THE DEVELOPMENT OF NURSING CASES FOR ETHICS RESEARCH:

A METHODOLOGIC ENQUIRY

Louise R Sanc hez-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-S weatman 1999

National Library 1+1 ofCamda Bibliothèque nationale du Canada

Acquisitions and Acquisitions et Bibliographie Senrices services bibliographiques 395 Wdlington Street 395, nie Wellingtal OtrawaON K 1 A W O&awaON KlAON4 Canada Canaeia

The author has granted a non- exclusive licence allowing the National Libra~y of Canada to reproduce, loan, distribute or sell copies of this thesis in microform, paper or electronic formats.

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 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.

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 0 WLEDGEMENTS

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 ~ g them 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 .......... ... ........es. 23

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 of Responses th& Occutred in the Hospital

and the Identifidon Number of the Practice N d v e s Used .................. 37

Table 3 : Case D: Type and Frequency of Responses 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 of the 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 ............................................................ 26

Figure 6: Five Steps to Develop Environmentaüy W d Ethical Case ................. 29

vii

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 Wth 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 mut 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, identi fi, 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, 199 1) 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

( 1 996) 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 md 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 amher 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 d ttiinku?g concurrently. This observation is incongruent

with Kohlberg's (1 984) 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, Kohlberg7s theory may be inappropnate for rneasuring

5

nurses' ethical decision making. His theory has been criticùed for its exclusive definition of

good moral reasoning in tems 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 (1 982), 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 ba 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-UD Study

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- 1 6).

Literature Review

This review surveyed two bodies of literature in case development, by s ea rchg 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 f irst 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 ( 1 952). Brunswick argued that judgement responses were a fiinction of bth

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 real-

Iife 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

(1 990) 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 ken 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, 1 992; Lowenstein & Sowell. 1 992:

Parker, 1995). Thus, the case-based method of teaching has been used in nucsing ethics

education (Dailey, 1992; Thompson, 199 1) 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 (1 996); Houts & Leaman (1983); Erksine,

Leenders, & Mauffette-Leenders (1 981)) 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 ram

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, 193 5). 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 between judgement 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, 193 5). 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 ] !

Environmental Validity

Cues

Cue Utilization

Figure 2: Brunswik's Lens Mode1

Summarv of t h e m e n t b o r y l i teraw- 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 iden t img 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 mal 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 king 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 -rt- 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. (1 997)

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 16-2 1) and then writing the cases. Because the

execution of Stages Two and Three was c o n ~ g e n t upon Stage One, al1 stages are described

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~ment of 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.

m r e 3. Template for the Practice Narratives Chart.

LDENTIFICATION NUMBER

Identification of the practice narrative

SEITLNG

Setting of the ethical situation -

PERSON

Main c haracter

FACTS

Summary of ethicai situation

ISSUES

Ethical issues

COMMENTS

Other relevant points

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.

Person. Because the cases, that were eventually to lx developed h m this process,

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 ~ g the type of

ethical situation or in detennining the îkquency of the situations encountered by the nurses

surveyed; it only provided a structure to i den 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 1 NUMBER OF OCCURRENCES 1 TOTAL NUMBER 1

Figure 4. Template for the Ethical Issues Frequency Table

Type of ethical issue.

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

Identification, using the "Issues" column of the Practice Narratives Chart, of every practice narrative that contained the type of ethical issue.

Frequency count for each type of ethical issue.

26

(see pages 1 8- 1 9) 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

Type of ethical issue (taken from the Issues column of the Practice Narratives Chart).

USE?

Decision as to whether to use the ethical issue in a case (Yes or No).

REASONS

Reasons why the ethical issue should or should not be used in a case.

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~ment of 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

wri te 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 identwg 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

' Setting C 1 1

i i I ! a l.<stions related to Se 1

1 t i

.- I , Writing of the C a s e , t

( Evaluate Response, !

CHAPTER m

RESULTS AM> 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 d bv N m

ISSUE

Death and dyhg

Tnith-telling

Consent

Confidentiality

Prolonging life (cardiopdmonary resuscitation)

Withdrawing treatment

Violating patient autonorny

Pain management

Reporting a colleague

TOTAL FREQUENCY

13

12

11

11

8

8

7

6

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 truth-

telling, 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 (1 99 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 verQ 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.

S t e ~ IV: Ouestions Related to the Sett iu

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 me 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 do-

not-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 used-

Table 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 Case 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, 1 1 described consent, and 1 1 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 inaccurate judgement response.

Table 3.

