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PubMed2002

Development of a model of moral distress in military nursing.

The purpose of this article is to describe the development of a model of moral distress in military nursing. The model evolved through an analysis of the moral distress and military nursing literature, and the analysis of interview data obtained from US Army Nurse Corps officers (n = 13). Stories of moral distress (n = 10) given by the interview participants identified the process of the moral distress experience among military nurses and the dimensions of the military nursing moral distress phenomenon. Models of both the process of military nursing moral distress and the phenomenon itself are proposed. Recommendations are made for the use of the military nursing moral distress models in future research studies and in interventions to ameliorate the experience of moral distress in crisis military deployments.

Adaptation, Psychological↗
PubMed1994

The fate of idealism in modern medicine.

William Osler's description of the ideal physician remains the dominant character-ideal for modern physicians. He believed that the personality traits that resulted from a belief in ascetic Protestantism, what has been called the Puritan temper, were essential in the practice of medicine. However, this idealism has been weakened by modern psychological theories which view idealism as an illness. In a culture oriented to health, rather than virtue, as an ultimate ideal, physicians can help develop a science of limits.

Altruism↗
PubMed1998

Changes in medical student attitudes as they progress through a medical course.

OBJECTIVES: To explore the way ethical principles develop during a medical education course for three groups of medical students--in their first year, at the beginning of their penultimate (fifth) year and towards the end of their final (sixth) year. DESIGN: Survey questionnaire administered to medical students in their first, fifth and final (sixth) year. SETTING: A large medical school in Queensland, Australia. SURVEY SAMPLE: Approximately half the students in each of three years (first, fifth and sixth) provided data on a voluntary basis, a total of 385 students. RESULTS: At the point of entry, minor differences were found between medical students and first year law and psychology students. More striking were differences between male and female medical students, suggesting early socialization had a substantial impact here. CONCLUSIONS: Results indicate that substantial changes in attitude have developed by the beginning of fifth year with little change thereafter. Gender difference persisted. Some difference in ethical attitudes were found when groups of different ethnic backgrounds were compared. The impact of a move to a graduate medical course, which gives high priority to ethics within a professional development domain, can now be evaluated.

Attitude of Health Personnel↗
PubMed1996

Moral valuation: a third domain of conscience functioning.

OBJECTIVE: To assess development of moral valuation in normal children and adolescents, that is, how moral rules for living are derived and justified, and to examine the relationship of this progression with previously identified stages of conceptualization of conscience. METHOD: Using three semistructured questions from the Stilwell Conscience Interview, 132 normal volunteers between the ages of 5 and 17 years were assessed. All moral valuation responses were examined within three aspects of social reference: authority-derived, self-derived, and peer-derived. Each aspect was scaled for complexity into six anchored levels. RESULTS: The levels of all three aspects correlated positively with conceptualization stages as well as with each other. When the covariate, age, was taken into consideration, peer-derived valuation was significantly correlated with both age and stage. CONCLUSIONS: Moral valuation is a domain of conscience functioning in which moral rules and their justifications are socially referenced in relationship to authority, self, and peers. Anchored levels of these three aspects of moral valuation provide developmental guidelines for mental status examinations in patients between 5 and 17 years of age as well as providing criteria for future comparative studies in various diagnostic categories of psychopathology.

Adolescent↗
PubMed1998

Ideals in action: the U.S. Schweitzer Fellows Programs.

The inclusion of formal courses in medical ethics as part of standard undergraduate medical education has not led to widespread confidence in the moral and professional development of young physicians. As important as classes on informed consent and other such topics are, alternative approaches to professional moral development are needed. One example can be found in The U.S. Schweitzer Fellows Programs, which now support over 100 health professions students annually in six locations. Fellows participate in activities designed to strengthen the ideals that originally attracted them to medicine and other health care fields. Because Dr. Schweitzer is remembered primarily for the way he translated his ideals of human service into action, the core activity of each program is a direct-service project that addresses an important unmet health need of the local community or individuals in the community, with the support of community-based and school-based mentors. Alumni of these programs report that their experiences as Schweitzer fellows have helped them integrate their own ideals into their professional and career development. Such systematic efforts to recognize and support the latent idealism of young health professionals may strengthen the moral dimensions of professional life in ways that have broad social benefits.

Education, Medical, Undergraduate↗
PubMed1985

Measuring dental students' ethical sensitivity.

This paper describes the development of stimulus materials and scoring procedures to measure an individual's ability to recognize the ethical issues often hidden within the dentist's professional problems. The importance of this ability is discussed as it relates to other abilities thought to be necessary conditions for ethical or moral behavior. Dental students completed the ethical sensitivity test and Rest's test of moral reasoning. The sensitivity test requires transcribing verbal responses to audio dramas, a technique that: (1) elicits sufficient data for making inferences about ethical sensitivity, (2) produces good interjudge agreement and interrater reliability, and (3) measures variability in student performance. Data indicate high internal consistency compared with previous efforts to measure components of sensitivity (e.g., empathy), acceptable test-retest reliability for a subsample. and the distinctiveness of sensitivity and reasoning scores. The results have broad application for the teaching of ethics and suggest new directions for the study of professional socialization.

