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Nurses’ ethical behaviour in nursing dilemmas

Key words: ethical behaviour; ethical decision making; ethical reasoning; Kohlberg

Significance of research problem and purpose of the study: A growing concern about
the capacity of nurses to perform ethically in daily practice can be observed.
Nurses tend to reason and behave in a conformist or conventional manner when
faced with ethical conflicts. Not what the patient really needs but contextual fac-
tors seem to determine nurses’ ethical decision making and ethical practice. A
conformist approach to ethical dilemmas in nursing practice affects the quality of
patient care and, in the long term, the well-being of nurses themselves.
There is a strong belief that the work environment might exert a significant
influence on nurses’ ethical behaviour, but empirical support for this presumed
relationship is scant at best. The purpose of this study is to explore the ethical
behaviour of nurses and, more specifically, the influence of the work environment
on their ethical performance.
Research methods: An adapted version of the cognitive theory of moral develop-
ment of Kohlberg has been used as a framework. The cognitive structural char-
acteristics of Kohlberg’s conceptualization of moral stages have been used.
However, Kohlberg’s definition of morality as justice – in term of duties and
rights, fairness and impartiality – has been refined by adding a care perspective.
This change is believed to relate to the postconventional stages of Kohlberg’s
theory and focus on nurses’ commitment to promote patients well-being.
The Ethical Behaviour Test has been used in this study to measure nurses’
response in five nursing dilemmas. Two components of ethical behaviour were
discerned: ethical reasoning and its associated decisions; and the actual imple-
mentation of ethical decisions. Thus, ethical behaviour not only refers to nurses’
ethical reasoning but also to the relationship between this reasoning and their
actual conduct. Both components are operationalized in terms of the refined ver-
sion of Kohlberg’s theory. Reliability and validity were thoroughly evaluated in
previous research and found to be adequate for the purpose of this study.
The sample consisted of 513 staff nurses and was obtained through a random
selection of 23 nursing units in an academic hospital in Belgium. The study
examined the ethical behaviour of nurses, as measured by the Ethical Behaviour
Test, and the relationship between ethical behaviour and personal variables (age,
gender, level of education, experience, etc.) as well as environmental variables
(field of nursing, ward climate, hospital climate, support of head nurse, ethical
committees or rounds, training in nursing ethics).

Nursing Ethics 1998 5 (5) 0969-7330(98)NE227XX © 1998 Arnold

Research abstracts 461

Results and implications: The data have been collected and were analysed in
February and March 1998. The results will permit us to describe how nurses rea-
son, decide and practice when confronted with daily ethical dilemmas and to
identify characteristics of the work environment that promote nurses’ ethical
development. The implications for the practice of caring and for the nursing work
environment will be discussed.

Bernadette Dierckx de Casterlé, Karen Caerlens and Annick Derwael

Address for correspondence: Bernadette Dierckx de Casterlé, Centre for Health Services and
Nursing Research, Catholic University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium.

Specificity and efficacy of palliative care in an

inpatient palliative care unit
Key words : efficacy; palliative care; qualitative research; specificity

Purpose and objectives: As part of a larger research project that attempts to describe
the specificity and efficacy of palliative care in an inpatient palliative care unit,
this qualitative study examined two questions: (1) Which interaction, care and
decision processes take place?; and (2) How do patients, relatives and members
of the palliative care team go through these processes?
Significance of the research question: The recent development of palliative care has
led to several concerns. First, a growing number and variety of initiators and orga-
nizations attempt to provide palliative care. This structural diversity could
enhance the already existing vagueness about the specificity of palliative care.
Secondly, the development of palliative care in Belgium is mostly based on vol-
untary initiatives. Palliative care is reproached as a discipline for lack of profes-
sionality. Frequently, it is reduced to ‘holding the patient’s hand’. Moreover, a
review of the available literature about palliative care shows that research mainly
directs attention to the control of symptoms or to other separate aspects of pal-
liative care. For these purposes, quantitative methods are frequently used. Most
studies employ the method of outcome measurement and only report incidentally
on processes occurring within palliative care. These are a few of the reasons why
a research-based description of the specificity of palliative care is needed. This
description is important to obtain professional appreciation in order for palliative
care to be treated as a valuable part of health care.
Methods: A qualitative approach was used to explore the processes that take place
on an inpatient palliative care unit, and the experiences of patients, relatives and
palliative care team members. This study was conducted in 12-bed palliative care
units in two cities. Ten patients, 10 relatives, 20 caregivers and three volunteers
participated. Patients participated when the physician considered that it would
not harm them. Family members were approached during their visits to the hos-
pital. Staff members were approached by the researcher. Selected staff members
were nurses, two doctors, the social work assistant, the pastor’s assistant and
volunteers. In-depth interviews were conducted with patients, relatives, care-

Nursing Ethics 1998 5 (5)

462 Research abstracts
givers and voluntary nurses. Data were also gathered through observation of care
and team meetings, and through analysis of patient records. The data were
analysed using ethnography. This method is concerned with developing in-depth
descriptions of the meanings to people of actions and events and with the under-
standing of social reality.
Results: Patients and relatives frequently used superlatives in describing their
experiences with palliative care. They contrasted these experiences with the rather
negative ones in the hospital. There were very few negative experiences of these
patients and their family members. The patient is ‘the king’ and is really consid-
ered as a person. Nurses show a real commitment to the patient and the family.
It is remarkable that this commitment is present throughout the entire team.
Patients, relatives and caregivers described several strategies that contribute to
the creation of an environment in which patients can live their lives rather than
just wait to die. The most mentioned strategies were the availability and presence
of the care team and their immediate and unremitting attention to problems that
are important to patients. Family members often mentioned that nurses also paid
attention to the family, almost as if this behaviour was rather unexpected. The
basic principles of palliative care were described by the participants. Patients and
relatives said they were taken seriously by the caregivers; this showed a non-
judgemental attitude and a willingness of the caregivers to listen to patients and
their families, even if their opinions were not shared by the caregivers. Relatives
and patients experienced that decision making by the caregivers was based on
concern for the patients. The caregivers tried to support the patients in doing what
they desired or what was meaningful to them. Relatives described the contribu-
tion of the home-like environment and of the nonimposed structure to the cre-
ation of a personalized and quiet environment. All these strategies contributed to
the patients and relatives feeling really at home. They described an atmosphere
of life, safety and peace. All this created space for the patients and families, per-
mitting them to ‘find themselves again’ in the ordeal they have, after all, to go
through alone. Time and truthfulness were mentioned by nurses as necessary con-
ditions to ‘get on the same wavelength’ as the patient.

Mieke Grypdonck, Bernadette Dierckx de Casterlé, Josepha de Buysscher and

Nancy Cannaerts
Address for correspondence: Bernadette Dierckx de Casterlé, Centre for Health Services and
Nursing Research, Catholic University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium.
Telephone: +32 (0)16 33 69 75; Fax: +32 (0)16 33 69 70; E-mail:

Nursing Ethics 1998 5 (5)