withdrawd of tx Palliative care Futility
Not a nursing ethical situation
Frequency Table of Ethicd Issues
NUMBER OF OCCURRENCES
1 Gift giving 1 Pain management
J
1 Violating patient autonomy --
1
1 TOTAL NUMBER 1
JJ JJJJ
16
JJJJJJJJJJJ
1 11
JJJJ
14
JJJJ
14
JJJJJJJJJJJ
111
-
Leaming procedures on the dead
1 Physical restraint 1 Physical abuse by RN 1 Verbal abuse by RN
Cornpetence -
Do-not-resuscitate
1 Substitute decision makers 1 Advance directives Death and dying
JJJJJ
5
JJJJJ
5
-
-
Prolonghg life: Cardiopulmonary resuscitation JJJ
Treatment agaïnst wishes Withdrawing treatrnent Withholding treatment Research ethics --
Reporting a colleague New reproductive technology Resource allocation Refisal to care for patient
RN incapacity Force feeding Use of threat or coercion to gain patient cornpliance Transplant Fdse documentation Assault by stranger Suicide Agressive treatrnent -by staff -wanted by family -
Patient safety Placebo
JJJJJJJJJJJ
Appendix D Completed Setting Chart for the Comrnunity-Based Practice Narratives -
- -
ID # of Narrative
-
Issue
Use? -dealhg with a retired nurse
patient unaware of dx and wife does not want husbanci to
-could occur in hospital -not uniquely community
-
know tnith-tehg
12 year old wants vaccine - parents r e h e - consent; minor; family vs. patient conflict; confidentiality
-couid use but decided to use #53a
tenninaily il1 f i e , husband makes ail decision, wife in pain -pain mgt. etc.
-could occur in hospitai -not uniquely commuity
terminally i11, patient wants DNR, family wants CPR -death & dying etc.
-could occur in hospital -not uniquely community
falsification of a home visit -prof accountability
-couid occur in hospital -not uniquely community -clearly wrong - not provide enough grey
assault of babysitter, RN tells policy w/out using names
-pecuiiar -scenario poorly written unclear as to what really happened
education
-
dying child - author asking for an ethical decision-making tool
-write-up does not describe an ethical or a specific situation -
Rn checked files after had Ieft department
--
-
--
-couid occur in hospital -not uniquely community -clearly wrong lack of material
-
-clearly in the community -numemus complex issues RN has to face -much detail provided
I
psychotic driving when no Licence
-interesthg but not enough detaii
AppendYr E Case A
It is three o'clock in the afternoon on a grey, snowy and very cold day in January. You are on your way to visit Enrico.
Enrico is a client in the community that you have k e n working with for three years. Enrico has epilepsy and a drinking problem. He is unable to work and is on a disability pension. Enrico Lives in the basement apartment of his sister's, Angela's, house. She is a single mother with three children aged eighteen months, three and four years old. When Angela's husbmd left
her, Enrico moved in to the basement to assist her with payment of the mortgage. He has told you that she struggles on her support payment. Enrico helps out by babysitting the children. You are sure he'll be home as he has few fnends or interests as far as you know. You are visiting Enrico to check his medication regiment and to see the children who al1 had coughs and looked pale the 1 s t time you visited.
When you arrive the basement apartment door is slightly ajar. You push it slightly and cal1 out. "Enrico, it's the nurse, are you there?" As you wait your eyes adjust to the dim lighting.
