Daily, nurses encounter situations which present ethical questions and dilemmas. Advances in technology and medical science have taken health professionals into new and unexperienced areas that involve moral issues. The boundaries of medicine and health care have expanded into what was once thought of as science fiction: organ transplants, artificial organs, and equipment that can sustain life indefinitely. These advances have prompted health professionals to examine such ethical issues as the impact of certain treatments on the quality of life, and competition for scarce resources. As health professionals, nurses are unavoidably confronted with these and other ethical problems. But as Fenner (1980) states, "the success of technology of health care has increased without increased sensitivity to the ethical implications of the process" (p. 7). In their focus on the technology, the "How-to's," are educators neglecting the ethics, the "Should Ts," of health care? Fenner's assertion indicates a valid concern for how, even whether, nursing students are being prepared for ethical decision making.
In the nursing students educational preparation one of the components that plays a critical role is textbooks. Texts are important as an information source to support and supplement classroom learning, and are also influential beyond the classroom as an ongoing reference source. One of the first textbooks nursing students use is a nursing fundamentals book. This resource presents essential elements, the foundation of the students education in the field. One such essential area is ethics and its relation to health care. Inclusion of ethically relevant content in nursing fundamentals texts permits an exposure that has relevance to all aspects of nursing. In addition, introduction to ethics early in the educational process allows subsequent content areas to expand on the subject and focus on particular ethical dilemmas encountered in the specialty areas. This article will first present an overview of ethics and decision making as they relate to nursing, and will then present results of a survey of nursing fundamentals texts to determine whether and to what extent they include content on ethics.
Morals and Ethics
Curtin (1978) described nursing as a "moral art," with its primary moral concern being the welfare of human beings. "Morals" refers to principles or habits with respect to right or wrong; a system of these principles is referred to as ethics. Ethics can be a publicly stated, formal set of rules or values set forth by a group of individuals, such as the American Nurses' Association Code of Ethics (1976). This systematic body of principles, values, and theories, provides the basis on which we question, critique, and eventually change our morals.
Types of Nursing Judgments
Nurses must exercise daily different types of judgments. The most common type is the clinical judgment: an expert scientific decision to promote a return to optimal functioning. For example, a clinical judgment might involve assisting a patient to ambulate while maximizing both safety and independence. In contrast is the ethical judgment: the lightness or wrongness of an action. Examples of areas requiring ethical judgments are abortion, informed consent, refusal of care, and resuscitation. These two types of judgments parallel the "descriptive" and "normative" aspects of nursing identified by Jameson (1984). He viewed descriptive aspects as the "how to's" - the scientific and technical aspects of nursing, such as how to perform cardiopulmonary resuscitation. Normative aspects deal with morality and ethics - whether cardiopulmonary resuscitation should be performed on a particular patient.
Davis and Aroskar (1983) proposed that health care ethics address four interrelated areas: clinical practice, allocation of scarce resources, human experimentation, and health care policy. They maintained that the task in health care ethics is neither to discover new moral principles on which to build a theoretical system, nor to evolve new approaches to ethical reasoning. Rather, the task is to "prepare the ground" for application of established principles and to sensitive health professionals to ethical issues in health care. "The health care professional must be confronted with the most difficult situations and then assisted to work through to a decision" (Davis & Aroskar, 1983). Often the most difficult situations arise when there is conflict between what is legal and what is ethical.
Jameson (1984) identified three types of ethical dilemmas nurses may encounter. The first is when the nurse is unsure of what moral principles apply to a situation, or even what the moral problem is - "moral uncertainty," in Jameson's terms. The second type of dilemma is a conflict between two or more moral principles that require inconsistent actions. The third type occurs when the nurse is aware of the right course of action, but is halted by institutional policies that make it difficult for him or her to pursue it.
Approaches to Decision Making
Martin (1980) suggested that people tend to take one of two approaches in ethical decision making: 1) they take the position that "whatever can be done should be done," or 2) they respond to a "mystical, moral reflex," an intuition for good, a gut feeling. Martin stated that the first approach is inadequate and irresponsible and reflects a superficial, egocentric way of thinking. He described the second approach as being a "standard of easy conscience" and warned that it is not foolproof.
Presenting a more thoughtful approach, Murphy (1976) offered nine steps to follow when confronted with an ethical dilemma:
1. Identify the health problem.
2. Identify the ethical problem.
3. State who is involved in making the decision (nurse? physician? patient? family? institution?).
4. Identify your role.
5. Consider all possible alternatives.
6. Consider and weigh the short- and long-term consequences of each alternative.
7. Make your decision (only if you were identified as one who is to make the decision in step 3).
8. Consider how your decision fits in with your philosophy of patient care.
9. After application, follow the situation until you see the actual results of your decision, and then use this information in future ethical decisions.