Case D: T-ype and F r e m c y of Re--

and the Identificationmber of the Practice N-tives Used.

TYPE AND FREQUENCY OF RESPONSES

Report a colleague - 6

Patient safety - 1 1

Consent - 1 1

IDENTIFICATION NUMBER OF THE PRACTiCE NARRATIVES USED

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 n of the Guideline 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 Case

CASE

A

B

C

D

ETHICAL ISSUE(S)

Violating patient autonomy

Withdrawal of treatment

Truth-teiling, pain management, and prolonging life

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 Chcal Areas a Four C m . .

CASE

A

B

c

D

AGE CLiMCAL AREAS

middle age mental health

86 years chroaic care

16 years acute care

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 e & N a . .

CASE ROLE

PATIENT PHYSICIAN OTHER

Enrico Not applicable Angela sister

Mrs. Marion Fraser Rodriguez J i . patient's cousin Nicole patient's niece Matthew patient's nephew

Jason Chu Maria Clara night nurse Duncan night nurse

Not applicable Not applicable Sonja part-tirne nurse Ramu 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 Included in fbe Cases: Ide@ Aswcts.

Institutionai Policv and Prof- Values

CASE THEORETICAL ELEMENTS

LEGAL ASPECT INSTITUTIONAL PROFESSIONAL POLICY VALUES

child neglect not applicable -confidentiality -choice -autonomy

consent -institutional policy -dignity on CPR -choice

-heaith and weH-king

cornpetence -institutionai policy -dignity on consuking -autonomy patients before -choice withdrawal of treatment

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 s to 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 e , fact, 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 princip tes, 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, king 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 king 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 l , short, 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 generalizability of 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 ac td ly 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.

C ase 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, cm 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 Develo-

The 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 (1 952) 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 cl inid 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. 1 986). The emphasis on environmentai validity is particularl y 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 cm 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),

260-264-

Barrows, H. S. (1985). How to desigl, a ~roblem-based curriculum for a

precl inical years. New York: Springer Publishing Co.

Berger, M. C., Seversen, A., & Chvatal, R (1 99 1 ). Ethical issues in nursing.

W W Re-(4), 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

103-

. . Bowiing, 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.

Psvchological 193-217.

Burns, N., & Grove, S. K. (1993) &- research: Conduct.

.. . critiaue and u- (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- 1 10.

Dailey, M. (1 992). Developing case studies. Nurse Edwtor. 1 7(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. (1 98 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: Cur~nts . connections. 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 stu- medical care: Soc id

psvchol @cal London: Pennsylvania State University

Press.

* . Johnstone, M. (1 998). Dete-d respondu

professional misconduct in nursing: A r w to -es board of Victo* Melbourne:

Royal Melbourne hstitute of Technology.

Kohlberg, L. (1 9%). The cognitive developmental approach to moral education. In

D. Puerpel & K. Ruan (Eds.), Moral eduçâtion: It cornes with the temtory @p. 176-1 95).

Berkeley, CA: McCutcheson.

Kohlberg, L. (1 984). m s on moral develoment. Volume iI. The psycholow of

. . moral develo~ment: The nature & vald~ty of 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), 15-1 8.

Mohide, E- A., Dnunmond-Young, M., Byrne, C., Baumann, A., Avilla, E., & Tew,

M. ( 1 996). DeveloDinP for le- in bacc&ureate nursing . *

-mes. Unpublished manuscript, McMaster University at Hamilton.

Moorhouse, A., Caulfield, P., D o ~ e r , G., & 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 Researc h Council of Canada strategic grant

proposal-

Moorhouse, A., Caulfield, P., Donner, G., & Thomas, J. (1993). A pilot study of

bioethics education of nursing students, =red N m June/July, 16-1 9.

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). the~pr of ideal decisipn

m a k i n ~ about bioethicai ~ r o b l ~ s for m t h c 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. (1 935). 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 ix 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~mittees and 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.

How 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. PkD.

.Assista~c Prorissor

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 hospice- 4. 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- YOU a 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 practice, today. We the ethical situations

current ethical issues in nursing want to leam from nurses about 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 1 6-978-495 3 email: amoorhouse@utoronto.ca Fax:- 4 1 6-9 78-8222

Other team members are: Gail Donner, Faculty of Nursing, University of Toronto Patricia Wall, School of Nursing, McMaster University.

