The development and psychometric evaluation of the Ethical Issues Scale.

PURPOSE: To describe the Ethical Issues Scale (EIS), its conceptual development and psychometric evaluation, and its uses in determining how frequently nurses experience ethical issues in practice. DESIGN: The EIS was validated with a sample (N = 2,090) of New England registered nurses (RNs) currently in practice. The sample was randomly split into two approximately equal samples. The calibration sample was used to derive the underlying components; the validation sample was used to confirm the component structure. METHODS: Psychometric analysis of the 35-item EIS included: (a) item analysis, (b) confirmatory principal components analysis (PCA), and (c) internal consistency reliability using Cronbach's alpha. RESULTS: Three components (end-of-life-treatment issues, patient care issues, and human rights issues) were demonstrated, confirming the original conceptually-derived structure. The calibration sample accounted for 42.4% of initially extracted common variance; the validation sample accounted for 41.5% of initially extracted common variance. CONCLUSIONS: The three EIS subscales had satisfactory internal consistency reliability and factorial validity for use as independent scales in future studies.

Evolution of a home health ethics committee.

In 1996, the Visiting Nurse Association of Boston established an Ethics Advisory Committee to address ethical issues that arise in patient care. This article describes the Committee's development from implementation of an ethics education plan for agency staff, to policy recommendations and consultation for ethical conflicts in patient care. Whether developing an ethics committee or evaluating your current one, this article can be helpful.

Nurses' ethical conflicts: what is really known about them?

The purpose of this article is to report what can be learned about nurses' ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as 'moral distress', the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse's advocacy role for patients.

The philosophy of nursing.

The purpose of this article is to provide an overview of the philosophy of nursing. First, the ontological, epistemological, and ethical issues that comprise the field of inquiry are identified. Second, we discuss how some of these issues are being addressed as demonstrated by the articles in this issue of Scholarly Inquiry for Nursing Practice. Finally, suggestions are made for the further development of the philosophy of nursing in the 21st century.

Ethical issues in Alzheimer disease research.

Research in Alzheimer disease (AD) is required to advance knowledge for the ultimate goal of finding a cure or prevention and to improve care for persons with AD and their caregivers. All research needs to be planned and conducted ethically, but research in AD has many ethical issues to consider due to the diminished cognitive capacity of potential subjects and genetic testing for AD. This paper describes the development of guidelines for ethical research, applying ethical principles to issues in human subjects research, and ethical issues in AD research. Important ethical questions must be addressed in AD research and basic moral and professional values will certainly be tested as the state of the science improves and research on AD, especially research involving genetic testing for the disease, becomes more acceptable and available.

Factors related to providers' decisions for and against withholding or withdrawing nutrition and/or hydration in adult patient care.

Decisions that are made near the end of life include consideration of withholding or withdrawing nutrition and/or hydration. These decisions present ethical challenges to health care providers who are caring for terminally ill patients. Clinical studies published during the last twenty years provide empirical data about the many factors that influence these decisions. The purpose of this systematic literature review is to synthesize the research findings related to provider decisions about withholding or withdrawing nutrition and/or hydration in adult patient care. The clinical, educational, and ethical implications of these decisions are proposed.

Factors related to adult patient decision making about withholding or withdrawing nutrition and/or hydration.

End-of-life decisions that focus on withholding or withdrawing nutrition and/or hydration present difficult choices at particularly vulnerable times for patients and families. Clinical ethics studies published in the last twenty years provide insight about the decision making process that can be useful to all parties involved. The purpose of the systematic research review is to synthesize empirical data about patient/surrogate decision making related to withholding or withdrawing nutritional sustenance toward the end of life, and contextual factors that influence their decision making. Future topics for clinical ethics research and clinical practice implications are posed.

Ethical conflicts experienced by certified pediatric nurse practitioners in ambulatory settings.

INTRODUCTION: The purpose of this descriptive study was to (a) identify the types of ethical conflicts and their resolutions reported by a group of certified pediatric nurse practitioners (CPNPs) in their ambulatory practice and (b) to examine demographic, educational, and practice-setting factors associated with these conflicts. METHOD: Five hundred fifty-nine CPNPs, identified by the National Association of Pediatric Nurse Associates and Practitioners, received survey questionnaires in the mail and were asked to participate by describing an ethical conflict in their practice. Questionnaires were completed by 118 CPNPs. Each ethical conflict was analyzed according to a four content analysis classification system to capture multiple relevant meanings. The relationship between types of ethical conflicts and demographic, educational, and practice-setting variables was examined. RESULTS: One third (34%) of the perceived ethical conflicts fell in the child/parent/practitioner relationship category. Most conflicts (31%) were experienced as a moral dilemma where 2 or more clear moral principles apply but they support mutually inconsistent courses of action. Most ethical conflicts (22%) were unresolved. DISCUSSION: Understanding the nature of ethical conflicts that CPNPs are experiencing in ambulatory settings is important. Professional and institutions/agencies need to collaborate on how to initiate appropriate ethics education and consultation for professional staff to recognize, discuss, and resolve ethical conflicts in the workplace.

Ethical conflicts reported by certified registered rehabilitation nurses.