Murphy's (1980) approach offers logical guidelines to assist health care professionals in times when the stress and emotion of a situation may interfere with the professional's usual thoughtful approach to decision making. But where do nurses learn such an approach? Is content on ethical decision making an integral part of nursing education, or is the neophyte nurse left to search alone for a professional approach to ethical dilemmas?
Clearly, nurses need a knowledge of ethics and ethical decision making. Davis and Aroskar (1983) spoke of the task of preparing the ground for application of ethical principles. Are we as educators "preparing the ground" with nursing students so they might better manage ethical dilemmas? Fenner (1980) maintained that we are not: "One area of learning - ethical and legal aspects of health care - is frequently neglected" (p. 3).
Because ethical issues are present in all areas of nursing, it seems mandatory that this content be introduced early in the educational process. As discussed above, one of the students' primary sources of information is their nursing fundamentals text. This text is one of the first the students encounter and is frequently retained as a reference for later use in the program, as well as throughout their careers. What content do these texts offer on ethics and ethical decision making? The purpose of this study was to research nursing fundamentals texts for the presence or absence of such content.
All nursing fundamentals texts published from 1960 to the present were examined from three major university libraries for content relating to ethics. Each library served a different constellation of nursing and medical programs. One library was on a campus which contained a school of nursing with a baccalaureate, master's and doctoral program totaling approximately 700 nursing students. The second library served a campus containing a school of nursing with a baccalaureate and master's program and a medical school, with approximately 300 nursing students and 250 medical students. The third library was on a campus with nursing baccalaureate and master's programs with approximately 550 students. All nursing fundamentals texts were assessed for: 1) inclusion of the code of ethics of the American Nurses' Association (ANA, 1976) and/or the International Council of Nurses (International Council of Nurses, 1973), 2) interpretive statements or a discussion of the code with the inclusion of examples, and 3) guidelines for ethical decision making.
Results and Discussion
The Table presents all 42 texts included in the study. A Pearson's product-moment correlation was performed to determine whether a relationship existed between the year of publication and the average number of pages of content on ethics. A moderate correlation was obtained, showing more ethical content in later years (r = 0.59, p<.005). This suggests a promising trend toward greater attention to the area of ethics as it applies to nursing.
Examination of the data revealed that 45% of the texts contained no code, interpretive statements or specific guidelines for ethical decision making (Beland & Passos, 1975; Burgess, 1978; Cooley & Shaffer, 1982; DuGas, 1972; Harmer & Henderson, 1972; Hood & Dincher, 1980; Hood & Dincher, 1984; Johnston, 1968; Juneau, 1979; Kaegel, Mousseau, Goldsmith & Arora, 1974; Levine, 1974; Matheney, Nolan, Hogan & Griffin, 1972; Mitchell & Lousau, 1981; Pearce, 1980; Price, 1965; Rines & Montag, 1976; Roper, 1982; Roy, 1984). However, four of these texts merit further comment.
Levine's (1974) only ethically relevant content was a statement that "Moral censure has no place in nursing care. The most expert physical care cannot be expert nursing care unless the personal integrity of the patient is zealously guarded and defended by the nurse" (p. 17). No other references were made to ethical standards, decision making or their relationship to nursing.
Roy's (1984) content on ethics was directed at the patient; no reference was made to ethical responsibilities of nurses. She described a "Moral-ethical-spiritual self and defined this as "A person's belief systems, morals and evaluator of one who is; a personal interpretation of one's own lightness or wrongness, goodness or badness" (p. 259). No attempt was made to relate this content to the nurse or apply it to the administration of nursing care.
Mitchell & Loustau (1981) presented an in-depth discussion of decision making and decision analysis, but did not include content on ethics. Although the content on decision making was extensive, no mention was made of its applicability to ethical dilemmas, and no code of ethics was presented.
Cooley & Shaffer (1982) presented general guidelines for performance of nursing skills. The second guideline stated, "Perform only procedures that are morally and ethically acceptable to you" (p. 2). They elaborated on the point that the nurse has the right to refrain from procedures that are morally and ethically unacceptable to him or her. At the same time, they made it clear that the nurse does not have the jurisdiction to decide whether the procedure will be done - only whether or not she will participate. They stated that the nurse then has the obligation to inform other health care professionals involved of her decision and rationale. The authors concluded by encouraging nurses to evaluate institutional policies relating to nursing activities for consistency with their own personal beliefs.
In the remaining 23 texts (55%) content on ethics was presented in varying depth. Six texts included only a nursing code of ethics, with no elaboration or application (Brill & Kilts, 1980; DuGas, 1983; Feeley, Shine & Sloboda, 1980; Flynn & Heffron, 1984; Fuerst, Wolff & Weitzel, 1974; Shortridge & Lee, 1980).
