DEVELOPING NURSES’ MORAL REASONING SKILLS

Analysis ofdatafrom a Nursing Dilemma Test administered to 69 registered nurses employed at the Groote Schuur Hospital in Cape Town revealed a pattern o f principled thinking in the groups with J to 9, 20 to 24, 2S to 29 and $0 to $4 years o f clinical experience, whereas the group with the least clinical experience (0 to 4 years) showed no distinguishable pattern o f thinking stages in moral judgement development.


INTRODUCTION
How do nurses learn moral reasoning skills?How is moral reasoning measured?An attempt was made to answer these questions from data collected at a series of 1 -day nursing ethics workshops for registered nurses at Groote Schuur Hospital in Cape Town.The assumption was that "The personal value structure o f the nurse and its impact on decision making in nursing remain vague and neglected.L ittle in nursing education prepares nurses to perceive moral issues that arise in practice or to make decisions in situations in which they must exercise moral judgment skills.In nursing situations that have no apparent clear-cut right or wrong solutions, nurses face typical moral dilemmas, th at is. p ro b lem s w ith tw o eq u a lly unacceptable alternatives.Nurses, therefore, regularly grapple with moral decisions" (Crisham 1981:105).

Problem statement
Registered nurses (RNs) in South Africa receive inadequate instruction in moral decision making and have to depend on intuition.

Purpose of the study
The purpose of this study was to measure RNs stage o f thinking in moral judgem ent development.

Research design
A quantitative descriptive study.

Ethical considerations
Study subjects were given a codc number and were told that only the investigator would have access to both the names and code numbers, in th is way en su rin g anonym ity and confidentiality.The study was approved by the Groote Schuur Hospital Nursing Division Ethics Committee METHODOLOGY Data were collected by the investigator by administering a Nursing Dilemma Test (Crisham 1981:107) (Appendix 1) to each study subject at a nursing ethics workshop.

Background to the ethics workshops:
Attendance at the ethics workshops was voluntary and aHer an informal "getting to know you" session over coffee, participants were given a codc number for purposes of confidentiality in the event o f future correspondence with the writer because of the sensitive nature of certain ethical issues.Analysis of the participants' expectations clearly indicated that there were senous knowledge deficits regarding nursing ethics and the programme was adjusted accordingly to meet learning needs Participants were asked to complete a Nursing Dilemma Test (NDT) at the start of the workshop so that results would not be influenced with new knowledge gained during the workshop.
Reconceptualization and clarification of ethical concepts such as values, codes of conduct, ethical principles and theories was achieved by group discussion.Smith & Davis (1985:337) list the following tasks for nursing ethics: "(1) to assist nurses to develop the ability to integrate ethical reasoning into their practice and to use this ability to reflect upon bioethical issues, (2) to identify the role o f nursing and nurses in any public debate on bioethical issues, (3) to identify the role o f nurses in providing input and participation in ethical decision-making about particular clients, and (4) to develop monitoring and reporting mechanisms in order to ensure that persons act ethically toward the client".Similarly, Davis & Aroskar (1983:4) maintain that the task in health care ethics is "neither to discover some new moral principles on which to build a theoretical ethical system nor to evolve new approaches to ethical reasoning, but to prepare the groundfor the application o f the established general moral rules " and to sensitise health professionals to ethical issues in health care.
At the workshops the ethical principles of autonomy, confidentiality, beneficence, nonmaleficence, justice and veracity served as a basis for small group discussions of realistic nursing dilemmas selected from the literature.Mitchell (1981:33-5) suggests the following benefits in using ease studies in bioethics courses: 1) sensitizing the student to the importance of analysing the data in each case, 2) alerting the student to the value of a carefully constructed methodology and applying it to a particular case, 3) providing the opportunity for different philosophical and theological perspectives to be heard; 4) allowing students to test different theoretical approaches to decision-making; 5) alerting students to the many conflicting rights in specific cases; 6) emphasising the importance o f different parties participating in the decision-making process; 7) revealing the role of creative imagination in the decision-making process; as well as an appreciation of 8) the significant intellectual and personal energy inv estm en ts that are required in the decision-making process.
In the current climate of increased awareness of legal rights and medical lawsuits in SA, there is a growing tendency by the nursing pro fessio n to em phasize the legal consequences o f nursing actions at the expense of ethical considerations resulting in a legal-moral tension in nursing (Johnstone 1988:149).E vidence o f professional discipline can be found in well entrenched control structures formalised in legislation such as the Disciplinary Committee of the South African Nursing Council (The Nursing A ct, No 50 o f 1978) as well as in hospital-based disciplinary committees (Du Preez 1988:19).
On the other hand ethical control o f professional conduct by members of the profession, although described in SA nursing literature as an essential characteristic of a profession (Mellish 1988:71), has not had the same treatment.The South African Nursing Association (SANA) has attempted to achieve this at a national level and certain hospitals have established nursing ethics committees (Du Preez 1988:17).There is no SA nurses' code of conduct such as the United Kingdom Central Council Code ofProfessional Conduct (Pyne 1987: 510) intended to improve standards of conduct.Instead, the Florence Nightingale Pledge of Service and later the SANA Pledge of Service have attempted to meet this need, but these pledges are limited in scope and therefore provide inadequate ethical guidance for nursing standards in SA in the 90s where trade unionism is threatening to replace professionalism and where an ethical tension exists between the obligation to benefit the individual client and the obligation to benefit society (Fry 1985:303).A solution to the legal-moral tension offered by Milner (1993:25) suggests that "Nurses do not need to be guided by rules: nurses can be guided by principles Before concluding the workshops participants were given guidance on how to do an ethical assessment of a patient based on the ICN Code for Nurses and a Patient's Bill of Rights (Woodruff 1985:300).This has produced interesting results but these will not be discussed here.Finally, analysis of the data collected during the nine workshops indicated that a useful retrospective study was emerging

