By Nurses on Ethical Issues like the ^ — Termination of Pregnancies —

T h is is p a rt o f a b ig g e r re s e a rc h p ro je c t u n d e r th e le a d e rs h ip o f P ro f M P o gg enp oel, spo n so red by th e NRF. Abstract A Botes " No nurse may unfairly discriminate against on ground of religion, conscience and belief. " This research forms part of a larger interdisciplinary research project on the termi­ nation of pregnancies. The focus of this part of the project is on the ethical issues related to termination of pregnancies. The practice of the professional nurse is confronted with ethical dilemmas and dis­ putes. Whether the nurse chooses to participate in the termination of pregnancies or not, the core function of the nurse is that of counseling and ethical decision­ making. Effective counseling requires empathy, respect for human rights and un­ conditional acceptance of a person. Making ethical decisions implies making criti­ cal decisions. It is self-evident, therefore, that such decisions should be based on sound arguments and logical reasoning. It is of vital importance that ethical deci­ sions can be justified on rational ground. Decision-making is a critical thinking ap­ proach process for choosing the best action to meet a desired goal. The research question that is relevant for this paper is: Are nurses thinking critically about ethical issues like the termination of pregnancies? To answer the research question a qualitative, exploratory, descriptive design was used (M outon, 1996:103-169). Registered nurses were selected purposively (Creswell, 1994:15). 1200 registered nurses completed the open-ended question­ naires. Focus group interviews were conducted with 22 registered nurses from a public hospital for women and child health services. Data analysis, using secondary data from open-ended questionnaires and tran­ scribed focus group interviews, were based on the approach of Morse and Field (1994:25-34) and Strauss and Corbin (1990). The themes and categories from open coding were compared, conceptualized and linked with theories on critical thinking related to sec­ ondary data analysis were employed to ensure trustworthiness. Based on these findings the researcher concluded that nurses are not thinking criti­ cally when making ethical decisions concerning the termination of pregnancies. Recommendations are made as a possible solution for this problem. Opsomming Hierdie navorsing vorm deel van 'n groter navorsingsprojek oor die beëindiging van swangerskappe. Die …


Opsomming
Hierdie navorsing vorm deel van 'n groter navorsingsprojek oor die beëindiging van swangerskappe.Die fokus van hierdie deel van die projek val op die etiese aspekte wat verband hou met die beëindiging van swangerskappe.Die praktyk van die verpleegkundige word gekonfronteer met etiese dilemmas en dispute.Of die verpleegkundige betrokke is by beëindiging van swangerskappe al dan nie, die kern funksie is die van berading en etiese besluitneming.Effektiewe berading vereis empatie, respek vir menseregte en onvoorwaardelike aanvaarding van 'n persoon.Etiese besluitneming impliseer kritiese besluitneming.Om die rede moet etiese besluit op logiese redenasie gegrond wees.Besluitneming is 'n kriese denkproses om die beste aksie binne die konteks van die doel te kies.Die navorsingsvraag wat relevant is vir die referaat is: Dink verpleegkundiges krities oor etiese aspekte soos die geëindiging van swangerskappe?Om die n a v o rs in g s v ra a g te b e a n tw o o rd is ' n k w a lita tie w e , ve rke n n e n d e , beskrywende navorsingsontw erp gebruik.Geregistreerde verpleegkundiges is doelgerig geselekteer.1200 geregisteerde verpleegkundiges het die oop-einde v ra e ly s te v o lto o i en fo k u s g ro e p o n d e rh o u d e is m et 22 g e re g is tre e rd e verpleegkundiges gevoer.Data analise, met sekondêre data, is gegrond op die benaderings van Morse en Field (1994) en Strauss en Corbin (1990).Die tem as en kategorieë uit die oop ko d e rin g is ve rg e lyk en g e ko n se ptu a lis e e r bin ne te o rie ë van kritie se denke.Die maatreëls van Guba en Lin coln (1985) en Morse (1994) is gebruik om die g e lo o fw a a rd ig h e id van die navorsing asook die sekondêre analise te verseker.
G egrond op die bevinding w ord die gevolgtrekking gem aak dat verpleeg k u n d ig e s nie k ritie s e o o r etiese aangeleenthede soos die geëindiging van sw a n g e rs k a p p e d in k nie.Aanbevelings om die probleem aan te spreek word gemaak.