The purpose of this study was to identify the types of ethical conflict reported by certified registered rehabilitation nurses (CRRNs) and their relationship to demographic, educational, and practice-setting variables. Ethical conflicts expressed by CRRNs in active practice in Maryland, Virginia, and the District of Columbia were analyzed according to four themes. Disagreements about medical or institutional practice, patients' rights, and payment issues were the most frequent practice contexts for ethical conflicts, reflecting these nurses' considerable underlying concerns about resource allocation in rehabilitation practice. Participants believed that 60% of the ethical conflicts were resolved, frequently through discussions with other team members and patients' family members. Ethics committees and consultants were used infrequently. There were no statistically significant relationships between the kinds of conflicts or their resolution and the participants' demographic, educational, and practice-setting variables.

Ethical conflicts reported by registered nurse/certified diabetes educators: a replication.

The purpose of this study was to identify types of ethical conflicts reported by certified diabetes educators who are also registered nurses (RN/CDEs) and to examine their relationship with demographic, educational and practice setting variables. This study is a replication of an earlier pilot study. Ethical conflicts expressed by RN/CDEs in active practice in New York and Pennsylvania were analysed according to four themes. Disagreement with medical practice was by far the most dominant clinical context for the conflicts (61%), as it had been in the pilot study (75%). Participants believed that 32% of the ethical conflicts were resolved. Ethics committees and consultants were very rarely used. Of the relationships between the kinds of conflicts and their resolution, and demographic, educational and practice setting variables of the participants, only kind of position was significantly (P < 0.005) related to practice context of the ethical conflict.

Presymptomatic and predisposition genetic testing: ethical and social considerations.

OBJECTIVE: To provide an overview of the ethical and social concerns that are raised by the use of new genetic tests in asymptomatic persons. DATA SOURCES: Review articles, research studies and legislation related to genetic testing. CONCLUSIONS: Predisposition and presymptomatic testing is possible to any age for adult onset disorders if a mutation is known. Testing without early effective interventions is controversial, especially prenatally and in children. Issues of privacy, discrimination, stigmatization and emotional stress are potential problems. Informed consent is essential before deciding to test. Awareness of the implications of testing can enhance the nurse's advocacy role. IMPLICATIONS FOR NURSING PRACTICE: More studies are necessary to identify the impact of presymptomatic testing on adults and children. Nursing research to identify the family concerns, and to develop effective educational, counseling, and supportive interventions would make a valuable contribution.

Ethical conflicts reported by Certified Nephrology Nurses (CNNs) practicing in dialysis settings.

OBJECTIVE: The purpose of the investigators was to describe and classify ethical conflicts experienced by Certified Nephrology Nurses (CNNs) practicing in dialysis settings in four eastern states and the District of Columbia, and to explore associated demographic, educational, and practice setting factors associated with these ethical conflicts. DESIGN: A descriptive survey design was used. SAMPLE/SETTING: All members of the American Nephrology Nurses Association (ANNA) who were CNNs working in Maryland, Virginia, and the District of Columbia, and a random sample of those in New York State and Pennsylvania were contacted. METHODS: Those CNNs working in dialysis settings were asked to complete the Demographic Data Form and the Moral Conflict Questionnaire developed by Fry (1990). Eighty-eight met inclusion criteria, agreed to participate, and described ethical conflicts. RESULTS: By far the most common practice context for the described ethical conflicts were decisions about discontinuation or initiation of dialysis (69%). Participants were clear about the moral problem and ethical principles involved. CONCLUSIONS: Participants reported being involved in serious ethical conflicts about patient care. Since two-thirds were not resolved, further research should investigate whether existing mechanisms in practice settings for resolution of ethical conflicts are not working or are not being used by nurses.

Ethical conflicts reported by registered nurse/certified diabetes educators.

The purpose of this pilot study was to identify types of ethical conflicts reported by Certified Diabetes Educators who also are Registered Nurses (RN/CDEs). Ethical conflicts expressed by RN/CDEs in active practice in Maryland, Virginia, and the District of Columbia were described by these healthcare professionals. Each conflict was analyzed according to three themes: the practice context, the ethical principles in conflict, and how the conflict was experienced by the nurse subject. The majority of ethical conflicts (75%) concerned disagreement with the quality of medical care the patient was receiving. The principles most often in conflict were beneficence and nonmaleficence. Most conflicts were experienced as dilemmas (two or more principles that seem to apply but support mutually inconsistent courses of action).

Ethics and human rights issues in perioperative nurses: a subsample of Maryland nurses.

The purpose of this study was to identify the ethics and human rights issues encountered by Maryland perioperative nurses in their practice. The most frequently occurring issues, the most disturbing issues, and content for ethics education are identified. Implications for education, management, and future research are presented.

Reaching consensus: the process of recommending treatment decisions for Alzheimer's patients.

Observational and interview data obtained from nurse caregivers and family members of patients with late-stage Alzheimer's disease were analyzed to explicate the nursing role in advance proxy planning. A four-phase model, Achieving Consensus: Decision Making to Determine Treatment Options for Patients with Alzheimer's Disease, was developed. Patient decline, family coping, professional development of nursing staff, and nursing unit philosophy were community characteristics found to be important antecedents to the process of reaching consensus. Achieving consensus constructs included interactive process components of patient, family, and staff adjustment, caring, and knowing. Timing and trust were influential catalysts to family and staff readiness factors for achieving consensus. Outcomes were the advice provided by staff and the family conference where treatment options were determined. Consequences included the advance proxy plan and patient care.