One of the basic assumptions in the study of moral development is that people functioning at the principled level of moral reasoning live by a code of moral principles which includes respect for the dignity, values, and rights of others. Such an assumption is particularly applicable to the nursing profession and is inherent in nursing practice.
All nursing situations involve some level of ethical decision making, a process described as cognitive by Bergman (1973). A nurse who reasons at a morallyprincipled level is more likely to make nursing decisions supportive of the rights of others. Do nursing programs foster the moral reasoning necessary for nurses to make principled decisions?
Within the last decade researchers began to study the relationship between moral reasoning and educational preparation (Ketefian, 1981; Murphy, 1976) but these studies were limited primarily to baccalaureate nursing students in the northeast (Munhall, 1979). Regional differences and level of nursing education have been suggested to influence this relationship (Munhall, 1979; Murphy, 1976). Additional studies in other regions are needed to further define the relationship between ethical/ moral reasoning and educational preparation.
The purpose of this study was to determine the influence of the level of formal education on three selected factors believed to be associated with ethical/moral decision making: ethical/moral reasoning, attribution of responsibility, and the ability of nursing students to resolve ethical/moral dilemmas. The study was based on Kohlbergfe theoretical framework of moral development and Heider's attribution of responsibility construct derived from attribution theory.
Kohlberg (1964) extended the ideas and research of Piaget and Dewey, and empirically investigated moral reasoning. He was thus able to define three distinct levels of moral reasoning: preconventional or premerai based on punishment and authority; conventional, based on conformity to personal expectations and maintenance of the social order; and autonomous principled morality, based on individual conscience and the principles of justice.
Heider (1958) stressed that as individuals make moral decisions, they do so through an attribution process, central to which is the concept of "ought." "Oughts" are basic determiners of behavior in certain situations - and in particular, moral behavior is often perceived as externally defined by the "ought" standards.
Individuals determine the meaning of certain actions and assign responsibility to others based on behavioral outcomes. Through this process one is able to influence the actions of others as well as the actions of one's self. Responsibility is assigned according to one's interpretation of the concept of responsibility.
Heider described five ordered levels of responsibility used by individuals in the assignment of responsibility for decision outcomes: association, commission, foreseeability, intentionality, and justification. The first level is that of association in which responsibility is attributed to a person for any event that he was associated with. Commission is simple causality. At this level responsibility is assigned as a result of the person having caused the outcome. Foreseeability is characterized by the assignment of responsibility for an act that a person caused and could have foreseen its outcome, however unintentional the outcome. The fourth level, intentionality, holds the individual responsible only for intended outcomes. The final level is justification. At this level responsibility is assigned when another person in the same situation would have acted accordingly (Heider, 1958).
The educational environment provides an opportunity for participation, shared decision making and the assumption of responsibility for the consequences of one's own actions. Advancement toward higher levels of principled ethical/moral decision making is a process most likely supported in an educational environment (Kohlberg, 1971).
Education has been identified as the strongest correlate of advanced levels of moral reasoning. Research supports that moral reasoning judgment increases greatly when an individual is in school. When an individual discontinues his or her formal education, levels of moral reasoning tend to crystalize (Rest, Davison, & Robbins, 1978). Crisham (1981) found that nurses with higher levels of education reasoned at higher moral levels than less well-prepared nurses. Nurses prepared at the associate degree level used more lower stage or conventional level responses to nursing dilemmas than did nurses with baccalaureate or higher degrees.
Similar trends were also found by Ketefian (1981) among practicing nurses. Comparing 79 nurses, she found baccalaureate prepared nurses scored significantly higher on a moral reasoning measure than nurses prepared at the associate degree or diploma level.
Crisham's (1981) findings indicated that master's prepared nurses demonstrated significantly higher (p < .01) levels of moral development than baccalaureate prepared nurses. Sleicher's (1978) study which included a sample of 16 "expert" nurses who were members of the American Academy of Nursing (of which 75% had earned doctorates) were more "moral" in their decision making than less educated subjects. More than 60% of the "expert" group were able to identify an ethical dilemma while only one third of the sample of staff nurses with baccalaureate degrees or less could identify ethical/moral dilemmas. Yet others believe that nurses recognize ethical dilemmas exist but do not have the educational preparation for solving dilemmas in an ethically responsible manner (Fromer, 1982). Health care professionals in general have been prepared to function in the scientific realm and yet value judgments are essential components of clinical decision making. Clinical decision making demands that health care professionals be taught logical analysis of ethical problems (Kollemorten et al, 1981).
Nurses are prepared at various educational levels and within educational programs whose ethical content is at least in question. The Hastings Center (Aroskor & Veatch, 1977) reported that professional nursing education programs had only six to ten clock hours per year of ethical content in the nursing curricula and only six of 86 baccalaureate programs surveyed required a course in ethics. Traditional values and ethics have been included as components of curricula in an attempt to foster moral integrity in nurses, but theory and research in the field of moral development indicates that traditional approaches by nurse educators cannot by their nature alone stimulate growth to more mature levels of principled thinking (Vito, 1983). Nursing educators assume they educate students to reason in the moral domain; however, Munhall (1979) found that although 97% of students and 100% of the faculty perceived that ethical content had been integrated into the curriculum, most of the students were functioning below principled levels of moral reasoning.
