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Responses of direct-care paraprofessional mental health staff to hypothetical ethics violations.

OBJECTIVE: The study examined the responses of paraprofessional mental health direct-care staff to hypothetical ethics violations in the care of persons with mental illness. METHODS: Eighty-five paraprofessionals in a medium-sized Midwestern psychiatric facility responded to a survey that presented ten hypothetical ethics violations varying in severity. For each scenario, respondents were asked to indicate the likelihood that they would ignore the violation, confront the care provider who had acted unethically, or report the violation to an immediate supervisor or to someone in authority over the immediate supervisor. The survey also assessed the paraprofessionals' perceived skills, knowledge, and need for additional training in professional ethics. RESULTS: Survey respondents were significantly less likely to ignore situations of moderate or high severity, compared with situations of low severity, and were significantly more likely to report a moderately severe or highly severe incident than an incident of low severity. CONCLUSIONS: The response of mental health paraprofessionals to hypothetical ethics violations suggests that they are able to recognize and evaluate the severity of ethics violations and weigh the potential effects of their responses. However, their responses to hypothetical situations may not reflect how they would respond to actual ethics violations on the job.

Adult↗

Decisions and justifications by community mental health providers about hypothetical ethical dilemmas.

OBJECTIVE: Community-based treatment of persons with serious mental illness requires providers to become involved in clients' personal lives to a greater degree than does hospital-based treatment. The study examined attendant ethical dilemmas, especially for staff who lack professional training or work in rural communities. METHODS: A total of 95 staff members from five community mental health centers read 14 vignettes describing ambiguous ethical dilemmas involving professional role boundaries or client confidentiality. Twenty-seven staff members were from rural agencies, and 68 from urban-suburban agencies; 60 were direct care staff, and 35 were supervisory. Participants were asked to make and justify a more conservative or a less conservative decision in response to each dilemma. RESULTS: Years of experience as a mental health provider and previous ethics training correlated positively with staff having experienced more situations similar to those in the vignettes; however, these variables were not related to the decision made or the type of ethical justification for it. When the analysis controlled for experience and previous ethics training, staff made fewer conservative decisions in boundary dilemmas than in confidentiality dilemmas. Compared with nonrural providers, rural providers had experienced more boundary dilemmas and made fewer conservative decisions in response to them. CONCLUSIONS: Boundary problems occur frequently in community-based services, especially in rural settings, and may or may not be handled conservatively. With the expansion of case management and other in vivo services, better understanding of ethical risks and informal practices will help improve services and provide appropriate training and supervision of staff.

Adult↗

Ethical awareness and healthcare professionals.

Reports the results of a survey that sought to measure the "ethical awareness" of healthcare professionals at a number of area hospitals and nursing homes. Notes that the survey was helpful in isolating areas for needed inservices on ethical issues. Indicates that in creating the ethical environment necessary for the making of ethical decisions, pastoral care staff can offer encouragement to administrators in assessing the ethical awareness of the hospital's employees in such a way that not only clinical staff, but support staff and administrators as well, become more aware that many "non-clinical" situations are also the arena for ethical decision-making.

Attitude of Health Personnel↗

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.

Conflict, Psychological↗

Building bridges: teaching ward-based ethics.

Ethics has traditionally been taught in the 'ivory towers' of academia. Recent developments and reforms in nurse education have given ethics a prominent position in most curricula. However, the vast majority of ethics teaching continues to take place in academic departments. This approach fuels the practitioner's views that nursing is a pragmatic activity whilst ethics is a cognitive endeavour; such perspectives entrench ethics firmly in the traditional gap between theory and practice. The focus of this paper presents an argument that the teaching of ethics must be versed in clinical reality if bridges are ever to be built and the theory-practice gap crossed.

Bioethical Issues↗

The relationship between role conception and ethical behaviour of student nurses in Hong Kong.

This paper was designed to explore the relationships of three role conception types (the professional, bureaucratic and service role conceptions) to the ethical behaviour of student nurses from the apprenticeship and degree nursing programmes in Hong Kong. The effect of role discrepancy on ethical behaviour will also be explored. A nonprobability convenience sampling of 140 certificate students from a hospital-based training course and 81 degrees nursing students from a tertiary programme were selected. Role conception and role discrepancy were measured by the modified Nursing Role Conception scale originally developed by Corwin. For ethical behaviour, the Judgement About Nursing Decisions scale developed by Ketefian was used. Multiple regression analyses showed that the ideal professional role conception was a significant predictor, accounting for 17% of the variance in the ideal ethical score of the degree students. Actual service role conception was a better predictor of the actual ethical score, explaining 10% and 14% of its variance for the certificate and degree students respectively. Professional and bureaucratic role discrepancies together were found to have a negative effect on the actual ethical behaviour of the degree students. These results suggest that professional values that have been developed through socialization in nurse education programmes could benefit patients only when degree students, in particular, could adapt successfully to the demands of bureaucratic organization.

Education, Nursing, Baccalaureate↗

Visiting nurses' situated ethics: beyond 'care versus justice'.