Data collection tool
The NOT (Crisham 1981:107) measures moral judgement in real-life nursing dilemmas as opposed to the DIT (Defining Issues Test) that m easures moral ju d g em en t in hypothetical general dilemmas (Crisham 1981:105) and for this reason the NDT was considered more appropriate.Furthermore the NDT measures the importance given to moral and practical considerations in the complex decision-making process (Crisham 1981:106) and is based on cognitive theory of moral development (Kohlberg 1969, Piaget 1%5 cited in Crisham 1981:107) which is well documented (Frisch 1987;Parker 1990, Parker 1990, Callery 1990, Felton & Parsons 1987).The structure o f the NDT was The question "What should the nurse do?" (Appendix 1) focusses on the inherent conflict in the dilemma.The 6 items that have to be ranked in order of importance include major moral and practical considerations pertaining to the dilemma, and the final section deals with the degree of familiarity with the dilemma on a Likert-type scale.

Study sample
O f the 109 registered nurses who attended the workshops, only 69 had provided information about the length of their clinical nursing experience so this became the study sample which included only one (1) male.Although there were spoilt questions in each section, this did not exclude participants.No distinction was made between those who held a degree or a diploma in nursing.

Data analysis
Unlike Crisham's study (1981)  Clearly, these participants argued in favour of the patient's right to information, thus defending the ethical principle of autonomy over the principleof confidentiality.However, of these participants, some qualified their decision with statements such as "assess patient's emotional, mental slate and coping skills: discuss with doctor; depending on circumstances'' indicating some uncertainty in moral decision-making.It is not clear what may have contributed to this uncertainty, but the participants may possibly have been concerned about the e^ect that the information may have on the patient.This implies conflict between upholding the ethical principle of beneficence vis-a-vis nonmaleficence, and it also implies an utilitarian approach to moral d ecisio n -m ak in g w hich considers consequences.

Length of clinical experience
When grouped by length of clinical experience (Table 2) most of the study subjects (n=15; 21,6V.)were found to have tetween 20 and 24 years of experience.O f note is the finding that of those who could not decide what to do, five participants had between 20 and 24 years of clinical nursing experience, and two had respectively between 25 and 29 years of experience and 30 and 34 years of experience Four participants had not completed this section, three of whom had between 5 and 9 years o f experience, resulting in spoilt questions.This could mean that these participants could not decide what do do, thus bringing the total number of participants for this category to eighteen (26,1*/*).This ambivalence could be attributed to the fact that these nurses, albeit very experienced, have not received instruction in moral decision-making or the ambivalence may be explained by Lyth's (1990:449) interpretation of the management of anxiety within a hospital as "Delegation in the hospital seemed to move in a direction opposite to the usual one Tasks were frequently forced upwards in the hierarchy so that all responsibility for their perform ance could be d isc la im ed " Altematively, they may have learnt from vast experience to view such ethical situations with caution until all the facts are known Those participants who indicated that the nurse should not answer the patient's questions, of v ^m the majority had more than 15 years of experience, qualified their decision with statements that reflect two ethical approaches to moral decision-making The deontological (duty) perspective is evident in phrases such as "doctor 's dutyafterwards answer questions: refer to doctor " implying that there is a duty towards the doctor as the team leader to make the decision.Utilitarianism is indicated in phrases such as "look at circumstances surrounding: should not leave the matter there -liaise with doctor and family about how to tell the patient about his diagnosis" which imply a consideration of the consequences of answering the patient's questions.However, without qualitative data w hich an interview w ith each o f the participants would have provided, it is d iffic u lt to m ake m ore sense o f the participants' level of moral reasoning.).Clearly, the ethical principle of autonomy for the individual is regarded as the most important consideration for the purposes of the present study.Furthermore, the results suggest that nurses do not need to be guided by rules but that they can be guided by principles (Milner, 1993).

