A major issue in the study of ethical responsibilities in nursing is the lack of a cumulative body of research in which studies have systematically built upon previous work (Ketefian, 1989). Replication provides a credible means of evaluating previous research for spurious or misleading findings and, thereby, is essential for building an empirically based body of knowledge (Connelly, 1986; Fox, 1982; Gortner, 1980) related to ethical responsibilities. One criterion for replication is the continuing relevance of the research problem in the discipline (Connelly, 1986). The study of ethical responsibilities in nursing meets this criterion. While nurses frequently encounter ethical problems in their practice, there is a lack of consensus about the role that nurses should play in addressing ethical issues (Cassells & Redman, 1989; Omery, 1989). In addition, the measurement of moral behavior in nursing and its correlates remains a relatively new area of inquiry.
The purpose of this study was to validate the findings of a previous study investigating the differences in perceptions of idealistic and realistic moral behavior and attitudes toward autonomy, patients' rights, and traditional nursing role limitations among four groups of nursing students (Cassidy & Oddi, 1988).
A literal replication as defined by Woolridge, Leonard, and Skipper (1978) was employed in this study. The instruments, methodology, and sampling procedures employed in the original study were replicated; however, the sampling unit was expanded to include students enrolled in two associate degree and two degree-completion programs. Participation in this study was also voluntary and anonymous; return of the completed questionnaires was viewed as consent to participate in the study.
Responses were received from 147 of the students invited to participate in the study. The final sample consisted of 23 associate degree, 11 generic baccalaureate, 52 degreecompletion, and 60 master's students. Except for the associate degree students, the proportion of students representing the subgroups of the sample in the replication differed from that of the original study. In the original study, generic baccalaureate students represented 22.3% of the sample; in the replication they represented only 7.4%. The proportion of degree-completion and master's students was 25.4% and 34.5%, respectively, in the original study; and 35.4% and 40.8%, respectively, in the replication.
The characteristics of the samples in both studies were similar. In the replication, the mean age of students was 32.3 years with a range of 19 to 54 years. Forty-one percent (n = 60) of the students in the replication had completed an ethics course and 50% (n = 73) had attended seminars or workshops in ethics.
Reliability of instruments
Reliability analyses were computed for the Judgments About Nursing Decisions (JAND) (Ketefian, 1981, 1982) and the Nursing Autonomy and Patient Rights Scale (NAPRS) (Pankratz & Pankratz, 1974) and for their respective subscales. As noted in the original study, a number of items in both study instruments were unreliable. These items were eliminated on the basis of item-total correlations. The modified instruments were essentially identical in numbers of items per subscale and reliability coefficients in both studies. The Cronbach's alpha coefficients for the three subscales of the NAPRS exceeded .75. Elimination of unreliable items in the idealistic behavior subscale of the JAND failed to improve its reliability beyond .54; application of the same procedure for the items on the realistic behavior subscale did produce an alpha coefficient of .70.
Difference by program
Significant differences among the four subgroups of the sample were found on rejection of traditional role limitations (F = 7.69, p = .0001) and autonomy (F = 7.69, p = .0000). Post hoc tests using the Scheffe procedure (p = .05) indicated that, for rejection of traditional role limitations, the associate degree and generic baccalaureate students scored significantly higher than did the master's students. Master's students scored significantly higher on autonomy than did the associate degree, generic baccalaureate, or degree-completion students. No groups were significantly different at the p = .05 level on patients' rights. No significant differences among subgroups were found on perceptions of idealistic (F = .21, p = .8923) or realistic (F = 2.42, p = .0685) moral behavior.
While identical results were obtained for patients' rights and perceptions of moral behavior in both studies, generic baccalaureate students did not score higher on rejection of traditional role limitations in the original study. Associate degree and generic baccalaureate students scored significantly higher on autonomy in the original study.
Differences by age
When the sample was divided into two groups by mean age, younger students scored significantly higher on autonomy (F = 5.55, p = .0199) and rejection of traditional role limitations (F = 5.01, p = .0268) than did older students. No significant differences by age were found on patients' rights (F = 2.58, p = .1106) and perceptions of idealistic (F = .03, p = .8594) or realistic (F = .04. p = .8368) moral behavior. The same effects of age were exhibited in the original study, with the exception that younger students scored significantly higher on patients' rights.
Status as registered nurse
Registered nurses scored significantly lower than nonregistered nurses on autonomy (F = 42.17, p = .0000), patients' rights (F = 6.51, p = .0118), and rejection of traditional role limitations (F = 24.36, p = .0000). No significant differences by status as a registered nurse were observed on perceptions of idealistic (F = .066, p = .7980) or realistic (F = 2.69, p = .1033) moral behavior.
These findings were directly opposed to findings in the original study, in that non-RNs scored higher in patients' rights and rejection of traditional role limitations. The findings on perceptions of moral behavior and autonomy were not significant in either study.