This article discusses Dutch visiting (district) nurses' moral considerations of their daily work. It is based on an empirical study using extensive semistructured interviews. The study is informed by the theoretical debate on the 'ethics of care' and the 'ethics of justice'. It is argued that this debate easily turns into an unfruitful contest between these two perspectives: which one is best? The results suggest that visiting nurses' moral considerations of their day-to-day work can be described well in terms of an ethic of care. At the same time, however, concepts and issues central to an ethic of justice are also of crucial importance to their considerations. Nurses' ways of managing to combine both perspectives, even in situations of apparent conflict between them, are described. Thus, clues are provided on how the debate on the ethics of care and the ethics of justice may be carried out in a more fruitful way apart from through hierarchically opposing both perspectives.

Adult↗

Medical ethics--an endeavour for social medicine?

In this paper twelve themes are pointed out as background for the increased interest for medical ethics: New medical knowledge, the democratisation of doctor-patient relationship, changes in the disease panorama, autonomy and its limits, research ethics, collegiate concern, prioritization, ethics of clinical training, immigration and cultural conflicts, changes in the view of the rationality of ethical reasoning, changes in the view of nature in relation to culture and medical students' requests for teaching in medical ethics. It is discussed whether teaching in medical ethics is a matter for social medicine or whether one should pass it on to hospital priests or philosophers.

Education, Medical↗

The activity of French research ethics committees and characteristics of biomedical research protocols involving humans: a retrospective cohort study.

BACKGROUND: Clinical trials throughout the world must be evaluated by research ethics committees. No one has yet attempted to clearly quantify at the national level the activity of ethics committees and describe the characteristics of the protocols submitted. The objectives of this study were to describe 1) the workload and the activity of Research Ethics Committees in France, and 2) the characteristics of protocols approved on a nation-wide basis. METHODS: Retrospective cohort of 976 protocols approved by a representative sample of 25/48 of French Research Ethics Committees in 1994. Protocols characteristics (design, study size, investigator), number of revisions requested by the ethics committee before approval, time to approval and number of amendments after approval were collected for each protocol by trained research assistant using the committee's files and archives. RESULTS: Thirty-one percent of protocols were approved with no modifications requested in 16 days (95% CI: 14-17). The number of revisions requested by the committee, and amendments submitted by the investigator was on average respectively 39 (95% CI: 25-53) and 37 (95% CI: 27-46), per committee and per year. When revisions were requested, the main reasons were related to information to the patient (28%) and consent modalities (18%). Drugs were the object of research in 68% of the protocols examined. The majority of the research was national (80%) with a predominance of single-centre studies. Workload per protocol has been estimated at twelve and half hours on average for administrative support and at eleven and half hours for expertise. CONCLUSION: The estimated workload justifies specific and independent administrative and financial support for Research Ethics Committees.

Clinical Protocols↗

The ethics of the caring conversation.

The aim of this study was to explore the ethical foundations for a caring The analysis is based on the ethics of Paul Ricoeur and deals with questions such as what kind of person the nurse ought to be and how she or he engages in caring conversations with suffering others. According to Ricoeur, ethics (the aim of an accomplished life) has primacy over morality (the articulation of aims in norms). At the ethical level, self-esteem and autonomy were shown to be essential for a person (nurse) to act with respect and responsibility. The ethical relationship of a caring conversation was found to metrical, because of the passivity inflicted by suffering. This asymmetry was found to be potentially unethical if not balanced with reciprocity. In the ethical context, the caring conversation is one in which the nurse makes room through the ethos of caritas for a suffering person to regain his or her self-esteem, and thus makes a good life possible.

Altruism↗

Everyday ethics in the care of elderly people.

This article analyses the general ethical milieu in a nursing home for elderly residents and provides a decision-making model for analysing the ethical situations that arise. It considers what it means for the residents to live together and for the staff to be in ethically problematic situations when caring for residents. An interpretative phenomenological approach and Sandman's ethical model proved useful for this purpose. Systematic observations were carried out and interpretation of the general ethical milieu was summarized as 'being in the same world without meeting'. Two themes and four subthemes emerged from the analysis. Three different ethical problems were analysed. The outcome of using the decision-making model highlighted the discrepancy between the solutions used and well-founded solutions to these problems. An important conclusion that emerged from this study was the need for a structured tool for reflection.

Aged↗

Ethical practices and beliefs of psychopathology researchers.

Ethical guidelines are vague concerning how situations should be handled when researchers encounter participants in preexisting psychological distress. Ethical issues of beneficence, autonomy, and the nature of informed consent may arise in these situations. This study investigated the ethical practices and beliefs of 84 psychopathology researchers when confronting research participants in distress. Results indicated that psychopathology researchers in general engaged in diverse ethical practices in providing debriefing, treatment referrals, and providing for distressed participants. Characteristics of the designated studies and of the researchers accounted for significant differences in ethical practices. In addition, the type of psychopathology being assessed accounted for significant differences in ethical practices and beliefs. Guidelines are offered to aid researchers who encounter participants in preexisting distress.

Altruism↗

Empirical research on research ethics.

