Factors that impact on emergency nurses’ ethical decision-making ability

Abstract

Background:

Reliance on moral principles and professional codes has given nurses direction for ethical decision-making. However, rational models do not capture the emotion and reality of human choice. Intuitive response must be considered.

Research purpose:

Supporting intuition as an important ethical decision-making tool for nurses, the aim of this study was to determine relationships between intuition, years of worked nursing experience, and perceived ethical decision-making ability. A secondary aim explored the relationships between rational thought to years of worked nursing experience and perceived ethical decision-making ability.

Research design and context:

A non-experimental, correlational research design was used. The Rational Experiential Inventory measured intuition and rational thought. The Clinical Decision Making in Nursing Scale measured perceived ethical decision-making ability. Pearson’s r was the statistical method used to analyze three primary and two secondary research questions.

Participants:

A sample of 182 emergency nurses was recruited electronically through the Emergency Nurses Association. Participants were self-selected.

Ethical considerations:

Approval to conduct this study was obtained by the Adelphi University Institutional Review Board.

Findings:

A relationship between intuition and perceived ethical decision-making ability (r = .252, p = .001) was a significant finding in this study.

Discussion:

This study is one of the first of this nature to make a connection between intuition and nurses’ ethical decision-making ability.

Conclusion:

This investigation contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions.

Keywords

Emergency nurse ethical decision-making ethics experiential thought intuition rational thought

Introduction

With the ever-increasing complexity of today’s workplace, nurses are presented with difficult patient care decisions, often on a daily bases. Technology, shortened length of stay, higher patient acuity, longer life expectancy, chronic illness, and pay for performance are just a few issues that have raised the stakes in nursing care, including the associated ethical questions that arise. Furthermore, every patient encounter has the potential for an ethical implication at the personal, professional, or social level.¹ How nurses approach such ethical decisions has been explored in the nursing literature. Here, reliance on moral principles² and professional codes³ gives direction for ethical decision-making while also providing the assumption that these decisions should be rational and analytic. However, ethical knowledge embedded in principles and codes do not necessarily result in ethical behavior.⁴ Rational models often fail to capture the emotion and reality of human choice^5,6 with an ability to fully understand how nurses make ethical decisions. Intuitive response must be considered.

Nevertheless, nursing research conducted over the past 20 years regarding intuition is limited. Most studies are qualitative in nature and lack quantitative rigor to support its use.⁷ Consequently, this has lead to a dearth of information regarding intuition as it relates to nurses’ ethical decision-making ability.⁸ With evidence-based practice as the gold standard,⁹ research using both qualitative and quantitative methods is needed to support the use of intuition as an important ethical decision-making tool for nurses. Here, two modes of thought—intuitive/experiential and analytic/rational—are considered for nurses when making ethical decisions.

Background

Intuition

Within the domain of nursing, there is little research on intuition prior to the 1980s. Planting the seed for what would become the complex and diverse concept of intuition, Sewall¹⁰ alluded to the nurse’s artistic ability in using instinct during decision-making. Decades later, Rew and Barrow¹¹ recognized intuition as a neglected concept of nursing practice. They conducted a literary search from 1900 to 1985 tracing the growth and development of the concept within nursing. With almost 15,000 articles reviewed, the concept appeared only once suggesting that nurses use formalized assessment, not hunch or intuition in clinical practice.¹² Other nurse researchers have explored intuition.^13

–17 Their findings support intuition as an essential component of nurses’ decision-making gained through experience.

Intuition is a concept that nursing has neither clearly articulated nor adequately explored.¹⁸ There is no single definition that can capture its full meaning and influence.¹⁹ Some definitions include the following: understanding without rationale,¹⁵ a way of knowing that bypasses the reliance on logic and linear analysis,²⁰ and instant understanding of knowledge without evidence of sensible thought.²¹ Outside of nursing, intuition has been described as accumulated and compiled experiences,²² no more and no less than the recognition of patterns.²³ It has also been recognized as tacit or implicit knowledge.^24,25 Despite the lack of concept clarity, the interplay of knowledge and experience for the development of intuition has been recognized.

