Ethical Decision-Making among Critical Care Unit Nurses

Abstract

The health care business has created complex relationships between consumers and health care institutions. Rising health costs, rationing of health care and medical technology have put critical care unit (CCU) nurses in complex environments where they must face ethical conflict. CCU nurses find themselves ill equipped to make sound decisions concerning ethical dilemmas. Nurses must ensure the patient's choices are respected and honored due to the duties inherent in the nurse-patient relationship. The purpose of this study was to explore the process of ethical decision making (EDM) as it is experienced by CCU nurses. Gaining an understanding of this process may assist nursing education programs, and provide a basis for ethical nursing practice in the critical care setting. The grounded theory method described by Glaser (1967) and Strauss (1978) guided data collection and analysis. The sample was comprised of 10 full-time critical care nurses. Data were collected over the course of two academic semesters using methods common to field research. The constant comparative method of data analysis was used. Results indicated that critical care nurses identified ethical conflict in four major areas: professional values versus personal values, respect for patient autonomy versus duty to do no harm, professional standards versus institutional policies, caring versus controlling. Constraining intervening conditions that inhibited resolution of ethical conflicts were: legal issues, professional relationships, paternalism, medical futility, and physician burnout. The intervening conditions that facilitated resolution of ethical conflicts were: cultural perspectives, open communication, and caring. Strategies for responding to the ethical conflicts evolved from the data: "opening up," "getting people to talk," and "supporting the patient." Consequences of these strategies were described as: "reaching understanding," and "sensing harm." The inter-relationship of these categories resulted in a core category of "facilitating resolution." Facilitating resolution, the basic social process, describes the linking of action/interactional sequences as they evolved over time. The major implications of this study are that shared decision making in ethical conflict will result in positive outcomes for patients and nurses involved in ethical dilemmas. Relationship enhancement methods increase perceptual abilities in EDM. Further nursing research should include inquiry into the use of power in interactions, therapeutic empathy, and permeability of nurses' internal and external boundaries in the "opening up" phase of EDM.