PLACE

Hospital

Appendix B

Completed Practice Narratives Chart

FACTS

Client oEered car, jewehy to volunteer (retired RN) -RN declined -but took an antique do11 -voiunteer wants car

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

ISSUE [ COMMENTS

Gifl giving by client and receiving by volunteer

RN supervising volunteer - institutional policy not to

. accept gift > $50.00 Not a registered nurse

Voluntary 1 Client and 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

Hospital

- --

Hosp

Hosp

Hosp Staff

--

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

Historically staf f can refbse to assist in an abortion - due to cutbacks this option not available

Residents doing procedures on the dead Head Nurse discusses with MDs

C's han& tied when remove tube feedings

Tm&-telling Profession rel- not follow order Patient safety Tx not given

Abortion Violation of personal values & mords Moral distress Professional integrïty Resource allocation

Dignity Respect Consent Autonomy

Physical restn.int use - Faise imprisoament Respect Dignity Consent Autonom y Patient safety

Lack of information

s-g Cutbacks

RN observing Treating corpses as instruments to learn on

Hosp

Hosp

Hosp

Hosp

Hosp

Hosp

Staff ? Other staff

Staff

RN + other staff

Hospital staff teiiing C & F that the care C is getting in nearby long t e m care facilities is not good

Staff observe abuse of a resident - refuse to report

- -

Client wheelchair bound - should be lifted w lift - C r e h s - staff womed about safety

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

Child booked for dental work w/out parent's consent - done al1 the time

Femaie with poor prognosis - team suggests DNR - parents refiise - child had appointed parents as SDM - parents wili not d1ow team to teli C she is going to die

Professional conflict Tnith teiiing

C. abuse by professionai Maleficence Refiised to whistie biow -

Beneficence Autonomy Patient safety Staff d e t y

Professional communication Patient safety Resource allocation

Consent Cornpetence Minor Common practice

Teenage = 17 yrs Truth telling Respecting wishes of SDM

institutional bashing?

-- - --

Fear of what implications are if C is hurt

- -

LegaI Protect F-Team tension

Hosp ICU

Hosp

Hospital

RN SUPM-

sor

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

Baby dying - parents agreed to let baby die but did not want to be present - RN said baby should be held by a staf f - given bolus morphine w parents knowledge - accused by some staff

Staff 'tvalking" C off elevator to room -restrained - not certified

- -

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

.-

Cornpetence DNR Futility Consent Prof, conflict w MD Death & dying Communication

Minor Beneficence Respect Dignity Euthanasia vs. palliative care Prof. conflict

- -

Prof. conflict over whether certifiable Physicai restraint False imprisonment Respect Digaity Consent Autonorny Patient safety The law

-

Minor Withdrawal of tx Pain management Euthanasia vs palliative care Futiliîy k a t h & dying

Elderly L ~ 4 P w e Religious belief Professional respect Nurses not involved in care

Psychiatry -if attempt to Ieave becomes certifiable

Hosp

Hosp

Hosp

Hospital

-

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

- - -

Replacing Rns w less qualified staff Closing beds

[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 - -

Friend having twins - fertiliîy drugs -colleague makes insensitive comment

Confidentiality Consent Accepting S fkom patients Fear of rizprisal

Unsafe care Professionai issues -unable to whistle blow -fear of layoff -1ack of respect of nurses Resource allocation

Pain mgt vs. fear of respiratory failure Suffering Professional conflict w Mds Dignity Respect Palliative m e

New reproductive technology Resource allocation Values

Research Conflict resolution

s e f 3 Not really a specific event or situation

Cornfort Caring Nurse doesn' t chriS. if euthanasia or not - dramatic telling

Not really an ethical issue

Hospital

Hospital

Hospital

- -

Hospital

- -

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

Putting abortion & heroin user on a paeds unit

Numbers of P on acute floors with casual, inexperienced s ta f f -1ittle training/orient

89 yr old terminally il1 - CPR given in ER - aggressive tx

OR rooms booked - emergency arrives - no staff

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

Resource allocation Respect Dignity Patient safety

Management Not much detail

Patient safety Resource allocation

Death & dying DNR/CPR Fear of law suit Quality of life Paüiative care Equity, justice

Resource allocation Quality of care

Inadequacy of care Staffmg Workload Pt, advocate

Hospital

Hospital

Hospital

Hospital

Hospital

Public abuses nurses in ER -administration not supportive - RN feels has no rights

87 yr, terminaily ili, w DNR order - F wants more done

- -

RN abuses OH - colieagues covering P care comptomised

13 yr oId w anorexia - wodd eat w threat of NG tube - parents want threat of NG at home

- --

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

Abusive Ps Professional conflict

-- - -

Palliative care Quality of life/death DNR Codict w F Equity, justice Resource allocation

Whistle-blowing Quality of care Drug abuse Incapacity Legal Regulatory

Minor Threat - force feeding Cornpetence Parent - child rd.