Intuition and knowledge

Most definitions acknowledge intuition’s relationship to knowledge. Reber²⁵ recognizes intuitive knowledge as the end product of implicit learning experiences stored below the conscious level. This has been linked to tacit knowledge; in other words, knowing more then we can clearly articulate.²⁴ Carper’s²⁶ four fundamental patterns of knowing—empiric, esthetic, personal, and ethical—have also had synonymous connection with intuition. Several authors have suggested that there is a need to develop esthetic²⁷ and personal^18,20,28 knowledge to gain intuition. Others emphasize the presence and reciprocity of all patterns of knowing with intuition serving as the bridge between the domains.^29,30

How intuitive knowledge is gained remains unclear. It has been described as knowledge acquisition that bypasses linear reasoning process^14,31 obtained through spiritual connections, or psychic, and instinctual means.²⁸ Benner and Tanner¹⁵ present a skills acquisition model describing “skilled know-how” or practical knowledge as the catalyst for intuition gained through experience. Klein²² echoes the use of practical knowledge as the medium for intuition and advises the use of analysis as a supportive tool. Here, cognitive processes realize reciprocity between intuitive/experiential and analytic/rational thought.^32
–34

Intuition and experience

Experience has been noted to have a strong association with intuition. The “Novice to Expert”¹⁶ model has been pivotal in the development and advancement of the intuitive experience and meaning for the expert nurse. As the nurse progresses from a novice to expert, intuition becomes proportional to experience.^15,16 Other researchers make the connection between experience and expert intuition.^11,22,23,29 With experience as a base line of awareness, situations become familiar allowing the person to act on appropriate recognized patterns.^{21,22,31,35,36}

Pattern recognition is a frequently mentioned concept in the literature on intuition. Simply stated, during an experience, the memory forms a pattern of certain aspects of the experience, which in turn is applied to future experiences. Researchers realize pattern recognition as proportional to experience, and hence expert intuition.^{6,15,22,31,37} Noticing incompatibility between “what is” and “what should be” provides the data needed through cognitive connection to make an intuitive decision. Such perceptual acuity could only develop through broad experience in similar situations.^6,13,37

Because of the many ways in which intuition can be labeled, for the purpose of clarity, terminology in this investigation will appear as such: intuitive/experiential will refer to thought processes relating to the Experientiality scale of the Rational Experiential Inventory (REI) and analytic/rational will refer to thought processes relating to the Rationality scale of the REI.³⁸ Table 1 shows the summary of terminology.

Table 1.

Summary of terminology.

Thought process	Process uses	Instrument labels	Concepts measured
Intuitive/experiential	Intuition, feelings, and emotions	Experientiality	Intuition
Analytic/rational	Analysis and logic	Rationality	Analysis and logic

Ethical decision-making

From a rational perspective, ethical decision-making is defined as the cognitive sense to morally justify a decision.³⁹ Ethical decision-making refers to the entire decision-making process starting with a moral judgment or recognition of the ethical issue. This leads to moral reasoning where thought processes are set in motion to determine right from wrong. This concludes with a final decision or action.⁴⁰ Four ethical principles (non-maleficence, beneficence, justice, and respect for autonomy)² are integrated in a Code of Ethics for Nurses³ providing direction for ethical decision-making.

Rational ethical decision-making

Two major theories underpin the traditional view of ethical reasoning; Utilitarianism and Deontology. First, the principle of utility asserts ethical decisions should result in the greatest good for the greatest number of individuals. Utilitarian subscribe to rules and codes for objective assessment to evaluate probable consequences. Through impartial review, the end may justify the means. Conversely, Deontology disputes a “means to ends” philosophy with ethical decision-making based on obligation and truth, and not on the promotion or avoidance of societal consequences or personal desires.² As a common denominator, both theories are grounded by the exclusion of personal intention and emotion.

