THE DEVELOPMENT OF NURSING CASES FOR …...ethics education in nursuig programs at five...
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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
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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
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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
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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.
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( 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
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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
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(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
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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.
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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
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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
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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
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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
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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
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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
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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.
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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: [email protected] 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?