Dentist-Patient Relations↗
PubMedDate not supplied

Moral decision making in neonatal intensive care.

OBJECTIVE: To gain information about the perspective that neonatal intensive-care unit nurses use to make moral decisions. DESIGN: Descriptive. SETTING: Neonatal intensive-care unit of a large teaching hospital in the midwestern United States. PARTICIPANTS: Convenience sample of 26 female nurses working in a neonatal intensive-care unit. METHOD: Audiotaped, semistructured interviews and demographic questionnaires. RESULTS: The results indicated that most (65%) of the nurses used the care perspective to make moral decisions. A small number (12%) used the justice perspective, and the remaining nurses (23%) used a combined care and justice perspective. CONCLUSIONS: Both the care and justice perspectives were found to be important for understanding how nurses make moral decisions.

Adult↗
PubMed1996

Ethics education and nursing practice.

This paper suggests that a consideration of health care practice is a necessary step in gaining insight into the appropriate composition of an ethics course for students in the health care professional. Health care practice, if it responds to the needs of society, is dynamic in nature. In the current climate of change in the health service, the author suggests that the nursing profession needs to become more proactive in analysing and attempting to determine the future shape of nursing. To protect patient care the nursing profession needs to have its eyes open to the ethical dimensions of changes in role and practice. The author argues that, in attempting to ensure that the education to which nursing students are exposed is of relevance, it is necessary to introduce an element of the ideal into the ethics component of their professional education. From early on in their professional development students should be aware of the scope and standards of practice, and the type of role enactment to which the profession requires them to aspire.

Clinical Competence↗
PubMed1995

Changes in moral reasoning and the teaching of medical ethics.

Courses in medical ethics are becoming an integral part of many medical school curricula in Europe. At the medical school of the University of Copenhagen, a course on philosophy of medicine has been compulsory for all medical students since 1988. The effect of such courses on the ethical awareness and reasoning of medical students is not well understood and we have therefore found it of interest to study the effects of the Copenhagen course. For the study, we used a Danish version of the Defining Issues Test (DIT) which measures development in moral reasoning (Rest J R, 1979 Development in Judging Moral Issues. University of Minnesota Press, Minneapolis). The study was conducted as a pre- and post-test study without a control group, and the subjects were all medical students attending the course in the autumn of 1993. The results show that moral reasoning scores measured by the DIT increase significantly, and we argue that this increase can only be explained as an effect of the course.

Adult↗
PubMed2005

Hidden shame.

Shame dynamics, after decades of neglect, reappeared in psychoanalytic thinking with increasing prevalence in the last thirty years. Shame that is hidden is an aspect of complex clinical phenomenology that is particularly likely to be missed and hidden further by partial psychoanalytic explanations that drive shame more and more from view. Shame is often hidden theoretically by formulations limiting conflict to conflict between drives or impulses and something opposing them. By contrast, the incompatible idea model propounded by Freud in Studies on Hysteria emphasizes awareness incompatible with the dictates of conscience, and hence is broader in scope and closer to actual experience. Although shame and guilt arise developmentally earlier than does a true sense of morality, these emotions and their unconscious variants become entwined with the individual's sense of morality as development proceeds. The dynamics of shame and guilt are considerably more complex than their phenomenology as overt emotions. Shame emphasizes weakness, vulnerability, and the likelihood of rejection--so much so that its acknowledgment often generates more shame. Guilt, however, since it is action- and power-oriented, often obscures shame and so defends against it.

Awareness↗
PubMed1985

Teaching ethics in dentistry.

This paper describes a curriculum project designed to help dental students identify, reason about, and adequately resolve ethical problems in their chosen profession. The project involved application of a theoretical approach to the study of ethical development that had not been applied previously in professional education. Tests were designed to measure the abilities defined by the theory and used to evaluate the program and to monitor student progress. To date, studies of student abilities and attitudes clearly indicate that the curriculum is needed. Learning activities, created to promote the abilities, are based on studies of the real-life ethical problems confronting dentists and dental students. A program of research and development has been established to study the influence of this curriculum on the abilities defined, and to link them to clinical performance. Half of the dental schools in the United States have requested these materials. Suggestions are made to professional schools considering expanding the teaching of ethics.

Achievement↗
PubMed1993

Ethical decision-making processes used by health care providers.