Intuitive ethical decision-making

Principles and theories fail to account for the complexity of thought required to solve complicated ethical dilemmas.⁴¹ Recognizably, decisions are not always rational as context, perceptions, and emotions vary with each situation.²⁶ As rational models fail to capture the reality of human choice and behavior,^5,6 intuitive response is needed.⁴²

Kitchener⁴³ describes two levels of moral reasoning: an intuitive level and a critical evaluative level. At the intuitive level, response to moral circumstance is immediate. It is the starting point for moral deliberation. Critical evaluation follows using professional codes and ethical principles or theory to defend a response initiated by a moral intuition. Here, ethical decision-making is defined as an intuitive response to a moral circumstance resulting in a quick moral judgment. Reasoning through rational approach begins after and in defense of this moral judgment. Similarly, Haidt⁴⁴ presents an intuitionist model that supports moral judgments made as a result of quick, automatic evaluation of a situation. After a moral judgment is made, reasoning through rational approach begins as one searches for an argument to defend an already made decision. By ignoring intuitive response, ethical reasoning becomes overly objective and devoid of passion.⁴¹

Theoretical framework

Cognitive-Experiential Self-Theory (CEST) provides the theoretical framework for this study. According to CEST, information is processed by two independent, interactive conceptual systems: a preconscious intuitive/experiential system and a conscious analytic/rational system. These are thought to function parallel from yet interactively with each other. CEST also assumes that behavior is automatically and emotionally regulated by an intuitive/experiential system that operates at the preconscious level. At this level, thoughts are interpreted and experiences are organized as the intuitive/experiential system searches the memory for related events. This system solves problems and makes decisions intuitively, beyond analytic/rational thought. Conversely, the analytic/rational system is slower in processing information as thoughts are organized. This system operates at a conscious level through logic and reason.³² Table 2 provides a comparison of these systems.

Table 2.

Comparison of the rational and experiential systems.³²

Experiential system	Rational system
1. Holistic	1. Analytic
2. Affective: pleasure-pain oriented	2. Logical: reason-oriented
3. Automatic, effortless	3. Intentional, effortful
4. Behavior mediated through “vibes” from past experiences	4. Behavior mediated through conscious appraisal of events
5. Encodes reality in concrete images and metaphors	5. Encodes reality in abstract symbols, words, and numbers
6. More rapid processing: oriented toward immediate action	6. Slower processing: oriented toward delayed action
7. Emotional; context-specific processing	7. Non-emotional; context-general processing
8. Experience is passive and preconscious: we are seized by our emotions	8. Experience is active and conscious
9. Self-evidentially valid: “Experiencing is believing”	9. Requires validity through logic and evidence
10. Slower and more resistant to change: changes with repetitive or intense	10. Changes more rapidly: changes with strength of new argument

Aim

The aim of this study was to explore the relationship between nurses’ use of intuition, years of worked nursing experience, and nurses’ perceived ethical decision-making ability. However, recognizing the relationship between the intuitive/experiential and analytic/rational systems, a secondary aim also explored analytic/rational thought processes and its relationship to years of worked nursing experience and nurses’ perceived ethical decision-making ability.

Research questions

Three primary and two secondary research questions explored the relationships between the following:

Intuition and perceived ethical decision-making ability;

Years of worked nursing experience and intuition;

Years of worked nursing experience and perceived ethical decision-making ability;

Rationality and years of worked nursing experience;

Rationality and perceived ethical decision-making ability.

Method

A non-experimental, correlational research design was used to examine the relationship between the independent (nurses’ use of intuition/rational thought and years of worked nursing experience) and dependent (nurses’ perceived ethical decision-making ability) variables. Intuition was measured using the Experiential scale of the REI capturing the capacity and reliance to use intuition. Rationality was measured using Rationality scale of the REI³⁸ capturing the capacity and reliance to use rational thought. Perceived ethical decision-making ability was measured with the Clinical Decision Making in Nursing Scale (CDMNS)⁴⁵ applied to an ethical dilemma within the participants’ own practice. Years of worked nursing experience was captured through a demographic data survey developed by the researcher.

Participants

The sample included participants from both genders (n = 182) who were electronically recruited through the Emergency Nurses Association (ENA). The resulting sample consisted of predominately white/Non-Hispanic, Christian, females. Ages ranged evenly in age groups 30–39, 40–49, and 50–59. Almost half the sample achieved a baccalaureate in nursing as their highest academic degree. Years of worked nursing experience ranged from 1 to 46 years with a mean of 18.7 years. The majority of the sample was currently working as an emergency nurse. Table 3 provides the demographic details.