Introduction and research questions
The choice for termination of pregnan cies in South Africa was introduced by the promulgation of the Act on the Ter mination of Pregnancies (no 92 of 1996).In accordance with the Constitution (no 200 of 1993) the act enables women, older than 12 years, to decide autono mously, without the permission of the partner or parents, on the termination of their pregnancies.Apart form being in line with the Constitution, the act also addresses the problem of backstreet abortions.
The Constitution also allows nurses the right to freedom of choice to participate in the act of abortions.No nurse may unfairly discriminate against on ground of religion, conscience and belief.This implies that denial of employment and victimization against nurses who choose not to participate in abortions will be unconstitutional.
This research forms part of a larger, inter disciplinary research project, funded by the National Research Foundation, and focuses on the health care ethics.
Ethics is the study of what is good or right for human beings (Hoffman and Moore, 1990:1).The two key concepts in ethics are thus "good" and "right" .Taking per sonal interest into account, as well as considering and protecting the interest of others means thinking and acting ethi cally.
Within the context of abortions the above definition creates an ethical dilemma and dispute.In the case of a personal ethi cal dilemma, the individual (woman) is faced with a tough choice between op tions, which normally serve different in terest.There is however, the luxury of making up one's mind without having to reach consensus with other parties in volved.In the case of ethical disputes, on the other hand, two or more parties, with contradictory ethical views (pro-life versus pro-choice) are involved and it is therefore much harder to come to con clusion on what the best suitable ethical s ta n d p o in t or a c tio n sh o u ld be (Rossouw, 1994:59).
The practice of the professional nurse is confronted with these ethical dilemmas and d is p u te s .W h e th e r the nurse chooses.toparticipate in the termination of pregnancies or not, the core function of the nurse is that of counseling and e th ic a l d e c is io n -m a k in g .E ffective counseling requires empathy, respect for human rights and unconditional accept ance of a person.Making ethical deci sions implies making critical decisions.It is self-evident, therefore, that such de cisions should be based on sound ar guments and logical reasoning (Botes, 1999:7).It is of vital importance that ethi cal decisions can be justified on rational ground.D ecision-m aking is a critical thinking approach process for choosing the best action to meet a desired goal (Strader, 1992:233).Sound practice is fo u n d e d on sound th in k in g (Paul & Heaslip, 1995: 40).
The objective of this research was to in vestigate health care ethics with regard to the termination of pregnancies.Dur ing the process of data analysis the fol lowing research question became rel evant: Are nurses thinking critically about ethical issues like the term ination of pregnancies?

Research design and methods
To answer the research question a quali tative, exploratory, descriptive design (Mouton, 1996:103-169) from a larger interdisciplinary study was used and secondary data analysis was employed (Morse, 1994: 263).

Population and sampling
R e g iste re d nurses w ere se le c te d purposively (Creswell, 1994:15).1200 registered nurses completed the openended questionnaires.These registered nurses come from all over South Africa and represent nurses who were never involved with the termination of pregnan cies as well as nurses who were involved with the termination of pregnancies.Fo cus group interviews were conducted with 22 registered nurses.These nurses work in a public hospital for women and child health services.

Data collection
Secondary data (Morse, 1994:263) was used from open-ended questionnaires (De Vos, 1998:160) and focus group in terviews (Krueger, 1994).The following o p e n -en de d q u e stio n s were asked, namely: •• In your opinion, may a pregnancy be terminated?
• When you hear the word "abortion" , what do you think?
• What do you think about the act of abortion?
• What do you think about a woman who chooses to have an abortion?
• How do you behave towards a woman directly after she had an abortion?
• What do you think about a medical practitioner/midwife who carried out an abortion?
• Open coding, using an em ic ap proach, to identify the categories and themes from the open-ended questions and focus groups.Data analysis contin ued until saturation of categories and themes were reached.
• From the interpretation of the open coding the central story line was identi fied as a lack of rationality and an emo tional response to the ethical issue.
• The categories and themes from the open coding were compared, linked and conceptualized within the characteristics of critical thinkers/thinking.These char acteristics of critical thinking are used to present the data.