There is a smell of uncleanliness and cigarette smoke. The house feels cold. You pull your winter jacket together and keep your hat and gloves on. Enrico responds, "Yes, corne on dom". He sounds very sleepy. You € i d Enrico slumped in his arm chair, smoking a cigarette. Beside him is an ash tray full of cigarette butts; Enrico is a chain smoker. You are surprised that he is only wearing a t-shirt and boxer shorts since the house is so cold. Enrico is watching television and hardly glances at you as you approach. He appears
82
more interested in the talk show than in taUcing with you. You ask him about his epilepsy. He swears and replies "Not so good, nurse". He then adds that he thinks his epiiepsy is 'how out of control". You ask some follow-up questions and end by asking him about the living arrangements with his sister. in the p s t you have offered to help Enrico find his o w n apartment but he always refuses. Today, as before, he says that he does not want to leave his sister and her children,
You ask him if you can say "Hi" to the children. Enrico replies, T o u can look at them, but don? wake them up". You see the children sleeping on Enrico's bed; they are covered by a blanket. You carefully l a up the blanket. The youngest child is not wearing a diaper. They are dressed in thin, tom and dirty pajamas. They still look thin and pale. You place the blanket around them gently. Based on your assessrnent you decide that the children are not well cared for and that the basement apartment is not a healthy environment in which to live. You tell Enrico you will discuss the management of his epilepsy with the team and visit him within a few days. At the team meeting, your colIeagues advise you that there is a legal obligation to protect
the children. A decision, therefore, is made ta cal1 the local child protection agency. Within a short time, the children are in a foster home, Angela and Enrico find separate accommodation, and the bank forecloses on the mortgage. Angela is afhid that she wiil never have custody of her chilàren. Enrico's epilepsy is stable and he likes his furnished room. However, on your last visit to Enrico he adds that he is very angry with you for having broken up the family home.
Appendix F Case B You are rushing in to do an evening shift at your community nursing home. The moming
has been spent doing e m d s and sitting on your patio enjoying the summer sun. You arrive at the nursing station just in t h e to hear report. As usuai you are the nurse in charge of this 45 bed home. At report you leam that Mrs. Fraser, one of the residents, has had a difficult day. You know that over the last few weeks she has been weakening and in your opinion does not have
many days lefi to live. Mrs. Fraser is an 86 year old resident with multiple diagnoses inçluding advancecl liver cancer and kidney failure. She has lived at the nursing home for one year and you have taken an interest in caring for this fiail lady. Communication is difficuit with Mrs. Fraser because she is in the final stages of Alzheimer's disease. To your knowledge she has three remaining f d y members: Jim, a younger cousin; Nicole, a niece and Michael, a nephew. Jim is Mrs. Fraser's substitute decision maker. As such you have spoken to him
frequently about Mrs. Fraser's care. Jim visits regularly and in good weather often takes Mrs. Fraser in her wiheelchair to sit for halfan hour in the nursing home's littie garden. Before leaving the home, Jim always asks the staffwhether Mrs, Fraser needs anything like clothing, toothpaste
and other toiletries. Nicole and Michael visit Mrs. Fraser whenever they c m , mostly on holidays and her birthdays. They both have young families and lead b q lives. As a registered nurse you are familiar with the institutional policies and consent
legislation. One of these policies is that upon admission al1 residents or their substitute decisionmaker m u t sign a form indicating what type of treatment, if any, they want adrninistered should
84
the resident go into cardiorespiratorydistress. On this form there are four categories to choose fiom. The categories range fiom comfort care at the nursing home, to transfer to a hospital with cardiopulmonary resuscitation (CPR)and al1 other measures adrninistered required to sustain life. When Mrs. Fraser was admitted Jim had checked off the category of comfort care at the nursing home. He said that he and Mrs. Fraser had discussed how she wanted to die and that she had
indicated that she wanted to die peacefully with no machines. To that end, the physician, Dr. Rodriguez, had written a do not resuscitate order (DNR). M e r listening to report on Mrs. Fraser, you make your rounds with the day charge nurse. She tells you Mrs. Fraser, has appeared weaker than usual, that her respiratory rate is elevated above her baseline, she has no appetite and is slipping in and out of consciousness. She tells you
that she believes that Mrs. Fraser will probably not live much longer. She suggests that you cal1 the farnily and Dr. Rodriguez. You do so immediately. Within the hour Jim, Nicole and Michael are at the nursing home. Afier they spend a few
minutes at Mrs. Fraser's bedside, Dr. Rodriguez and you speak to the family in the conference room about Mrs. Fraser's care. Jirn says he is sorry to hear about his cousin and repeats his view
that c o m f k t care shouid be provided and that Mrs. Fraser be allowed to die in comfort at the nursing home. Nicole and Michael are upset. Nicole says, ''1 knew nothïng about Jim being appointed the substitute decision-maker. 1 know that Aunt Marion would want as much done as
possible - after al1 she was like a second mother to me." Michael agrees with Nicole. You explain that to provide aggressive treatment at this time wodd hami her and be fûtile. Dr. Rodriguez says that maybe an ambulance should be called. Nicole and Michael insist that an
ambulance be called to take their aunt to a nearby teaching hospital.