Seventeen went beyond the code. Murray (1976) addressed the development of ethical standards in relation to Erickson's young adult stage of development, emphasizing that these standards are influenced by the individual's co-workers. The individual was said to form a "coherent personal ethical structure" and there was reference to "standards on which value judgments are made," but no nursing implications were presented. In a later edition, Murray (1980) provided définitions for ethics, morals and values, but did not include a code of ethics. She did relate the definitions to nursing and was one of the few authors who included content on values clarification, which many experts view as a prerequisite to participating effectively in ethical decision making.
Saperstein & Frazier (1980 ) presented both the ANA and ICN codes of ethics. Their brief discussion viewed the code as providing the nurse with "a framework for integrating the qualities of accountability, authority and autonomy into nursing practice" (p. 224). No elaboration was provided on the interpretation of this statement, and it is questionable as to whether a beginning nursing student would understand its meaning or implications. No examples were included of ethical dilemmas that might be encountered in nursing practice, nor methods for dealing with such dilemmas.
Maas & Jacox (1977) spoke about ethics more abstractly. They maintained that nurses can demonstrate accountability in several ways. One way is to collectively define a code of ethics describing the behavior of professionals that is appropriate for their relationships with patients. They suggested that such a code should emphasize proper behavior with patients, reinforce the professional system of values, and serve as a measuring stick for peer review of ethical behavior.
The text by Readey, Teague & Readey (1977) presented more detailed content on ethics. The authors began with a definition of ethics and discussed the prevalence of ethical dilemmas in nursing. They then introduced the code of ethics and included limited elaborations of each point, including examples. Although this text was an improvement over many others, this content was accorded only one and a half pages out of 570.
NURSING FUNDAMENTALS TEXTS AND THEIR CONTENT ON ETHICS
In a chapter, "Legal and Ethical Aspects of Nursing," Sorensen & Luckmann (1979) included both the ANA and the ICN codes. Interpretive statements were included. The issue of abortion was presented as a model case of an ethical dilemma and a nursing process approach was discussed. The presentation of the model case was effective in relating the concepts to a specific example. This was one of the few texts to use this approach. Narrow & Buschle (1982) also included a code of ethics with some elaboration of each section of the code, but with a less comprehensive coverage of the content than Sorensen & Luckmann.
The earliest text to include all three components defined by the study - code of ethics, discussion and/or interpretive statements, and guidelines for ethical decision making - was authored by Wolff, Weitzel, Zornow & Zsohar (1983). In the chapter, "Legal and Ethical Considerations in Nursing," they included both the ANA and ICN codes. Their discussion provided elaboration on the relationship among ethics, the codes, and nursing practice. This was also the first text to relate ethics to nursing research. The chapter concluded with guidelines for managing ethical dilemmas.
Taking a different approach, Atkinson & Murray (1985) related ethics to the specific patient care areas of safety, enteral nutrition, medication administration, and patient teaching. This approach had merit in that it went beyond the mere presentation of a concept to its application to areas nurses frequently encounter. The demonstration of the direct relationship of ethics to patient care areas also conveyed the notion that ethical considerations are an integral part of nursing and not a concept addressed in isolation. They concluded with the application of the nursing process to selected ethical dilemmas, a noteworthy inclusion. Both the nursing process and ethical decision making necessitate the collection of data. The nurse, being familiar with the nursing process approach, is likely in times requiring ethical judgments to be more confident in using this process as a basis for decision making than one that is less familiar.
Only two texts (Kemp & Pellitteri, 1984; Potter & Perry, 1985) devoted an entire chapter to content on ethics and addressed many related areas not included in other evaluated texts. In their chapter entitled "Ethical Considerations of Nursing Practice," Kemp & Pellitteri began with a discussion of the development of personal ethics in relation to life span development. Clear examples were presented which enhanced the content. The authors also presented content on value formation, related this to the process of value clarification, and included specific steps of clarification. Value clarification was then related to patient care and how a nurse might assist a patient in the clarification process. Relevant examples were provided and emphasis was placed on the effects values have on the person who holds them. Both ANA and ICN codes were included. With the ANA code, the authors also included a clear interpretation which related the code of ethics to daily nursing practice. Another unique feature of this text was its discussion of circumstances that could generate ethical dilemmas. Areas of potential conflict were: 1) the nurse's values and the code of ethics, 2) personal values and agency policies, and 3) personal values and patient beliefs. The chapter concluded with guidelines for ethical decision making.