Trustworthiness
The m easures of Lincoln and G uba (1'985) w ere'em p lo yed to ensure the credibility, transferability, dependability and c o n firm a b ility o f the rese arch project.Triangulation of m ethods and researchers, peer group debriefing, and saturation of data were som e of the measures employed.To overcome the hazards of secondary analysis the con clusions and interpretations were dis cussed during a consensus discourse with the project leader.During the origi nal planning of the larger project the re searchers ensured that all the research q ue stion s in the p ro je c t fit the data (Morse, 1994:270).

Ethical considerations
The researcher adheres to the ethical standards for nurse researchers as de scribed by Denosa (1997).Although an inductive strategy was em p lo y e d in the re se arch the conceptualization and literature review on the termination of pregnancies and critical thinking will be presented before the discussion of the data to ensure a better understanding of the findings.

Perspectives on the termination of pregnancies
The key ethical problem of abortion (ter mination of pregnancy) is under what conditions, if any, an abortion is morally justifiable.Three view points can be practically distinguished, namely (Olen & Barry, 1996:171-172): • The so-called conservative view holds that abortion is never morally justifiable, or at most, justifiable only to save the mother's life.
• The so-called intermediate or moder ate view consider abortion acceptable up to a certain level of fetal development and/or claim that some reasons, not all, provide a sufficient justification for abor tion.
• The so-called liberal view holds that abortion is always morally justifiable, re gardless of the reasons or fetal devel opment.
The pro-life perspective will be congru ent with the conservative view.The prochoice perspective however, is not con gruent with the intermediate or liberal views, but rather acknowledge the right of the women to make an autonomous decision.
It seems that there is no consensus on the moral acceptability of abortions.The agreement to any answer will depend on one's view of what sort of entity fetuses are and w hether such e ntitie s have rights.This brings us to the develop mental, ontological, moral and legal sta tus of the fetus.

The ontological status of the fetus
Ontology refers to the theory and nature of being or existence and embraces a number of questions, namely: Whether the fetus is 1.
An individual organism 2.
Biologically a human being 3.
Psychologically a human being 4.
A person All of these questions depend on the meaning of " human life" (Olen & Barry, 1996:172).Since most of the controversy surrounding the abortion issue concerns precisely when a human individual or a person is considered to exist, it is impor tant to understand the development of the human fetus.

Developmental timetable
Conception occurs when a sperm ato zoon penetrates an ovum.The result is a zygote.It takes the zygote two to three days to journey down the fallopian tube to the uterus.When the zygote reaches the uterus it develops into a blastocyst.By the end of the second week the blas tocyst implants itself in the uterine wall.
Between the third and eight-week the entity is called an embrio.Until it is born the unborn entity is called a fetus.The fetus becomes viable around the twentyfourth week (Olen & Barry, 1996:170).

Moral status of the fetus
The moral status of the fetus is gener ally, but not always, discussed in terms of the rights of the fetus (Olen & Barry, 1996:174).To grant moral status to the fetus does not deny the moral status or rights of the woman.Indeed, the ques tion of whose rights should take prec edence when a conflict develops raises difficult questions for the moderate and conservative views.

Legal status of the fetus, women and the nurse
According to the Constitution (Act 200 of 1993) the fetus is not a person and does not have human rights.The act on the termination of pregnancies (Act 92 of 1996) is based on the right of self de termination or autonomous decisions of a rational person and grants the woman the right to make the decision about the termination of pregnancy autonomously, without the consent of any other person, including the married partner.The nurse does have a legal responsibility to nurse, council and refer the patients but may refuse to participate in the act of abor tion.