--

Communication Professional conflict -between team and between nurses Removal of Iife support Respect Autonomy Death & dying

Not really an incident

Compassion Ethical decision- making requied

Hospital

Hospital

Hospital

Hospital

Patient unaware of prognosis & severity of cancer - Wife knew but didn't wan busband to know - RN mcomfortable - spoke with colleagues

Male with HTV - did not want M e prolonged - SDM said do everyîhing

-

Terminally iil - son insisting on hydratioi - RN opposed - W was SDM

Family members asking that P not be toid s/he is dying

- --

17 yr transplant candidate - not know boy's wishes - staff divided on transplanl

Truth teiling Respect Family wishes Respect Autonomy

SDM Respecthg wishes Mds a h i d of Iaw suit Advance directives Futiiity Withdrawal of tx Suffering Dignity Consent

SDM Palliative care Futility Withholding of tx Death & dying Conflict w F

Truth telhg Disclosure Death & dying Family vs. P Palliative care Family vs. staff

Family vs. staff Organ donation Transplantation Inter-professional cod ic t Hann Futility Consent

SDM religion Ethics commi ttee

Hospital

Hospital

School

School

Hospital

student

student and faculty - RN

Colteague working out scope of practice; gives money to patient

Patient not infonned of risks of surgery - painfitl treatment - no support fiom management

Wife on Me-support - Husband aEraid this was killing wife - RN provided support - technology removed

Student had problems - mental, familial - Instnictor womed about P dety - told to leave program

Tension between faculty - impact on students

Hemodialysis patient compIaining about nurses - threatening re. CNO, licenses - decided to try a contract - mgt said no

12 yr wants vaccine - parents do not

Professional conduct Whistle blowing

Regulatory

Consent Professional conflict Patemalism

- --

Withdrawai of treatment Communication

Safety

Interpersonal confiict

Violence Abuse of staff Dialysis Duty to treat Professional tension Right to health care

Consent Family vs. patient Minor C ~ ~ d e n t i a i i t y

Education No repercussions - tolerated

Education

Ethics cornmittee

--

Hospital

Hospital

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

-

Tenninally il1 - Pt. wants DNR - Family insist on CPR - Husband uncertain

Mother is non- responsive and dying - daughter wants to stop treatment - staff of mixed views - daughter has power of attorney

Introduce clean instrument into sterile environment - costly equipment

Told by colleague that a staff person had documented a home visit when in fact she had not done so - reported to management

Pain management Family vs. Patient SDM Abuse Family vs. staff Duty to treat Autonomy

Pt. wishes Family vs. Pt. DNR Death & dying Palliative care

Withdrawal of tx SDrnOA Staff codicted Cornpetence

Patient d e t y Costs Professional accountability

Documentation Falsification Dishonesty Regdatory Obligation to report

Religion Ethics committee

Hospital

Nursing Home

Hospital

Hospitai

PHN 15 femaie babysitting - assault by male stranger? - wanted emergency 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

End stage Alzheimer's -family want CPR + transfer to hospital if necessary - RN feels doing for family & not patient

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

MD suggested to RN to increase meds wlout telling patient - RN refûsed

Assault Minor Confidentiali ty Patient d e i y

Withdrawal of treatment MD vs. Family kath & dying Palliative care

DNR Fuiility Withholding of tx Advocacy Family vs. staff Abuse SDM Autonomy Law

Death & dying Patient wishes Digni ty 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 lawyer to conferences

-

Resource allocation Lack of facility Futility Family vs. staff

- --

Community HIV passes through condom - fear patient wiU stop using condom

Education Not clinical

Community Education Values Religion

Not clinical Student ref'used to participate in ALDS education - moral grounds

Community - -

Students not taught bhth control

Education Societal, refigious values

Not clinical

Community Dying children - whether to let die or have surgery - RN had no tools to assist

Death & dying Prolonging life Quality of life Education

--

Ethical decision making -not really a specific situation

Hospital - --

Single morn decided to pursue new re producitve 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 - father unaware - twias receiving meds to HIV - father not living with mother

Disclosure Truth-te lling Law

Hospital Patient in pain - palliative care - staff lack of knowledge - no advocacy for patient

RN checked P files after no longer employed - HR dept- did nothing - s t a f f left

Pain management Palliative care Advocacy Death & dying

Where is ethics?