Data in
Item  3).

Relationship of stage of thinking in moral judgement development to length of clinical nursing experience and familiarity with dilemma t
In the present study the sample of registered nurses (N=69) showed a pattern of principled thinking by ranking items in order of importance, featuring a satisfactory level of moral judgement development (   In the present study the degree of familiarity with the dilem m a was indicated on a Likert-type scale on the NDT (Appendix 1).A scoring of \-2 (I = "Made a decision in a similar dilemma; 2 = Knew someone else in a similar dilemma") was accepted as being familiar with the dilemma, whereas a scoring of 3-5 (3 = "Not known anyone in a similar dilemma, but dilemma is conceivable: 4 = Difficult to imagine the dilemma as it seems remote; 5 = Difficult to take the dilemma seriously as it seems unreal") indicated unfamiliarity with the dilemma.Spoilt questions were regarded as indicating unfamiliarity with the dilemma.The degree of familiarity with the dilemma is indicated in a frequency distribution table (Table 4).
The group with 0 to 4 years of experience was the least familiar with the dilemma, while the group with 25 to 29 years of experience was the most familiar (75%).An unexpected fmding is that the group with 15 to 19 years of experience showed only 36,4% familiarity with the dilemma and the group with 30 to 34 years of experience showed only 37,5% fam iliarity with the dilem m a.This is particularly interesting because previous involvement with the dilemma is assumed to enhance principled thinking (Crisham 1981:110).Data for these two groups suggest principled thinking although strongly suggestive of a practical approach to moral decision-making for the group with 30 to 43 years of experience, while data for the group with 0 to 4 years o f experience reflect unfamiliarity with the dilemma as well as no clear pattern of judgement development.

CONCLUSION
The inconclusive fmdings ofthe present study confirm the assumption that little is known about the impact o f the personal value structure of the nurse on decision-making (Crisham 1981:105) and that the values held by nurses need to be explored if nursing principled thinking is to be enhanced.Furthermore, the application of cognitive theory to explain moral development may be too limited, and the phenomenological tradition should be explored to provide a deeper understanding of moral development.
The ethics workshops provided a much needed opportunity to reflect upon bioethical issues and to review the role of nurses and nursing in bioethical debates, but more particularly, to sensitise the participating nurses to ethical issues in health care (Davis & Aroskar, 1983).Evaluation ofthe workshops revealed that the case study discussions, through the process of coaching, had provided an opportunity for participants to clarify their values, to practice ethical reasoning, applying new ethics terminology with confidence and to gain deeper understanding of moral issues in nursing practice.P articipants also suggested that all categories of nurses would benefit from attending the workshops thus confirming the value of bioethics case studies (Mitchell 1981) for teaching ethics.From the discussions, it appears that there is now, in the history of nursing in SA, an urgent need for a code of conduct to guide moral standards which addresses not only responsibility to patients or clients, but also responsibility for professional standards by m aintaining knowledge and skills, responsibility to colleagues and professional and personal responsibility.Unless personal responsibility is accepted at all levels of the hierarchy of a health care service, there can be no perceived moral obligation to make principled decisions.Let'iMl;

Curationis
Nursing principled thinking (NP) representing Stage 5: The mordity o f tocieul consensus: "Wh*t laws the people wmt to make are whal ought to be" and Suge 6: The morality o f nonart>itrary social cooperation: "How rational and impartial people would organize cooperation is moral."Stage one thinking (SI): The morality of obedience: "Do whal you're told."Suge three thinking (S3): The morality o f personal concordance: "Be considerate, nice, and kind, and you'll get along with people Stage two thinking (S2): The morality of instnimenul egoism and simple exchange; "Let's make a deal" Practical considerations (PC).Suge four thinking (S4): The morality o f law and duty to the social order: "Everyone m society is obligated and protected by the law".(Rest 1979 cited in Crisham 1981:107) (representing Stage 5: The morality of societal consensus; "What laws the people want to make are whal ought to be" and Suge 6: The morality of nonarbitrarv' social cooperation: "How rational and imparual people would organize cooperation is moral' Stage one: The morality of obediencc: "Do what you're told."Stage two: The morality of instrumental egoism and simple exchange: "Let's make a deal " Suge three: The morality of personal concordance: "Be considerate, nice, and kind, and you'll get along with people.Stage four: The morality o f law and duty to the social order: "Everyone in society is obligated and protected by the law".Practical considerations