Of all the texts surveyed, Potter & Perry (1985) provided the most comprehensive coverage on values and ethics in nursing. The content was presented in two chapters, the first on values, and the second on ethics. The chapter entitled "Values in Nursing" addressed how values influence behavior and how values are learned, with a developmental approach taken for the latter. The role of ethnicity in values formation was also discussed. The authors then presented a process of values clarification and related it to nursing. The process was further expanded to patients, with techniques presented to assist patients in clarifying their values. Of particular interest was the identification of behaviors that might indicate a need for values clarification. Two exercises were included to allow readers to analyze their personal values. The chapter concluded with the application of the process of value clarification to a case study.
Potter & Perry (1985) began their next chapter, "Ethics in Nursing," with a definition of ethics. They then showed that ethical dilemmas exist in what may seem ordinary nursing situations. This was clearly conveyed through the presentation of three examples. The relationship between personal and professional values was discussed. Both ANA and ICN codes were included, followed by an elaboration of the principles of accountability, responsibility, and client advocacy. The next section identified specific ethical problems within each of four specialty areas, as well as in the nurse-physician-client and the nurse-nurse relationship. Case examples were used throughout the chapter to facilitate the application of the content to nursing practice. The chapter concluded by presenting a process for resolving ethical dilemmas, and applying this process in a case example. This text surpassed all other 41 texts surveyed in its comprehensive coverage of content on values and ethics in nursing.
It is evident that of the nursing fundamentals texts surveyed there is, with only a few exceptions, a striking lack of content on ethics and its relation to nursing. This is not to say that content on ethics and nursing does not exist in the libraries. There was an abundance of specialty texts devoted exclusively to ethics and nursing; e.g., Jameson, 1984; Davis & Aroskar, 1983; Murphy & Hunter, 1983; Thompson & Thompson, 1983; Curtin & Flaherty, 1982. This highlights two points: 1) There seems to be much to say in relation to ethics and nursing, and 2) content on ethics is not located where the majority of beginning nursing students are likely to see it. The concern is that this content may not be reaching the beginning students. There does appear to be a trend toward increasing content on ethics in fundamentals nursing texts, but there is great scatter around the trendline. For example, of the five evaluated texts that were published in 1984, only one included a code of ethics, discussion of the code, and guidelines for making ethical decisions.
The limited content on ethics in nursing fundamentals texts decreases the probability that nursing students will receive, early, content that will assist them with the ethical dilemmas they will inevitably encounter. If this educational deficit is not addressed elsewhere in the education program, the neophyte nurse is placed at an immediate disadvantage when exposed to dilemmas which he or she is inadequately prepared to handle. These conflicts may lead to frustration and attempts to avoid areas where ethical dilemmas are apparent. However, no area in nursing is void of ethical dilemmas; some nurses may eventually leave nursing as the ultimate method of avoidance.
The trend toward inclusion of content on ethics in nursing fundamentals texts reflects an increased awareness of the relevance of ethics to nursing. As faculty members are exposed to the changing clinical nursing scene, they are becoming more aware of the ethical dilemmas nursing students will encounter. Faculty should take the responsibility to communicate on this issue with the publishers of the texts. The need for content on ethics must be made clear to them. This could be done by making inclusion of this content a priority criterion for faculty selection of a text, and so informing the publisher representatives. Correspondence with the authors of texts will also serve to alert them to the need.
A second possible faculty action is to include ethics as a part of curriculum. After introducing ethics at the beginning of the educational program, each subsequent specialty area could identify content appropriate for their particular segment. For example, parent-infant nursing could address abortion, nursing care of children could address informed consent, and adult nursing could address withdrawal of life support and living wills. This approach would allow the students repeated exposure to content on ethics, its relationship to nursing, and guidance through ethical decision making.
A third approach is the use of small-group workshops to sensitize faculty to the need for preparation of students in ethical decision making. Faculty could present ethical dilemmas they or their students have encountered to give added meaning and application to the workshop content.
Finally, the department could offer an elective course on nursing ethics. The professor could draw on the expertise of other faculty members throughout the university, such as philosophers, lawyers, and faculty in hospital administration, as well as nurse ethicists in the community. The disadvantage of this approach is that only a subset of students will receive this elective content.
As faculty members, we accept the responsibility for the preparation of nursing students for professional practice. Faculty members are also responsible for curriculum design and implementation. Closely associated with the implementation of the curriculum is the choice of texts. Content in these texts should be a reflection of what is considered important by faculty members. If the text fails to address ethics in nursing, this may convey the unintended message to students that ethics is not important. Faculty members must send a clear and consistent message to nursing students of the importance and relevance of ethics to nursing. By preparing nursing students in the process of ethical decision making we help narrow the gap between academic preparation and the reality our students face upon graduation.
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NURSING FUNDAMENTALS TEXTS AND THEIR CONTENT ON ETHICS