Table 3.

Descriptive statistics for demographic data.

Variables	n	%
Race
White	151	83
Black/African American	10	5.5
American Indian/Alaskan Native	1	0.5
Asian	12	6.6
Native Hawaiian/Pacific Islander	1	0.5
Other	7	3.8
Ethnicity
Hispanic	18	9.9
Non-Hispanic	164	90.1
Gender
Male	29	15.9
Female	153	84.1
Religion
Protestantism	17	9.3
Roman Catholic	73	40.1
Other Christian	52	28.6
Judaism	7	3.8
Buddhism	3	1.6
Hinduism/Taoism	1	0.5
Other religion	7	3.8
No religion	22	12.1
Age (years)
22–29	17	9.3
30–39	49	26.9
40–49	46	25.3
50–59	52	28.6
60–69	18	9.9
Education
Diploma	7	3.8
Associates	31	17
Bachelors	88	48.8
Masters	51	28
Doctoral	5	2.7
Experience (years)
<10	58	31.9
10–25	59	32.4
>25	65	39
Currently working as emergency nurse
Yes	147	80.8
No	35	19.2

Instruments

The REI is a 40-item self-report instrument used to measure rationality and experientiality. There are 20 items in each scale. Items are based on a 5-point Likert scale with responses ranging from 1 (definitely not true of myself) to 5 (definitely true of myself). The Rationality scale measures capacity and reliance to use analytic/rational thought, while the Experiential scale measures capacity and reliance to use experiential/intuitive thought. The higher the score, the higher is the capacity and reliance to use either thought process. Reliability reports Rationality α = .90 and Experientiality α = .87.³⁸

The CDMNS is a 40-item self-report instrument that measures nurses’ perception of their normative decision-making ability. Each item is based on a 5-point Likert scale. Responses range from 1 to 5 indicating whether a person is likely to behave in the described way. Scores range from 40 to 200. The higher the scores, the higher one’s perceived decision-making ability. Reliability reports α = .83.⁴⁵

Data collection

The researcher sent 1000 letters to ENA members containing an electronic survey link. Participants were directed to an informed consent. By clicking “next,” the participants acknowledged consent and were prompted to a survey consisting of three instruments. These instruments consisted of the demographic data questionnaire and the REI.³⁸ Then, participants were asked to think of ethical dilemma involving a clinical situation in their own practice and next apply this ethical dilemma to the CDMNS.⁴⁵ Reminder notices were sent out after 1 month. Data were collected for 5 months. Only completed surveys were used for the final analysis.

Ethical considerations

Approval to conduct this study was obtained by the Adelphi University Institutional Review Board (IRB). Confidentiality, freedom to withdraw, and risks/benefits of the study were explained to each participant through an electronic informed consent.

Data analysis

Statistical Package for Social Sciences (SPSS) version 22 was used to code and tabulate scores collected from the three instruments. Descriptive statistics analyzed the demographic data of the sample population. All variables were treated with continuous data. Pearson’s r correlation provides the most robust statistical method to answer three primary and two secondary research questions.

Results

Three primary research questions frame the purpose of this investigation. They explore the relationships between intuition, perceived ethical decision-making, and years of nursing worked experience. Additionally, two secondary questions explore rationality as it relates to years of worked nursing experience and perceived ethical decision-making ability.

The first primary question asks, Is there a relationship between intuition and perceived ethical decision-making? Pearson’s r correlation yielded a significant relationship (r = .252, p = .001) between the Experientiality scale of the REI and total CDMNS scores. However, the correlation was weak (R² = .063). Conversely, no significant relationships were noted between years of worked nursing experience and intuition (experientiality) or years of worked nursing experience and perceived ethical decision-making. Secondary research questions also yielded no relationship between rationality and years of worked nursing experience or rationality and perceived ethical decision-making. Table 4 reports Pearson’s r correlations.

Table 4.

Pearson’s r correlations (N = 182).

