.. t or patient, the nurse acts to promote, maintain, or restore the health of the person; wellness is the goal. A collegial collaborative of relationship with other health professionals who share a mission and a common data base furthers the practice of nursing. Guided by a humanitarian, ethical principles, the nurse practices in a personal, nurturing, and protective manner that promotes health in all ways. The nurse may be a generalist or a specialist and, as a professional, is ethnically and legally accountable for the nursing activities performed and for the actions of others to whom the nurse has delegated responsibility” (Mosbys Medical & Nursing Dictionary, 1996).
Questionnaire: A written or printed form comprising a series of questions submitted to a number of persons in order to obtain data for a survey or report ” (Britannica World Language Dictionary, 1995). Operational Definitions DNR order: An order made by a physician (of one of the three hospitals involved in the UCO DNR study) after consultation with family members which entails the lack of effort to revive a patient that has naturally ceased to breath or has experienced cardiopulmonary arrest. Attitude: An inner personal feeling toward a certain subject, person, or philosophy that could be positive or negative held by one or more nurses involved in the UCO descriptive DNR study. Nurse: A graduate of a one (Licensed Practical Nurse), two, or a four year, accredited nursing program, or a graduate of a certificate program and licensed by any state to practice as a nurse and currently employed at any one of three metropolitan hospitals in the Southwestern United States which are currently assisting with the UCO DNR research project. Questionnaire: The tool used to ascertain attitudes and acquire information about DNR orders from participating nurses employed at one of the three Southwestern United States Hospitals involved in the UCO DNR study. CHAPTER II Review of Literature Introductory Statement The Review of Literature has been organized into Kohlberg’s Theory of Moral Development. Kohlberg’s theory was used in this study because it directly addresses moral development in children and adults, and focuses on the reasons an individual makes a decision; rather than the actual morality of their decision. Kohlberg’s Moral Development Theory progresses through three levels and six stages.
The first level, the Pre-Moral or Pre-Conventional, consists of two stages. Stage one involves punishment and obedience orientation. Stage two involves instrumental-relativist orientation in which action is taken to satisfy one’s needs. Incorporated into this level is Piaget’s stage one of moral reasoning, which consists of Moral Realism and attitude formation (Coffey and March, 1983). At this level, nurses attitudes begin to formulate in relation to deep rooted origins of beliefs and values. Furthermore, these beliefs and values often influence nurses attitudes towards Do- not – resuscitate(DNR) orders.
The second level, The Conventional Level, includes stages three and four. Stage three involves interpersonal concordance, which focuses on individuals adhering to a good boy/nice girl morality. Stage four involving law and order orientation states that right behavior is obeying the law and following the rules. This level includes Piaget’s second stage of moral reasoning called Morality of Cooperation. As previously stated nurses formulate attitudes, however at this level ethical consideration takes precedence over the DNR order. The last level of Kohlberg’s theory is called The Post-Conventional, Autonomous, or Principled Level.
This level consists of stages five and six. Stage five involves social contract and legalistic orientation, and focuses on adhering to laws that protect the welfare and rights of others. Stage six involves universal/ethical principles. This focuses on the fact that universal moral principles are internalized. Nurses are often confronted with ethical dilemmas due to oppositions between their own conscience of what is right and wrong and ethical considerations. In retrospect, our Review of Literature has focused on Kohlberg’s Theory of Moral Development which may be the basis for a nurses moral reasoning. Conceptual Framework Moral development is a continuous process in which a person learns to consciously accept right and wrong, according to their own beliefs and values.
An individual learns throughout childhood a sense of what is right and what is wrong. Through this, a sense of morality is formed by their behavior as “good” or “bad”. This is established through rewards and punishments. An individual must understand how morality is formed throughout childhood (Kozier & Erb, 1995). A childs moral development is highly influenced by the parent or guardian. A child is rewarded for what a parent or guardian considers good behavior and punished for what a parent or guardian considers a bad or negative behavior. Therefore, a child’s belief of what is right or wrong is developed by their parent’s disciplinary actions.
PRE- CONVENTIONAL LEVEL. Kohlberg developed a structure to form a theory of moral development. Moral development is a complex process, which involves learning what ought to be and what ought not to be done (Kozier and Erb, 1995). According to Kohlberg, moral development progresses through each stage of each level. Levels and stages are not always linked to a particular developmental stage, because some persons progress to a higher level of moral development that others (Kozier & Erb, 1995). The first stage of the Pre-conventional level is the Right of literal obedience to rules and authority, avoiding punishment, and not doing physical harm (Kohlberg,1927).
This stage takes an egocentric point of view. A person at this stage does not recognize the interests of others. They do not relate two points of view. Instead, they value their own beliefs. Actions are judged in terms of physical consequences rather than in terms of psychological interests of others (Kohlberg, 1927).