Participation in ethics education
Students who had taken a formal course in ethics scored significantly higher on autonomy (F - 4.42, p = .0373) and perceptions of realistic moral behavior (F = 4.12, p = .0443). No significant differences by ethics course were found on patients' rights (F = .002, p = .9654), rejection of traditional role limitations (F = .01, p = .9111), or perception of idealistic (F = .87, p = .3522) moral behavior. These findings differed from those in the original study, in that there was no significant difference among subgroups on perceptions of realistic behavior, and those who had taken a formal course also scored significantly higher on rejection of traditional role limitations.
Those students who had not attended a continuing education seminar on ethics scored higher on autonomy (F = 4.92, p = .0283) and rejection of traditional limitations (F = 9.75, p = .0023) than did those who had attended a seminar. No significant differences by attendance at an ethics seminar were found on patients' rights (F = 2.99, p = .0859) and perceptions of idealistic (F = .78, p = .3793) or realistic (F = 1.60, p = .2083) moral behavior. The effects of attendance at an ethics seminar on autonomy were comparable in both studies, while only in the replication was there significant effect on rejection of traditional role limitations.
The samples in both studies were very similar in age and education in ethics, while there were some disparities, as noted previously, in the distribution of subjects among types of program. In addition, a lower response rate (40%) was obtained in the replication study. These characteristics could contribute bias and must be considered when findings between the two studies are compared.
The disproportion among subgroups by program may account for the inconsistency of findings between the original and replication studies on rejection of traditional role limitations and autonomy. The only consistent finding was that associate degree students scored significantly higher on rejection of traditional role limitations than did master's students. Assuming that this difference is real, experience in professional practice and advanced education in nursing may provide insight into the realities of professional practice, thus leading master's students to be less inclined to reject the limits of the nursing role.
Significant effects on autonomy and rejection of traditional role limitations by age were consistent in both studies. This finding suggests that younger students may score higher because their experience and education leads them to have idealistic expectations, which are modified as real life situations are encountered.
Inconsistent effects of status as an RN were observed between the studies on autonomy, rejection of traditional role limitations, and patients' rights. No conclusions can be drawn about the effects of this variable on the basis of these findings.
In both studies, formal ethics education had a positive effect on attitudes toward autonomy, while continuing education experiences had a negative effect on attitudes toward autonomy. One explanation for this finding may be that attitudes toward autonomy are enhanced in formal educational situations. The depth and duration of formal courses may foster changes in attitudes, while briefer, more superficial encounters (such as continuing education programs) may confuse participants or reduce confidence in their autonomous role.
In both studies, no subgroups were significantly different on the idealistic moral behavior. This finding provides further evidence of Ketefian's (1989) observation that this subscale of the JAND lacks reliability and should not be used for hypothesis testing. A difference in realistic moral behavior by ethics education in the replication was the only significant finding related to this variable in either study. Due to the relatively low reliability of this JAND subscale, firm conclusions about the effects of the independent variables on the perceptions of realistic moral behavior cannot be drawn. These findings raise questions about the ability of researchers to use the JAND with confidence as a measure of moral behavior.
To summarize, replication of the original study of the differences in perceptions of idealistic and realistic moral behavior and attitudes toward autonomy, patients' rights, and traditional role limitations validated only three findings from the original study - that both age and ethics education have effects on attitudes toward autonomy as measured by the NAPRS and that there is, overall, a consistent lack of significant findings related to the JAND. Both instruments should be evaluated for reliability before being used in future studies.
- Cassells, J.M., & Redman, B.K. (1989). Preparing students to be moral agents in clinical nursing practice: Report of a national study. Nursing Clinics of North America, 24, 463-473.
- Cassidy, V.R., & Oddi, L.F. (1988). Professional autonomy and ethical decision making among graduate and undergraduate nursing majors. Journal of Nursing Education, 27, 405-410.
- Connelly, CE. (1986). Replication research in nursing. International Journal of Nursing Studies, 23(1), 71-77.
- Fox, D.J. (1982). Fundamentals of nursing research (4th ed.). Norwalk, CT: Appleton-Century-Crofts.
- Gortner, S.R. (1980). Nursing science in transition. Nursing Research, 29, 180-183.
- Ketefian, S. (1981). Critical thinking, educational preparation, and development of moral judgment among selected groups of practicing nurses. Nursing Research, 30, 98-103.
- Ketefian, S. (1982). Tool development in nursing: Construction of a scale to measure moral behavior. New York State Nurses' Association Journal, 13(2), 13-18.
- Ketefian, S. (1989). Moral reasoning and ethical practice in nursing: Measurement issues. Nursing Clinics of North America, 24, 509-521.
- Omery, A. (1989). Values, moral reasoning, and ethics. Nursing Clinics of North America, 24, 499-508.
- Pankratz, L., & Pankratz, D. (1974). Nursing autonomy and patients' rights: Development of a nursing attitude scale. Journal of Health and Social Behavior, 15, 211-216.
- Woolridge, P.J., Leonard, R.C., & Skipper, J.K. (1978). Methods of clinical experimentation to improve patient care. St. Louis: Mosby.