Appendix G Case C
You are sitting in a large evergreen coloured vinyl chair in a smaii room off the intensive
Care Unit nursing station waiting for your shift to begia. The night nurses seem to be behind schedule and yet they do not appear to be nishing. There is a certain Iethargy in the atmosphere
which you cannot place. You shut your eyes briefly reflecting on your vacation. You have k e n on vacation for two weeks and want to relive the experiences before they become ffeeting memories pushed out by the reality of workiag. Maria Clara, the night shift charge nurse enters the room and says she has an announcement before everyone can get report about their patients-
Maria Clara announces that the hospital wili be merging with another hospital and forming a new corporate e n t i ~ .You knew before going on vacation that this was probably going to happen but the announcement is s t i i i u n n e h g You become preoccupied thuiking about the
implications of this announcement and tune-out the &one of Maria Clara' voice. When you hear the name of Jason, however, you are drawn back into the reality that you are a registered nurse
having to care for some seriously il1 patients. Jason is a patient you have cared for in the past. Maria Clara finishes his announcement by saying that the unit is short-staned because some sraff have to go to a meeting about the merger. The resdt is that you will have two patients to care for instead of one. Jason is a 16 year old with muscular dystrophy. Over the last few years he has been adrnitted to the Intensive Care Unit several times for various complications. The 1 s t tirne he was
adrnitted for an episode of cerebral anoxia cauing neurological damage. Due to some respiratory distress, he was stabiiized on a ventilator. He also has a urinary catheter and a
86 nasogasttic tube. Before going in to hear report fiom the night nurse, Duncan, who cared for Jason, you briefly recail the £iratirne you met Jason. He was small for his age but was bnght, articulate and intelligent. He was acutely aware of his smaii stature which he perceived as limiting his credibility with the heaIth care team and his f h l y . He was, therefore, constantly stniggiing to assert himself so that adults wodd speak and M e n to him directiy. You are informed by Duncan that during the last two weeks there have k e n some preliminary discussions with the family and staff about Jason's care. Due to probable poor outcorne, discussions have ensued about whether to tel1 Jason that he is dying. Duncan tells you that Jason is refùsuig to speak to health care team members and that he has asked his parents to
make al1 decisions regardiig his care. You ask him whether Jason is competent to make bis own
decisions. He replies "yes"; the nurses have overhead him carrying on conversations with his parents that indicate he is alert and competent. Before Duncan leaves he tells you that pain
management has also been an issue of discussion and that Jason's case is to be presented at the next ethics cornmittee five weeks from now. You enter Jason's room. He does not respond to your cheerful "hello" but watches as you corne towards the bed. You talk to Jason as you check the various monitors, IV and catheter sites. He looks pale, gaunt and he is groaning. You wonder if he is in pain. When you check the medication chart the morphine ordered is, in your opinion, very low. It is also obvious to you that the nurses have been using the PRN morphine order to the fullest: every 4 hours with little
effect according to the nursing notes. You infonn the resident, Dr. Chu, that the pain relief plan is not relieving Jason's discornfort. She responds that she does not want to "create an addict" and
87
that she is tired of the nurses "bothering her about this".