Conceptualisation of critical thinking
A ccording to Daly (1998:324) critical thinking differs conceptually from other forms of thinking because of the follow ing characteristics.
Firstly, it is purposeful thinking.Critical thinking selectively attends to something to achieve a goal.With regards to ethi cal decision-making critical thinking will focus on the promotion of good and fair ness.This makes the thinking clear, pre cise, specific and relevant.These char acteristics are also standards for good thinking (Paul, 1990).
Secondly, critical thinking is based on rationality.This implies that decisions are based on reason and evidence rather than on personal preference and selfinterest (Kozier, Erb & Blais, 1997:224).Decisions, made in a rational manner, must be, in some way or another, justi fied.Logical reasoning is the tool by which one can justify one's decisions.The decision-m aker must provide evi dence in support of the decision.For this reason knowledge is a prerequisite for critica l th inking .W atson and Glaser (1991:29) are of the opinion that critical thinking is a composite of knowledge, attitudes and skills.Attitudes involve an ability to recognize the existence of prob lems and the acceptance of the need for evidence in support of what is asserted to be true.Skills refer to the ability to em ploy and a pply the attitudes and knowledge.
Thirdly, critical thinking is reflective in nature.In this sense critical thinking is retrospective, because one must first be confronted with information before one can evaluate it (Daly, 1998:423).The reflective process is interactive and the result is that one becomes aware of per sonal values and personal biases.Sen sitivity for the values and rights of others is developed.
Fourthly, c ritic a l th in k e rs are openminded in the sense that they are open for alternative perspectives and they are willing to debate other possibilities.This implies that they are willing to reconsider.During dialogue critical thinkers demon strate the characteristics of persever ance and tolerance (Paul, 1990).
Lastly, critical thinkers are autonomous (Kozier, Erb & Blais, 1997:224).This m eans th a t th e y can, on ra tio n a l grounds, make decisions independently.They are willing to make decisions and take responsibility for the decisions.They are not intimidated by fallacies.
These five characteristics of critical think ing were organized into four categories (as reflected in table 1) for the dataanalysis.In conclusion a critical thinker can be described as follows: The ideal critical thinker is habitually in quisitive, well-informed, trustful of rea son, open-minded, flexible, fair-minded in evaluation, honest in facing personal biases, prudent in making judgements, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in selection of criteria, focused on inquiry, and persistent in seeking results which are as precise as the subject and circum stances of the inquiry permit (American Philosophical Association, 1990:3).

Findings and conclusions
The findings are reflected in table 1. Ta ble 1 will guide the discussion of the find ings and conclusions of the research.
The majority of nurses have a pro-life perspective on abortions.Hardly any of this group justified their thinking and opinions.The nurses with a pro-choice perspective, were the minority but as a rule justified their thinking and opinions.
The co nclusio n of the study can be stated that the majority of nurses do not think critically about ethical issues like the termination of pregnancies.The fol lowing discussion will support this con clusion.Direct quotations will be in Ital ics format.

Open-minded and tolerance
If nurses were critica l th in ke rs they should be open-minded, willing and tol erant to discuss alternative views and opinions.
The data from the questionnaires and focus group interviews reflects the op posite characteristics.Nurses don't want to listen/talk or think about the termina tion o f pregnancies.They are not will ing to participate in a dialogue to con sider alternatives.They find it irritable to talk about the issue.The general re sponse was: I was brought up this way.
Nurses are not tolerant for other per spectives and just view abortion as a crime, murder and a sin.
They viewed the ethical issue very nar row-minded in the sense that they re sponded that abortions are unfair, a self ish act and no babies are available for adoption.They did not reflect on fairness and the decision of the woman not to continue with the pregnancies.They rea ct ve ry ju d g m e n ta l to w a rd s the woman who decides on the termination of the pregnancy.
Nurses were comfortable with the con ditions and grounds for the termination of pregnancies from the old act (Abor tion and Sterilization Act, Act 2 of 1975) but are not willing to accept the princi ples in the new act on the Termination of Pregnancies (Act 92 of 1996).It is diffi cult for nurses to see the termination of pregnancies as part of the promotion of health.