Confidentiality Regdatory

Management

- -

Hospital - -

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

- -

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 s'w==Y

Consent

P given false hope re. diagnosis

Hospital End stage COPD - RN asking for increase pain rned -

Pain management Fear of creating an addict

Patient in septic shock - died - autopsy: NG tube in wrong place - f d y never told - lawyer contacted staff saying not to speak with famil y

Truth-tehg Law

Student Student witnesses med error - no harm done - tell anybody?

Truth-teiling Whistle blowing

Hospital MD orders normal safine vs. morphine

Pain management Placebo Drug addiction Truth-telling

AIDS diagnosis - tell famil y?

Disclosure consent Confïdentiality

Hospital Student Student notices another student is intoxicated on clinical

Incapacity Whistle blowing Patient safety

Drug abuse DELETE

RN had baby with damage - DNR - MD wanting to provide tx - RN called palliative care consult - MD ~ ~ g r y

Palliative care DNR Technology vs. nature Suffering MD vs. P

Personal essay on RN's experience - relates to conflict resolution

Hosp Baby boni - intubated - dways be dependent on respirator - infection - given palliative care - Iives

Withholding of tx Pailiative care Minor

, Futility , Staff vs. staff

Wriiten in French

Hospitai

Hospitai

Brain injured patients - policy: DNR on al1 patients before transfered to long term care facility

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

Psychotic patient - driver's ticense removed - still drives short distances - financial incornpetence

RN refuses to assist with abortion - little support fiom management

DNR Quality of life Policy Staffvs. staff Autonomy Digniîy Resowce allocation

DELETE- I d e n m g Idormation

DELETE - Identifj6ng Information

DELETE - Identifying Information

"Noncornpliance" Poverty Patient safety Truth-telhg Patient self- detennination

Competency SDM when psychotic Patient and societal safety Autonomy

Moral and religion Professional rights vs. duties

?

?

RN

RN

Conceiving a baby for bone marrow transplant for sibling

Baby dying - staff suggest withdrawal of treatment - mom unable to decide

Family dynarnics

Death & dyuig Withdrawd of tx Palliative care Futili ty

Not a nursing ethical situation

Frequency Table of Ethicd Issues

NUMBER OF 1 TOTAL NUMBER

1 Gift giving

OCCURRENCES

J

1 Pain management

1

JJ JJJJ 16

JJJJJJJJJJJ 1 11 -- -

1 Violating patient autonomy

Leaming procedures on the 1 dead

1 Physical restraint

1 Physical abuse by RN

1 Verbal abuse by RN

JJJJ 14

JJJJ 14

JJJJJJJJJJJ 111

Cornpetence

Do-not-resuscitate - - -

JJJJJ 5

JJJJJ 5 1 Substitute decision makers

1 Advance directives

Death and dying

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 JJJJJJJJJJJ

Placebo

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 know - tnith-tehg

12 year old wants vaccine - parents r e h e - consent; minor; family vs. patient conflict; confidentiality

-could occur in hospital -not uniquely community

-couid use but decided to use #53a

tenninaily il1 f i e , husband makes ail decision, wife in pain -pain mgt. etc.

terminally i11, patient wants DNR, family wants CPR -death & dying etc.

-could occur in hospitai -not uniquely commuity

-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

Rn checked files after had Ieft department

I psychotic driving when no Licence

-write-up does not describe an ethical or a specific situation

- - - - - -

-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

-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 €id 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 cm, 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 decision-

maker m u t sign a form indicating what type of treatment, if any, they want adrninistered should

84

the resident go into cardiorespiratory distress. 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 comfkt 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 1s 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 £ira tirne 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 Men 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?"

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 shi f t wiii be no different fiom any other: short-

staffed. Two patients were transferred to the unit from the ICU and will require ahost 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 hding that

registered nurses are king replaced by less qualified smfX 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 sho r t -ded . 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

Identification nwnber of the narrative

DEATH & DYING

Identification number of the narrative

ID fC of Narrative

Appendix J

One Nursing Home and Two Hospital Practice Narratives Used in Case B

Place

Nursing Home

Hospital

Facts

-alzheimer - family wants CPR to be given + transfer to hospital if necessary - RN disagrees

- - - -- --

-89 tenninally il1 - CPR given in emergency - aggressive treatment

Issues

DNRKPR competency fiitility withholding advocacy famiiy versus staff conflict abuse? substitue decision making autonomy respect dignity quality of Life palliative care law

death & dying DNR/CPR quality of life paliiative care dignity equity justice fear of law suit abuse?