Research questions	r	p
Intuition/perceived ethical decision-making ability	.252	.001
Years of worked nursing experience/intuition	.030	.690
Years of worked nursing experience/perceived ethical decision-making ability	.023	.763
Rationality/years of worked nursing experience	−.040	.593
Rationality/perceived ethical-decision making ability	.129	.087

Discussion

Three primary research questions explored the relationships between intuition and perceived ethical decision-making ability, years of nursing worked experience and intuition, and years of worked nursing experience and perceived ethical decision-making. In looking at the latter two of these, research suggests relationships tying nursing experience to intuition and expert decision-making.^15,16,46,47 These relationships were unsubstantiated in this investigation. However, a relationship between intuition and perceived ethical decision-making was found.

Results of the latter two research questions yielded no correlation between the variables. These results are contrary to some of the literature that makes the connection between experience, intuition, and decision-making. In particular, Benner’s¹⁶ seminal work applies a skills acquisition model to describe transition from novice to expert nursing practice. Five levels of practice are defined: novice, advanced beginner, competent, proficient, and expert. Here, intuition becomes proportional to experience as thought processes transform from analytic thinking to intuitive decision-making. It is the expert nurse who has an “intuitive grasp” of the situation.

Sumner⁴⁸ extends these aligning five stages of professional development to pre-conventional, conventional, and post-conventional levels of moral development as described by Kohlberg.⁴⁹ At the pre-conventional level of moral development, novice and advanced beginner nurses are task-oriented and focused on checklists. With transition to a conventional level of moral maturity, competence and proficiency improve as the nurse recognizes unethical behavior, but lacks the skill and knowledge to act on it. Finally, at the post-conventional level, the expert nurse is said to possess “experiential intuition” recognizing and acting on unethical behavior. Again, this was unsubstantiated in this investigation. Nevertheless, some explanations may exist.

First, the word “expert” is used widely throughout the literature to explain the nurse who intuitively makes decisions.^{18,47,50
–52} However, experience and expert are not synonymous, interchangeable terms. It is the expert nurse who has an intuitive grasp of the situation.¹⁶ Experience is necessary for moving from one level to another, but experience is not equivocal to longevity or seniority. Experience means living through actual situations in such a way that it informs the practitioner’s perception and understanding of all subsequent situations.^8,53 Experience does not always translate to expert decision-making.⁵⁴ Some nurses, despite years of experience, never reached expert status.¹⁶ Additionally, some literature support intuition at beginner⁵⁵ and new graduates⁵⁶ levels of practice, as well as at all skills levels.^18,47,50,52

The first primary research question explored the relationship between intuition and perceived ethical decision-making ability. A correlation supported a relationship between intuition and perceived ethical decision-making ability. This study is one of the first of this nature to make this connection. However, these results should be taken with caution noting a weak relationship (R² = .063). Nevertheless, some assumptions may be made based on these results. First, emotional response is the core of ethical decision-making ability, and second, nurses use two modes of thought: intuitive/experiential system and analytic/rational.

Emotional response is the core of ethical decision-making ability.⁵⁷ This was supported through research conducted by Greene⁵⁸ indicating that emotion-based intuition and analysis both matter, but automatic emotional processes tend to dominate. These findings indicate the importance of intuition while allowing reasoning to play a restricted, but significant role in moral judgment. Preliminary research also points toward intuitive processes as having an effect on certain brain functions thereby influencing moral judgment.⁵⁹ This was tested using magnetic resonance imaging (MRI). Subjects responded to a series of questions involving both moral and non-moral dilemmas. Neuroimaging found different areas of brain to be effected in each case. Findings from this current investigation support an emotional intuitive component to perceived ethical decision-making ability.⁶⁰

Additionally, nursing studies have recognized ethical behavior in nurses to be as much an emotional response as a rational response. In one grounded theory analysis, solutions to moral problems were noted to include personal involvement and intuition.⁶¹ A similar study found nurses to have an emotional orientation using intuition to solve ethical issues.⁶² These studies support the growing importance of ethics to nursing.