Later in the moming when you begin reading Jason's chart you find yourseif reading over and over again certain passages. Despite your sporadic levels of concentration, you leam that the
health care team informed the parents about ten days ago that Jason should be told that he is very il1 and likely will die. The parents, however, are adamant that Jason should not kaow this information. They want to protect him and do not want him to hear any news that mÎght destroy any hope he might have. Upon M e r reading of the chart, you leam that Jason's parents still do not want him to be told that he is dying. However, they now want Jason's feedings and hydration to be discontinued and have asked that he be extubated. They believe that Jason's quality of life is
deteriorathg Notes fiom a team meeting inciicate that some staff are coaflicted about withdrawing treatment without first ùifonning Jason. There is disbelief by some staff that such a
decision could be reached which appears inconsistent with the hospital's policy that patients be consulted about treatment withdrawal before any order is written. You look up fiom your reading and notice that Jason is watching you. He opens bis mouth and you bend forward to hear what he is saying. He asks: 'Tm dying aren't I?"
smfX
Appendix H Case D
You are the charge nurse on a medical-surgical unit in a medium-sized hospital near a major highway. The unit is to provide care and treatment for medical and surgical patients. Lately there is a range of patients: Aides patients with pneurnonia; patients recovering from various surgeries; patients trying to control their diabetes and a few chronicdly il1 patients with
dementia waiting for placement in the community.
The unit usually has about forty patients aImost ail of whom require about 2-3 hours of
care. You Men to report and realize that this shift wiii be no different fiom any other: shortstaffed. Two patients were transferred to the unit from the ICU and will require a h o s t constant
care. In the early morning there was a major auto accident and because the K U was understaffed these two patients were transferred earlier than desired. In addition, five patients have to be prepped for surgery and will return to the unit after surgery as the recovery room can only accommodate half the nurnber of patients that it used to. Five patients are immunosuppressant and one patient is in isolation. You know that with the cut backs in heaith care h d i n g that
registered nurses are k i n g replaced by less qualified
There are two registered nurses and
four health care aides to assist you. A year ago there were five registered nurses and two health care aides.
You believe that the current staffing complement is putting patient care at risk. While the unit has always coped with a similar patient staff ratio and nothing untoward has happened you
worry that one day a tragedy will happen. However, you do not dwell on these thoughts as you
have more immediate concerns.
89
Your k t task is to assign the patients to the nurses and aides. You review the staff on
shift with you. Sonja, one of the registered nurses, is a part-the nurse and has not worked on the unit for several months. The health care aides are full-time staff to the unit and are reliable and helpful. You try to figure out how to make the patient a r e assignment. You and Sonja agree that you will not have time to do many of the complicated procedures needed by patients on thÏs shift even when you l a v e procedures that can wait for the
next shift, knowing they are just as s h o r t - d e d . You set priorities and make sure the two patients fkom the ICU are safe. But you know that more nursing help is needed- Sonja and the
hedth care aides are also worried about how they can manage. You are tempted to speak with Ramu, the Unit Manager, about this situation but decide it would be useless and may even jeopardize your relations with hùn. Last week for the third time you explained to Ramu that you believed patient safety was at risk and that an acceptable standard of quality of care could not be maintained with such a low number of registered nurses
and the increased use of casual staff. Rarnu explains that he is doing the best he can on the unit's budget, and that he cannot increase the staffing. You get the impression he thinks you are a
complainer.
Appendk 1
Practice Narratives Related to Prolonging Life and Palliation
PROLONGING LEE
DEATH & DYING
Identification nwnber of the narrative
Identification number of the narrative
Appendix J One Nursing Home and Two Hospital Practice Narratives Used in Case B
ID fC of
Place
Facts
Issues
Nursing Home
-alzheimer - family wants CPR to be given + transfer to hospital if necessary - RN disagrees
DNRKPR competency fiitility withholding advocacy famiiy versus staff conflict abuse? substitue decision making autonomy respect dignity quality of Life palliative care law
Narrative
--
Hospital
-
--
--
-89tenninally il1 - CPR given in emergency - aggressive treatment
death & dying DNR/CPR quality of life paliiative care dignity equity justice fear of law suit abuse?