This paper reports the results of a study conducted with 18 health care providers (HCPs) in two Toronto hospitals. The study examined and assessed how these HCPs make clinical-ethical decisions in the light of a theoretical model of clinical-ethical decision making. Nine nurses and nine doctors were interviewed through two-phased, in-depth, semi-structured interviews. The results suggest that, in relation to the two major elements of the model, namely the ethical component and the decision theory component, the HCPs did not follow a consistent and systematic pattern of ethical decision making. Differences emerged between their actual self-reported behaviour and their potential more capability (i.e. their abstract thought process). The general picture that emerged was that decisions were made in a narrow, habitual manner, through the elimination of the most significant and demanding elements of the process. HCPs' ethical approaches affected the entire process of the decision making: their perception of the problem, their search for and selection of information and evidence, and their development of alternatives and resultant consequences. It is suggested to (a) further investigate and understand the subjective realities of the individuals involved in the decision making processes, their values and the meaning they ascribe to their choices, and (b) to establish extensive educational programmes to enhance HCPs' decision-making capacity and subsequently promote an effective and responsible professional practice.

Adult↗
PubMed1993

Metacognitive aspects of moral reasoning and behavior.

This study explored the notion that the development of moral reasoning and moral behavior may be linked to metacognition. The awareness of moral processes involved in moral reasoning and behavior was examined in 139 adolescents in three age groups. A number of significant moral metacognition-reasoning-behavior correlations were found. Intercorrelations for all dependent measures increased by age. A factor analysis revealed several components of moral metacognition (person, task, and strategy variables), and these were significantly related to increases in moral reasoning and behavior scores. More important, a contingency analysis supported the notion that specific types of metamoral knowledge (e.g., understanding the purpose, scope, and requirements of moral action) are related to high and low moral reasoning and behavior.

Adolescent↗
PubMed1990

Teaching medical humanities through film discussions.

Following a brief consideration of two contrasting purposes for teaching the medical humanities, a description is given of a film discussion elective course. In contrast to the usual teaching of medical ethics which is primarily a cognitive activity emphasizing the development of a code of principles such as justice, autonomy, and beneficence, the film discussion elective was primarily an affective activity emphasizing the development of an ethical ideal of caring, relatedness, and sensitivity to others. The pass/fail elective, offered for one credit each quarter for two quarters, met once a week for one hour for twenty-four weeks. Each week a film was shown followed by a group discussion. A wide variety of social issues were covered. The objective of the course was to increase the ethical sensitivity of the medical students through promotion of introspection and reflection on social issues. A brief discussion is given of the importance and appropriateness of using film to promote the affective focus of medicine on the relief of the suffering. Examples are given of how the course achieved its objective. A detailed description of the resource materials is provided.

Audiovisual Aids↗
PubMed1991

Describing and testing a moderator of the moral judgment and action relationship.

The relationship between moral judgment development and action for Ss who differ in the degree to which justice-based moral judgments influence moral decision making was investigated. First, a method for quantifying Ss' use of justice-based moral judgments in moral decision making (the utilizer variable) is described. Second, 5 moral judgment and action studies are reanalyzed to assess the moderating effect of the utilizer variable information. Results indicate that the relationship between moral judgment scores and action intensifies as utilization increases. Moreover, the utilizer effect appears uniform across different age and educational levels and behavioral domains. These findings support the validity of the utilizer variable and are consistent with recent multiprocess models of moral action that suggest that moral judgements are a necessary, but insufficient, factor in the production of moral action.

Decision Making↗
PubMed1993

Medical students' attitudes toward providing care for the underserved. Are we training socially responsible physicians?

OBJECTIVE: To investigate the association between attitudes toward caring for the medically indigent and years of medical training. DESIGN: Questionnaire comparing attitudes of first-year medical students (MS-Is) and fourth-year medical students (MS-IVs). SETTING: Southwest medical school. PARTICIPANTS: A total of 83 (67%) male and 41 (33%) female MS-I and 65 (73%) male and 24 (27%) female MS-IV volunteers. MAIN OUTCOME MEASURE: Self-report, attitudinal scale developed for this study that provided a measure of overall attitudes, perceived societal expectations, physician/student responsibility, personal efficacy, and provision of basic services and expensive procedures. RESULTS: Overall attitudes were significantly less favorable for MS-IVs (95% confidence interval [CI], 99.6 to 106.2) than MS-Is (95% CI, 109.5 to 114.3, P < .0001). Except for basic services (P = .46), MS-IVs had worse attitudes on all attitudes subscales. Male MS-IVs reported significantly less favorable attitudes than male MS-Is in the areas of general attitudes (P = .03) and physician/student responsibility (P = .01). Female medical students showed no significant differences across classes (P > .05). Except for physician/student responsibility, female medical students' attitudes were more favorable than those of males, regardless of class. CONCLUSIONS: The MS-IVs are less favorably inclined toward caring for the medically indigent than MS-Is, though these differences are apparent only for males. Further research is needed to explore why females appear to be more resistant to attitude changes, and what educational interventions are necessary to better train physicians to respond to national health care issues.

Attitude of Health Personnel↗