For instance, a nurse follows a physician’s orders so as not to be fired, although many nurses may have conflicting beliefs it is their duty to carry out DNR orders. Many statutes provide immunity to health care providers who do. Failing to honor an DNR order could lead to a battery suit by the patient or his family, and disciplinary action by the Board of Nursing (Sloan, 1996). Individuals function in order to avoid punishment. Rules are sacred and unchangeable, and those who violate rules must be punished according to the magnitude of their offenses (Shultz, 1997). Health care as a profession involves far more ethical principles than perhaps any other profession. Nurses, as well as other health care professionals with a principle- centered life and practice, create an internal structure that will help them consistently meet ethical obligations to themselves, patients, families, and communities. Developing a central set of Principles, encourages nurses to apply the same set of ethics to themselves as well as to their patient (Moss, 1995). Jezewski (1994) conducted a study to describe the conflict that occurs during the process of consenting to do-not-resuscitate status and the strategies used by critical care nurses to attempt and prevent, minimize, and/or resolve these conflicts.
His study consisted of a grounded theory design. Twenty-two critical care nurses practicing in upstate New York in urban and rural, profit and nonprofit hospitals were involved in the study. Of the 22 participants, 21 were female and 1 was a male. The age range was 26-53 years old, with a mean of 34 (+ or – 6 years). Years in practice ranged from 4-31 years.
Semi-structured, in-depth interviews were used to collect data. The interview schedule consisted of open-ended questions and were formulated to elicit nurses’ experiences in the context of interacting with patients and family members during the process of their deciding whether to consent to a DNR status. The data was analyzed with the continuous comparative method of grounded theory. The results show that conflict occurred during the process of consenting to DNR status. Two major categories of conflict were intrapersonal (inner conflict in coming to terms with DNR-status decision) and interpersonal (conflict that took place between individuals involved in consenting to a DNR status). Intrapersonal conflict, for the nurses occurred while determining the appropriateness of DNR order for their patients and coming to terms with the meaning of DNR status.
Nurses had to come to terms that a DNR order was appropriate or inappropriate for the patient. To do this, the nurse assessed the patient’s physical status in conjunction with quality of life issues, conferred with other health care professionals, and talked with the patient and/or family. It was important for the nurses to personally resolve any conflict about the appropriateness before they could optimally assist patients and families with the decision to consent to DNR status. Interpersonal conflict occurred between family members, patients, and staff. Nurses descriptions of their role were reflective of a culture broker framework incorporating advocacy, negotiation, meditation, and sensitivity to patients and familys needs. They would talk with family members to try to understand their feelings about consenting to a DNR status.
The nurses emphasized the importance of allowing time for family members to come to terms with the patient’s status and the meaning of DNR for themselves individually and as a group (Jezewski, 1994). Attitudes, values, and ethics set the stage for managed care nursing (Salladay, 1997). Ajzen and Fishbein(1980) theorized that human beings base their actions on rational, systematic use of information; persons consider the implications of their actions before they decide to engage in a given behavior. Attitudes are defined as the persons evaluation of the positive or negative effects of the outcomes of specific behaviors or actions taken. Whereas, Behavioral intention is the reported degree of likelihood that the nurse will perform a certain action (Ajzen & Fishbein, 1980).
Nurses must decide what their own moral actions ought to be in a situation concerning a DNR order. Because of the special nature of the nurse-client relationship, they must support and sustain clients and families who are facing difficult moral decisions. On the other hand, nurses must also support clients and families who are living out the decisions made for and about them by others, or themselves. Nurses can make better moral decisions and have a positive attitude to any given situation by thinking in advance about their beliefs and values (Moss, 1995). Schaefer and Tittle (1994) conducted a study to explore the attitudes and perceptions of registered nurses (RNs) and physicians (MDs) regarding the care of patients with do-not-resuscitate (DNR) orders in the intensive care units (ICU).
Structured interviews were conducted with twenty RNs and MDs from the ICUs of twenty-five Veterans Administration Hospitals. The questionnaire included four hypothetical cases which tested a statement as to who would best support the autonomy of the patient in making a DNR decision: (a) when the patient is incompetent, (b) when the patient is not competent and a close relationship exists with the family, (c) when the patient is not competent, has no close relationship with family but a therapeutic relationship exists between the physician and the patient, and (d) when the patient is not competent, has no close relationship with the family but a therapeutic relationship exists between the nurse and the patient. A total of 226 (45.2%) questionnaires were received; 160 (70.8%) from the RNs and 66 (29.2%) from MDs. The mean age of RNs was 38.4 with a range of 22-58. The mean age of the MDs was 42.4 with a range of 27-76.
The RNs and MDs did not agree who would best support patient autonomy in any of the four cases (p.