The attribution of responsibility construct may provide a link between how an individual responds to dilemmas based on how he or she "ought" to respond. If the individual perceives that he or she will be held accountable for his decision, he or she is more likely to make a principled decision if the same "ought" standard applies across situations and for all people. As in Kohlberg's theory, this would be consistent with "making a decision after having considered how everyone else would have acted in the same situation." Based on the theoretical work of Kohlberg and Heider and the review of literature, it was hypothesized that undergraduate and graduate nursing students would differ in their ethical/moral reasoning and attribution of responsibility. It was further hypothesized that undergraduate and graduate nursing students would differ in the number of dilemmas resolved.
Sample: The participants in the study were female senior undergraduate and master's nursing students who had completed 18 semester hours of course work. The students were enrolled in either the baccalaureate or the graduate nursing program in one of six selected schools of nursing located in the southern region of the United States. The schools were selected from a population of 11 state-supported schools which had both NLN accredited undergraduate and graduate programs. Schools included also had 50 or more senior nursing students and 20 or more graduate students who met the credit hour criterion. Consent forms for participation were signed by 361 senior nursing students and 184 graduate nursing students. Participants completed both the Defining Issues Test (DIT) (Rest, 1979) and a pilot -tested Attribution of Responsibility (AR) instrument. The questionnaire return rate was 227 (62.8%) for the undergraduate students, and 111 (60.3% ï for the graduate students. The combined return rate for the two groups was 62%. Twenty-seven questionnaires were determined to be unreliable because of inconsistent responses and were deleted from the sample.
Procedures: The deans of the six selected schools of nursing were sent letters requesting permission for their senior baccalaureate and master's nursing students to voluntarily participate in the study. The letter explained the purpose of the study, the manner in which subjects would be contacted, and the task required of the participants. Permission to conduct the study was obtained from the appropriate representative of each institution.
The investigator or the investigator's representative in the participating school of nursing contacted all students who met the credit hour criterion during a regularly scheduled class meeting, fall semester 1983, or the first weeks of class, spring semester 1984. The date and time of the meeting was at the convenience of the institution and the course instructor. The students were given packets containing information regarding the study, the questionnaires, and written instructions for completing and returning the instruments. At that time, those students who wished to participate were asked to read the cover letter, and to sign the consent forms which described the procedures and guaranteed protection of their rights. Each participant who signed a coded consent form placed it in a designated envelope and deposited the envelope in a box in the classroom. Participants were asked to complete the demographic sheets and the questionnaires outside of class.
An exception to the above procedure occurred at one institution; the participants from that institution received their packets by mail as required by the institution. Questionnaires were returned to the investigator or the investigator's contact person at the next class meeting by students in four of the participating schools. The remaining two institutions requested that students return the questionnaires by mail. Participants from these two institutions received in their packets stamped, addressed envelopes with instructions for returning the questionnaires.
Defining Issues Test: The DIT is a highly structured objective test composed of six hypothetical stories, each dealing with a moral dilemma. The DIT requests that subjects respond to a question regarding the story character's action. This information was used to determine the subject's dilemma resolution (DR) score and their overall index of ethical/moral reasoning (D score). The D score indicates the individuals relative preference for principled reasoning over conventional and preconventional reasoning.
The DIT has convergent construct validity ranging from .60 to .70 with an average of .50 with various versions of Kohlbergs test and the Comprehension of Moral Concepts Test. Correlations with divergent constructs such as attitudes and personality have been nonsignificant and usually inconsistent. Cronbach's alpha yielded a .79 for the D scores based on a sample of 160 subjects. The D score ranges from O to 60 (Rest, 1979).
The DIT requests that subjects respond to a question regarding the story character's action. The respondent was instructed to select one of the following alternatives: "should," "should not," "can't decide." This information was used to determine the subject's dilemma resolution ability (DR). A value of 1 was assigned to each "should" or "should not" response and a value of O to each "can't decide" response. The subjects DR score was determined by summing the responses to each of the six dilemmas. A subject's possible score ranged from zero to six with a higher score indicating greater dilemma resolution.
Attribution of Responsibility Instrument: This instrument was developed to measure the attribution of responsibility in relation to ethical/moral dilemmas. Attribution of Responsibility (AR), measured the commission, foreseeability, intentionality, and justification levels of responsibility. The association level was not assessed. Content validity for the AR component of the instrument was established by two social psychologists who agreed that each statement represented the designated AR level.
A pilot study to test the AR instrument was conducted with 53 senior female baccalaureate nursing students and 25 female graduate nursing students who met the criterion for inclusion in the study. The AR instrument yielded a Cronbach's alpha reliability coefficient of .85. Stability was established by readministering the questionnaire five weeks after the initial administration. Twenty-five subjects were randomly selected from the original sample of 78 subjects. Eighteen of the 25 subjects returned the questionnaire yielding a 72% return rate. The AR instrument testretest reliability coefficient was .63.