Nurses use two modes of thought: intuitive/experiential system and analytic/rational. Understanding the relationship between these thought process is difficult. The development of the CDMNS was based on normative decision-making theory. Here, thought processes are logical and rational. So how can there be a relationship between an abstract concept such as intuition and rational thought? One possible explanation might lie in the theory that supports this investigation. CEST recognizes two modes of thought: an intuitive/experiential system and an analytic/rational system which are independent from each other, yet interactive with each other. Nurses in this investigation most likely recounted an ethical situation which elicited an emotional response followed by rationalization of the problem.

Nursing studies have suggested reciprocity of intuitive/experiential and analytic/rational processes. In one study, “Nursing Gestalt” or all at once coming together of intuitive/experiential and analytic/rational thought directs nurses’ actions.¹³ In a similar study, nurses identified patient cues that signal transition to or from deterioration and/or recovery. Cues were based on subjective data and intuition.⁶³

Recognizing that ethical decisions are grounded in both intuitive/experiential and analytic/rational thought processes^32,44,58 led this researcher to further investigate the next two research questions. Rationality as it relates to years of worked nursing experience and perceived ethical decision-making was explored. Neither case yielded any statistical relationship to rationality in this sample.

Such findings dispute some literature on moral reasoning and ethical decision-making. In particular, Kohlberg’s⁴⁹ Theory of Moral Development posits that moral reasoning follows a sequence from pre-conventional, conventional, and post-conventional levels of moral development. Transition from one stage to another is influenced by age maturity and level of education. Sumner⁴⁸ applies this theory to Benner’s¹⁶ skills acquisition model noting that moral development at the post-conventional level is gained as the nurse transitions from novice through to expert levels of practice. The expert nurse is said to be at the post-conventional level recognizing and acting on unethical behavior. However, this was not the case in this investigation.

The majority of the nurses in this sample held a bachelors degree or higher (80%), were 30–59 years of age (81%), and had an average of 18.7 years of worked nursing experience. Following these theories, the nurses in this study should be experts at the post-conventional level of moral development. However, results did not translate as such noting that the nurses’ ability to reason bore no association to their work experience or perceived ability to make ethical decisions. Two plausible reasons may exist. The first may be related to a healthcare environment built on policies and procedures limiting nurses’ ability to reason through an ethical dilemma, and second, emotions are the significant driving force in moral judgment.

With growing concern about nurses’ ethical competence, Dierckx de Casterle et al.⁶⁴ conducted a meta-analysis examining nurses’ responses to ethical dilemmas in nursing practice. Data were collected from nine studies (n = 1592) that used the Ethical Behavior Test (EBT) which is based on Kohlberg’s⁴⁹ Theory of Moral Development. Findings of this analysis noted nurses in all nine studies to be practicing at a conventional level of moral development. Here, nurses had an inability to autonomously separate their own ethical viewpoints while caring for patients from organizational standards and rules.

Emotions are the significant driving force in moral judgment. Here, theories present intuition as the dominate mode of thought with analytic/rational processes used to justify the intuitive/experiential response.^43,44,58 At the intuitive level, response to moral circumstance is emotional and immediate. It is the starting point for moral deliberation. Critical evaluation is then used to justify a response initiated by a moral intuition. Critical evaluation follows professional codes, ethical principles, and theory.⁴³

Limitations

Several limitations where noted in this study. First, this homogeneous sample consisted largely of older experienced nurses, thus creating a sample bias. As a result, findings are not generalizable to the larger population of emergency nurses. Second, a sample size of 182 fell slightly short of the 191 participants estimated through power analysis. However, the additional risk of statistical error is small and not likely to have altered the results of this study.

Conclusion

This investigation is a step toward bridging the gap between logic and intuition. It also contributes to a broader understanding of the different thought processes used by emergency nurses to make ethical decisions. As with any preliminary research, further investigation is needed to broaden the scope of knowledge. This should include both qualitative and quantitative methodologies with nurses from diverse specialties such as critical care, obstetrics, or general medicine recognizing that different role expectations and context shape ethical practice. Future research must also incorporate both intuitive/experiential and analytic/rational thought processes recognizing the reciprocity between them. Models that link both processes require evidence to promote and support the intuitive response in ethical decision-making. Notably, the soundest assessments are based on analysis and intuition.

Footnotes

Acknowledgements

The author thanks the participants of the Emergency Nurses Association.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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