Rational, purposeful decisions
Nurses who think in a rational, purpose ful manner use logical reasoning in their decision-making.This means that they can justify their decisions on rational grounds.Their decisions can be justified as fair and with the purpose of the pro motion of health.Before they make their decisions they will make a thorough as sessment and ensure that they are well informed.Critical thinkers do not jump to conclusions.They take time to col lect data, weigh the facts and think the matter through.Critical thinkers do not accept or reject an idea unless they un derstand it (Kozieretal, 1997:224).Prob lem-solving skills are internalized in their

Categories (characteristics of critical thinking)
Data from open-ended questionnaires and focus group interviews

Reflective Autonomous
• Don't want to hear/think/ talk about it Only five percent of nurses gave a ra tionale for their perceptions.In ninety five percent of the cases the responses were emotion-loaded without any justifi cation.Nurses perceive abortions as a sin, murder, a crime, a threat to the com munity, act of disgrace, waste o f tax pay er's money and not fair.
The fact that nurses responded that they were not consulted and question the rights of the fetus, demonstrate that they are not well informed and did not make an assessment of the issue.In the nor mal p rocess to p ro m u lga te the act, nurses were involved through the pro fessional organization, as well as other organizations.According to the consti tution, the fetus is not a person and is not entitled to human rights.
N urses d e m o n s tra te n a rro w mindedness in the sense that they only considered one option and did not think about or consider alternative options.Responses like abortion is a disadvan tage to the community, they m ust ju st deliver their babies and love them, sup port the conclusion.

Reflectiveness
Reflective practitioners are honest about their personal biases and aware of per sonal values that may influence their decisions.A prerequisite for reflective thinking is empathy.This means that a reflective practitioner can put them in the position of another person and has a holistic understanding of the position of that person.Respect for the dignity, the rights and values of the other person are a foundation for empathy and reflective practice.
Nurses' general responses were from their own personal value fram ework.They did not show any sensitivity for per sonal biases.The values of the women and other role players were not consid ered.Nurses did not want to learn or talk about the issue.They are not willing to participate in an ethical discourse.

Autonomous
Autonomous practitioners are willing to make decisions and take responsibility for their decisions.
Nurses dem onstrate that they do not want to become involved.They perceive decision-making on abortion as the doc to r's responsibility.They ignore their re sponsibility by saying that only God can decide and that they will be judged by God if they participate.

Recommendations
Emphasis should be on the develop ment of critical thinking during nursing education.However, the development of critical thinking is not easy, but with ef fort, everybody can achieve some level of critical thinking and become effective decision-makers.The following are a few recommendations in the development of critical thinking (Kozier et al, 1997:236-237).

Self-assessment and reflection
Curiosity, open-m indedness, humility, courage and perseverance are attitudes that facilitate critical thinking.A nurse might benefit from a rigorous personal assessment and reflection to determine which attitudes she or he already pos sesses and which need to be cultivated.This self-assessment and reflection can also be done with a partner or in a group.

Tolerating dissonance and ambiguity
It is a human tendency to seek out infor mation that corresponds to one's beliefs and opinions and ignore evidence that may contradict our viewpoints.This phe nomenon is explained by the theory of cognitive dissonance (Festinger, 1957).To develop a critical thinking attitude and skills, nurses should take deliberate ef fort to seek information that is in opposi tion with their own views.A thorough study of the fundamentals of the oppo site views should be made in an effort to understand the theoretical foundation of other opinions.In this way nurses can develop open-mindedness and a toler ance for opposing views.
To tolerate ambiguity, judgm ent should be suspended until more is known.A thinker who can live with such ambigu ity and cognitive dissonance will be in an advantage and will not fall prey to quick fixes.

Seeking situations where good thinking is practiced
Nurses should attend conferences, sym posia and debates that support open examination of all sides of issues and respect opposing views.A suspicious attitude should be developed to anyone presenting something as " proven facts" unless it is supported by sufficient and convincing evidence.Cultivating a ques tioning attitude is of great importance in the development of critical thinking.
Nurses should become aware of their own and other people's reasoning and thinking to detect reasoning and think ing errors.

Creating an environment that supports critical thinking
Critical thinking cannot be developed or maintained in a vacuum.Nurses in lead ership positions should actively create an environment that is conducive to the tolerance as well as the examination of o p p o s in g view s.In d iv id u a l nurses should be encouraged to think inde pendently and avoid thinking like the group.Every individual must learn to make decisions and to take responsibil ity for these decisions.

Summary
The more nurses practice standards of good thinking, the better thinkers they will become.It is a matter of "practice it and enjoy it" .