Results and Discussion
Data analyses were conducted to determine if a difference existed between the graduate and undergraduate samples in relation to the major variables in the study. Given that education had been identified as the strongest correlate of advanced levels of ethical/moral reasoning (Rest et al., 1978) independent two-tailed ¿-tests were computed to determine the influence of education on ethical/moral reasoning, attribution of responsibility, and dilemma resolution scores.
A comparison of the overall index of ethical/moral reasoning (D score) showed that the graduate students had a higher mean D score (M = 28.21) than the undergraduate students (M = 25.78). This finding indicated that formal education had an impact on overall ethical/moral reasoning levels as graduate students scored significantly higher than undergraduate students (t = 3.00, p - .002). This result supported previous research findings that formal education is a significant variable in the development of ethical/moral reasoning.
The senior nursing students' index of overall ethical/ moral reasoning score was comparable to that reported for senior students in Munhall's study. Munhall (1979) reported a mean D score of 25.06 for a group of senior students in a northeastern nursing program. This finding is equivalent to the mean D score (25.78) found in this study. An overall index of ethical/moral reasoning for graduate nursing students has not been reported in the literature.
The amount of attribution of responsibility assigned did not differ for the two groups (t = 0.02, p>. 05). AR scores for both graduate and undergraduate students were within the commission and intentionality categories. The dominant attribution of responsibility level based on raw mean percentages was that of commission (graduate M = 80%; undergraduate M = 82%). The justification level of responsibility was rarely considered by the participants as an appropriate reason for the actions in the situations presented (graduate M ~ 12%; undergraduate JVf = 13%).
The dilemma resolution scores of undergraduate and graduate students were not significantly different (t = 1.53, p>.05). Both groups were able to resolve an average of four of the six dilemma situations. The high dilemma resolution scores indicated the students' willingness to make decisions in given situations which lack universally accepted right or wrong answers. However, there was no significant correlation between dilemma resolution and overall ethical/moral reasoning levels.
Conclusions and Implications
The results of this study supported findings reported in the literature that students with more formal education morally reason at higher levels (Crisham, 1981; Ketefian, 1981). Accordingly, nurse educators have a continued obligation to facilitate student growth toward the principled level of ethical/moral reasoning. Nursing faculty should teach moral development and identify its linkage with other variables as a means of raising the level of moral development in nursing students. Nursing education does not appear to foster the assignment of responsibility at higher levels, i.e., justification level. Lerners (1970) findings suggested that the attributing of responsibility at lower levels allows the person to maintain his belief in a just world, which in general advocates that people "get what they deserve." The "just world" belief may have been an influencing factor as nursing students assigned responsibility in dilemma situations presented in this study. Certainly there is reason to believe that the attributions of responsibility which nurses make affect the quality of their decisions and the resulting nursing care. If this is true, nurse researchers must continue to study how nurses respond in dilemma situations and how personal characteristics, factors in the environment, and the assignment of responsibility affect nurses' ability to resolve ethical/moral dilemmas.
Given the high dilemma resolution scores of both groups and the lack of correlation between dilemma resolution and ethical/moral reasoning one must question if the students recognized the situations presented as dilemmas. Aroskar (1982) stated, "It is appalling to discover how frequently nurses are unaware that they are involved in situations requiring consideration of ethical elements" (p. 31). Ketefian (1982) stressed that awareness must be created to distinguish issues that are moral from those that are not. Nursing programs have the responsibility to prepare nurses who make ethical decisions and who do so for the "right" reasons rather than on the basis of self-interest, intuition, or pragmatic concerns. Those "right" reasons should be based on the concept of justice and reflect principled reasoning. Hence, nurses may be educationally qualified and knowledgeable, yet not know how to respond in a principled manner to ethical/moral situations.
Although the results of this study are inconclusive, they suggest that undergraduate and graduate nursing programs must place more emphasis on identifying dilemmas, ethical/moral reasoning, and the attribution of responsibility. Educational environments must be created to foster the development of higher levels of moral reasoning. Students must be given more opportunities to make nursing care decisions consistent with principled moral reasoning. The process of advancing individuals toward principled reasoning is a step-by-step process supported in a fluid environment. Opportunities for "testing out" reasons, exploring alternative viewpoints, and experiencing conflict through group dilemma discussions enhance the likelihood that when faced with these or similar decisions again, the student will respond in an ethical/moral manner.
Ethical/moral decision making requires critical reflective thinking in order for responsible principled choices to be made. Not only does principled decision making require higher levels of moral reasoning, it also requires an element of risk-taking. Responsible ethical/moral decisions do not allow individuals to "play it safe" or to serve one's self at the expense of others. Nursing education has a responsibility to prepare practitioners for the many moral dilemmas, varied viewpoints, and conflicts encountered in nursing practice.
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