Ethics is normative; ethics indicates, in broad terms, what researchers should do. For example, researchers should respect human participants. Empirical study tells us what actually happens. Empirical research is often needed to fine-tune the best ways to achieve normative objectives, for example, to discover how best to achieve the dual aims of gaining important knowledge and respecting participants. Ethical decision making by scientists and institutional review boards should not be based on hunches and anecdotes (e.g., about such matters as what information potential research participants would want to know and what they understand, or what they consider to be acceptable risks). These questions should be answered through empirical research. Some of the preceding articles in this special issue illustrate uses of empirical research on research ethics. This article places empirical research on research ethics into broader perspective and challenges investigators to use the tools of their disciplines to proactively solve ethical problems for which there currently exist no empirically proven solutions.

Behavioral Research↗

Ethical dimensions of leadership in community health nursing.

This article deals with ethical leadership. Community health nurse (CHN) leaders are confronted with ethical problems in increasing numbers and complexity. To deal successfully with these dilemmas, nurse leaders must be aware of leadership qualities, know the ethical obligations of leaders, and use actions that produce the best decisions in tough financial times. The main purpose of the article is to present several helpful strategies for CHN leaders to use for ethical decision making. Types of ethical decisions that nurse leaders make are given. Six recommendations for action to be taken for ethical decisions in today's changing health-care climate are explored.

Beneficence↗

Ethics and nursing research. 2: Examination of the research process.

In this article, the second in a series on ethics in nursing research, the author explores the relationship between the guiding ethical principles and the steps of the research process. In the first article (Vol 8(13): 888-92) the two dominant theories of ethics, utilitarianism and deontology, along with the guiding principles of beneficence/non-maleficence and respect for human dignity, justice, informed consent and vulnerable subjects were discussed as they relate to the rights of individuals undergoing the research. In this article, the author describes the association between these principles and the elemental steps of the research process which are: the selection of the research problem; data collection; sampling; informed consent; data analysis; and research presentation. The ethical conduct of many of these research steps is guided by ethics committees but for those that are not nurses need to rely on their own integrity, honesty and committment to the current prevailing ethical principles.

Data Collection↗

Ethical dilemmas in general hospitals: differential perceptions of direct practitioners and directors of social services.

Two distinct groups of social workers in general hospitals, fourteen directors of social work services and eighteen direct practitioners, were interviewed concerning their perception, ranking and resolution patterns of ethical dilemmas. The reverse order of importance and somewhat different content of ethical dilemmas identified by the two groups reflect their differential position in the hierarchy of hospitals and the difference in their experience in dealing with ethical dilemmas vis-à-vis clients. The directors tended to depend more on internal loci of authority, and were far more concerned with how to interpret and apply the relevant laws than the direct practitioners. Their decision making patterns seemed to be more virtues focused in contrast to the utilitarian and rights based focus of the direct practitioners. The findings emphasize the need for social workers' knowledge of ethical theories, rules and principles, and ethical self-knowledge. They also point out the need for written protocols of debates and/or detailed descriptions of applications of ethical decision making models to case situations in practice. The latter may provide guidelines for social workers in similar situations in the future, and at the same time be used as material for teaching and supervision.

Adult↗

[Bioethics and primary care: an outline of ethical problems experienced by nurses and physicians in the Family Health Program, São Paulo, Brazil].

This is a qualitative empirical study of descriptive ethics conducted with nurses and physicians working in the Family Health Program (FHP) in the city of Sao Paulo, Brazil. The objective was to identify ethical problems experienced by these professionals, who were asked to record ethical problems they had faced through a short written description of such events. The results revealed ethical problems involving patients and their families, the health team, organization, and the health system. The study addresses ethical issues permeating daily health care practice and requiring immediate solutions, rather than the classical dilemmas usually found in bioethics literature. The peculiarity of ethical problems in primary care may hinder their identification as such and jeopardize the relationships upon which the FHP is built.

Bioethical Issues↗

Psychiatrists and compulsion: a map of ethics.

OBJECTIVE: The aim of this study is to analyse the ethical underpinning of involuntary treatment and to create a guide for psychiatric practice which clarifies its relationship with modern mainstream clinical ethics. METHOD: Literature on ethics, involuntary treatment, civil commitment, diagnosis and law was searched and examined. RESULT: Hospitalisation for involuntary treatment and control has blurred two important discriminations: the discrimination between clinical and social constructions of mental illness and the discrimination between therapeutic actions and policing control. Plotting these discriminations creates a map of ethics in involuntary treatment. Although there are clinical roles throughout involuntary treatment, the ethical issues vary according to whether clinical actions are taken on clinically or socially constructed diagnosis and whether the purpose of the actions is therapy or control. CONCLUSION: Paternalist involuntary treatment should be undertaken more readily when it is for clinically defined illness and for the benefit of the patient. Where the conditions are defined by social behaviours alone, where treatment is not useful to the patient, or where actions have policing intent, particular ethical approaches need to be taken to defend the patient, the clinician-patient relationship and the reputation of the profession.

Australia↗